ML13294A024
| ML13294A024 | |
| Person / Time | |
|---|---|
| Site: | University of Wisconsin |
| Issue date: | 10/17/2013 |
| From: | Agasie R Univ of Wisconsin - Madison |
| To: | Document Control Desk, Office of Nuclear Reactor Regulation |
| References | |
| RSC 1173 | |
| Download: ML13294A024 (6) | |
Text
I! Nuclear Reactor Laboratory UWNR University of Wisconsin-Madison 1513 University Avenue, Room 1215 ME, Madison, WI 53706-1687, Tel: (608) 262-3392, FAX: (608) 262-8590 email: reactor@engr.wisc.edu, http://reactor.engr.wisc.edu October 17, 2013 *RSC 1173 United States Nuclear Regulatory Commission Attn: Document Control Desk Washington, D.C. 20555 Subj ect: Docket 50-156, License R-74 University of Wisconsin Nuclear Reactor Violation of Technical Specification 6.1.3(i) (a) and Technical Specification 6.6.2(1) 14 Day Follow Up Special Report to Event Notification Report Number 49409 in Accordance with Technical Specification 6.7.2(l)(c), 6.6.2(4) and 6.6.2(5)
Dear Sir or Madam:
The following is the 14 day follow up special report to Event Notification report number 49409 in. accordance with Technical Specifications (TS) 6.7.2(i) (c) in response to violating the staffing requirements at the University of Wisconsin Nuclear Reactor as defined in TS 6.1.3(1) (a). Furthermore, in preparing this report it was discovered that a second violation of technical specifications occurred, specifically TS 6.6.2(1) as detailed below. This report also meets the requirements of TS 6.6.2(4) to the Reactor Safety Committee.
VIOLATIONS TS 6.1.3(1) (a)
The definition of REACTOR SECURED, in accordance with TS 1.3, is when the following conditions exist:
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- a. All control elements are fully inserted, with the exception of the regulating blade in the event of an emergency,
- b. The reactor is shut down,
- c. The console key switch is in the "OFF" position and the key is removed from the console and under the control of a licensed operator or stored in a locked storage area,
- d. No work is in progress involving core fuel, core structure, control elements, or control element drives unless the work on the drive can not move the control element, and
- e. No experiments are being moved or serviced that have, on movement, a positive reactivity worth exceeding 0.7% Ak/k.
Technical Specification 1.3 further defines REACTOR OPERATIONS as any condition wherein the reactor is not secured.
During such time when the reactor is in operations (i.e. not secured) TS 6.1.3(1) requires the following minimum staff:
- a. A licensed reactor operator in the control room (if licensed senior reactor operator, may also be the person required in c).
- b. A second designated person present at the facility or readily available by phone or radio and within 1000 feet capable of carrying out prescribed written instructions.
- c. A designated senior reactor operator shall be readily available at the facility or on call. On call means the individual can be rapidly reached by phone or radio and is within 30 minutes or 15 miles of the reactor facility.
Contrary to TS 6.1.3(1) (a), on Friday October 4, 2013, for a period of 67 seconds a licensed reactor operator was not in the control room while the console key switch was in the "ON" position (not in the "OFF" position) and the key remained in the key switch and not under the control of a licensed operator.
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TS 6.6.2(1)
Technical specification 6.6.2 describes the actions to be taken in the event of a reportable occurrence as follows:
In the event of a reportable occurrence (see TS 1.3) the following actions shall be taken:
- 1. The reactor shall be shut down until operation is authorized by the Reactor Director.
- 2. The Director or designated alternate shall be notified and corrective action taken with respect to the operations involved,
- 3. The Director or designated alternate shall notify the Chairman of the Reactor Safety Committee,
- 4. A report shall be made to the Reactor Safety Committee which shall include an analysis of the cause of the occurrence, efficacy of corrective action, and recommendations for measures to prevent or reduce the probability of recurrence, and
- 5. A report shall be made to the NRC in accordance with Section 6.7.2 of these specifications.
Contrary to TS 6.6.2(1), on Friday October 4, 2013, following the initial violation of technical specifications 6.1.3(1) (a) which constitutes a reportable occurrence in accordance with TS 1.3, the licensed reactor operator failed to shut down the reactor.
SEQUENCE OF EVENTS The follow sequence of events has been prepared following a review of written records, electronic records and interviews of the individuals involved.
On Friday October 4, 2013 at 9:53AM CDT a licensed rector operator and licensed senior reactor operator (who also served as the designated second person at the facility per TS 6.1.3(1 (b)) signed in on the UWNR 112 "Operating Log" to conduct a reactor operator training session in support of the university's NE 234 "Principle and Practices of Reactor Operations" course. At 9:54AM CDT a student commenced the UWNR 111 "Reactor Start-Up Check Sheet" under the direct supervision Page 3 of 6
of the licensed reactor operator. At this time the senior reactor operator (also serving as the designated second individual at the facility) proceeded to his office located within the operations boundary.
The UWNR 111 requires certain actions to be checked prior to turning the reactor control console master key switch, hereinafter referred to as the key switch, to the "ON" position.
One such action is to verify the whale tubes (a hydraulic irradiation facility) are empty. This is determined by physically walking to the pool top and visually checking the tubes to be empty. The student inadvertently skipped this step on the procedure and proceeded to turn the key switch to the "ON" position. The student then realized he had skipped the required check and asked the reactor operator how to proceed.
The reactor operator explained how to conduct the required check and at precisely 10:01:58AM CDT the reactor operator and student left the control room and proceed to the pool top to complete the required check. The reactor operator and the student reentered the control room at precisely 10:03:05AM CDT. For a period of 67 seconds the reactor control room was unmanned while the reactor was not secured.
During the duration of non compliance all control elements were fully inserted, the reactor was shut down, no work was in progress involving core fuel, core structure, control elements, or control element drives and no experiments were being moved or serviced. Furthermore, electrical current to the control element drive SCRAM magnets was unavailable by nature of the SCRAM relays being de-energized. There were no visitors to the facility at the time and the protected area remained secured in full compliance with the facility security plan at all times.
Upon reentering the reactor control room and continuing with UWNR 111 the reactor operator then realized that he had violated the UWNR 001 "Standing Operating Instructions" step 3 which promulgates the requirements of TS 6.1.3(1). However, at this time the reactor operator did not recognize this was a reportable occurrence as defined in TS 1.3 and did not comply with the requirements of TS 6.6.2(1) and continued with a normal reactor start up. Following the NE 234 training session the reactor operator shutdown and secured the reactor at 10:50AM CDT. Subsequently the reactor operator reviewed the technical specifications and recognized leaving the reactor control room unmanned was indeed a reportable occurrence and promptly notified the Reactor Director.
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IMMEDIATE ACTIONS By nature of the reactor operator re-entering the control room the facility was again in compliance with TS 6.1.3(1) (a) at 10:03:05AM CDT. The facility remained in non compliance with TS 6.6.2(1) until 10:50AM CDT at which time the reactor was shut down.
The licensed reactor operator promptly notified the Reactor Director in accordance with TS 6.6.2(2). The Reactor Director subsequently relieved the reactor operator from licensed duties.
The Chairman of the Reactor Safety Committee was notified of the event by the Reactor Director on October 4, 2013 at 2:38PM CDT in accordance with TS 6.6.2(3).
ANALYSIS OF THE CAUSE The UWNR 111 is a check off type procedure with the steps specifically ordered to preclude the need for a reactor operator to leave the control room after the key switch is turned to the "ON" position. The reactor operator was distracted as a result of conducting the NE 234 training session and inattentive of the actions being performed by the student under his direct supervision.
Furthermore the reactor operator's knowledge of the administrative controls of the technical specifications was weak as a result of safety limits, limiting conditions of operations and surveillance requirements being stressed in requalification training and annual exams.
Finally, prior to this event, there was no facility procedure that promulgated the requirements of 6.6.2(1) following a reportable event as described in TS 1.3.
CORRECTIVE ACTIONS Follow up corrective actions include:
- 1. The facility was returned to full compliance with all licensed conditions at 10:50AM CDT on October 4, 2013.
- 2. The reactor operator described above was relieved of licensed duties immediately following notification to the Reactor Director until it was determined that the operator's attentiveness was commensurate with safe Page 5 of 6
operations while conducting an NE 234 training session.
The reactor operator was authorized to resume licensed activities as of 12:00PM on October 10, 2013.
- 3. All operations staff was made aware of the event at 2:38PM on October 4, 2013.
- 4. A training session for all operations staff covering the event, TS 6.1.3(1), TS 1.3 and TS 6.6.2 was conducted on October 7, 2013.
- 5. The actions required by TS 6.6.2 following a reportable occurrence have been promulgated in a new emergency procedure, UWNR 158 "Reportable Occurrence", which was issued October 17, 2013. All operations staff will be trained on this new procedure on October 21, 2013.
- 6. The requirements of TS 6.1.3(1), TS 6.6.2 and the definition of reportable occurrences in TS 1.3 will be evaluated on the next annual written exam being conducted in accordance with the facility Proficiency Maintenance Program on November 25, 2013.
- 7. As a result of the reoccurring nature of violating TS 6.1.3(I) (a) the facility is committed to implementing an electronic surveillance system to prevent further occurrences within 1 year.
If you should have any further questions, please do not hesitate to contact me at (608) 262-3392 or ragasie@wisc.edu.
Sin ely, Ro 4ert asie Reactor Di ector Cc Craig Bassett, US NRC Facility Inspector Geoffrey Wertz, US NRC Facility Project Manager James Blanchard, UW Engineering Physics Department Chair Reactor Safety Committee - RSC 1173 Page 6 of 6