ML20215K352

Ro:On 860813,console Key Left in Keyswitch & in on Position.Caused by Personnel Error.Reactor Operator & Duty Senior Operator Suspended from Licensed Duties for 1 Wk

ML20215K352
Person / Time
Site:	North Carolina State University
Issue date:	08/20/1986
From:	Bray T North Carolina State University, RALEIGH, NC
To:	Fredrickson P NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II)
References
NUDOCS 8610280137
Download: ML20215K352 (2)

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Nortg Carolina StateUniversity ,

[ 5 g *, 9 School of Engineering h *9o n e d Department of Nudear Engineering Nuclear lleactor Program ihm 799 Zip asw-ry9 (9i9) 737-23n August 20, 1986 Mr. Paul Fredrickson, Chief Project Section 2A U. S. Nuclear Regulatory Commission 101 Marietta Street, N. W.

Atlanta, GA 30323 Docket No. 50-297 Facility License R-120

Dear Mr. Fredrickson:

This letter is transmitted as required by North Carolina State University PULSTAR Technical Specification 6.7.2.c. and describes a Reportable Event meeting the definition of T.S.1.17.f.

At 0410 on 13 August 1986, when preparing to execute a reactor startup checklist, the oncoming duty Reactor Operator observed the console key in the keyswitch and the keyswitch in the "0N" position. At this time (0410) the reactor was shut down (control rods entirely down) and subcritical by the same margin as would be expected under routine conditions. Upon entering the control room at 0410, the Operator and Senior Operator coming on duty should have observed the console keyswitch "0FF" and the key should have been removed from the keyswitch. An examination of the console operator's -log by the Senior Operator who came on duty at 0410/13 August 1986 indicated that the reactor had been shut down at 2108 hours0.0244 days <br />0.586 hours <br />0.00349 weeks <br />8.02094e-4 months <br />'on 12 August 1986. Ordinarily the keyswitch would have been turned off approximately three (3) minutes later (at 2111) as no further operating was scheduled on 12 August 1986. Therefore the keyswitch had been left "0N" since the preceding reactor shutdown had been performed, approximately seven (7) hours prior to the 0410/13 August 1986 discovery. During that interval, the reactor control room was doubly locked, as usual, and the facility intrusion alarm was properly set and armed. Hence the reactor controls were not accessible to the public.

The Reactor Operator who failed to turn off the keyswitch and remove the console key was interviewed by the Reactor Operations Manager and was asked to describe the circumstances leading to the event. At the conclusion of the interview, it was determined that failure of the Reactor Operator to follow the established shutdown procedure was due to inattention by the Reactor Operator to his duties. The existence of control room distraction has not been identified.

Imediate action ~ taken by Management was sygension of the Reactor Operator and duty Senior Operator from licensededottes-for a-weak.._.  %

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• ENGlON l' S UFFICIAt cars North Carolina State University is a Land-Grant University and a constituent institution of The University of North Carolina.

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Mr. Paul Fredrickson Page 2 1 August 20, 1986 l Corrective measures shall be taken to avoid further occurrences of this type and those measures are:

1. Requalification lecture of all Reactor Operators and Senior Operators concerning the subject occurrence, said lecture to be given by the R.0. and S.R.0. responsible for this event.

2. Revise the PULSTAR Operations Manual, Section 3.3.1., to add a shutdown procedural step specifying that the console key is 4

"0FF" and " REMOVED".

3. Revise the Console Operations Log rubber stamp utilized after shutdown to reflect the same additional procedural step stated in 2. above.

Please contact me at (919) 737-2323 should you desire additional infor-mation concerning this report.

Sincerely,

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Thomas C. Bray Reactor Operations Manager TCB:edt cc: Director, NRR, USNRC  !

Associate Director, NRP

Chairman RPC, NCSU i

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