ML20006G231

Ro:On 880229,reactor Room Primary Continuous Air Monitor Accidently Left in Test Mode During Operations.Two Sets of Corrective Actions Taken to Prevent Recurrence Including Flashing Visual Light Installed on Console in Control Room

ML20006G231
Person / Time
Site:	Armed Forces Radiobiology Research Institute
Issue date:	03/23/1988
From:	Irving G ARMED FORCES RADIOBIOLOGICAL RESEARCH INSTITUTE
To:	NRC
Shared Package
ML20006F188	List: ML20006F186 ML20006G226 ML20006G228 ML20006G231
References
NUDOCS 9003060216
Download: ML20006G231 (3)

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DEFENSE NUCLEAR AGENCY ]

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Memorandum 23 March 1988 ,

LICENSEE' EVENT REPORT (LER)

Abstract: The- Reactor room primary Continuous Air Monitor (CAM) was accidently left in TEST mode during the reactor operations on 29 February 1988. Two sets of corrective action were taken to p prevent reoccurance. One was to instruct the Safety and Health p Department staff to be more attentive to their routine mr.intenance -

on the Reactor CAMS. The second was the installation of a l flashing visual light on the reactor auxiliary instrumentation console in the control room. This flashing light is illuminated by a signal from the Primary Reactor Room CAM when the TEST circuit is -

activated. This will alert the operator when the CAM is in TEST mode. >

l, Cire==tances surroundina the event - 29 February 1988:

0640 Startup checklist ' completed, all required systems are operable.

0434 Console locked by reactor operator after two experimental runs; reactor i operator proceeded downstairs for an Exposure Room opening.

0845 Routine maintenance of reactor CAM's in-progress by a member of the -

Safety Reactorand RoomHealth.

Primary Department CAM was place (SHD)d into TEST mode by a memberDurin of SHD, a non-licensed individual, and was accidently left in TEST mode upon completion of the routine maintenance (SHD routinely performs the maintenance of all CAM's in the Reactor Facility).

0921 Reactor operator returned to the control room to continue with the experimental runs; the reactor operator did not know that the SHD member had performed a daily check on the CAM, and that the CAM had been accidently left in TEST mode.

The reactor operations for the day, after 0921, included a series of one minute-runs at low power of 1 Kw (five runs total), and a series of medium power pulses between 82.05 and 82.15 step reactivity insertions. During the pulse mode operations in the afternoon, the reactor operator on console first noticed above normal CAM readings on the readout meter in the control room, but attributed y these above normal readings to those levels which are expected for medium power pulse operations.

At 1521, while doing the Shutdown chxklist, the reactor operator printed out an hourly report from the Stack Gas Monitor, which is adjacent to the CAM on the Reactor deck. The Reactor Operatoc then noticed that the tracing on the strip chart on the CAM was not commensurate with the operations conducted 9003060216 900222 PDR ADOCK 05000170 S PDR 75

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j Memorandum 23 March 1988 Page 2 I during the day; the CAM trace on the CAM chart recorder was a straight line trace as would be expected from a test ' input signal, instead of a fluctuating trace

as would be expected from a series of medium power pulse operations. Upon further inspection, it was discovered that the CAM was in TEST mode and had been accidently left in TEST mode by the SHD member upon completion of routine maintenance that morning. l This event was due to a Safety and Health Department staff member not following the proper procedures to turn the CAM back to the OPERATE mode after completion of routine maintenance on the CAM. In. addition, due to the type of l cperations performed that day, the reactor control room CAM Readout Monitor l

levels appeared approximately correct when observed by the Reactor Operator.

This was particularly significant as the. Startup Checklist was completed earlier that morning, ensuring that all required instruments were operable.

The event was reported to the Reactor Facility Director, who notified the USNRC telephonically, the following morning. .

Probable consecuences:

f I- Leaving the CAM in the TEST mode during reactor operations would not ensbie the reactor ventilation system to be automatically secured via closure dampers by a signal from the CAM If the high alarm setpoint had ben reached. However, ,

manual closure of the dampers would occur if initiated by operator action. The ,

reactor operations during the day of the incident consisted of a series of short, low power experimental runs and a series of medium power pulses, and thus any L release of airborne radioactivity would have' been unlikely. In addition, none of L the Reactor Room Radiation Area Monitors (R1, R2, RS, R5) nor the Reactor Stack Gas Monitor registered any above normal ~ readings, consistent with the l reactor operations throughout the day. The Reactor Stack roughing and HEP A filter systems were functional throughout the day and were capable of performing mitigation had a release occurred. Based on the above, there w :o radiation releases due to the incident and no adverse effects on the faciuy.

Hatus of corrective action - 1 March 1988:

L L The' event was reported by the Reactor Facility Director to the USNRC, Region 1 (Curtis Cowsill) by telephone at 1130.

(- Two sets of corrective actions were taken to prevent recurrence. The first was to

) instruct the SHD staff to be more attenti e to their routine maintenance on the f Reactor CAMS. The second was the installation of a flashing visual light on the

! reactor auxiliary instrumentation console in the control room. This flashing light is illuminated by a signal from the primary Reactor Room CAM when the TEST circuit -is activated. This alerts the reactor operator when the CAM is in TEST mode.

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Reference:

There have been no previous similar events at this' Facility.

' Point of

Contact:

Reactor Facility- Director, M. L. Moore (202) 295-1290.

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George' ing,III '

( Colone , AF, BSC Directo

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