ML082550482
| ML082550482 | |
| Person / Time | |
|---|---|
| Site: | Armed Forces Radiobiology Research Institute |
| Issue date: | 09/03/2008 |
| From: | Lillis-Hearne P US Dept of Defense, Armed Forces Radiobiology Research Institute |
| To: | Document Control Desk, Office of Nuclear Reactor Regulation |
| References | |
| 44396 | |
| Download: ML082550482 (4) | |
Text
ARMED FORCES RADIOBIOLOGY RESEARCH INSTITUTE 8901 WISCONSIN AVENUE BETHESDA, MARYLAND 20889-5603 DIR 3 SEPTEMBER 2008 U.S. Nuclear Regulatory Commission Document Control Desk Washington, DC 20555 Gentlemen:
Attached is the Licensee Event Report (LER) for the reportable event that occurred on 29 July 2008, and was reported to the USNRC Operations Center and the AFRRI Project Manager Mr. Alexander Adams telephonically (NRC Notification Number 44396).
The point of contact for further information is Stephen Miller, Reactor Facility Director at (301) 295-9245, millers(tafrri.usuhs.mil Patricia K. Lillis-Hearne COL, MC, USA Director Copy to:
USNRC Attn: Mr. Alexander Adams Mail Stop 12G13 Washington, DC 20555 USNRC Attn: Mr. Johnny Eads Mail Stop 12G15 Washington, DC 20555
,4c) 2-
Licensee Event Report For the AFRRI TRIGA Reactor Facility Docket 50-170 I declare under penalty of perjury that this eve ep is true and correct TEPHE MILLER DA E Reactor Faclity Director
Abstract The Gas Stack Monitor (GSM) pump was discovered to be making more noise than was normal for this unit. It was determined that the bearings were worn, but other that the increased noise, the GSM was able to perform its intended function. Until a new pump could be secured, the GSM was placed out of service unless required to perform reactor operations. All operators were informed of the condition, and told to place the GSM back in service prior to operating the reactor.
Approximately one week later on 29 July 2008, a Senior Reactor Operator (SRO) completed her morning equipment checkout. Prior to performing a K-excess measurement, the operator failed to place the GSM back into operation as required by AFRRI Technical Specifications 3.5.1. The reactor was operated for 4 minutes at a power of 5 watts, with a total power produced of 0.33 watts.
Later that same day, the same operator performed an operation, but this time did put the GSM back into operation.
The error was discovered by a routine review of the log book on 6 August verified by the Reactor Facility Director on 7 August 2008, and reported to the USNRC on 8 August 2008. The USNRC Operations Center logged the report on 8 August 2008, report number 44396. The SRO was reprimanded for failing to follow procedures, and all operators participated in a special training class on Reactor Technical Specifications and the importance of following procedures and attention to detail.
Root Cause The root cause of this event was lack of attention to detail. Typically, the GSM is left on 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> per day, seven days per week, so that turning the machine on prior to performing an operation was an unusual requirement. The operator failed to notice the green entry in the log book calling attention to the fact that the GSM was required to be placed back in service prior to normal operations.
Assessment of Safety Consequences There are no safety consequences of this event. The Argon 41 effluent is calculated based on calibrations performed during the course of the maintenance cycle. Should there have been an unexpected release, other radiation monitoring equipment would have alerted the operator to the abnormal condition.
Description of Corrective Actions Facility management investigated the circumstances of the event, and concluded that an operator error occurred. The following actions will be completed by September 20, 2008.
- 1.
The operator was reprimanded and cautioned that future failure to follow procedures would result in further disciplinary action.
- 2.
All operators were required to attend a training class on the importance of attention to detail, and the Technical Specifications
- 3.
A strobe light was placed in service in the control room which will alert the operator if the pump were to be turned off in the future.
- 4.
The startup checklists were modified to verify that the strobe light is operational prior to the days' operations.
Reference to Any Previous Similar Events A review of records for the past 10 years did not find any similar events.
Point of Contact for any Ouestions Point of contact for additional information is Stephen Miller, Reactor Facility Director, (301) 295-9245