ML20077B473

Ro:On 910507,operator Failed to Perform Surveillances & Channel Tests for All 6 Scram Channels & 2 Interlocks Prior to Reactor Operation.Caused by Personnel Error. Tailgate Meeting Held & Mods to Hardware Initiated

ML20077B473
Person / Time
Site:	Dow Chemical Company
Issue date:	05/10/1991
From:	Kocher C DOW CHEMICAL CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
NUDOCS 9105140384
Download: ML20077B473 (2)

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$ Dow U.S. A.

1602 iluildmg 10 hiay IWI US Nuclear Regulatory Conunission ATTN: Document Control Desk Washington DC 20555 DOW TRIG A Iti:SI:AltCII Iti: ACTOlt . DOCKl:T 90 264 VIOLATION OF TECllNICAL SPECIFICATIONS On hiay 71991 a licensed openitor operated the Dow TRIG A Research Reactor before the daily checkout had been perfo med. Part 4 of the Tet hnial Specifications f or this facihty seguires

4. Allowable sun eillante intervals shall not escced the following:

daily . must be done before the conunencement of operation cac h day of operation 4.2.3 A channel test shall be perf ormed at least daily . . for each of the sit scram channels and each of the two interlocks listed in table 3.3A, and the top thannel The operator discovered the error at the conclusion of the operation and reported to the Reactor Supervisor. The daily checkout was then perfonned and the scrarn channels, interlocks, and the log power channel were found to be perfonning as required. %ere was no safely concem associated with this violation.

CIRCUh1 STANCES Normally the reactor daily chec Lout is perfonned shortly after the start of the woit day at 8 am by one of the licensed operators. The staf f of heensed operators perfonus this task on a rotation; on hiay seventh the operator assigned to perf orm the daily checkout did not do so.

In the middle of the af ternoon an operator prepared some samples for irradiation and operated the reactor at i kilowatt for a period of ten minutes, assuming that the daily checkout had already been ivrfonned The procedure for oltratmg the reactor requires that the operator check to make sure that all of the required checkouts has e been gwrfonned. He operator failed to follow this pnxedure and thus did not determine that the daily checkout had not been ivrfonned.

PRlh1ARY CAUSE The primary cause of this incident was the failure of the operator to follow the established procedure for operating the reactor.

ACTIONS TAKEN i

e immediately alter discovery of the violation all reactor operators, the facihty director, and members of the Reactor Operations Committee were notified; the Reactor Supervisor described the incident in a letter to the facility director; and the Reactor Sulervisor notified a person at US NRC P.cgion 111 of the event and requested advice conterning w ritten notifict tions. [

9105140304 910510 PDR ADOCK 05000264 i ff S PDR s J i

v On May 9 a tailgate meeting waa held in the reactor control mom at w hich time the incident was reviewed, all operators were reminded of the need to follow putedures, the consequences of such es ents were discussed, and the operators and the facility director nok part in a session intended to evole ideas j for lossible modi 0 cations of procedures or hardware which couki prevent recurrences of this type of I siolation. The facility director strongly emphasired the need for contmuation of the self reporting procedure.

It w as decided that, ai: hough cettain hardware modifications could te made w hich would partially l prevent such an event, such roodifications woukt not climinate the need for personal decisions and  ;

actions and could not be depended ujon to by fully fail proof; at this time, no hardware modifications will te made.

l Most importantly, the individual responsibility for the operators to know and follow the procedures has been stressed by the facility diutor and the Reactor Supervisor. A wpy of all of the procedures is icpt at the reactor console and the pnredure for startup, operation, and shutdown of the reactor is posted on the console in a prominent position.

The procedure for assigning responsibility for performing the daily checkout will te rnodified to help assure that the reactor checkout is reliably perfortned each working day, w hether the reactor is to be otheraise operated or not. '!his does not relieve any operator from the responsibility for following the procedures.

All pmeedures for this reactor are in the process of being review ed for applicability, clarity, and accuracy. Decause of this incident the procedures will also be evaluated in terms of providing the clearest possible directions for proper ogwrution.

Finally, the Reactor Supervisor has reviewed the incident with the operator involved, emphasizing the need for continuous attention to detail w hile operating the reactor and for following the pn>cedures.

Documentation of the notifications and the tailgate meeting will be kept in the minutes of the Reactor Operations Committee. The incident will be reported to the Radiation Safety Comtnittec, which has oversight function for the Reactor Operation Committee and the operation of the reactor, at the next scheduled meeting.

[g /( Ir C. W. Kocher Reactor Supenisor cc: Regional Administrator US Nuclear Regulatory Commission Region !!!

799 Roosevelt Road Glen Ellyn IL 60137

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