Information Notice 1986-42, Improper Maintenance of Radiation Monitoring Systems: Difference between revisions

From kanterella
Jump to navigation Jump to search
(Created page by program invented by StriderTol)
(Created page by program invented by StriderTol)
 
(3 intermediate revisions by the same user not shown)
Line 3: Line 3:
| issue date = 06/09/1986
| issue date = 06/09/1986
| title = Improper Maintenance of Radiation Monitoring Systems
| title = Improper Maintenance of Radiation Monitoring Systems
| author name = Jordan E L
| author name = Jordan E
| author affiliation = NRC/IE
| author affiliation = NRC/IE
| addressee name =  
| addressee name =  
Line 14: Line 14:
| page count = 6
| page count = 6
}}
}}
{{#Wiki_filter:SSINS No.: 6835IN 86-42UNITED STATESNUCLEAR REGULATORY COMMISSIONOFFICE OF INSPECTION AND ENFORCEMENTWASHINGTON, D.C. 20555June 9, 1986IE INFORMATION NOTICE NO. 86-42: IMPROPER MAINTENANCE OF RADIATIONMONITORING SYSTEMS
{{#Wiki_filter: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==
==Addressees==
:All nuclear power reactor facilities holding an operating license (OL) or aconstruction permit (CP).
:
All nuclear power reactor facilities holding an operating license (OL) or a
 
construction permit (CP).


==Purpose==
==Purpose==
and Summary:This notice is issued to alert licensees to the potential for defeating thesafety function associated with radiation monitoring systems by not properlyadhering to established surveillance and maintenance procedures. A recentevent at a BWR, when an electrical jumper was inadvertently left in place aftera planned surveillance, led to failure to maintain secondary containmentintegrity during irradiated fuel movement.It is expected that recipients will review the information for applicability totheir maintenance and surveillance program and consider actions, if appropriate,to preclude similar problems at their facility. However, suggestions containedin this notice do not constitute NRC requirements; therefore, no specific actionor written response is required.Previous Related CorrespondenceIE Information Notice No. 83-23, "Inoperable Containment AtmosphereSensing Systems," April 25, 1983.INPO Significant Event Report, 35-83, "Compromise of Secondary ContainmentIntegrity," 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 DuringMaintenance or Surveillance Testing," May 10, 1984.
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==
==Description of Circumstances==
:On November 18, 1985 the Cooper Nuclear Station was in a shutdown condition(reactor coolant temperature less than 2120F and vented) with acceptancetesting for a plant design change in progress. When this testing failed toprovide for the required Group VI isolation (various containment isolation andCopies 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 86-42PGE OAR Action -M. H. Halmros (Due 8/12/86)NSRD Action -M. H. Malmros IN 86-42June 9, 1986 engineered safety feature (ESF) initiations), the licensee investigated anddiscovered that electrical jumpers were installed in the reactor building (RB)ventilation radiation monitors (VRM) auxiliary trip units. These jumpersprohibited a Group VI isolation by a high radiation signal from the RB VRM.The jumpers were immediately removed and the NRC was promptly notified asrequired by 10 CFR 50.72.The licensee's subsequent investigation revealed that the electrical jumpershad been installed on November 13, 1985 by an instrument and control technicianduring a routine surveillance procedure to functionally test the VRM. Thesejumpers are used to prevent trip and equipment operations during the requiredfunctional/calibration testing. The technician had signed off the proceduralstep requiring jumper removal (before actually removing the electrical jumper)and then started checking control room annunciator and trip signal status. Thetechnician then became involved in other unrelated craft work and forgot to goback and remove the jumpers.On November 18, 1986, before discovery of the jumpers, 18 irradiated fuelbundles were loaded into a spent fuel shipping cask. Failure to properlyimplement the surveillance procedure for operability checks of radiationmonitors rendered inoperable the automatic initiation of the standby gastreatment system (SBGTS) and automatic isolation of the reactor building uponreceipt of a high radiation signal. This degraded condition lasted approxi-mately 5 days. However, control room annunciators and instrumentation thatwould provide warning to operators of any high radiation problems remainedoperational during the 5 days. Manual-start of the SBGTS and reactor buildingisolation capabilities from the control room remained available during theevent.Discussion:This event clearly demonstrates that the level of attention given to theprocedural controls for the maintenance of radioactive monitoring systemsproviding ESF actuation can be significantly improved. While there were noactual radiological consequences of this event, the NRC took escalated enforce-ment actions (issued civil penalty) to emphasize the importance of correctlyperforming surveillance procedures on systems designed to mitigate or preventaccidents. Attachment No. 1 contains 6 summaries of related events taken fromthe Licensee Event Report files. Further examples of how improper maintenancepractices have degraded radiation monitoring systems are provided in the listedPrevious Related Correspondence section.The Cooper Station initiated the following corrective actions to preventrecurrence: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 offthe procedural step after completing the required actio IN 86-42June 9, 1986 . All surveillance procedures requiring temporary modifications to system orplant components were reviewed for deficiencies, and these procedures willbe modified to provide for independent verification to ensure that tempo-rary modifications are removed and the system/component is fully restoredto 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 RegionalAdministrator of the appropriate regional office or this office.4'-CJ1ward L. Jord, DirectorDivision of Edergency Preparednessand Engineering ResponseOffice of Inspection and EnforcementTechnical Contacts: James E. Wigginton, IE(301) 492-4967Roger L. Pedersen, IE(301) 492-9425
:
On November 18, 1985 the Cooper Nuclear Station was in a shutdown condition
 
(reactor coolant temperature less than 212 0F 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 investigated and
 
engineered safety feature (ESF) initiations), the licenseereactor building (RB)
discovered that electrical jumpers were installed in the           These jumpers
 
ventilation radiation monitors (VRM) auxiliary trip units. from the RB VRM.
 
prohibited a Group VI isolation by a high radiation signal           notified as
 
The jumpers were immediately removed and the NRC was promptly
 
required by 10 CFR 50.72.
 
The licensee's subsequent investigation revealed that the and  electrical jumpers
 
control technician
 
had been installed on November 13, 1985 by an instrument             the VRM. These
 
during a routine surveillance procedure to functionally test               the required
 
jumpers are used to prevent trip and equipment operations during off  the   procedural
 
functional/calibration testing. The technician had signed electrical jumper)
step requiring jumper removal (before actually removing the signal status. The
 
and then started checking control room annunciator and trip           and forgot to go
 
technician then became involved in other unrelated craft work
 
back and remove the jumpers.
 
18 irradiated fuel
 
On November 18, 1986, before discovery of the jumpers, Failure        to properly
 
bundles were loaded into a spent fuel shipping cask.               of  radiation
 
implement the surveillance procedure for operability checks standby gas
 
monitors rendered inoperable the automatic initiation of       the
 
building upon
 
treatment system (SBGTS) and automatic isolation of the reactor     lasted    approxi- receipt of a high radiation signal. This degraded condition                     that
 
mately 5 days. However, control room annunciators and     instrumentation
 
problems      remained
 
would provide warning to operators of any high radiation and reactor building
 
operational during the 5 days. Manual-start of the SBGTS                 during the
 
isolation capabilities from the control room remained available
 
event.
 
Discussion:
                                                                    given to the
 
This event clearly demonstrates that the level of attention monitoring      systems
 
procedural controls for the maintenance of radioactive While there were no
 
providing ESF actuation can be significantly   improved.
 
took escalated enforce- actual radiological consequences of this event, the NRC importance      of correctly
 
ment actions (issued civil penalty) to emphasize the
 
systems designed to mitigate     or prevent
 
performing surveillance procedures on                    related    events    taken from
 
accidents. Attachment No. 1 contains   6 summaries of
 
how improper maintenance
 
the Licensee Event Report files. Further examples of are provided in the listed
 
practices have degraded radiation monitoring   systems
 
Previous Related Correspondence section.
 
actions to prevent
 
The Cooper Station initiated the following corrective
 
recurrence:
                                                                        fuse removal)
    1. All temporary modifications (e.g., electrical jumpering,     1985 were indepen- performed by the involved technician since October 5, dently verified.
 
adherence--sign off
 
2. Site management stressed the importance of procedural
 
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 hours 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)
  LER81-061 (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 hours. With this loss of monitoring capability, the technical specifications require a reactor hot shutdown within
 
12 hours. 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          Evaluation Of Questionable    6/9/86  All byproduct
 
Exposure Readings Of Licensee        material licensees
 
Personnel Dosimeters
 
86-32          Request For Collection Of    6/6/86  All power reactor
 
Sup. 1          Licensee Radioactivity                facilities holding
 
Measurements Attributed To            an OL or CP
 
The Chernobyl Nuclear Plant
 
Accident
 
86-40          Degraded Ability To Isolate  6/5/86  All power reactor
 
The Reactor Coolant System            facilities holding
 
From Low-Pressure Coolant            an OL or CP
 
Systems in BWRS
 
86-39          Failures Of RHR Pump Motors  5/20/86 All power reactor
 
And Pump Internals                    facilities holding
 
an OL or CP
 
86-38          Deficient Operator Actions    5/20/86 All power reactor
 
Following Dual Function Valve        facilities holding
 
Failures                              an OL or CP
 
86-37          Degradation Of Station        5/16/86 All power reactor
 
Batteries                            facilities holding
 
an OL or CP
 
86-36          Change In NRC Practice        5/16/86 All power reactor
 
Regarding Issuance Of                facilities holding
 
Confirming Letters To                an OL or CP
 
Principal Contractors
 
86-35          Fire In Compressible Material 5/15/86 All power reactor
 
At Dresden Unit 3                    facilities holding
 
an OL or CP
 
86-34          Improper Assembly, Material  5/13/86 All power reactor
 
Selection, And Test Of Valves        facilities holding
 
And Their Actuators                  an OL or CP -
  OL = Operating License


===Attachments:===
CP = Construction Permit}}
1. Event Summaries2. List of Recently Issued IE Information Notices Attachment 1IN 86-42June 9, 1986 EVENT SUMMARIESUnplanned Gaseous Release (Connecticut Yankee, PWR)LER 85-025Event Date: 9/19/85Cause: Personnel Maintenance ErrorAbstract: With the plant operating at 100 percent power, a main stack highradiation alarm was received during routine scheduled maintenanceon a pressure actuated valve in the gaseous waste stream. Theunplanned release occurred through an isolation valve inadvertentlyleft open, allowing the on-line waste gas decay tank a release path.The maintenance tag-out procedure correctly required the isolationvalve to be isolated, but the operator shut the wrong valve. Thetotal noble gas release was approximately 20 curies (about 14 percentof technical specification limit). Licensee corrective actionincluded clearly relabeling associated valves and discussion of theevent with operation staff.Containment Radiation Monitor Isolated (Byron 1, PWR)LER 85-026Event Date: 2/28/85Cause: Improper Valve PositionAbstract: With the reactor at zero percent power, a containment radiationmonitor used for required reactor coolant leakage detection wasinadvertently left isolated for 72 hours from containment aftermaintenance on an associated valve. Abnormal in-leakage at themonitor caused normal-range readings on RM-li console in the maincontrol room (leakage was later repaired). Licensee correctiveaction included implementing administrative controls to ensuresystem integrity/proper restoration after completion of maintenanceactivities.Liquid Radwaste Effluent Monitor Isolated (Cooper, BWR)LER 84-008Event Date: 6/09/84Cause: Monitor Discharge Valve ShutAbstract: A liquid discharge occurred without required continuousradiation monitoring because the liquid effluent radiation monitorwas isolated. No discharge limits were exceeded. Two days beforethe event, a technician apparently shut the radiation monitor outletvalve during maintenance without permission or knowledge ofoperations personnel. As corrective actions, the licensee revisedcontrolling procedures and informed all plant operators of theeven Attachment 1IN 86-42June 9, 1986 Off-Gas Stack Monitor Inoperable (Cooper, BWR)LER 84-006Event Date: 4/18/84Cause: Personnel ErrorAbstract: With the reactor at 70 percent power, the off-gas stack effluentsampler was found inoperable. The sampler was drawing air fromthe surrounding off-gas filter building ambient atmosphere insteadof sampling the plant stack effluent. The event resulted from achemistry technician failing to follow the approved procedure forchanging the inline particulate filter/iodine cartridge (routineoperation). In addition to making appropriate supervisors and allchemistry technicians aware of the event, the licensee revised andclarified the governing procedure to prevent recurrence.Liquid Radwaste Auto-Isolation Valve Inoperative (Hatch 1, BWR)LER 82-093Event Date: 11/07/82Cause: Jumper InstalledAbstract: During a liquid radwaste discharge, the licensee discovered thatthe radiation monitor auto control (provides isolation signal uponhigh radiation) to the discharge isolation valve was inoperable.However, the monitor's alarm function remained operable. Anelectrical jumper used during corrective maintenance had not beenremoved after the work was completed.Containment Atmosphere Radiation Monitors Isolated (FitzPatrick 1, BWR)LER 81-061 (Rev 1Event Date: 8/21/81Cause: Containment Isolation Valve IsolatedAbstract: The NRC resident inspector discovered that during normal 85 percentpower operations the containment isolation valves for the containmentatmosphere gaseous and particulate monitoring system had been shutfor approximately 22 hours. With this loss of monitoring capability,the technical specifications require a reactor hot shutdown within12 hours. The event occurred because a surveillance procedure didnot direct the operator to re-open the isolation valves following'the surveillance activities. As a corrective action, the licenseecorrected the subject procedure and reviewed all other surveillanceprocedures for similar deficiencie 'Attachment 2IN 86-42June 9, 1986LIST OF RECENTLY ISSUEDIE INFORMATION NOTICESInformation Date ofNotice No. Subject Issue Issued to86-4186-32Sup. 186-4086-3986-3886-3786-3686-3586-34Evaluation Of QuestionableExposure Readings Of LicenseePersonnel DosimetersRequest For Collection OfLicensee RadioactivityMeasurements Attributed ToThe Chernobyl Nuclear PlantAccidentDegraded Ability To IsolateThe Reactor Coolant SystemFrom Low-Pressure CoolantSystems in BWRSFailures Of RHR Pump MotorsAnd Pump InternalsDeficient Operator ActionsFollowing Dual Function ValveFailuresDegradation Of StationBatteriesChange In NRC PracticeRegarding Issuance OfConfirming Letters ToPrincipal Contractors6/9/866/6/866/5/865/20/865/20/865/16/865/16/86All byproductmaterial licenseesAll power reactorfacilities holdingan OL or CPAll power reactorfacilities holdingan OL or CPAll power reactorfacilities holdingan OL or CPAll power reactorfacilities holdingan OL or CPAll power reactorfacilities holdingan OL or CPAll power reactorfacilities holdingan OL or CPAll power reactorfacilities holdingan OL or CPAll power reactorfacilities holdingan OL or CP -Fire In Compressible Material 5/15/86At Dresden Unit 3Improper Assembly, Material 5/13/86Selection, And Test Of ValvesAnd Their ActuatorsOL = Operating LicenseCP = Construction Permit}}


{{Information notice-Nav}}
{{Information notice-Nav}}

Latest revision as of 03:02, 24 November 2019

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)
v • d • e


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 0F 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 investigated and

engineered safety feature (ESF) initiations), the licenseereactor building (RB)

discovered that electrical jumpers were installed in the These jumpers

ventilation radiation monitors (VRM) auxiliary trip units. from the RB VRM.

prohibited a Group VI isolation by a high radiation signal notified as

The jumpers were immediately removed and the NRC was promptly

required by 10 CFR 50.72.

The licensee's subsequent investigation revealed that the and electrical jumpers

control technician

had been installed on November 13, 1985 by an instrument the VRM. These

during a routine surveillance procedure to functionally test the required

jumpers are used to prevent trip and equipment operations during off the procedural

functional/calibration testing. The technician had signed electrical jumper)

step requiring jumper removal (before actually removing the signal status. The

and then started checking control room annunciator and trip and forgot to go

technician then became involved in other unrelated craft work

back and remove the jumpers.

18 irradiated fuel

On November 18, 1986, before discovery of the jumpers, Failure to properly

bundles were loaded into a spent fuel shipping cask. of radiation

implement the surveillance procedure for operability checks standby gas

monitors rendered inoperable the automatic initiation of the

building upon

treatment system (SBGTS) and automatic isolation of the reactor lasted approxi- receipt of a high radiation signal. This degraded condition that

mately 5 days. However, control room annunciators and instrumentation

problems remained

would provide warning to operators of any high radiation and reactor building

operational during the 5 days. Manual-start of the SBGTS during the

isolation capabilities from the control room remained available

event.

Discussion:

given to the

This event clearly demonstrates that the level of attention monitoring systems

procedural controls for the maintenance of radioactive While there were no

providing ESF actuation can be significantly improved.

took escalated enforce- actual radiological consequences of this event, the NRC importance of correctly

ment actions (issued civil penalty) to emphasize the

systems designed to mitigate or prevent

performing surveillance procedures on related events taken from

accidents. Attachment No. 1 contains 6 summaries of

how improper maintenance

the Licensee Event Report files. Further examples of are provided in the listed

practices have degraded radiation monitoring systems

Previous Related Correspondence section.

actions to prevent

The Cooper Station initiated the following corrective

recurrence:

fuse removal)

1. All temporary modifications (e.g., electrical jumpering, 1985 were indepen- performed by the involved technician since October 5, dently verified.

adherence--sign off

2. Site management stressed the importance of procedural

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)

LER81-061 (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 Evaluation Of Questionable 6/9/86 All byproduct

Exposure Readings Of Licensee material licensees

Personnel Dosimeters

86-32 Request For Collection Of 6/6/86 All power reactor

Sup. 1 Licensee Radioactivity facilities holding

Measurements Attributed To an OL or CP

The Chernobyl Nuclear Plant

Accident

86-40 Degraded Ability To Isolate 6/5/86 All power reactor

The Reactor Coolant System facilities holding

From Low-Pressure Coolant an OL or CP

Systems in BWRS

86-39 Failures Of RHR Pump Motors 5/20/86 All power reactor

And Pump Internals facilities holding

an OL or CP

86-38 Deficient Operator Actions 5/20/86 All power reactor

Following Dual Function Valve facilities holding

Failures an OL or CP

86-37 Degradation Of Station 5/16/86 All power reactor

Batteries facilities holding

an OL or CP

86-36 Change In NRC Practice 5/16/86 All power reactor

Regarding Issuance Of facilities holding

Confirming Letters To an OL or CP

Principal Contractors

86-35 Fire In Compressible Material 5/15/86 All power reactor

At Dresden Unit 3 facilities holding

an OL or CP

86-34 Improper Assembly, Material 5/13/86 All power reactor

Selection, And Test Of Valves facilities holding

And Their Actuators an OL or CP -

OL = Operating License

CP = Construction Permit


Retrieved from "https://kanterella.com/w/index.php?title=Information_Notice_1986-42,_Improper_Maintenance_of_Radiation_Monitoring_Systems&oldid=2200064"