Information Notice 1986-42, Improper Maintenance of Radiation Monitoring Systems

Improper Maintenance of Radiation Monitoring Systems

ML031250045
Person / Time
Site:	Beaver Valley, Millstone, Hatch, Monticello, Calvert Cliffs, Dresden, Davis Besse, Peach Bottom, Browns Ferry, Salem, Oconee, Mcguire, Nine Mile Point, Palisades, Palo Verde, Perry, Indian Point, Fermi, Kewaunee, Catawba, Harris, Wolf Creek, Saint Lucie, Point Beach, Oyster Creek, Watts Bar, Hope Creek, Grand Gulf, Cooper, Sequoyah, Byron, Pilgrim, Arkansas Nuclear, Three Mile Island, Braidwood, Susquehanna, Summer, Prairie Island, Columbia, Seabrook, Brunswick, Surry, Limerick, North Anna, Turkey Point, River Bend, Vermont Yankee, Crystal River, Haddam Neck, Ginna, Diablo Canyon, Callaway, Vogtle, Waterford, Duane Arnold, Farley, Robinson, Clinton, South Texas, San Onofre, Cook, Comanche Peak, Yankee Rowe, Maine Yankee, Quad Cities, Humboldt Bay, La Crosse, Big Rock Point, Rancho Seco, Zion, Midland, Bellefonte, Fort Calhoun, FitzPatrick, McGuire, LaSalle, University of Lowell, 05000000, Zimmer, Fort Saint Vrain, Shoreham, Satsop, Trojan, Atlantic Nuclear Power Plant, Skagit, Marble Hill
Issue date:	06/09/1986
From:	Jordan E NRC/IE
To:
References
IN-86-042, NUDOCS 8606040007
Download: ML031250045 (6)

SSINS No.: 6835 IN 86-42 UNITED STATES

NUCLEAR REGULATORY COMMISSION

OFFICE OF INSPECTION AND ENFORCEMENT

WASHINGTON, D.C. 20555 June 9, 1986 IE INFORMATION NOTICE NO. 86-42: IMPROPER MAINTENANCE OF RADIATION

MONITORING SYSTEMS

Addressees

All nuclear power reactor facilities holding an operating license (OL) or a

construction permit (CP).

Purpose

and Summary:

This notice is issued to alert licensees to the potential for defeating the

safety function associated with radiation monitoring systems by not properly

adhering to established surveillance and maintenance procedures. A recent

event at a BWR, when an electrical jumper was inadvertently left in place after

a planned surveillance, led to failure to maintain secondary containment

integrity during irradiated fuel movement.

It is expected that recipients will review the information for applicability to

their maintenance and surveillance program and consider actions, if appropriate, to preclude similar problems at their facility. However, suggestions contained

in this notice do not constitute NRC requirements; therefore, no specific action

or written response is required.

Previous Related Correspondence

IE Information Notice No. 83-23, "Inoperable Containment Atmosphere

Sensing Systems," April 25, 1983.

INPO Significant Event Report, 35-83, "Compromise of Secondary Containment

Integrity," June 9, 1983.

IE Information Notice No. 83-52, "Radioactive Waste Gas System Events,"

August 9, 1983.

IE Information Notice No. 84-37, "Use of Lifted Leads and Jumpers During

Maintenance or Surveillance Testing," May 10, 1984.

Description of Circumstances

On November 18, 1985 the Cooper Nuclear Station was in a shutdown condition

(reactor coolant temperature less than 212 0F and vented) with acceptance

testing for a plant design change in progress. When this testing failed to

provide for the required Group VI isolation (various containment isolation and

Copies to: Withers, Yundt, Lentsch, Orser, Steele, E. Burton, E. Jordan, A. Holm, iLIS;.j. A. Olmstead, S. Hoag, S. Sautter, TNP:GOV REL F:NRC CHRONO,

TNiPGOV REL F:NRC IE Information Notice 86-42 PGE OAR Action - M. H. Halmros (Due 8/12/86)

NSRD Action - M. H. Malmros

IN 86-42 June 9, 1986 investigated and

engineered safety feature (ESF) initiations), the licenseereactor building (RB)

discovered that electrical jumpers were installed in the These jumpers

ventilation radiation monitors (VRM) auxiliary trip units. from the RB VRM.

prohibited a Group VI isolation by a high radiation signal notified as

The jumpers were immediately removed and the NRC was promptly

required by 10 CFR 50.72.

The licensee's subsequent investigation revealed that the and electrical jumpers

control technician

had been installed on November 13, 1985 by an instrument the VRM. These

during a routine surveillance procedure to functionally test the required

jumpers are used to prevent trip and equipment operations during off the procedural

functional/calibration testing. The technician had signed electrical jumper)

step requiring jumper removal (before actually removing the signal status. The

and then started checking control room annunciator and trip and forgot to go

technician then became involved in other unrelated craft work

back and remove the jumpers.

18 irradiated fuel

On November 18, 1986, before discovery of the jumpers, Failure to properly

bundles were loaded into a spent fuel shipping cask. of radiation

implement the surveillance procedure for operability checks standby gas

monitors rendered inoperable the automatic initiation of the

building upon

treatment system (SBGTS) and automatic isolation of the reactor lasted approxi- receipt of a high radiation signal. This degraded condition that

mately 5 days. However, control room annunciators and instrumentation

problems remained

would provide warning to operators of any high radiation and reactor building

operational during the 5 days. Manual-start of the SBGTS during the

isolation capabilities from the control room remained available

event.

Discussion:

given to the

This event clearly demonstrates that the level of attention monitoring systems

procedural controls for the maintenance of radioactive While there were no

providing ESF actuation can be significantly improved.

took escalated enforce- actual radiological consequences of this event, the NRC importance of correctly

ment actions (issued civil penalty) to emphasize the

systems designed to mitigate or prevent

performing surveillance procedures on related events taken from

accidents. Attachment No. 1 contains 6 summaries of

how improper maintenance

the Licensee Event Report files. Further examples of are provided in the listed

practices have degraded radiation monitoring systems

Previous Related Correspondence section.

actions to prevent

The Cooper Station initiated the following corrective

recurrence:

fuse removal)

1. All temporary modifications (e.g., electrical jumpering, 1985 were indepen- performed by the involved technician since October 5, dently verified.

adherence--sign off

2. Site management stressed the importance of procedural

the procedural step after completing the required action.

IN 86-42 June 9, 1986 3. All surveillance procedures requiring temporary modifications to system or

plant components were reviewed for deficiencies, and these procedures will

be modified to provide for independent verification to ensure that tempo- rary modifications are removed and the system/component is fully restored

to operational status.

No specific action or written response is required by this information notice.

If you have any questions about this matter, please contact the Regional

Administrator of the appropriate regional office or this office.

4'-CJ1ward L. Jord, Director

Division of Edergency Preparedness

and Engineering Response

Office of Inspection and Enforcement

Technical Contacts: James E. Wigginton, IE

(301) 492-4967 Roger L. Pedersen, IE

(301) 492-9425 Attachments:

1. Event Summaries

2. List of Recently Issued IE Information Notices

Attachment 1 IN 86-42 June 9, 1986 EVENT SUMMARIES

Unplanned Gaseous Release (Connecticut Yankee, PWR)

LER 85-025 Event Date: 9/19/85 Cause: Personnel Maintenance Error

Abstract: With the plant operating at 100 percent power, a main stack high

radiation alarm was received during routine scheduled maintenance

on a pressure actuated valve in the gaseous waste stream. The

unplanned release occurred through an isolation valve inadvertently

left open, allowing the on-line waste gas decay tank a release path.

The maintenance tag-out procedure correctly required the isolation

valve to be isolated, but the operator shut the wrong valve. The

total noble gas release was approximately 20 curies (about 14 percent

of technical specification limit). Licensee corrective action

included clearly relabeling associated valves and discussion of the

event with operation staff.

Containment Radiation Monitor Isolated (Byron 1, PWR)

LER 85-026 Event Date: 2/28/85 Cause: Improper Valve Position

Abstract: With the reactor at zero percent power, a containment radiation

monitor used for required reactor coolant leakage detection was

inadvertently left isolated for 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> from containment after

maintenance on an associated valve. Abnormal in-leakage at the

monitor caused normal-range readings on RM-li console in the main

control room (leakage was later repaired). Licensee corrective

action included implementing administrative controls to ensure

system integrity/proper restoration after completion of maintenance

activities.

Liquid Radwaste Effluent Monitor Isolated (Cooper, BWR)

LER 84-008 Event Date: 6/09/84 Cause: Monitor Discharge Valve Shut

Abstract: A liquid discharge occurred without required continuous

radiation monitoring because the liquid effluent radiation monitor

was isolated. No discharge limits were exceeded. Two days before

the event, a technician apparently shut the radiation monitor outlet

valve during maintenance without permission or knowledge of

operations personnel. As corrective actions, the licensee revised

controlling procedures and informed all plant operators of the

event.

Attachment 1 IN 86-42 June 9, 1986 Off-Gas Stack Monitor Inoperable (Cooper, BWR)

LER 84-006 Event Date: 4/18/84 Cause: Personnel Error

Abstract: With the reactor at 70 percent power, the off-gas stack effluent

sampler was found inoperable. The sampler was drawing air from

the surrounding off-gas filter building ambient atmosphere instead

of sampling the plant stack effluent. The event resulted from a

chemistry technician failing to follow the approved procedure for

changing the inline particulate filter/iodine cartridge (routine

operation). In addition to making appropriate supervisors and all

chemistry technicians aware of the event, the licensee revised and

clarified the governing procedure to prevent recurrence.

Liquid Radwaste Auto-Isolation Valve Inoperative (Hatch 1, BWR)

LER 82-093 Event Date: 11/07/82 Cause: Jumper Installed

Abstract: During a liquid radwaste discharge, the licensee discovered that

the radiation monitor auto control (provides isolation signal upon

high radiation) to the discharge isolation valve was inoperable.

However, the monitor's alarm function remained operable. An

electrical jumper used during corrective maintenance had not been

removed after the work was completed.

Containment Atmosphere Radiation Monitors Isolated (FitzPatrick 1, BWR)

LER81-061 (Rev 1 Event Date: 8/21/81 Cause: Containment Isolation Valve Isolated

Abstract: The NRC resident inspector discovered that during normal 85 percent

power operations the containment isolation valves for the containment

atmosphere gaseous and particulate monitoring system had been shut

for approximately 22 hours2.546296e-4 days <br />0.00611 hours <br />3.637566e-5 weeks <br />8.371e-6 months <br />. With this loss of monitoring capability, the technical specifications require a reactor hot shutdown within

12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br />. The event occurred because a surveillance procedure did

not direct the operator to re-open the isolation valves following'

the surveillance activities. As a corrective action, the licensee

corrected the subject procedure and reviewed all other surveillance

procedures for similar deficiencies.

4'

Attachment 2 IN 86-42 June 9, 1986 LIST OF RECENTLY ISSUED

IE INFORMATION NOTICES

Information Date of

Notice No. Subject Issue Issued to

86-41 Evaluation Of Questionable 6/9/86 All byproduct

Exposure Readings Of Licensee material licensees

Personnel Dosimeters

86-32 Request For Collection Of 6/6/86 All power reactor

Sup. 1 Licensee Radioactivity facilities holding

Measurements Attributed To an OL or CP

The Chernobyl Nuclear Plant

Accident

86-40 Degraded Ability To Isolate 6/5/86 All power reactor

The Reactor Coolant System facilities holding

From Low-Pressure Coolant an OL or CP

Systems in BWRS

86-39 Failures Of RHR Pump Motors 5/20/86 All power reactor

And Pump Internals facilities holding

an OL or CP

86-38 Deficient Operator Actions 5/20/86 All power reactor

Following Dual Function Valve facilities holding

Failures an OL or CP

86-37 Degradation Of Station 5/16/86 All power reactor

Batteries facilities holding

an OL or CP

86-36 Change In NRC Practice 5/16/86 All power reactor

Regarding Issuance Of facilities holding

Confirming Letters To an OL or CP

Principal Contractors

86-35 Fire In Compressible Material 5/15/86 All power reactor

At Dresden Unit 3 facilities holding

an OL or CP

86-34 Improper Assembly, Material 5/13/86 All power reactor

Selection, And Test Of Valves facilities holding

And Their Actuators an OL or CP -

OL = Operating License

CP = Construction Permit