ML20205Q292

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Final Ro:On 860501,unanticipated or Uncontrolled Change in Reactivity Greater than One Dollar Occurred.Caused by Removal of Rotisserie from Face Water Notch.Proposed Changes to SOPs Developed as Listed
ML20205Q292
Person / Time
Site: 05000128
Issue date: 05/16/1986
From: Feltz D
TEXAS A&M UNIV., COLLEGE STATION, TX
To: Johnson E
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
References
NUDOCS 8605280250
Download: ML20205Q292 (30)


Text

{{#Wiki_filter:. . TEXAS ENGINEERING EXPEllIM ENT STATION THE TEXAS A&M UNIVERSITY SYSTEM COLLEGE STATON. TEXAS 77843-3575 1

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16 May 1986 NUCLEAR SCIENCE CENTER 409/845-7551 Mr. Eric Johnson, Director Division of Reactor Safety and Projects Region IV D$@@@@h U.S. Nuclear Regulatory Commission 611 Ryan Plaza Drive, Suite 1000 Arlington, Texas 76012 Nl$E y RE: Final Report of Reportable Occurrence of 1 May 1986

Dear Mr. Johnson:

I am forwarding the final report of the reportable occurrence of 1 May 1986 on an unanticipated or uncontrolled change in reactivity greater than one dollar. This report is being submitted in accordance with NSCR Technical Specification Section 6.6.2(3), License R-83, Texas A&M University. Respectfully, Donald E. Feltz Director DEF/ym Enclosure cc: Dr. H. H. Richardson, Vice Chancellor, Dean of Engineering and Director, Texas Engineering Experiment Station Feenan Jennings, Chairman, Reactor Safety Board K. L. Peddicord, Head, Dept. of Nuclear Engineering C. A. Erdman, Associate Dean of Engineering Les Constable, Nuclear Regulatory Commission, Region IV Bruce Ernst, American Nuclear Insurers 9605280250 e60516 0 DR ADOCK 0500 qy @1 nt l RESEARCH AND DEVELOPMENr FOR MANKINO \

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NUCLEAR SCIENCE CENTER REACTOR (NSCR) TEXAS A&M UNIVERSITY Final Report of Reportable Occurrence #86-02 UNANTICIPATED OR UNCONTROLLED CHANGE IN REACTIVITY GREATER THAN ONE DOLLAR INTRODUCTION On 2 May 1986 a Reportable Occurence was issued by the Nuclear Science Center, Texas Engineering Experiment Station, Texas A&M University to the U.S. Nuclear Regulatory Commission Region IV office regarding the violation of Technical Specifications to facility operating license R-83. The. Reportable Occurrence was issued as the result of the removal by reactor operations personnel of an experiment from the reactor core having an unanticipated reactivity worth greater than $1.00. The specifications violated are 3.6.1(a)

            " Reactivity Limits on Experiments" and 4.6.c " Experiment Surveillance Requirements". They are, stated as follows:

3.6.1 Reactivity Limits The reactor shall not be operated unless the following conditions governing experiments exist. (a) Non secured experiments shall have reactivity worths less than one dollar. 4.6.c Experiments The reactivity worth of an experiment shall be estimated or measured, as appropriate, before reactor operation with said experiment. This report provides a description of the incident, results of safety analysis and evaluation by NSC management, a discussion of corrective measures taken or planned to prevent a reoccurrence, and a summary statement of the incident. ~ ._ DESCRIPTION OF INCIDENTS LEADING TO THE REPORTABLE OCCURRENCE On 1 May 1986 at 0930 hours, the initial reactor startup of the day was completed to a reactor power level of 1 l@. The reactor operator noted that the control rod positions were higher than expected for that power level and for the experiments logged in the core. Co.apletion of the Trend Analysis portion of the operations log confirmed that the total reactivity inserted during the startup was higher than normal for comparative xenon conditions. This situation was brought to the attention of the Manager of Reactor Operations at approximately 0935. Upon a visual inspection of the reactor, the Manager noted that a boron rotisserie that had been placed in a face water notch the previous night for a gamma irradiation experiment had not been removed prior to reactor startup as desired. The SRO on duty initiated routine procedures to remove the rotisserie by first reducing reactor pnwer by approximately 50%. At 0938 the RO reduced power to approximately 550 kW and the sample was removed by an off duty SRO. At 0939, during sample removal, the reactor scrammed due to high power trips on both safety channels. Upon subsequent reactor startup to 1 MW, the worth of the boron rotisserie in the face notch (core position B-5) was determined by the difference in control rod heights from the previous startup to be $1.09. Thus, the removal of the rotisserie resulted in an unanticipated and uncontrolled change in reactivity of greater than one dollar. Since the experiment was moved during reactor operation, it was no longer secured and became by definition an unsecured experiment. Thus, as a consequence of events, fechnical Specif ication 3.6.1, limiting the worth of unsecured experiments to $1, was' violated, unknowingly, by the removal of the rotisserie. Since the reactivity value of the experiment was not properly estimated or measured before reactor operation, a violation of Technical Specification 4.6.c also occurred. 2

SAFETY ANALYSIS AND EVALUATION in evaluating this incident, it was noted that the same experiment had been removed under a different set of conditions from a cold critical reactor during a previous startup resulting in a period scram. This earlier incident occurred on 10 March 1986. In this incident there was no reactor safety question as the observed fuel temperature increase was an insignificant amount (approximately 20*F) from an initial ambient temperature of 80"F. It was assumed during Management review of the scram that the reactivity worth of the sample was known and was obviously less than a $1.00 value. The scram log entry and recorder charts from this incident are attached to this report as Appendix A. To prevent reoccurrence it was stated in the scram log review that the rotisserie would be removed in the future only when the reactor was shutdown or on a negative period. This restriction was not followed by the SRO and R0. The high power scram of 1 May 1986 which resulted f rom the removal of the boron rotisserie from the reactor at a reduced reactor power of approximately 550 kW was terminated by the action of the safety channels. The safety channel scram point is set at 115 1 3% and is checked each morning during the pre-startup check. From an investigation of the reactor log power, linear power and temperature channel recorder charts, (see Appendix A), it appears that the reactor power could have only slightly exceeded the scram set point of 1150 kW before the high power scram occurred. The log power channel which reacts slower than the safety channels, indicated on the reactor chart a reactor power of approximately 800-900 kW when the scram occurred. The linear power channel indicated a power of 650 kW at the time of the scram. Of most importance in the safety analysis and evaluation was that no increase in fuel temperature was ob- ! 3-L.

served. A fuel thermocouple temperature of approximately 560*F was recorded at the time of the scram. Since the experiment removal resulted in a reactivity insertion slightly greater than that required for prompt criticality, this excursion was similar to a reactor pulse at power which produces lower temperatures and power levels than the same reactivity insertion produces when pulsing from just critical. The SAR for the NSCR provides an analysis of temperatures and reactor powers resulting from the accidental pulsing of the TRIGA at power. Since our present reactivity insertion limit for pulsing operations is S2.10, this excursion could have proouced, at the most, a peak power and temperature well below that allowed during pulsing operations. In review of this incident, safety of the reactor was analyzed for the assumption that the safety channels had failed to perform their safety function. In this case, the excursion would have been terminated by the negative reactivity inserted as the fuel tenverature increased. Using the reactivity loss versus reactor power data for Core Vill an:1 assuming a linear relation above 1 MW, the reactor power at which the negative reactivity from fuel heat-up would have balanced the positive worth inserted by removing the rotisserie is 1280 kW. At this power level, the maximum core temperature is calculated to be 1230 F (665 C) which is well below the restrictive peak core temperature of 1740 F (950 C) which is the Limiting Safety System Setting. The predicted peak core temperature in this case would be some 485'C from the fuel safety limit of 1150 C. It should be noted that this temperature value is conservatively high since the temperature versus reactor power curve tends to level off as power increases, and a linear increase was assumed here. The reactivity loss and thermocouple temperature versus reactor power from Core Vill are included in Appendix A. In order to better understand the incident of 1 May 1986 and that of 10 March 1986 and to verify the boron rotisserie reactivity worth calculation done following the high power scram, the worth of the rotisserie was measured at 300W { cold critical) on the 'af ternoon of 1 May 1986. The worth was measured to be

         $1.12, and this measurement agrees quite well with the value determined from the pre- and post-scram rod heights.

In conclusion, it can be determined from the data available from reactor instrumentation following the reactor scram and from subsequent analysis of the incidents that:

1. There was no reactor safety question as the fuel safety limit and Limiting Safety System Setting was not exceeded during the excursion nor would they have been had the high power scram not occurred.
2. There was no radiation exposure to facility personnel or the general public. .
2. There was no loss of facility operations.
4. Thre was no damage to the reactor or experiments.
5. The Trend Analysis portien of the operations 109 served its intended function of alerting the operator to unexpected changes in reactivity.

It can also be concluded from the events surrounding the incident that:

1. The operations staff did not question the reactivity worth of the boron rotisserie, ihey were obviously misled in their thinking due to previous handling of the experiment in core positions of known reactivity worth. Only after a series of events did they realize that the experiment's reactivity worth was greater than $1. Had they known this they would have removed the sample only if the reactor was shutdown. Thus, the incident did not involve a flagrant violation of Technical Specification 3.6.1 or 4.6.c.
2. _ The operations staf f did not follow certain procedures in log keeping, transfer of inf ormation between shif ts, sample handling and the review and approval of experiments.
3. The operations staff did not recall and utilize the results of review of the period scram incident of 10 March 1986 in their decision to remove the sample. The restrictions placed on the boron rotisserie at that time were not followed.
4. Existing procedures need to be upgraded in regard to experiment handling and reactivity worth determination.
5. Inmediate retraining of operations personnel is required in the areas of log keeping, sample handling and experiment reactivity determi-nation. .
6. The NSCR operator training program which is already an extensive and detailed program needs to be expanded by placing emphasis on the attention to detail in the handling of experiments and properly analyzing their effects on reactor operations.

6-

CORRECTIVE MEASURES TO PREVENT RE0CCURRENCE Several immediate corrective measures were taken to prevent a reoccurrence of an incident involving the handling of experiments and to insure knowledge and control of experiment reactivity worth. First, the Director of the NSC met with each individual involved to discuss and gather facts concerning their actions leading up to, during, and following the high level trip incident. Those individuals in error were informed of their improper performance of duty. Secondly, since human error and a let down in job performance was realized, it was decided to retrain all reactor operations personnel and to discuss and evaluate procedures to determine if they were adequate and if not what changes could be implemented to prevent reoccurrence. A subject outline was prepared and classroom training sessions were held on 8 May 1986 and 9 May 1986. The training consisted primarily of reviewing the requirements for the performance of experiments as stated in, the Technical Specifications and existing facility 50P's and a review of experiment reactivity worth measurements. The retraining outline is presented in Appendix B and documentation of operations staff attendance is also provided in Appendix B. Each training session was of approximately 3 hours duration. A written examination will be administered on 16 May 1986 by the Director of the NSC and additional retraining is required for overall scores less than 80. Proposed changes to SOP's were developed using input from all reactor operations personnel to strengthen the procedures in areas of record keeping, review and approval of experiments and the surveillance of experiments. The

i. proposed changes are as follows:

l 1. As per a request of the USNRC Region IV, experiments having a i w

n reactivity worth greater than $.30 will not be removed from the reactor while the reactor is critical. A

2. The reactor power will be reduced to 600 kW or less for the removal at power of experiments having a reactivity worth of $.30 or less.
3. During continued reactor operations the reactivity worth will be verified for experiments removed at power and documented in the Reactor Operations Log.
4. NSC Form 514 (Experiment Authorization) will be changed to include experiment reactivity measured values or estimates at both cold critical and at power.
5. Signature blocks will be added to the scram log review, NSC Form 539 Section V, to authorize startup following a scram as approved by the SRO on duty or Management approval in the event the scram resulted in a Reportable Occurrence.

A memorandum from the Manager of Reactor Operations to all licensed NSCR operators documenting ttaining on proposed changes to procedures and of measures to improve operator performance is included in Appendix B.

SUMMARY

STATEMENT The administration of the NSCR consisting of licensee Dr. H. H. Richardson, Vice Chancellor, Dean of Engineering and Director of the Texas Engineering Experiment Station, Dr. K. l.. Peddicord, Head, Department of Nuclear Engineering dfid D. E. Feltz, Director of the Nuclear Science Center Reactor are all very concerned about this incident as it involves human error and poor job performance. The individuals involved are dedicated, hard working, and have out-k

standing performance records. It is regretable that their good performance over a long period of time can be so easily offset by a single incident that has an unfortunate element of " catch 22" to it. Since procedures were in place that if followed would have prevented the incident, one concludes that training emphasis in critical areas of operation is the only measure available to hopefully eliminate human error. The NSCR administration and management will continue with efforts to achieve this goal through corrective measures as outlined in this report. it'should be noted that much progress has been made at the NSCR in the upgrade of 50P's and operator perf ormance since the overpower incident of December 1982. That incident also revealed the need to improve the training of operators in specific areas. Also of note is that the NSCR is one of the highest utilized 1 Mw reactor in the U.S. and its operation involves the performance of experiments of numerous descriptions. Licensed reactor operators at the NSCR are well aware of the inherent safety features provided by the TRIGA uranium /zir-conium-hydride fuels. This knowledge plays an important part in decision making by operators concerning experiments, however, this is not an excuse for not following procedures. The inherent safety of the NSCR was recognized in the evaluation of this incident and the comparisons of an unexpected reactivity insertion of this magnitude in designs of other reactors is irrel'evant. The attention to duties of licensed reactor operators and the need to emphasize certain areas of training is the issue here which is generic to all operating reactors. 9

4 t P APPENulX A SCRAM LOG. RECORDER CHARTS, CORE Vill DATA I i i t I

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c Retraining of Reactor Operations Personnel Reportable Occurrence of 2 May 1986 Training Outline Tech Spec Review 1.23. Reactivity Worth of an Experiment 1.25 Reactor Operating 1.27 Reactor Secured 1.29 Reportable Occurrence 3.6.1 Reactivity Limits 4.6 Experiments 6.1.3(c) Staffing 6.4- Experiments Review and Approval 50P Review , II-B-1 Operations Records, General (Records required by Tech Specs and associated logs) Il-B-2 Operations Records, Reactor Operations Log (Changes are proposed) Il-B-4 Operations Records, Scram Log (Changes are proposed) 11-B-5 Operations Records, Supervisor Log II-B-6 Operations Records, Instrumentation Corrective Maintenance Log 11-B-7 Operations Records, Reactor Data Log II-C-2 Reactor Startup, Prestartup Check (Figure Il-C-1(a) i- Il-C-3(h)(o) Reactor Startup, Startup for Steady State (Trend Analysis) Il-C-6 Reactor Startup, Startup following an Unscheduled Scram (Changes are proposed *) 11-0-2 Steady State Operation, Log Entries (Changes are proposed) i

Il-D-5 Steady Sta'te Operation, Shift Change (Changes are proposed) II-F-1 Reactor Shutdown, General (Reactor Secured) Il-N Response to Abnormal Reactivity Changes IV-A-1 Experiment Approval, General T IV-A-2. Experiment Approval, (Figure IV-A-1) Routine Sample Irradiation Approval (Changes are proposed to NSC Form 514 " Irradiation Information Sheet")

                     - IV-B-4 Sample llandling Procedures, Sample Routing Theory Lecture by John Krohn on experiment reactivity measurements and estimation of reactivity.

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SPECIAL REACTOR O'ERATIONS TRAINING REPORTABLE OCCURRENCE - MAY 2,1986

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Nuclear Sc ience Center Operations Memorandum #182 14 May 1986 TO: All Licensed Operators .

                                                                                 .f-FROM:       John L. Krohn, Manager of Reactor Operations, NSC StmJECT: procedure Changes following Reportahir 0<<urrente of 1 May 1986 As we discussed last week during our re-training sessions, there have been some new restrictions placed on sample handling by ti el NRC in response to the Reportable Occurrence of 1 May. In addition. re have decided on some procedural changes that should help to prevent a repeat of this occurrence.        I have listed below the new procedures that will be followed until further notice involving reactor operations, log keeping and sample handling. Mos t of these will be con-solidated into the 50P's, but until that time, we will follow the procedures given in this niemo.

As per the NRC's request, we have agreed to not remove a sample from the reactor while critical unless the reactivity worth is known and is less than $0,30. In addition to this restriction which we must impose, we have taken some further steps to attempt to do a better job of sample handling. First, reactor power will be reduced to 600 Kw or less before a' sample is removed. Secondly, the worth of each sample will be measured each time it is removed while the reactor is critical and this value will be enterted in a new column on the right-hand side of the operations log. The sample worth sip et at the front of the log book will contain the cold critical worth of each experimental device and an average 1 MW worth with a variance determined from the worths recorded in the log right-hand column mentioned above. Our NSC form 514 will also be changed to provide a location for the cold tritical (300W) worth of the sample and the worth at power. In order to comply wi t h the rest riction on not removing samples of unknown worth from a criticaI reacLor, we wi11 measure the worth of any new devices prior to the first time that they are used whether the experiment is to be removed while the reactor is critical or not. In addition to the above changes in sample handling, we have also decided on some other improvements to our operating procedures. The shift change will be kept in a more formal manner and should be labelled by the day and not by the operators' names. All activities related to reactor operations sht ald be noted in the log. An entry should be made when these activities commence and the entry should be checked off when the activity is finished. This includes sample runs but should not be stretched to the point of logging routine pump operations, scram checks, etc. In addition to reactor activities, any activities in the f acility which a RO or SRO coming on duty without a verbal turnover needs to be aware of should also be noted in the Shift Change Log. Also, entries in the log should be made only by the SR0 or R0 on duty, or with their consent and knowledge. It might be beneficial to initial entries that you make, but I don't want to make this a requirement at this time. One other log that we will make changes to is the Scram Log. A signature block will be added to NSC Form S39 in Section V for the

c . , ,. ,. , Opirations Memorandum #182 Page 2 SR0 on duty to authorize re-start following an unscheduled shutdown. Also included here will be space for management authorization to re-start following a shutdown due to a reportable ou urrence. I know that everyone understands the seriousness of the incident that occurred and that we all have been more careful since Lt.en. Hawever, nobody should relax now that we have decided on the procedure changes that.are designed to keep this from happening again. We violated procadures this time and the new procedures alone will not guarantee something similar from happening in the future. We all, myself included, need to pay closer attention to the small details in our sample handling both for safety purposes and to give the customer the best service that we can. If anyone has any rurther suggestions to improve sample handling safety or customer service, please let me know. 1

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