Information Notice 1986-42, Improper Maintenance of Radiation Monitoring Systems

Improper Maintenance of Radiation Monitoring Systems

ML031250045
Person / Time
Site:	Beaver Valley, Millstone, Hatch, Monticello, Calvert Cliffs, Dresden, Davis Besse, Peach Bottom, Browns Ferry, Salem, Oconee, Nine Mile Point, Palisades, Palo Verde, Perry, Indian Point, Fermi, Kewaunee, Catawba, Harris, Wolf Creek, Saint Lucie, Point Beach, Oyster Creek, Watts Bar, Hope Creek, Grand Gulf, Cooper, Sequoyah, Byron, Pilgrim, Arkansas Nuclear, Three Mile Island, Braidwood, Susquehanna, Summer, Prairie Island, Columbia, Seabrook, Brunswick, Surry, Limerick, North Anna, Turkey Point, River Bend, Vermont Yankee, Crystal River, Haddam Neck, Ginna, Diablo Canyon, Callaway, Vogtle, Waterford, Duane Arnold, Farley, Robinson, Clinton, South Texas, San Onofre, Cook, Comanche Peak, Yankee Rowe, Maine Yankee, Quad Cities, Humboldt Bay, La Crosse, Big Rock Point, Rancho Seco, Zion, Midland, Bellefonte, Fort Calhoun, FitzPatrick, McGuire, LaSalle, University of Lowell, 05000000, Zimmer, Fort Saint Vrain, Shoreham, Satsop, Trojan, Atlantic Nuclear Power Plant, Skagit, Marble Hill
Issue date:	06/09/1986
From:	Jordan E NRC/IE
To:
References
IN-86-042, NUDOCS 8606040007
Download: ML031250045 (6)

SSINS No.: 6835 IN 86-42 UNITED STATES NUCLEAR REGULATORY

COMMISSION

OFFICE OF INSPECTION

AND ENFORCEMENT

WASHINGTON, D.C. 20555 June 9, 1986 IE INFORMATION

NOTICE NO. 86-42: IMPROPER MAINTENANCE

OF RADIATION MONITORING

SYSTEMS

Addressees

All nuclear power reactor facilities

holding an operating

license (OL) or a construction

permit (CP).

Purpose

and Summary: This notice is issued to alert licensees

to the potential

for defeating

the safety function associated

with radiation

monitoring

systems by not properly adhering to established

surveillance

and maintenance

procedures.

A recent event at a BWR, when an electrical

jumper was inadvertently

left in place after a planned surveillance, led to failure to maintain secondary

containment

integrity

during irradiated

fuel movement.It is expected that recipients

will review the information

for applicability

to their maintenance

and surveillance

program and consider actions, if appropriate, to preclude similar problems at their facility.

However, suggestions

contained in this notice do not constitute

NRC requirements;

therefore, no specific action or written response is required.Previous Related Correspondence

IE Information

Notice No. 83-23, "Inoperable

Containment

Atmosphere

Sensing Systems," April 25, 1983.INPO Significant

Event Report, 35-83, "Compromise

of Secondary

Containment

Integrity," June 9, 1983.IE Information

Notice No. 83-52, "Radioactive

Waste Gas System Events," August 9, 1983.IE Information

Notice No. 84-37, "Use of Lifted Leads and Jumpers During Maintenance

or Surveillance

Testing," May 10, 1984.Description

of Circumstances:

On November 18, 1985 the Cooper Nuclear Station was in a shutdown condition (reactor coolant temperature

less than 212 0 F and vented) with acceptance

testing for a plant design change in progress.

When this testing failed to provide for the required Group VI isolation (various containment

isolation

and Copies to: Withers, Yundt, Lentsch, Orser, Steele, E. Burton, E. Jordan, A. Holm, iLIS;.j. A. Olmstead, S. Hoag, S. Sautter, TNP:GOV REL F:NRC CHRONO, TNiPGOV REL F:NRC IE Information

Notice 86-42 PGE OAR Action -M. H. Halmros (Due 8/12/86)NSRD Action -M. H. Malmros

IN 86-42 June 9, 1986 engineered

safety feature (ESF) initiations), the licensee investigated

and discovered

that electrical

jumpers were installed

in the reactor building (RB)ventilation

radiation

monitors (VRM) auxiliary

trip units. These jumpers prohibited

a Group VI isolation

by a high radiation

signal from the RB VRM.The jumpers were immediately

removed and the NRC was promptly notified as required by 10 CFR 50.72.The licensee's

subsequent

investigation

revealed that the electrical

jumpers had been installed

on November 13, 1985 by an instrument

and control technician

during a routine surveillance

procedure

to functionally

test the VRM. These jumpers are used to prevent trip and equipment

operations

during the required functional/calibration

testing. The technician

had signed off the procedural

step requiring

jumper removal (before actually removing the electrical

jumper)and then started checking control room annunciator

and trip signal status. The technician

then became involved in other unrelated

craft work and forgot to go back and remove the jumpers.On November 18, 1986, before discovery

of the jumpers, 18 irradiated

fuel bundles were loaded into a spent fuel shipping cask. Failure to properly implement

the surveillance

procedure

for operability

checks of radiation monitors rendered inoperable

the automatic

initiation

of the standby gas treatment

system (SBGTS) and automatic

isolation

of the reactor building upon receipt of a high radiation

signal. This degraded condition

lasted approxi-mately 5 days. However, control room annunciators

and instrumentation

that would provide warning to operators

of any high radiation

problems remained operational

during the 5 days. Manual-start

of the SBGTS and reactor building isolation

capabilities

from the control room remained available

during the event.Discussion:

This event clearly demonstrates

that the level of attention

given to the procedural

controls for the maintenance

of radioactive

monitoring

systems providing

ESF actuation

can be significantly

improved.

While there were no actual radiological

consequences

of this event, the NRC took escalated

enforce-ment actions (issued civil penalty) to emphasize

the importance

of correctly performing

surveillance

procedures

on systems designed to mitigate or prevent accidents.

Attachment

No. 1 contains 6 summaries

of related events taken from the Licensee Event Report files. Further examples of how improper maintenance

practices

have degraded radiation

monitoring

systems are provided in the listed Previous Related Correspondence

section.The Cooper Station initiated

the following

corrective

actions to prevent recurrence:

1. All temporary

modifications (e.g., electrical

jumpering, fuse removal)performed

by the involved technician

since October 5, 1985 were indepen-dently verified.2. Site management

stressed the importance

of procedural

adherence--sign

off the procedural

step after completing

the required action.

IN 86-42 June 9, 1986 3. All surveillance

procedures

requiring

temporary

modifications

to system or plant components

were reviewed for deficiencies, and these procedures

will be modified to provide for independent

verification

to ensure that tempo-rary modifications

are removed and the system/component

is fully restored to operational

status.No specific action or written response is required by this information

notice.If you have any questions

about this matter, please contact the Regional Administrator

of the appropriate

regional office or this office.4'-CJ1ward

L. Jord, Director Division of Edergency

Preparedness

and Engineering

Response Office of Inspection

and Enforcement

Technical

Contacts:

James E. Wigginton, IE (301) 492-4967 Roger L. Pedersen, IE (301) 492-9425 Attachments:

1. Event Summaries 2. List of Recently Issued IE Information

Notices

Attachment

1 IN 86-42 June 9, 1986 EVENT SUMMARIES Unplanned

Gaseous Release (Connecticut

Yankee, PWR)LER 85-025 Event Date: 9/19/85 Cause: Personnel

Maintenance

Error Abstract:

With the plant operating

at 100 percent power, a main stack high radiation

alarm was received during routine scheduled

maintenance

on a pressure actuated valve in the gaseous waste stream. The unplanned

release occurred through an isolation

valve inadvertently

left open, allowing the on-line waste gas decay tank a release path.The maintenance

tag-out procedure

correctly

required the isolation valve to be isolated, but the operator shut the wrong valve. The total noble gas release was approximately

20 curies (about 14 percent of technical

specification

limit). Licensee corrective

action included clearly relabeling

associated

valves and discussion

of the event with operation

staff.Containment

Radiation

Monitor Isolated (Byron 1, PWR)LER 85-026 Event Date: 2/28/85 Cause: Improper Valve Position Abstract:

With the reactor at zero percent power, a containment

radiation monitor used for required reactor coolant leakage detection

was inadvertently

left isolated for 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> from containment

after maintenance

on an associated

valve. Abnormal in-leakage

at the monitor caused normal-range

readings on RM-li console in the main control room (leakage was later repaired).

Licensee corrective

action included implementing

administrative

controls to ensure system integrity/proper

restoration

after completion

of maintenance

activities.

Liquid Radwaste Effluent Monitor Isolated (Cooper, BWR)LER 84-008 Event Date: 6/09/84 Cause: Monitor Discharge

Valve Shut Abstract:

A liquid discharge

occurred without required continuous

radiation

monitoring

because the liquid effluent radiation

monitor was isolated.

No discharge

limits were exceeded.

Two days before the event, a technician

apparently

shut the radiation

monitor outlet valve during maintenance

without permission

or knowledge

of operations

personnel.

As corrective

actions, the licensee revised controlling

procedures

and informed all plant operators

of the event.

Attachment

1 IN 86-42 June 9, 1986 Off-Gas Stack Monitor Inoperable (Cooper, BWR)LER 84-006 Event Date: 4/18/84 Cause: Personnel

Error Abstract:

With the reactor at 70 percent power, the off-gas stack effluent sampler was found inoperable.

The sampler was drawing air from the surrounding

off-gas filter building ambient atmosphere

instead of sampling the plant stack effluent.

The event resulted from a chemistry

technician

failing to follow the approved procedure

for changing the inline particulate

filter/iodine

cartridge (routine operation).

In addition to making appropriate

supervisors

and all chemistry

technicians

aware of the event, the licensee revised and clarified

the governing

procedure

to prevent recurrence.

Liquid Radwaste Auto-Isolation

Valve Inoperative (Hatch 1, BWR)LER 82-093 Event Date: 11/07/82 Cause: Jumper Installed Abstract:

During a liquid radwaste discharge, the licensee discovered

that the radiation

monitor auto control (provides

isolation

signal upon high radiation)

to the discharge

isolation

valve was inoperable.

However, the monitor's

alarm function remained operable.

An electrical

jumper used during corrective

maintenance

had not been removed after the work was completed.

Containment

Atmosphere

Radiation

Monitors Isolated (FitzPatrick

1, BWR)LER 81-061 (Rev 1 Event Date: 8/21/81 Cause: Containment

Isolation

Valve Isolated Abstract:

The NRC resident inspector

discovered

that during normal 85 percent power operations

the containment

isolation

valves for the containment

atmosphere

gaseous and particulate

monitoring

system had been shut for approximately

22 hours2.546296e-4 days <br />0.00611 hours <br />3.637566e-5 weeks <br />8.371e-6 months <br />. With this loss of monitoring

capability, the technical

specifications

require a reactor hot shutdown within 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br />. The event occurred because a surveillance

procedure

did not direct the operator to re-open the isolation

valves following'

the surveillance

activities.

As a corrective

action, the licensee corrected

the subject procedure

and reviewed all other surveillance

procedures

for similar deficiencies.

4'Attachment

2 IN 86-42 June 9, 1986 LIST OF RECENTLY ISSUED IE INFORMATION

NOTICES Information

Date of Notice No. Subject Issue Issued to 86-41 86-32 Sup. 1 86-40 86-39 86-38 86-37 86-36 86-35 86-34 Evaluation

Of Questionable

Exposure Readings Of Licensee Personnel

Dosimeters

Request For Collection

Of Licensee Radioactivity

Measurements

Attributed

To The Chernobyl

Nuclear Plant Accident Degraded Ability To Isolate The Reactor Coolant System From Low-Pressure

Coolant Systems in BWRS Failures Of RHR Pump Motors And Pump Internals Deficient

Operator Actions Following

Dual Function Valve Failures Degradation

Of Station Batteries Change In NRC Practice Regarding

Issuance Of Confirming

Letters To Principal

Contractors

6/9/86 6/6/86 6/5/86 5/20/86 5/20/86 5/16/86 5/16/86 All byproduct material licensees All power reactor facilities

holding an OL or CP All power reactor facilities

holding an OL or CP All power reactor facilities

holding an OL or CP All power reactor facilities

holding an OL or CP All power reactor facilities

holding an OL or CP All power reactor facilities

holding an OL or CP All power reactor facilities

holding an OL or CP All power reactor facilities

holding an OL or CP -Fire In Compressible

Material 5/15/86 At Dresden Unit 3 Improper Assembly, Material 5/13/86 Selection, And Test Of Valves And Their Actuators OL = Operating

License CP = Construction

Permit