ML20195J159
| ML20195J159 | |
| Person / Time | |
|---|---|
| Site: | Neely Research Reactor |
| Issue date: | 06/17/1988 |
| From: | Grace J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II) |
| To: | Downs W AFFILIATION NOT ASSIGNED |
| References | |
| EA-88-122, NUDOCS 8806290065 | |
| Download: ML20195J159 (26) | |
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JUN 171988 Docket No. 55-6161 License No. S0P 20327-1 EA 88-122 Mr. William H. Downs 2250 Cheshire Bridge Road, No. C-14 Atlanta, GA 30324
Dear Mr. Downs:
This letter refers to the Enforcement Conference held at our request on May 20, 1988.
This meeting concerned activities authorized by your senior reactor operator license for the Georgia Tech Research Reactor (GTRR) located at the Georgia Institute of Technology Neely Nuclear Research Center.
The issues discussed at this conference related to NRC concerns over your operating, administrative and health phystes practices over an extended period of time.
A summary, a list of attendees and applicable portions of your handout are enclosed.
The NRC enforcement policy with respect to licensed operators is such that enforcement action is not normally taken unless the performance of the operator is knowingly and very significantly below accepted operator standards.
In your case, we have determined that your actions do not fall into this category.
Nevertheless, we are concerned over your lack of adherence to l
procedures, your lack of diligence in recording information in operating logs and experiment fonns, and your casual attitude displayed during the August 1987 contamination incident.
While we are not taking enforcement against you, your perfonnance may have set a poor example for students at GTRR and could contribute to enforcement action that is under consideration against the Georgia Institute of Technology.
You are cautioned to pay more attention i
to detail in your work and ensure that procedures are either adhered to or are immediately recomended to be changed.
I In accordance with Section 2.790 of the NRC's "Rules of Practice," Part 2, Title 10, Code of Federal Regulations, a copy of this letter and its enclosures l
will be placed in the NRC Public Document Room.
8806290065 880617 PDR MISC
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l 8806290065 DCD ac w
e JUN 171988 Mr. William H. Downs 2
' Should you have any questions concerning this matter, please contact us.
Sincerely, ORIGINAL SIGNED BY J. NELSON GRACE J. Nelson Grace Regional Administrator
Enclosures:
1.
List of Attendees 2.
Enforcement Conference Summary 3.
Handout Infonnation cc w/encis:
J. P. Crecine, President T. E. Stelson, Vice President of Research R A. Karam, Director, NNRC Docket File 55-6161 bec w/ encl:
J. Lieberman, OE DRS Technical Assistant Director, DRS Director, DRP Document Control Desk Ftate of Georgia 4
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JUN 171988 ENCLOSURE 1 LIST OF ATTENDEES Licensee W. H. Downs, Senior Reactor Operator, NNRC Nuclear Regulatory Commission (Region II)
,M. L. Ernst, Deputy Regional Administrator LA. F. Gibson, Director, Division of Reactor Safety G. R. Jenkins, Director, Enforcement and Investigation Coordination Staff R. J. Goddard, Regional Counsel P. E. Fredrickson, Section Chief, Division of Reactor Projects Others A. E. Evans, Jr., Senior Assistant Attorney General, State of Georgia R. N. MacDonald, Associate Director, NNRC i
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JUN 17 588 ENCLOSURE 2 ENFORCEMENT CONFERENCE
SUMMARY
The conference was opened by the Deputy Regional Administrator (DRA) who discussed the purpose of an enforcement conference and the possible NRC actions that could be taken as a result of the conference.
Also the DRA clarified the differences between an enforcement conference conducted with an individual licensee and a facility licensee.
After this introduction, the Director, Division of Reactor Safety (DRS) initiated the formal discussion of the applicable issues.
At this point, the licensee provided to the NRC a handout containing his position on the issues plus relevant supporting documents. Applicable portions of this hand-out are contained in Enclosure 3.
The discussion covered those items con-tained in an enclosure to a letter sent to the licensee by the Region II Regional Administrator on April 28, 1988.
The DRS first explained that although most of the issues were described in NRC inspection reports, relevant information was also taken from the licensee's testimony to the NRC Office of Investigation on February 8 and 29, 1988.
With respect to Item 1, the licensee's prepared statement and subsequent discussions revealed that the licensee was not on duty during this ever,t.
The licensee admitted Item 2, but explained that he struck the window accidentally during horseplay; he stated that he regretted his actions.
Discussion revealed that the licensee remembers being orally counseled on his actions.
The DRS asked the licensee what he would recommend to be contained in a research reactor operator code of conduct.
The licensee stated that proper conduct would be a requirement as it leads to continued good operation.
For Item 3, the licensee explained his actions and the safety significance of those actions using a schematic of the pipe and valve configuration.
The DRA stated that the actual safety significance of failing to isolate the valve appeared to be negligible.
The licensee stated that procedures are explicitly adhered to at the present time.
The NRC asked if other procedures were l
violated simply for convenience, as was this procedure.
The licensae could not recall any other such violations.
An additional issue with respect to procedural adherence was surfaced by the DRA.
Specifically, where equipment l
apparently required for startup is possibly not operable, but the reactor operator annotates the precritical checklist as not requiring the equipment and l
the reactor is started up with the equipment inoperable.
The NNRC Associate Director clarified the checklist to be within the discretion of the Operations Supervisor to commence startup, if at least all equipment required by Technical Specifications is operable.
The NRC asked the licensee if he had requested the l
NNRC management to change the sampling procedure to reflect the more convenient l
method.
The licensee stated that he could not recall requesting procedure changes at that time.
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2 JUN 171988 Item 4 was then discussed.
The DRA stated that Items 4, 6 and 8 appeared to be related, in that they all tend to reveal a history of neglect towards completing required documentation.
The discussion then shifted to Item 8.
Discussion involved other experiments ongoing besides the topaz experiment and the completing of the schedule form for irradiation levels.
The DRA expressed concern over the apparent casualness of conducting experiments at the NNRC.
The licensee disagreed with the statement, stating that although proc'edures and actions could be improved, the management attitude toward reactor operation and experiments has always been professional.
The NRC questioned why the licensee did not suspect that something was wrong when the high levels of radiation were observed on an experiment that was supposed to read "Nil."
The licensee stated that "Nil" referred to the sample only and it was common for the canister and sample to be hot, with the sample relatively low in dose rate.
In this instance, the licensee stated the topaz read several hundred mr/hr at one foot, which certainly was not "Nil."
Returning to Item 4, the licensee stated that he was counseled by the NNRC Director on procedural adherence, after the NRC violation was issued.
Item 5 was next discussed.
The licensee could not recall any failure to wear dosimetry or protective clothing when they were required.
For Item 7, the licensee stated, in addition to providing his statement, that he was not teaching a class, that he believed that he definitely reacted in a safe manner to the event, and that the time between the power excursion and his actions was not excessive.
He blamed the event on a stuck power level recorder, which he said was the principal power level indicator.
- However, there were other indicators.
The event took place over a period of approxi-mately 10 minutes, and it was not terminated until radiation monitors alarmed.
A brief discussion continued on item 8, specifically on the process for conducting and maintaining records for a number of multi-shift experiments.
This type of experiment (an example being the topaz experiment) requires maintaining a cumulative figure on irradiation exposure data. During discussion of the topaz experiment, the licensee reiterated his position that he cannot recall whether or not he surveyed his residence for radioactivity during August 1987.
The NRC asked the licensee to evaluate himself as an operator.
The licensee stated that he believed himself to be a good operator and a hard worker. He is actively involved in the NNRC operator training program and is working well with the new \\ssociate Director of the NNRC, reviewing and recommending changes to procedures.
The DRA closed the meeting by thanking the licensee for his presentation, providing the NRC with helpful information on the issues.
+
.O JUN 17 G88 l
ENCLOSURE 1, LIST OF ATTENDEES' h
Licensee.
W. H. Downs, Senior. Reactor Operator, NNRC Nuclear Regulatory Commission (Region II)
M. L. Ernst, Deputy Regional Administrator A. F. Gibson, Director, Division of Reactor Safety -
G. R. Jenkins, Director, Enforcement and Investigation Coordination Staff R. J. Goddard, Regional Counsel P. E. Fredrickson, Section Chief, Division of Reactor Projects Others A. E. Evans, Jr., Senior Assistant Attorney General, State of Georgia R. N. MacDonald, Asfociate Director, NNRC i
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P JUN 171988 ENCLOSURE 2 ENFORCEMENT CONFERENCE
SUMMARY
The conference was opened by the Deputy Regional Administrator (DRA) who discussed the purpnse of an enforcement conference and the possible NRC actions that could be taken as a result of the conference.
Also the DRA clarified the differences between an enforcement conference conducted with an individual licensee and a facility licensee.
Af ter tnio
'-+raductian.
the n4 ::;or, ?'"ision of Reactor Safety (DRS) initiated the formal discussion of the appiicable issues.
At this point, the licensee provided to the NRC a handout containing his position on the issues plus relevant supporting documents.
Applicable portions of this hand-out are contained in Enclosure 3.
The discussion covered those items con-tuined in an enclosure to a letter sent to the licensee by the Region II Regional Administrator on April 28, 1988.
The DRS first explained that although most of the issues were described in NRC inspection reports, relevant information was also taken from the licensee's testimony to the NRC Office of Investigation on February 8 and 29, 1988.
With respect to Item 1, the licensee's prepared statement and subsequent discussions revealed that the licensee was not on duty during this event.
The licensee admitted Item 2, but explained that he struck the window accidentally during horseplay; he stated that he regretted his actions.
Discussion revealed that the licensee remembers being orally counseled on his actions.
The DRS asked the licensee what he would recommend to be contained in a research reactor operator code of conduct.
The licensee stated that proper conduct would be a requirement as it leads t0 continued good operation.
For Item 3, the licensee explained his actions and the safety significance of those actions using a schematic of the pipe and valve configuration. The DRA stated that the actual safety significance of tailing to isolate the valve appeared to be negligible.
The licensee stated that procedures are explicitly adhered to at the preser,t time.
The NRC asked if other procedures were l
violated simply for convenience, cs was this procedure. The licensee could not recall any other such violations, An additional issue with respect to procedural adherence was surfaced by the DRA.
Specifically, where equipment apparently required for startup is possibly not operable, but the reactor operator annotates the precritical checklist as not requiring the equipment and the reactor is started up with the equipment inoperable.
The NNRC Associate i
l Director clarified the checklist to be within the discretion of the Operations Supervisor to commence startup, if at least all equipment required by Technical Specifications is operable.
The NRC asked the licensee if he had requested the NNRC management to change the sampling procedure to reflect the more convenient i
l method.
The licensee stated that he could not recall requesting procedure l
char.ges at that time, i
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JUN 171988 a
Item 4 was then discussed.
The DRA stated that Items 4, 6 and 8 appeared to be related, in that they all tend to reveal a history of neglect towards completing required documentat1on.
The discussion then shifted to Item 8.
Discussion involved other experiments ongoing besides the topaz experiment and the completing of the schedule form for irradiation levels.
The DRA expressed concern over the apparent casualness of conducting experiments at the NNRC.
The licensee disagreed with the statement, _ st? ting that although procedures and
~
actions could be improved, the management attitude toward reactor operation and experiments has always been professional.
The NRC questioned why the licensee did not suspect that something was wrong when the high levels of radiation were observed on an experiment that war supposed to read "Nil."
The licensee stated that "Nil" referred to the sample only and it was comon for the canister and sample to be hot, with the sample relatively low in dose rate.
In this instance, the licensee stated the topaz read several hundre:' mr/hr at one foot, which certainly was not "Nil."
Returnino to Item 4, the 1; ensee stated that he was counseled by the NNRC Director on procedural adherence, after the NRC violation was issued.
Item 5 was next discussed.
The licensee could not recall any failure to wear dosimetry or protective clothing when they were required.
For Item 7, the licensee stated, in addition to providing his statement, that he was not teaching a class, that he believed that he definitely reacted in a safe manner to the event, and that the time between the power excursion and his actions was not excessive.
He blamed the event on a stuck power level recorder, which he said was the principal power level indicator.
- However, there were other indicators.
The event took place over a period of approxi-mately 10 minutes, and it was not terminated until radiation monitors alarmed.
A brief discussion continued on Item 8, specifically on the process for conducting and maintaining records for a number of multi-shift experiments.
This type of experiment (an example being the topaz experimont) requires maintaining a cumulative figure on irtadiation exposure data.
During discussion of the topaz experiment, the licensee reiterated his position that he cannot recall whether or not he surveyed his residence for radioactivity during August 1987.
l The NRC isked the licensee to evaluate himself as an operator.
The licensee
(
stated that he believed himself to be a good operator and a hard worker. He is actively involved in the NNRC operator training program and is working well with the new Associate Director nf the NNRC, reviewing and recomending changes to procedures.
The DRA closed the meeting by thanking the licensee for his presentation, j
providing the NRC with helpful information on the issues.
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ENCLOSURE 3
Event 1:
Overranging of a r4J monitor utilized in isolating containment building exhaust, such that it would not isciate unless levels were 100 times the maximum release rate permitted.
Response
Please note on page 84 of the log sheets attached to Dr. J.
Mahaffey's report (attached to Dr. Karan's letter of July 22, 1986, to Mr. Roger D. Walker) that I signed off duty at.1320 on the day of the event.
I lef t the containment building after being relieved.
I was not present when the event occured between the reactor shutdown at 1335 and the subsequent startup at 1431 and had no knowledge of it.
Page 1 of Dr. Mahaffey's report states that Dean McDowell and Jim Hendrix inserted the sample in V-28.
Page 2 states that Mr. McDowell ranged the rad monitor up.
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Event 2:
Striking of Hot Cell Window with a wrench while manipulations were in progress
Response
First, may I respectfully remind you that I was not performing licensed duties at the time of the incident.
I deeply regretted the incident then as I do now.
Striking the window was accidental and unintentional.
It was wrong, I know and understand that.
I apologized to the Hot Cell operator involved.
It will not happen again.
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Event 3:
Failure to isolate sample line per procedure when performing monthly surveillance.
Response
The sampling valves referred to in procedure 7200 (III A.
and B.) are shown in the drawing at the throttle and sampling valves.
The throttle valve is the one that was not being closed per procedore.
There is no safety significance in whether or not the throtte valve is closed.
You can see from the drawing that if there is a break or failure anywhere in the sampling line, it will result in a D,0 leak to the floor, regardless of the position of the throttle valve.
The inspection report statement that "isolation of the line as required by procedure would lessen the potential for accidental contamination" is incorrect.
I recognize that I was wrong to not close the valve per nre,edure.
I admitted my error at the time and I have manipulated the valve according to procedure since that time.
I will continue to manipulate the valve properly.
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3 Event 4:
Failure to fill out or complete Experiment Schedule Forms or Experimenter's Checklist.
Response
There should have been an Experimenter's Checklist filled out for experiment R6512 on 9/10/86.
Experiment Schedule Forms should have been filled out for every run in the pneumatic facility and for Nuclear Engineering class laboratory experiments.
I admit that I was wrong.
Sometimes the paperwork just didn't get done.
The forms which were cumbersone and complicated have been consolidated and much staplified.
It has not and will not happen again.
I have since assisted in reviewing and revising the forms used for controlling experiments.
Originally, only the Minor Experiment Approval form was required.
The Experiment Schedule fore was added to comply with Quality Assurance requirements.
The Experimenter's Checklist was added to check on chan;tes from previous xperiment runs.
The checklist was subsequent:.y merged with the tenedule form.
The checklist and schedule form was subsequently merged with the Experiment Approval form in an effort to further increase our control over experiments.
This review is continuing.
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s Event 5:
Failure to wear dostmetry and protective clothing in areas requiring their use.
Response
I wear my TLD and film badge when I'm in the Control Zone and protective clothing when and where it is required.
I do not recall instances where I was told that I wasn't wearing either my dosimetry or protective clothing.
I know of oo report was made to management for corrective action (as is required).
The only place this charg~e appears is in a logbook maintained by one of the former H.P.
technicians.
I believe that the incidents never happened.
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Event 6:
Failure to log Initial Conditions and Equilibrium Conditions per Procedure 2000, "Reactor Operation" on f requent occasions, as well as numerous missing / incomplete log entries.
Response
Initial Conditions:
For the three dates specified, May 19, May 21, and May 23, 1986, you can see f rom looking at the logsheets that an Initial Critical Data (ICD) stamp appears f or each s ta rtup, once I reached the desired operating power level.
I reviewed the console logbook for 1986 and found only 3 instances where the ICD stamp was not com aletely filled out.
On 2/12 and 10/6, a reactor scram occured witain 2 minutes of reaching power and I was unable to complete them.
The third occured on 4/28, when I put the IC stamp in the logbook cut of sequence and forgot to go back and cross it out after completing my log entries.
The ICD stamp was filled out af ter being restamped at the proper time.
Equilibrium Data:
Thermal equilibrium may not be reached on every run, so a stamp is not required.
For low power or short runs, a stamp would not be a ppropriate.
Even some high power runs do not reach thermal equili'>rium.
By procedure it is unclear how thermal equilibrium is established.
Procedure 2000 (III A.
13.) gives no guidance.
If all we did was to go to a particular power and stay there, ' thermal equilibrium would be eary to establish.
But operation of a research/ test reactor requires different power levels for different lengths of time.
Being certain thermal equilibrium conditions exist simply takes time and judgement.
In reviewing the console logbook f or 1986, I found a few instances out of approximately 350 startups wher. thermal equilibrium might, in the absence of fluctuations in outside conditions, have been established and no stamp was filled out.
Even an experienced operator cannot deters'ine solely f rom the logbook when thermal equilibrium is established.
I will pay more attention to this in the future and will endeavor to log it when appropriate.
In addition, I have brought to managements a t tention the deficiency in tNis procedure.
Missing / Incomplete Entries:
My review of logbook concerning the items listed in the inspectxan report show that 3 of the 6 items were incorrect.
The experiment R6530 was not entered in the console logbook as having been remov2d on 3/24.
It was properly entered on the experiment schedule form.
There is no requirement that this information be entered in the console logbook only convention.
This was due to oversight.
l This was due to oversight.
The incomplete ICD stamp on 4/28 was discussed above.
The expe riment number R4791 was not written down during the runs on 6/18.
This was due to oversight.
The only check missing on 11/25/85 (log #29, page 71) is the one to indicate who was on the console.
There must have been a possibility of reactor operation on that day.
That is the reason for the stamp.
Since it wasn't known who would do the s tartup, the check for "On Console" wa s left blank.
When no operation occured, I logged that fact "no op" and initiated the entry as I as supposed to.
Since there was no operation, nobody could be "On Console", and was properly lef t blank.
The incomplete ICD stamp on 2/12 (log #29, page 133) was discussed above.
The dose rates on pages 125, 131, 139, and 147 of logbook
- 29 were missing.
In these cases, the rabbit was not removed from the receiver and the dose rate checked until sometime later.
I f ailed to follow up and make sure that the dose rates were entered.
We have changed the procedure so that all dose rates are recorded on the experiment approval form.
This should eliminate this probles.
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Event 7:
Power excursion f rom 300 Kw to approximately 2 Mw while power was supposed to be stabilized.during conduct of Beam Port operations.
Response
There was a NE 4205/6205 class in the control room for a lab after the conclusion of the H-1 irradiation.
One of the students had performed a startup under my supervision.
When he reached power and had completed his log entries, I checked and initialed them.
I had been checking the instruments throughout this process.
The most sensitive instrument for indicating power level changes is the picoammeter indicating on the Power Level recorder.
At some point during the H-1 irradia tion, the Power Level recorder "f roze" or continued to indicate a stable power even though the power was changing.
The Power Level recorder is the primary instrument used to monitor operating power and as a result, both the Auto-controller and the "Outside Servo Deviation" alars are tied into this recorder.
The breakdown occured in such a way that the Auto-controller thought that the "actual" power was less than the "set" or "desired" to raise the "actual" power and drove the regulating rod out power.
Since the recorder did not change to indicate that the "actual" power had increased, the regula ting rod continued to drive out.
The breakdown also served to disable the "Outside Servo Deviation" alara since the dif ference between the "actual" and "set" power was small and did not change.
An "Outside Servo Deviation" alars would have taken the regulating rod drive out of automatic control.
t The H-1 irradiatica had begun and had to be logged.
Since it was broken, the Power Level recorder continued to indicate a stable power level.
I became aware of the discrepancy in instrument readings between the Power Level recorder and other l
instruments at approximately the same time that the area monitor alarm was received.
I quickly acted to bring the reactor under control.
I reduced power and shut the reactor down.
No scrans were actuated.
5 Why didn't I see the discrepancy sooner?
If I was looking directly at the Log N - Period recorder when the event occured, it still would have taken 3 - 10 seconds before I would have decided that action was required on the basis of what I was seeing.
The instrument panel contains 38 instruments and recorders to be checked.
If I give each one a cursory glance (.5 to 1 second), that occupies 20 to 30 seconds.
So the Log N -
Period recorder could have been fine when I began my scan of the instruments and been in the position I found it when I brought the reactor under control.
In addition to scanning the instruments, I had to keep track of the time remaining on the H-1 irradiation.
I had to adjust the cooling tower overflow and keep
several times before the contamination was discovered on 8/19 and detected nothing.
I found the contamination on my pants leg when I frisked myself near the reactor top after taking off my protective clothing on 8/19 after decontamination work was stopped for the day.
If H.P.
suspected that the contamination on my pants leg was from the previous day and not from the clean-up work, then it was their job, training, and responsibility to make sure that it was not from the previous day or assist me in taking a apropriate action if it was.
Subsequent investigation showed t1at no contamination got out of the containment building.
f I
l
1 track of the primary coolant temperature so that I could log Equilibrium conditions if thermal equilibrium was established.
The incident occured due to a mechanical failure in the primary instrument relied upon to indicate power change and control the regulating rod.
I believe I acted in a timely manner and was not distracted or kept from doing my job.
In fact, this event is a demonstration of why operators are trained so thoroughly.
As a result of my training and understanding of how the GTRR functions, I was able to take both timely and proper action to avoid a scram.
s l
Event 8:
Inadequate log keeping and control of an experiment resulting in the overexposure of a topaz experiment.
Subsequent contamination event due to poor Health Physics practices and inadequate communications with facility management.
Inconsistent information provided to the NRC regarding post-spill activities, in particular the radiation monitoring of your residence.
Response
While it is true that the day-to-day irradiation information wasn't recorded on the schedule forms, it was recorded on the Experiment Status log.
But both the schedule form and the status log in use at the time (see procedure 2012 rev.3) were deficient in that neither allowed for the cumulative MWH for a multi-day irradiation to be tracked.
Also, the desired MWH was not recorded on the experiment status log.
The experiment status log has been modified to include the total MWH and the desired MWH (see procedure 2012, rev. D).
The experiment a> proval forms and experiment status log were not required to >e updated and reviewed before startup (see procedure 2004, rev. A). They are now (see procedure 2004, rev. B).
These changes should eliminate tracking problems.
I was wrong not to have recorded the day-to-day irradiation information on the schedule form.
It will not happen again.
But I would,have had to go beyond procedural requirements to gather all the information to properly control the experiment.
It was not required that the ex be opened in a fume (see procedure 3107)perimentTwo people were required hood.
It is now for experiment insertion into or removal from the reactor, not after removal.
H.P. permitted operators to handle or move irradiated er.periments after they had been removed from the reactor.
I have been following this practice for several years in getting samples from the containment building for GT experimenters or shipping samples to off-campus users.
This is the first time I have had a problem of this nature.
' When the contamination was discovered on 8/19, I discussed with Dean McDowell and Dr. Karan what might have been the source.
I was handling the topaz within the normal pervue of my responsibility to keep track of experiments af ter removal from the reactor.
Explicit communication with management at every step was not required.
I did not withhold information from management.
I cannot say why I cannot remember definatively the sequence of events regarding the radiation monitoring of my residence.
But it should not have been lef t up to me.
I detected no contamination when I frisked myself before leaving the Control Zone on 8/18.
I was in and out of the Control Zone