*George Powin Company

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333 heanort AnnueAtt2nta, Georg.a 30308.

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December 21, 1989W. G Hairston. Illsenor vec Prei.ent ;

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ELV-Oll830176

fDocket No. 50-424

U. S. Nuclear Regulatory Commission fATTN: Document Control Desk |

Washington, D. C. 20555 :

Gentlemen:

V0GTLE ELECTRIC GENERATING PLANTLICENSEE EVENT REPORT

PERSONNEL ERROR LEADS TO CONTAINMENT VENTILATION ISOLATION

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in accordance with 10 CFR 50.73, Georgia Power Company hereby submits the,

enclosed report relating to an event which occurred on December 11, 1989. :| .

Sincerely,

h. .

W. G. Hairston, Ill'

WGH,Ill/NJS/gm

Enclosure: LER 50-424/1989-020 ,

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xt: Georaia Power Company| Mr. C. K. McCoy'

Mr. G. Bockhold, Jr.Mr. P. D. Rushton

| Mr. R. M. Odom '

| NORMS

!l M. S. Nuclear Reaulatory Commission || Mr. S. D. Ebneter, Regional Administrator -

Mr. J. B. Hopkins, Licensing Project Manager, NRRt

Mr. J. F. Rogge, Senior Resident Inspector, Vogtle1

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On 12-11-89, an Instrument and Controls (I&C) technician was preparing to checkthe fuses in Containment low range area radiation monitor 1RE-0003. At 1034

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CST, he removed power from the monitor prior to lifting the leads to theEngineered Safety Features (ESF) actuation circuits. The loss of power causedthe monitor to revert to its failed, or safe, condition which sent a high alarmsignal to ESF actuation circuits, initiating a Containment VentilationIsolation.

The root cause of this event was cognitive personnel error on the part of thetechnician in not adequately following procedure. The technician will bedisciplined and provisions for blocking the ESF actuation signal duringmaintenance and testing are currently planned for installation in 1990.

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A. REQUIREMENT FOR REPORT ]This report is required per 10 CFR 50.73 (a)(2)(iv) because an unplanned |Engineered Safety Feature (ESF) actuation occut red, j

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B. UNIT STATUS AT TIME OF EVENT

At the time of the event, Unit I was operating in Mode 1 at 100% of ratedthermal power (RTP). Other than that described herein, there was no !

inoperable equipment which contributed to the occurrence of this event. i

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C. DESCRIPTION OF EVENT '

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On 12-11-89, an Instrument and Controls (l&C) technician was preparing tocheck the fuses in Containment low range area radiation monitor 1RE-0003.At 1034 CST, he removed power from the monitor prior to lifting the leads to i

the Engineered Safety Features (ESF) actuation circuits. The loss of power,caused the monitor to revert to its failed, or safe, condition and this safe '

condition sent a high alarm signal to ESF actuation circuits. A Containmeat |Ventilation Isolation (CVI) occurred and the appropriate valves and damperJ iactuated to their proper positions. Control room personnel responded to |verify that no abnormal radiation condition existed and the CVI signal was ireset at 1153 CST.

D. CAUSE OF EVENT.

The root cause of this event was personnel error on the part of the GeorgiaPower Company technician. Procedure 24623-1, " Containment Low Range AreaRadiation Monitor Analog Channel Operational Test," which is used for '

general maintenance activities as well as Technical Specificationsurveillances, was attached to and referenced on the work order for checkingthe fuses. The procedure requires the ESF actuation circuit leads to belifted prior to removing power from the monitor. However, the technicianneglected to consult the procedure. This cognitive personnel error was not

,

the result of any unusual characteristics of the work location.!

The following are contributing causes for this event:

1. Department policy did not require use of procedure check-off blocks whenperforming non-routine activities of this type. The procedure is usedfor performing Technical Specification surveillances as well as forgeneral maintenance activities but does not detail all possibleactivities which may need to be performed. However, the procedureprovides a means for self-checking which should be employed whenpossible,

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2. No caution label exists on the monitor to advise personnel of thepotential for initiating an ESF actuation by removing power.

3. Operational needs for blocking the ESF actuation signal duringmaintenance and testing were not addressed in the original design.

E. ANALYSIS OF EVENT

During this event, the CVI signal actuated the proper valves and dampers andcontrol room operators responded correctly in verifying that no abnormalradiation condition existed. Therefore, plant safety would have beenmaintained if an abnormal radiation condition had, in fact, existed. Basedon these considerations, there was no~ adverse effect on plant safety orpublic health and safety as a result of these events.

F. CORRECTIVE ACTIONS

The Positive Discipline Program will be enacted for the technician involvedin this event.

The following are contributing factor corrective actions:

1. An I & C policy statement will be issued stressing the need for usingself-checking blocks when appropriate. Also, all appropriate personnelwill be coached on the importance of using procedures.

2. Permanent caution labels will be placed on the exterior of the radiationmonitor data processing modules"(DPM's) advising of the potential forinitiating ESF actuations.

3. A blocking capability is being designed with installation currentlyplanned for 1990.

G. ADDITIONAL INFORMATION

1. Failed ComponentsNone

2. Previous Similar Events:LER 50-424/1988-027, dated 10-26-88.

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Corrective action addressed lack of a switch to block the CVI actuationsignal. Installation of these switches is scheduled to occur during1990,

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3. Energy Industry Identification System CodeContainment Isolation Control System - JMRadiation Monitoring System - IL

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