ML20129H519

Ro:On 961015,loss of Facility Power Occurred Causing Reactor Scram Due to Lack of Attention to Detail & Excessive Distractions to Operations.Startup Checklist Had Several Individual Instrument Checks Combined Into Single Items

ML20129H519
Person / Time
Site:	05000128
Issue date:	10/30/1996
From:	Reece W TEXAS A&M UNIV., COLLEGE STATION, TX
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
NUDOCS 9611050271
Download: ML20129H519 (3)

Text

__ _

TEX AS ENGIN EERING EXPERIM ENT STATION

~

TEKAS A&M UNIVERSEY COLLEGE STATION, TEXAS 77843-3575 #

1 d$EEE: I l L_

NUCLEAR SCIENCE CENTER 409/845-7551 30 October 1996 96-0332 U.S. Nuclear Regulatcry Commission ATTN: Document ContJol Desk Washington, DC 20555

SUBJECT:

Reportable Gecurrence, Cause and Corrective Actions REF: Reactor Facility License R-83, Docket 50-128

Dear Sir:

An evaluation of the reportable occurrence of 10/15/96 at the Texas A&M University Nuclear Science Center has been completed. All corrective actions have been implemented.

Description of Event on 15 October 1996 at approximately 3:51 PM a loss of facility power occurred causing a reactor scram. At 3:55 power had been restored and the Reactor Operator (RO) began the performance of the facility pre-startup checks. The duty health physicist was not present at the facility.

Therefore the Senior Reactor Operator (SRO) performed the Facility Air Monitor (FAM) alarm checks. This is allowed by our procedures. In general, the Health Physicist performs the checks if he or she is available. The FAM system will automatically shutdown the building exhaust fan when there is an alarm on the stack effluent particulate monitor as required by T.S. 3.4. A shutdown bypass is provided to prevent building ventilation shutdown during testing.

After performing the alarm checks the SRO went immediately to the control room for reactor startup and forgot to remove the key from the bypass switch. There is a line item of the pre-startup checklist that states:

" Air monitors verified operable and key removed from reception room control panel."

- (

9611050271 961030 PDR g

ADOCK 05000128 PDR

[b []

050102 neseancu suo oevaopueur von usuxiuo

. . I 96-0332

~

Fage 2 The RO performing the pre-startup checklist failed to read the entire step and initialed for the completion of the step. The SRO and RO signed for completion of the pre- I startup checklist prior to reactor startup. i At about 10:00 PM that evening the on-duty SRO discovered the Shutdown Bypass Key was in the control panel in the i reception room and in the bypassed position. The reactor !

had operated for six hours with the FAM automatic shutdown bypassed.

i i

Cause of Event i l

The cause is considered to be a lack of attention to detail, excessive distractions to operators, and personal desire to return the reactor to full power operations. The RO had not routinely performed a reactor startup involving pre-startup checklist performance for several months. The RO was familiar with the procedure, but he did not fully read each checklist item. The SRO had rarely performed the FAM alarm checks because a Duty HP was normally available.

During the power failure, several RO trainees were observing the RO. The on-duty RO used this as an opportunity to perform impromptu training and discussed the power failure with the trainees. This contributed to a lack of concentration to the pre-startup checklist he was performing.

The SRO and RO wanted to return the reactor to full power as soon as possible to turn over to the oncoming shift. The SRO admitted that he felt he should have the reactor in steady state conditions for the evening shift arriving by 5:00 PM. This was a professional courtesy and not based on operational commitments, but this self-imposed pressure contributed to the overall events.

Corrective Actions The pre-startup checklist had several individual instrument checks combined into single items. This allowed the operator to initial for partial completion of an item. The pre-startup checklist has been rewritten to separate and provide additional check boxes for these multiple checks.

96-0332 Page 3 l

The FAM shutdown bypass switch is located remotely in the l reception room for access during a facility emergency. The l RO can not visually verify the key position (or if the key j is removed) without leaving the control room. 'A warning  ;

light is now installed in the control room to provide remote  !

indication of the bypass feature. l All licensed operators and trainees have been counseled on attention to detail, minimizing distractions in the control room during reactor operations and that there'is never a  ;

reason to feel pressed for time when performing their licensed duties.

If you have any questions or comments on this event or our ,

corrective actions please contact me or Sean O' Kelly at the i Nuclear Science Center, 409-845-7551.

Respectfully, ,

.( c[ ~

.D. Reece, Ph.D.

Director WDR/sjm ,

xc: Dr. James Holste )

Reactor Safety Board Chairman l

Samuel J. Collins Director, Region IV ,

Division of Radiation Safety and Safeguards 12110/ Central File

!