ML20045G057

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Insp Rept 50-062/93-02 on 930603-04.Noncited Violation Noted.Major Areas Inspected:Onsite Review of Details of Incident That Occurred on 930428 & Corrective Actions Taken by Licensee in Response to That Event
ML20045G057
Person / Time
Site: University of Virginia
Issue date: 06/18/1993
From: Bassett C, Mcalpine E
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II)
To:
Shared Package
ML20045G052 List:
References
50-062-93-02, 50-62-93-2, NUDOCS 9307120039
Download: ML20045G057 (13)


See also: IR 05000062/1993002

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UMITED STATES

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NUCLEAR REGULATORY COMMISSION

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101 MARIETTA STREET, N.W., SUITE 2900

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ATLANTA, GEORGIA 303234199

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Report No.:

50-62/93-02

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Licensee: University of Virginia

Charlottesville, VA 22901

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Docket No.:

50-62

License Nos.: R-66

Facility Name: University of Virginia Reactor (UVAR)

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Inspection Conducted: June 3 & 4, 1993

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Inspector:

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<0 ate / Signed

C. H. Bassett

Accompanying Personnel:

A. Adams, NRR

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Approved by:

E. J. McAlpine, Chief

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Date Signed

Radiation Safety Projects Section

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Nuclear Material Safety and

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Safeguards Branch

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Division of Radiation Safety and

Safeguards

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SUMMARY

Scope:

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This special, announced inspection involved onsite review of the-details of an

incident that occurred on April 28, 1993, and the corrective actions taken by

the licensee in response to that event. The incident is recorded in the NRC

Event Database as Event #25465.

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Results:

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The incident involved operation of the licensee's non-power reactor while five

automatic scram functions were" inoperable. This had occurred following the

licensee's attempts to isolate the cause of an ongoing problem with spurious

scrams.

As a result of the inspection, four apparent violations were identified.

These included:

(1) operating the reactor without all.of the required safety

system channels operable, (2) performir.g maintenance on a safety system

component without subsequently: verifying that the system was operable- before

it was returned to service, (3) failure to have adequate procedures for

performing troubleshooting and maintenance, and (4) failure to follow

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9307120039 930610

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a procedure by not obtaining specific approval for removing jumpers in the

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reactor control console.

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Following the incident, the licensee had taken various corrective actions.

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These actions included:

(1) modifying two mixer / driver modules from the scram

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logic drawer .of the reactor console, (2) assessing other. modules in the

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console, (3) Tabeling the modules, (4) revising those procedures which

addressed maintenan :e or troubleshaoting activities, (5) generating checklists

to be uSed followin : -aintenance activities and following a scram that cannot

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be explained, (6;

fdi-q a new v. amber to the Reactor Safety Committee, and

(7) having a paei :-eviev.

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REPORT DETAILS

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1.

Persons Contacted

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Licensee Employees

  • P. Benneche, Services Manager

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T. Doyle, Reactor Operator

B. Hosticka, Seniur Reactor Operator

D. Krause, Senior Reactor Operator

  • R. Mulder, Director, University of Virginia Reactor Facility

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L. Scheid, Senior Reactor Operator

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Other licensee employees contacted during this inspection included

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technicians and administrative personnel.

  • Attended exit interview on June 4, 1993.

2.

Background Information (92700)

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According to the licensee, they had been experiencing a series of

spurious scrams since November of 1992. The scrams were occurring

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without any annunciator indication.

Because of the design of the scram

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annunciator system, the licensee staff did not feel that the

unannunciated scrams were being caused by line noise. The member of the

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licensee's staff who was in charge of the-electronic maintenance at the

facility reasoned that the most likely source of the problem was in the

scram logic system. Therefore, when he experienced unannunciated scrams

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on April 28, 1993, while per forming the duties of the Senior Reactor

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Operator (SRO), he independently began troubleshooting the problem to

try and isolate the source of the scrams. There was no specific

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procedure in place to provide guidance for the troubleshooting

activities.

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With the reactor shutdown, he first switched the two solid state relays

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(SSRs). That action had no effect on the rate of spurious scrams so he

next interchanged two mixer / driver (MD) modules.

The MD modules had

identical part numbers and appeared to be identical from their external

appearance. After approximately 30 minutes, no spurious scrams were

received.

The SRO then briefly conferred with the Reactor Administrator

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about the situation and was given authorization to restart the reactor.

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Because neither the SR0 nor the Reactor Administrator recognized the

troubleshooting _ activities (exchanging the MD modules) as maintenance,

no post-maintenance testing was performed to ensure that the safety

systems were functioning as required.

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The reactor was operated at full power for the next 5.5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br /> with a

change in SR0s every two hours. No scram signal was received during

that period. At approximately 5:45 p.m.,

another SRO, who was present

when it was time to shutdown the reactor, decided to complete the

shutdown by introducing a spurious period scram in the system. This was

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accomplished by moving a test switch on the intermediate range

instrument channel. Moving the switch, however, failed to produce the

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expected period scram and the SR0 manually scrammed the reactor. The

Reactor Director was notified of the problem and an investigation was

begun into the cause of the problem.

It was subsequently determined

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that exchanging the MD modules had caused the problem and that five

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automatic reactor system scrams required for operation had not been

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available during the afternoon run.

On April 29, 1993, the licensee informed Region 11 management by

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telephone of the incident and issued a Preliminary Report concerning

this reportable event. The Preliminary Report contained a summary of

the incident and an overview of the licensee's initial corrective

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actions.

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A Confirmation of Action Letter (CAL) was issued by Region II on

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April 30, 1993. The CAL stipulated that the licensee:

(1) maintain the

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reactor shutdown until the incident was evaluated and the extent of the

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effect on any circuitry on the reactor console and reactor safety

systems was determined, (2) maintain the reactor shutdown until the

Reactor Safety Committee had reviewed the incident evaluation and the

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. . corrective actions taken, and (3) maintain the reactor shutdown until

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the results of the evaluation and the implemented corrective actions had

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been discussed with the Region II Regional Administrator or his

designee. The CAL additionally confirmed that UVA would notify Region

II in writing when the corrective actions stated therein were completed.

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A team consisting of staff members from Region II and NRR visited the

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facility on May 3,1993, to review the incident and the initial

corrective actions. As a result of that inspection, NRC Inspection

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Report No. 50-62/93-01 was issued.

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On May 12, 1993, UVA submitted a 14-day Report which contained a summary

of the incident, the initial actions taken, the results of their

investigation of the root causes of the problem, the state of the

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console systems, an assessment of the safety significance of the event,

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a compilation of the technical specifications and procedures violated,

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and a summary of the corrective actions taken or to be taken to preclude

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recurrence.

A second NRC inspection performed by staff members from Region II and

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NRR was conducted at the facility on June 3 & 4, 1993, to further review

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the incident and the corrective actions that had been completed by the

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licensee.

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(On June 8,1993, UVA submitted a letter stating that all corrective

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actions that had been identified as being required for restart had been

taken and what actions would be taken if the cause of the spurious

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scrams had not been isolated and corrected, i.e., the reactor would be

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shutdown and not restarted until the console electronics had been

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diagnosed for the source of the scrams and additional corrective actions

taken.)

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3.

Operational Review (92700)

a.

Reactor Safety System Channels

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Technical Specification 3.2, Reactor Safety System, states that

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the reactor shall not be operated unless the safety system

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channels in Table 3.1, Safety System Channels, are operable. The

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safety system channels listed in Table 3.1 include:

two pool

water level monitor channels, one bridge radiation monitor

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channel, one pool water temperature channel, one power- to primary

coolant pump channel, one primary coolant flow channel, one

startup count rate channel, one manual button channel, two reactor

power level channels, one reactor period channel, and one air

pressure to header channel.

As noted in Paragraph 2 above, on April 28, 1993, an SR0 exchanged

two mixer-driver modules in the scram logic drawer of the console.

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Subsequently, the reactor was operated for 5.5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br /> with the MD

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modules interchanged. The effect of interchanging the MD modules

was that certain safety system channels were not operable. The

inoperable safety system channels included:

(1) two power-level

channels, (2) the reactor period channel, (3) the primary coolant

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flow channel, (4) power to primary coolant pump channel. The

failure to comply with the requirement to have these safety system

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channels operable when operating the reactor was identified as an

apparent violation of Technical Specification 3.2 (50-62/93-02-

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b.

Maintenance of a Safety System Component

Technical Specification 4.5, Maintenance, states that, following

maintenance or modification of a control or safety system

component, it shall be verified that the system is operable before

it is returned to service or during its initial operation.

As noted in Paragraph 2 above, neither the SR0 nor the Reactor

Supervisor recognized that maintenance had been performed on the

console when the MD modules were interchanged. As a result, no

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post-maintenance testing was performed and the

'ety system was

not verified to be operable before it was returned to service.

The failure to comply with the requirement to verify that a safety

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system component is operable before it is returned to service was

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identified as an apparent violation of Technical Specification 4.5

(50-62/93-02-02).

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c.

Approved Operating Procedures

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Technical Specification 6.3, Operatina Procedures, states that,

written procedures, reviewed and approved by the Reactor Safety

Committee, shall be in effect and followed for the items listed

below. These procedures shall be adequate to ensure the safe

operation of the reactor, but should not preclude the use of

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independent judgement and U. tion should the situation require

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such.

(Procedures shall be in effect for the following:)

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(1)

startup, operation, and shutdown of the reactor,

(2)

installation or removal of fuel elements, control rods,

experiments, and experimental facilities,

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actions to be taken to correct specific and unforeseen

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potential malfunctions of systems or components, including

responses to alarms, suspected primary coolant system leaks,

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abnormal reactivity changes,

(4)

emergency condition involving potential or actual release of

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radioactivity, including provisions for evacuation, re-

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entry, recovery, and medical support, and

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preventative and corrective maintenance operations that

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could have an effect on reactor safety.

At the time of the incident, Standard Operating Procedure

(S0P) #7, " System Calibration and Maintenance," was the approved

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procedure in effect at the facility which contained the licensee's.

guidance for performing maintenance of a system. The.S0P did not

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contain a definition of what maintenance is nor did it address

such activities as troubleshooting. Also, the 50P did not contain

any general or specific guidance for performing such functions as

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switching the mixer / driver modules in the scram logic drawer.

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failure to have adequate procedures for performing troubleshooting

or maintenance functions was identified as an apparent violation

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of Technical Specification 6.3 (50-62/93-02-03).

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Standard Operating Procedures

Technical Specification 6.3, Operatina Procedures, states in part

that, written procedures, reviewed and approved by the Reactor

Safety Committee, shall be in effect and followed.

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UVAR Standard Operating Procedures, Section 2, " General

Regulations," Revision dated January 1990, states in Part 2.D that

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no jumpers or by-passes shall be installed or removed in the

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control console unless the following conditions are met:

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No safety system is compromised,

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A record is made in the logbook, and

(3)

Specific approval is obtained from the Reactor Supervisor or

Facility Director.

When the SRO interchanged the MD modules in the reactor control

console, he was trying to isolate the source of spurious scram

signals in the console electronics. He did not, however, seek or

receive the specific approval of the Reactor Supervisor or the

Facility Director for such activities. The interchange of modules

subsequently.resulted in by-passing some of the reactor protective

systems. The failure follow procedure to obtain specific approval

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for interchanging the MD modules which effectively allowed removal

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of various jumpers was identified as an apparent violation of

Technical Specification 6.3 (50-62/93-02-04).

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4.

Followup of Licensee Corrective Actions (92700)

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Initial Actions

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When it was discovered that several of the scram functions were

not operational, the licensee began an investigation into the

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cause of the problem. During that evening and the following day,

the licensee initiated various corrective actions as a result.

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These included

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maintaining the reactor shutdown until the problem was

investigated, understood, and reviewed with the Reactor

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Safety Committee (RSC) and with the NRC,

(2)

notifying the University, the community, and the NRC of the

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problem,

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requesting a peer review from the Test, Research, and

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Training Reactor (TRTR) national organization,

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(4)

determining the root cause(s) of the event,

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determining if there were any problems with the hardware,

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schematics, and Standard Operating Procedures (S0Ps) which

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contributed to this event, and

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(6)

determining if any administrative corrective actions were

needed.

Through document review and interviews with various licensee

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personnel, the inspector verified that the licensee had completed

the initial actions as outlined above. The reactor operations log

book revealed that the reactor had been shutdown'on April 28 and

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had not been operated since. Licensee records reviewed by the

inspector indicated that, following discovery of the problem, the

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licensee had notified the University administration, the

community, and the NRC. The _ inspector also noted that these

notifications had been timely and made within the time frame

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required by regulation.

The records also indicated that a peer review of the incident had

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been requested from the TRTR organization. This review was

subsequently conducted during May-17 & 18, 1993. The inspector

reviewed the TRTR Peer Review / Evaluation Report and noted that it

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contained various recommendations that had been submitted for the

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li ensee's review and possible implementation,

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The inspector reviewed the licensee's 14-Day Report which included

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a summary of those items that had been identified as root causes

of the event. The root causes identified were:

(1) a recent

history of " spurious" automatic scrams, (2) judgement error on the

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part of the SR0 as to what should have been regarded as

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maintenance of a safety-critical reactor console system, (3) error

on the part of the Reactor Administrator to rely on the greater

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electronic expertise of the SR0 without testing the SR0's

assumptions involved in making the MD interchange, (4) lack of

definitions in the SOPS for the terms " troubleshooting" and

" maintenance," and (5) the non-performance of a scram operability

test prior to restart of~ the reactor following the exchange of the

modules. The inspector concluded that the root causes identified

appeared to be adequate and appeared to be the root causes and/or

contributing factors.

The licensee actions to determine whether or not there were any

problems with the hardware, schematics, and SOPS resulted in a -

significant expenditure of manpower. These actions are outlined

in Paragraph 4.b below.

b.

Short-term Corrective Actions

As more information became available to the licensee, the need for

further corrective actions became apparent.

Various short-term

actions were then initiated. These actions included:

(1)

conducting a briefing of the Reactor Safety Committee (RSC)

within 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> of the event,

(2)

appointing a new member to the RSC with a background in

electronics and getting assistance from the newly qualified

RO who has an advanced degree in Engineering Physics,

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initiating procedural improvements including:

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(a)

generating a new checklist for maintenance _(in S0P #7)

and a new checklist to be used following every

unplanned reactor scram to check out the reactor

safety systems (in S0P #4) and modifying the

appropriate S0Ps to require use of the checklist,

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revising 50P #7 to include definitions for the terms

" maintenance" and " troubleshooting" and develop a-new

Maintenance / Troubleshooting Analysis Sheet, and

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revising and changing S0P #2 to:

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increase management control over maintenance,

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require that restart authorization following a

scram would take agreement of an SR0 not at the

console and the Reactor Supervisor or his

designee,

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make the Reactor Supervisor the " focal point"

for maintenance and all operations-related

activities,

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emphasize the general conditions requiring an

operator to manually trip the reactor,

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suggest that a manual trip be initiated whenever

there is any question about the safe operation,

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add the requirement that the reactor be taken

out of service immediately upon the discovery of

a violation of the Tech Specs,

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(4)

initiating a search for similar " traps" associated with

modified reactor console modules when compared to off-the-

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shelf modules,

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checking the reactor console electronics against the

available schematics for conformity,

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relabeling the modules so that no module could be switched

or exchanged without a check to see that it is identical to

the original,

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returning the M/D modules to their unmodified state,

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disconnect the unused inputs from each other,

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checking the past reactor Daily Checklists for any

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indication of non-available scrams to assure that the M/D

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modules had not been exchanged before and the reactor

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operated in that condition,

(9)

checking the reactor console circuitry and the reactor

circuitry and evaluate it to ensure that no damage was done

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as a result of exchanging the M/D modules and the solid-

state relays (SSRs),

(10) checking to ensure that the reactor is operable with the

" unmodified" M/D modules back in the original locations,

(11)

searching for the source of the spurious scrams,

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(12)

keeping the reactor shut-down until the RSC had reviewed the

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staff evaluation of the event and the corrective actions had

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been implemented,

(13) obtaining restart authorization from the RSC and discussing

the event evaluation and corr (clive actions with the NRC,

(14) notifying the NRC when all the actions in response to the

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incident have been completer', and

(15) holding self-critiques starf meetings to discuss the event

and clarify what constitutes maintenance and trouble-

shooting.

Again the inspector reviewed licensee documentation of their

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actions and interviewed those personnel at the facility who are

responsible for or involved in the operation of the reactor.

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Meeting minutes of the RSC indicated that a briefing had been

provided by the licensee concerning the event within 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br />.

The RSC meeting minutes also indicated that a new member had been

added to the committee and that the new member did have a

background in electronics.

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A review of the affected procedures indicated that they had been

revised by the licensee, the revisions had been reviewed and

approved by the RSC, and that the new procedures had been

implemented at the facility.

The inspector verified that the

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changes / revisions (outlined above) were included and in effect in

the current 50P Manual in use at the facility. The revised

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procedures appeared to be adequate.

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The licensee examined the existing reactor console modules and

reviewed the schematics in an attempt to search for similar

situations that could cause a problem.

It was determined that the

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schematics at the facility were not up-to-date and various changes

had been made in the hardware that were not reflected in the

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schematics. These instances were corrected in the schematics as

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they were found. Other actions were taken as well which included

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modifying the MD modules. The two MD modules were changed so that

they are now identical.

(Although licensee procedures now

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prohibit it, the two modules could be interchanged and they would

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function adequately in the switched locations.) The inspector

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reviewed selected schematics located in a book in the Control Room

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and verified that they had been updated.

The licensee further determined that two other situations existed

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in which interchanging two apparently identical modules could

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cause a problem. The licensee is currently reviewing the

advisability and necessity of modifying these other modules. Any

proposed changes will be reviewed and approved by the RSC before

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implementation.

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The modules in the reactor were relabeled to indicate whether or

not they had been modified and could only be used in one unique

application. And, as noted above, the console modules were

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visually inspected to verify that they were wired as dep,cted in

the schematics. When differences were detected, the changes were

noted on the schematics. The inspector examined selected modules

and verified that 'they had been labeled as indicated.

(Following

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the inspection, the licensee also posted a sign on the reactor

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console indicating that the electronic modules inside were not

interchangeable.)

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A check of the past reactor Daily Checklists, performed by the

Reactor Supervisor, indicated that the reactor had not been-

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operated in the past with non-available scram functions. Also, a

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calibration check of all the modules and console circuitry

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indicated that no electrical damage had resulted from switching

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the MD modules on April 28. A bench test of the MD modules also

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indicated that they were functioning properly. These calibration

checks were performed with the " unmodified" MD modules back in the

original locations in the scram logic drawer. The inspector

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reviewed the records of the calibrations that had been performed

and observed the bench tests of the modules.

The results of the

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calibration records and the bench tests indicated that the safety

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system would function as required.

While performing these visual inspections and checks of the

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various modules, a " cold" solder joint was found in one of the MD

modules. The licensee determined that this cold joint, which

resulted in a variable increase of electric resistance, could have

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been the cause of the spurious drops in voltage in the MD modules.

The licensee stated that an occasional temporary drop in voltage

could explain the problems that were occurring and that resulted

in this incident.

After the cold joint was discovered, the joint

was resoldered, the output signals in the MD modules were bench

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tested, and the availability of all scrams successfully tested

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following return of the MD modules to the console.

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The issue of changing the MD modules back to their original state

and of what was causing the spurious scrams was discussed and

evaluated by NRC personnel (with backgrounds in electronics) in

Region II and in Headquarters.

It was agreed that changing the MD

modules (removing the jumpers) would not cause any adverse

effects. The NRC personnel also agreed that the cold solder joint

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was probably not the cause of the spurious scrams and that further

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evaluation would probably be necessary by the licensee.

Because

of this concern the licensee committed in a letter dated June 8,

1993, that, in the that event of two unexplainable scrams were

received over a 30-day period, the UVAR would be shutdown and not

restarted until the console electronics had been diagnosed for the

source of the scrams and additional corrective actions taken.

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In an effort to have input from those staff members who were

responsible for or who helped operate the reactor, various self-

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critique staff meeting were held by the licensee. The purpose of

the meetings was to discuss the event, to review the chain of

command at the facility with the Reactor Supervisor responsible

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for all operations-related activities, and to clarify what

constitutes maintenance and troubleshooting. Although several

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meetings had been held, the inspector noted that a meeting with

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all operations personnel to discuss and review the event and all

the corrective actions had not been conducted. Therefore,

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subsequent to the inspection, the licensee held another training

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session for all licensed operators on June 7, 1993, to review the

event, all the changes made to the various procedures, and the

correct chain of command for operation of the reactor. Also

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reviewed was the importance of following procedures.

As indicated in Paragraph 4.a above, a review of the reactor

operations log book by the inspector indicated that the reactor

had been shutdown on April 28 and not operated again. A review of

the RSC meeting minutes for the meetings held on May 6, May 10,

May 12, May 20 and May 27, 1993, indicated that the incident and

the corrective actions had been discussed by the committee at

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length. The minutes from the May 27 meeting of the RSC also

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indicated that the committee agreed that all the corrective

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actions that had been identified as being required for restart had

been taken. The RSC subsequently voted to authorize restart of

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the reactor.

In the letter dated June 8, 1993, the licensee

verified that all corrective actions necessary for restart of the

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reactor had been taken and that the RSC had authorized restarting

the reactor.

c.

Long-term Corrective Actions

Other actions that the licensee considered were those that

required more time for implementation. These actions included:

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(1)

reviewing and addressing the TRTR Peer Review Report

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recommendations,

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(2)

revising S0P #3 to more clearly define the Reactor

Supervisor's responsibilities and the reactor staff's

responsibilities, and

(3)

reviewing the need for modification of the other modules in

the reactor console that were found to pose a problem if

they were to be interchanged with one another.

The licensee is in the process of evaluating the recommendations

made in the TRTR Peer Review Report. All the recommendations will

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be addressed and a response will be formulated and sent to the RSC

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for review. With the approval of the RSC, a final submittal will

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be made in response to the TRTR Report and will be submitted in

July.

The responsibilities outlined in S0P #3 will be the same as now

detailed in 50P #2. There will be an expansion of the details of

the responsibilities in S0P #3 but the basics will not be changed.

A licensee staff member proposed that the other modules in the

console be modified to make them identical and interchangeable.

The 1icensee is still evaluating this proposal and will make a

recommendation to the RSC. Based on the changes to the procedures

and the recent retraining, the licensee has determined that there

will be no likelihood that a staff member would switch any modules

that may appear identical. Over the long term, however, the

licensee has indicated that there may be a benefit to modifying

the modules to ensure that they are-identical rather than depend

on administrative controls.

Based upon the results of this inspection and the inspection conducted

on May 3,1993, it was determined that the licensee had completed the

actions identified for restart.

5.

Exit Interview

The inspection scope and results were summarized on June 4,1993, with

those persons indicated in Paragraph 1.

The inspector described the

areas inspected and discussed in detail the inspection findings.

The licensee did not identify as proprietary any of the material

provided to or reviewed by the inspector.

i

Item Number

Descriotion and Discussion

1

50-62/93-02-01

VIO - Failure to have all required safety system

channels operable while operating the reactor

(Paragraph 3).

.

.

.

4

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-

,

!

11

,

Item Number

Description and Discussion

(cont'd)

50-62/93-02-02

VIO - Failure to verify that the system was-

operable before it was returned to service

following maintenance or modification of a

safety system component (Paragraph 3).

50-62/93-02-03

VIO - Failure to have adequate procedures for

performing troubleshooting and maintenance

activities involving safety system components

l

(Paragraph 3).

l

'

50-62/93-02-04

VIO - Failure to follow procedures for obtaining

specific approval prior to installing / removing

jumpers in the control console (Paragraph 3).

,

i

f

,

l

1

l

'!

u