ML20086A361

Trtr Peer Review for Oh State Univ Nuclear Reactor Lab, for 950214-15

ML20086A361
Person / Time
Site:	Ohio State University
Issue date:	05/10/1995
From:	Ernst J, Hughes D, Richards W OHIO STATE UNIV., COLUMBUS, OH
To:
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ML20086A359	List: ML20086A357 ML20086A361
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NUDOCS 9507030185
Download: ML20086A361 (27)

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i TRTR PEER REVIEW for OHIO STATE UNIVERSITY NUCLEAR REACTOR LABORATORY 14-15 February 1995 .

Yd Dr Wade J. flichards L d-to-9s Date McClellan Nuclear Radiation Center a m S$15 Mr Daniel E. Hughes / Date Pennsylvania State University b 4-sl 8-96~

Mr John Ernst Date 1 University of Missouri-Columbia 307!Oo!!o!oogjo )

1 TABLE OF CONTENTS- l i

i: l I. Executive Summary l II. Review i

A. Facility ,

i.- B. Reactor Operations ,

C. Health Physics Program D. Administrative Controls III. Observations and Reconunendations IV. Exit Meeting i V. - Appendices [

i A. OSU Letter of Request ,

B. Agenda i C. Engineering Administration and Reactor Operations Committee j 4

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j L EXECUTIVE

SUMMARY

On 7 September 1994, Ohio State University's Nuclear Reactor Laboratory (NRL) ,

requested that TRTR perform peer review of the OSU research reactor operations (Appendix A). On 14-15 February 1995, Dr Wade Richards, Mr Daniel Hughes, i and Mr John Ernst performed the requested TRTR peer review. The review was conducted using the agenda at Appendix B.

The facility housekeeping was excellent, especially considering the confined space relative to the amount of equipment, the age of the facility, and the increased - _

activity. The staff commitment to facility rad equipment upgrades and .

maintenance is commendable.  ;

A number of new facility personnel radiation exposure area problems .were pointed out by the staff during the facility tour. These new problems are the result of increasing the reactor power from 100 kW to 500 kW. It was also clear during the tour that the reactor staff, has in the past, handled the radiation protection-program, the equipment upgrades and maintenance. >

The recent increase from 100 kW to 500 kW resulted in a number of observations.

In the past, the 100 kW power level radiation safety problems and associated tasks t were handled by the reactor operations staff very effectively. With the increased power and the new 10 CFR Part 20 requirements, the reactor staff needs help with  ;

the implementation of the radiation safety program. It is recommended that a i health physicist from the Campus Radiation Safety Office be assigned to assist the reactor operations staff in this effort. Furthermore, the radiation safety program should follow the ANS 15.11 " radiation protection at research reactor facilities" ,

standard as a guide.

l Reactor operations, operating procedures and staff training were reviewed. The NRL staff are very well qualified and are doing an excellent job of operating the l facility.- The written operating procedures are clear and easy to follow._ There are some problems that were observed with the. changes to procedures. The routing j slips to individuals was incomplete and should be watched carefully. Also, there  :

was some confusica concerning changes to procedures and the approval cycle-before implementation could take place. This confusion needs to be eliminated. .l The review group also recommends that written procedures be used for those activities required by the Technical Specifications. For instance, the power calibration, calibration of the control rods, etc. These operations are presently being done very well and safely, but if there was staff turnover these procedures 8

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would help as training documents and ensure that the present staff are all doing )

the operations the same way. l The staff commitment to and the accomplishment of the equipment upgrades for 3 the increased power are commendable. With the limited staff and technical j resources, further efforts are going to be very difficult. This is especially true in j the area of electronic upgrades and maintenance of new digital equipment. It is I recommended that the staff receive help from other university resources in the area of review of electronic upgrades and maintenance of electronic equipment.

The facility's review and audit function was also reviewed. This was also an issue of concern with the last NRC inspection. The Reactor Operations Committee l (ROC) review and audit function responsibilities are not being done in a timely manner or as required by the Technical Specifications. It is recommended that the reactor administrator and the reactor management reassess the necessity for the ROC to meet every quarter and the possibility of having qualified individuals from other reactor organizations perform the annual audit function and report the results to the ROC. A process of review by the ROC to ensure timeliness must also be addressed.

4 It is the opinion of the peer review members based on this brief review that the Ohio State University Nuclear Reactor Laboratory Reactor is being operated in a safe manner by a very qualified and dedicated staff. As in any organization there is always room for improvement. These observations and recommendations are intended to help to achieve those goals.

II. REVIEW ,

A. Facility Mr Richard Myser, Associate Director, gave the reviewers a tour of the facilities. l This tour included:  ;

l 1. Nuclear reactor and its associated secondary systems such as the pool water cooling system, and the pool water purification systems.

2. Nuclear reactor control console and associated instrumentation such as the pool water level alarms, radiation detection systems, nuclear power level l instrumentation, pool water temperature instrumentation, control rod drives and l SCRAM instrumentation.

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3. Irradiation facilities such as the pneumatic sample system and gas handling system, neutron beam facilities, thermal column facilities, and the Co-60 irradiator pool and associated systems.

4. Gamma spectroscopy laboratory and the associated instrumentation.

The reviewers found the facilities to be very clean and organized considering the confining space relative to the amount to equipment and activity. The commitment to and the accomplishment of the equipment upgrades by the limited staff is vary commendable. The recent rewriting of the SAR and Technical Specifications for the power upgrade to 500 kW is indicative of a staff dedicated to excellence and progress.

The tour also verified that appropriate radiation detection instrumentation were available and readily accessible. All instruments examined were found to have up-to-date calibration labels.

During the tour, Mr Myser pointed out a number of new problems that have been encountered as a result of the increased power, specifically the placement of the demineralizer resins close to the personnel walkways and the increased radiation levels at the pool top in the vicinity of the irradiation tube. These issues are addressed in the report.

B. Reactor Operations The reactor operations review consisted of the following:

1. Facility Technical Specifications

2. Operating procedures

3. Observation of pre-startup checkout Specific Items Reviewed Appendix A to Facility Operating License No. R-75, Technical Specifications and bases for the Ohio State University Pool Type Nuclear Reactor, Columbus Ohio, Docket No. 50-150.

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l Sections Reviewed: i 1

6.2.4 ROC Review and Approval Function  !

'(1) Review and approval of experiments utilizing the reactor i facilities.  !

(2) Review and approval of procedures.

(3) Review and approval of all proposed changes to the license and .

Technical Specifications.  ;

(4) Determination of whether a proposed change, new test, or experiment would constitute an unreviewed safety question or require a change in l the Technical Specifications per 10 CFR Part 50.59. i (5) Review of audit report.

a (6) Review of abnormal performance of plant equipment and operating abnormalities having safety significance.

(7) Review of unusual occurrences and incidents which are  :

reportable under 10 CFR Parts 19,20, and 50, or Section 6.64 of this document. ,

1 (8) Review of violations of technical specifications, heense, or procedures having safety significance.

Note relative to 6.2.4(2) - The NRL Director or his designee shall be responsible for approval of procedures or changes to procedures on a day-to-day basis. He shall provide a summary of all procedure changes to the ROC for their review and approval. ,

i 6.3.1 Reactor Operating Procedures Written procedures, reviewed and approved by the Director and the ROC, shall be -I in effect and followed. The procedures shall be adequate to assure the safety of 4

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the reactor, but should_not preclude the' use of independent judgment and action should the situation require such. All new procedures and changes to existing procedures shall be documented by the NRL staff and subsequently reviewed by the ROC. At least the following items shall be cove-red:

(1) Startup, operation, and shutdown of the reactor.. )

(2) Installation, removal, or movement of the fuel elements, control I rods, experiments, and experimental facilities. .

(3) Actions to be taken to correct specific and foreseen potential malfunctions of systems or components; including responses to alarms, suspected  ;

cooling systems leaks, and abnormal reactivity changes. ,

l (4) Emergency conditions involving potential or actual release.of radioactivity including provisions for evacuation, re-entry, recovery, and medical-  ;

support.

(5) Preventive and corrective maintenance procedures for systems U which could have an effect on reactor safety.

(6) Periodic surveillance of reactor instrumentation and safety-systems, area monitors, and radiation safety equipment. j (7) Implementation of Security, Emergency and Operator training ,

and requalification plans.

(8) Personnel radiation protection. l 4.2 Reactor Control and Safety Systems (Surveillance)  ;

4.2.1 Control Rods Specifications:

(1)-The reactivity worth of the shim safety rods and regulating rod  :

shall be determmed annually and prior to the routine _ operation of any new core configuration.  !

(2) Shim safety rod drop and drive times and regulating rod drive i l

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I time shall .be determined annually or after maintenance or modification is l completed on a mechanism.  !

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(3) The shim safety rods and regulating rod _ shall be visually

. inspected annually, for indication of corrosion, and indication of excessive friction with guides.

Bases: The reactivity worth of the rods is measured to assure the required shutdown margin and reactivity insertion rates are maintained. It also provides a  !

means for determining the reactivity of experiments. Measuring annually will provide corrections for burnup and after core changes assures that altered rod  ;

worths will be known prior to continued operations.

The visual inspection of the rods and measurements of drive and drop times are  ;

made to assure the rods are capable of performing properly. Verification of i operability after maintenance or modification of the control system will ensure proper reinstallation.  ;

4.2.2 Reactor Safety System  !

Specification:

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a. A channel check of each measuring channel shall be performed daily when the reactor is operatmg.

b. A channel test of each measuring channel shall be performed prior i to each day's operation, or prior to each operation extending more than one day.

c. A channel calibration of the reactor power level measuring l channels shall be made annually. (Linear Level and Log-N.) l

d. A channel calibration of the Level and Period Safety. Channels  !

1 shall be made annually. Channel tests are done on these before each days operation.  ;

e. A channel calibration of the following shall be made annually:

(1) Core inlet temperature measuring system (2) Pool water level measuring system 6

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I (3) Coolant' system pumps measuring system -

(4) Primary coolant flow measuring system j l

f. The control room manual scram shall be verified to be operable  !

prior to each days operation. All other manual scram switches shall be tested ,

annually. l

g. Other scram channels shall be tested / calibrated annually.  !

h. Any -instrument channel replacement shall be calibrated after -i installation and before utilization. i

i. Any instrument repair or replacement shall have a channel test

. prior to reactor operation.

Bases: The daily channel tests and check will assure that the scram channels ,

are operable. Appropriate annual tests or calibrations will assure that long term functions not tested before daily operation are operable.

I 4.6.1 Effluent Monitor l Specification: The effluent monitor shall have a channel calibration annually and ' j a channel test before each days operation.  ;

4.6.2. Rabbit Vent Monitor Specification: The monitor shall have a channel calibration annually and a channel test before each days reactor operation. l 1

4.6.3 Area Radiation Monitors (ARMS)

Specification: A channel test of the ARMS'shall be completed before each days operation and a channel calibration shall be completed annually.

4.6.4 Portable Survey Instrumentation Specification: Beta-gamma and neutron survey meters shall be tested for operability each day the reactor is to be operated and shall be calibrated annually.

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Operating Procedures Administrative Procedures (AP)

AP-03 Filing Requests for Reactor Operations AP-04 Approval of Requests for Reactor Operations AP-06 Format for Writing. Revising and Approving Procedures AP-07 Review of Procedures AP-15 Logging Emergency Scrams General Reactor Operations and Maintenance (OM)

OM-01 Reactor Power Changes OM-02 Control Rod AnnualInspections OM-15 Process-System Checks--No ROC Approval Noted Radiation Safety (RS)

RS-06 Annual Radiation Monitor Calibrations--No ROC Approval Noted RS-11 Routine Shipment of Radioactive Material--No ROC Approval Noted RS-17 Ar-Release Calculation--No ROC Approval Noted Instrumentation Use and Maintenance (M)

IM-01 Scram Checks--No ROC Approval Noted IM-02 Adjusting Reactor Control Instrumentation Meter Zeros IM-03 OSURR Pre-Start Checkout IM-04 Post Shutdown Checkout IM-07 Rod parameter Testing--No ROC Approval Noted IM-08 Compensating Voltages--No ROC Approval Noted IM-12 Rx Instrumentation Calibration / Checks--No ROC Approval Noted Emergency Procedures (EP)

EP-01 Emergency Procedures EP-02 Handling Precautions for Non-Reactive Hazardous Materials EP-04 Emergency Equipment Inventory 8

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1 Security Procedures (SP)  !

SP-01-12 i C. Health Physics Program The health physics program review included procedures, records, and interviews with the reactor staff and the University Radiation Safety Officer. The following  ;

paragraphs outline the results of the review. .

1. Management Policy The " Standards for Protection Against Radiation" contained in 10 FR 20 were  :

revised effective 1 January 1994. Part 20.1101 and 20.2102 of- the revised standard require a licensee to develop and document a radiation protection program. The administrative procedures in Section 1 and the radiation safety  !

procedures in Section 3 of the standard operating procedures of the Nuclear  ;

Reactor Laboratory provide the basic documentation of a radiation safety program.  ;

Documentation of the program can be improved by the addition of a written  ;

management policy statement that includes a clear definition of the areas of l responsibility assigned to the NRL staff and those assigned to the OSU Office of l Radiation Safety. l Personnel wo'rking at the NRL are included in the ALARA program administered ,

by the Office of Radiation Safety because radiation dosimeters are issued by that ,

office. A restatement of this ALARA policy or a policy specifically designed for q the NRL should be included as a part of a document radiation protection program.

i Regulations require the radiation protection program to be audited at least annually. This review could be documented as part of the audit' required by i Technical Specification or as a stand-alone document. The "American National  !

Standard for Radiation Protection at Research Reactor Facilities, ANSI /ANS-15.11-1993" provides guidance on implementing a program and conducting audits, t

NRC Form 3 is conspicuously posted on the bulletin board near the entrance to the j laboratory. Requirements in 10 CFR 19.11 specify other documents that should l be posted, including the regulation in Parts 19 and 20, facility license, operating )

procedures, and any notice of violation. If it is not possible to post these I document a notice should be posted describing them and where they may be 9

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2. Procedures )

The reactor laboratory has a comprehensive set of approved radiation safety l procedures that appear to provide adequate guidance for performing routine health I physics functions. Several have been recently revised to reflect the requirements of revised regulations in 10 CFR 20. Some procedures appear to have been revised and implemented prior to review and approval by the ROC. NRL

! Technical Specifications may require ROC approval prior to implementation.

l Experimental samples irradiated at 500 kilowatts will have higher dose rates and l contamination levels than those experienced in the past. Removal of samples from the pool dry well and the rabbit system may require tighter radiological controls. NRL staff should evaluate the need for procedures covering these evolutions under the current operating conditions.

l 3. Training Operating procedure RS-15 " Radiation Safety Instruction" provides initial training for individuals with access to NRL. Although this procedure provides adequate instruction and documentation on most topics, it should be revised to include the l current doe limits specified in 10 CFR Part 20. NRL staff should consider providing Draft Regulatory Guide DG-8012 " Instruction Concerning Risks From Occupational Radiation Exposure" and Draft Regulatory Guide DG-8014

" Instruction Concerning Prenatal Radiation Exposure" to new trainees. These .

i document provide useful and up to date information concerning dose limits and health risks associated with exposure to radiation.

4. Radioactive Material Control Areas where radioactive materials are handled are clearly defined and adequately posted. Several containers in these areas were examined and found to be correctly j labeled. Within the NRL building, locations with dose rates exceeding normal background are identified with HOT SPOT signs including the measured dose rate. A HOT SPOT identified over the top of the reactor pool appears to indicate that a high radiation area exists at that location when the reactor is operating at 500 kilowatts. NRL staff should document an evaluation of this area with regard to the definition of High Radiation Area and the associated posting requirements contained in 10 CFR 20. In any case, the requirement for control of access to a 10

high radiation area appear to be met by compliance with 10 CFR 20.1601(b). '

The reactor staff makes infrequent shipments of radioactive material and all recent shipments have been classified as Limited Quantity. Operating procedure, RS-11

" Routine Shipment of Radioactive Material" provides guidance for the transfer of radioactive material. No records associated with shipping were reviewed.

Only small quantities of solid radioactive waste are generated during normal operations. The radioactive waste storage container was clearly marked and -

required information was recorded on the Radioactive Waste Disposal Log Sheet.

Interviews with the staff indicate that there.are no routine radioactive releases to  ;

the sanitary sewer. Upcoming special maintenance procedures may require radioactive liquid releases in the near future. Prior to effluent releases to the sewer, operating procedure RS-02 should be revised to address new regulations regarding the solubility of radioactive materials in liquid waste streams.

5. Radiation Monitoring Personnel radiation dosimetry is provided to the NRL staff by the OSU Office of i Radiation Safety. Radiation dosimeters provided are: film badges for beta / gamma dose monitoring, nutrex track etch for fast and thermal neutron dose monitoring, and TLD finger rings for extremity dose monitoring. Personnel exposure records were reviewed and doses to individuals are reasonable for the i work performed. l A tour of the facility verified that appropriate radiation detection instruments are .

l available and readily accessible. Technical Specifications require annual calibrations, all instruments examined were found to have up to date calibration labels. Calibration records were reviewed for four types of instruments. The records indicate that the instruments were calibrated according to approved procedures.

Records of radiation and contamination surveys were reviewed and found to be

-adequate. The surveys covered areas of the facility accessible to personnel and were completed at the frequency specified by procedure. Dose rates found to higher than normal were investigated and an explanation provided on the survey.

Particulate air samples were performed at the specified intervals and the results recorded. Gaseous effluent records were reviewed and they indicate that the-facility is in compliance with Technical Specifications requirements. The l procedure for calculating Ar-41 releases was reviewed and no problems were 11 l

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l identified. l

6. Emergency Planning The Emergency Preparedness Plan for the NRL was revised in December,1994. ,

The revisions appear to correct the deficiencies identified by the NRC in. l Inspection Report No. 50-150/94001. Specifically, Section 5.9 of the Emergency l Preparedness Plan was modified to require a' single annual emergency drill and define what aspects of the plan the emergency drill should test. An emergency  ;

drill was conducted in December,1994. The drill involved personnel from the -

Office of Radiation Safety and the University Hospital emergency room. The-written critique of the drill indicated that NRL staff received good cooperation  ;

from the outside organizations involved in the drill. i Operating Procedure EP-01 " Emergency Procedures," requires the reactor operator j to evacuate the building carrying five notebooks in addition to two radiation detection instruments and the Van de Graaff Laboratory key. In the event of a real i emergency, these items may not only be too numerous to remember, but could  !

also be too much to carry. The staff should consider establishing an emergency ,

locker in the Van de Graaff Laboratory containing copics of procedures and other j documents as well as instruments and emergency supplies. j The implementing procedures for the emergency plan do not provide guidance for  ;

determining the dose to members of the general public. Despite the fact that the design base accident does not show significant radiation exposure to the public, it will be the first question asked by any agency contacted for assistance. A procedure should be developed which provides the methodology for calculating a i dose to emergency personnel and the public from the information provided by air j samples and the data recorded by the gaseous effluent monitor.

D. Administrative Controls The review of Administration, Audit and Review specifically looked at Section 6.0, Administrative Controls of the OSU Technical Specifications. Special emphasis was given to the Reactor Operating Committee's (ROC) review and audit function.

1. The ROC Charter, committee meeting minutes, and actions taken were reviewed.

a. The administrative organization chart (Fig 6.1), generally follows the i

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ANS 15.1, " Technical Specifications for Research Reactors." The reactor comes l

under the College of Engineering, and the Radiation Safety Office comes under the Vice President for Health Services. This division of responsiFlity is typical of university organizations and works in the majority of cases. The division should

( be monitored closely to assure both organizations are responsive to each others needs.

b. The charter for the Reactor Operations Committee (ROC) is outlined in i

the Technical Specifications (6.2). The conditions constituting a quorum are l confusing, but seem to be understood by committee members.

c. The requirement for the ROC to raeet quarterly (6.2.2) is putting a great strain on the reactor staff to armnge the meeting and also on the committee members to assemble that often. The reactor management needs to reevaluate the need to meet quarterly. There are other reactor facilities that meet semi-annually. )

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d. A large portion of the ROC's time is spent approving operating i procedures. It may be helpful to have this approval function at the reactor )

director's position and reviewed by the ROC. This would also eliminate some of 1 the confusion found in the reactor operations area of this report.

e. The ROC is required (6.2.5) to perform an annual audit of NRL operations. The ROC is not performing this function (see audit report, Feb 94).

The ROC is not closing out audit reports in a timely manner (i.e., ROC still discussing in August 1993 the disposition of the 1991 audit). This situation must be addressed immediately. Consider having individuals from outside the university perform the audits and report results to the ROC. The ROC must then address these audits in a timely manner.

f. The facility staffing is adequate to safely run the reactor. The staff is well trained, highly motivated, and dedicated. With the increased power level and its associated concerns, the instrumentation upgrades to reactor systems, the staff needs additional assistance. This assistance does not need to be full time, but need to be available when needed for specific tasks (i.e., health physics and electrical engineering assistance).

g. The reactor training and requalification program should follow the guidance provided in ANS 15.4, " Selection and Training of Personnel for Research Reactors." The requalification program must be completed every two years (i.e.,24 months + 0).

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l III. OBSERVATIONS AND RECOMMENDATIONS This peer review was done in very limited areas and in a very short time period.

The observations and recommendations should be evaluated by the OSU l management and staff with these constraints in mind. Nevertheless, the TRTR peer review goals are to help improve the operational and administrative programs at research reactors and to that end the following observations and recommendations are made.

l 1. Reactor Onerations Observations ~

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a. The procedures were well written and seemed complete. The only problem that was noted was that IM-02 (Adjusting Reactor Control Instrumentation Meter Zeros) was required to be done prior to performing IM-01 (Scram Checks), but the latter did not list the former as a prerequisite. Periodic reviews will eventually catch those types of omissions, especially if occasionally {

the review.;is not the person that normally performs the procedure. {

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b. The NRL facilities were very clean and organized considering the j confining space relative to the amount of equipment and activity. The i commitment to and the accomplishment of the equipment upgrades by the limited staff is very commendable. The recent rewriting of the SAR and Technical Specifications (TS) for the power upgrade to 500 kW is indicative of a staff dedicated to excellence and progress. Such a vibrant program of upgrade is necessary at a small aging research reactor for continued survival. The staff at NRL are doing a great job with limited resources. With both the increased work i necessitated by the power upgrade and added work from increased utilization, the  !

demand on the staff and limited resources must be carefully monitored to ensure safety is not compromised.

c. The staff at the NRL are very well qualified and seem to be doing an i excellent job of operations. With well trained, well qualified people, the need for l detailed approved written procedures, outside the minimum required by the TS is less urgent. Unfortunately, with a small staff and specialized duties the reality of staff turnover necessitates more than the minimum approved written procedures.

The NRL had recently sustained such a changeover in staff and approved written procedures helped with the transition. It is suggested below in f.

d. There seems to be contradictory requirements in the TS concerning the 14

approval process for written procedures. Compliance withTS Section 6.3.1 requires that written procedures be (1) documented by the NRL staff, (2) reviewed and approved by the Director of NRL, (3) reviewed and approved by the ROC, and then (4) shall be put into effect and followed. On the other hand, TS Section 6.2.4 and the note relative to 6.2.4(2) states that the "...NRL Director or his designee shall be responsible for approval of procedures or changes to procedures on a day-to-day basis. He shall provide a summary of all procedure changes to the ROC for there review and approval." It is clear that Section 6.3.1 is not being complied with, but injome cases (i.e., OM-15, RS-06, RS-11, RS-17, IM-01, IM-08, IM-12) there has not been timely approval by the ROC to comply with TS Section 6.2.4(2).

e. The completion of some of the routing slips for procedural changes (from AP-07) are incomplete or some of the routing sign off blanks are marked NA (i.e., OM-01, IM-02, IM-07).

f. Compliance to TS Section 6.3 is questioned. Some areas of operations do not have approved written procedures in effect as required. For example, TS sections:

6.3.l(2) (Installation, removal, or movement of fuel elements, control rods, experiments, and experimental facilities.) There are no fuel handling procedures or experiment handling approved written procedures.

6.3.l(3) (Actions to be taken to correct specific and foreseen potential malfunctions of systems or components; including responses to alarms, suspected cooling system leaks, and abnormal reactivity changes.) There are no malfunction or abnormal event handling and recovery approved written procedures.

6.3.l(4) (Emergency conditions involving potential or actual release of radioactivity including provisions for evacuation, re-entry, recovery, and medical support.) There are no re-entry, recovery, or medical support approved written procedures.

6.3.l(6) (Periodic surveillance of reactor instrumentation and safety systems, area monitors, and radiation safety equipment) and TS 2.2.(1). (Steady state power level shall not exceed 500 kW thermal.) There is no thermal power  ;

calibration, rod worth calibration, or shutdown margin and excess reactivity measurement approved written procedures.

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s 6.3.l(7) (Implementation of Security, Emergency and Operator training and requalification plans) and Emergency Plan 2.15 (... documented instmetion that detail the implementation of specific actions and methods required to achieve the objectives of the emergency plan.) Approved written procedures implementing the Emergency Plan are not complete.

g. AP-15, the procedure for logging emergency scrams, states that the log be "... updated as often as convenient but at least semiannually." The TS 6.6.l(4) requires that an annual report be made to the NRC which re-quires that "a table of unscheduled shutdowns and inadvertent scrams, including their reasons and the corrective action taken" be submitted. The sample Emergency Scram Log included with AP-15 has no corrective actions or place for corrective action to be listed. The infrequent updating of the Emergency Scram Log from the incomplete information in the reactor log and the lack of approved written procedures for malfunction or abnormal event handling and recovery reduces the likelihood that it will be complete.

Recommendations The following recommendations refer to the similarly numbereo paragraphs of the Observation section above.

a. Recommend that the review of individual procedures be rotated among the NRL staff so that the different view points of those staff members can be used to advantage. Review from different view points will increase the likelihood of catching procedural errors not noticed because of familiarity.

b. Recommend that a periodic review be made to ensure that the resources at NRL are adequate to accomplish the tasks required to maintain safe operation and compliance with the regulations.

c. and f. Recommend that TS Section 6.3 be reviewed and procedures be written, approved, and placed in effect in the categories of operations required. Some '

areas of deficiency are noted in the observation paragraph 6 above. Having a complete set of written approved procedures in critical areas of operation facilitate requalification of staff and initial training of new or replacement staff members.

d, Recommend that the approval process for new or updated written l procedures be resolved and appropriate changes to TS Section 6.3.1 and/or the 16

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I note relative to 6.2.4(2) be made. In addition, the staff must ensure that the l

approval process is followed strictly and completed in a timely manner. {

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1 e. Recommend that all routing slips be completed in a consistent manner.

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g. Recommend that a procedure to handle and recover from malfunctions or I

abnormal events be written and approved to facilitate completion of AP-15, l review by the ROC as per TS Sections 6.2.4(6), (7), and (S), and compliance with l TS 6.6.1(4).

2. Health Physics Program Observations and Recommendations 1

i Management Policy

a. Documentation of the radiation safety program can be improved by the addition of a written management policy statement that includes a clear defm' ition l of the areas of responsibility assigned to the NRL staff and those assigned to the l OSU Office of Radiation Safety.

b. The ANS 15.11, " Radiation Protection at Research Reactor Facilities" standard provides guidance on implementing a program and conducting audits.

This standard should be use.d to establish the program at OSU.

c. A restatement of the ALARA policy specifically designed for the NRL should be included as a part of the radiation protection program.

l d. There have been a number of changes to radiation safety procedures to ensure compliance with the new 10 CFR Part 20. It would appear that these changes have been implemented before being approved by the ROC. This same question appears in a number of operating procedures as well.

e. The increased power level will result in samples being removed from the pool having higher dose rates and contamination levels than those experienced in the past. The NRL staff should evaluate the need for procedures covering these operations.  ;

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f. The NRL staff should consider providing Draft Regulatory Guide DG-8012, " Instructions Concerning Risks From Occupational Radiation Exposure"  ;

and Draft Regulatory Guide DG-8014, " Instructions Concerning Prenatal Radiation Exposure" to new trainees or individuals with access to the NLR 17

s facility.

g. A HOT SPOT identified over the top of the reactor pool appears to indicate that a higher radiation area exists when the reactor is operating at 500 kW.

The NRL staff should document an evaluation of this area with regard to the definition of high radiation area and the associated posting requirements contained in 10 CFR 20.

h. Prior to effluent releases to the sewer, operating procedure RS-02 should l be revised to address new regulations regarding the solubility of radioactive  !

materials in the liquid waste system.

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i. Operating Procedure EP-01, "Emergeng Procedures," requires the reactor operator to evacuate the building carrying five notebooks in addition to two radiation detection instruments and the Van de Graaff laboratory key. In the event of a real emergency these items may not only be too numerous to remember, but could also be too much to carry. The staff should consider establishing an emergency locker in the Van de Graaff laboratory containing copies of procedures and other documents as well as instruments and emergency supplies.

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j. A procedure should be developed which provides the methodology for calculating a dose to emergency personnel and the public from the information  ;

provided by air samples and the data recorded by the gaseous effluent monitor. )

3. Administrative Controls Observations and Recommendations

a. This review identified a number of areas where the Technical Specifications requirements and their implementation are confusing. The NLR staff should consider revising these areas using the ANS 15.1, " Technical Specifications Format and Content for Research Reactors" as guidance.

b. The Technical Specifications regarding the Reactor Operating Committee structure and functions should be reevaluated. Especially in the areas of meeting frequency and procedural reviews.

c. The Technical Specification require that the ROC performs an annual audit. This requirement must be met. The reactor management should reevaluate the annual audit requirement and consider having individuals from outside the i

university do the audit and report results to the ROC.

18

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d. The ROC needs to establish a system of dealing with procedural reviews  !

and audit results in a timely manner.

e. In accordance with 10 CFR 55, the reactor training and requalification program must be completed in 24 months + 0. The NRL staff is highly trained and qualified. A system should be in-place to assure all requalification training is completed within the 24 month time interval. Guidance for training programs can be found in ANS 15.4, " Selection and Training of Personnel for Research  ;

Reactors."

IV. EXIT MEETING On 15 February 1995, the TRTR peer review group met with the Reactor Administrator and the Reactor Operations Committee (Appendix C). The TRTR ,

peer reviewers presented their observations and recommendations to the group.

V. APPENDICES (see attachments)

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APPENDIX A I

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THE Nuclear Reactor Laboratory 1298 Kinnear Road W Columbus, OH 43212-1154 Phone 614-2924755 UNIVERSTIY September 7,1994 Wade J. Richards Chief, Nuclear Licensing and Operations SM-ALC/TI-1 5335 Price Ave McClellan AFB, CA 95652-2504

Dear Wade,

f

} As we recently discussed, I am requesting that TRTR select a group to audit the i operations of The Ohio State University Research Reactor. This request is as a result of the routine NRC inspection of our reactor May 23-26,1994 that resulted in four violations as stated in the Notice dated July 21,1994. Ibelieve we should schedule this before the end of 1994. Due to a rather full schedule which includes the TRTR Meeting, commitments made in the response to the violations, and an operator licensing exam scheduled for October 18,1994 I would prefer this audit be conducted iu late October or early November.

} There are various areas that I think the audit should encompass. These include:

l l 1. Procedures- do we have too many? are they the right ones?

2. Technical Specifications- are changes needed (i.e. Reactor Operations Comm)?

3. Notice of Violation- are we meeting our response obligations?

There may be other arras the TRTR group sees the need to audit. I will work with you in establishing the audit agend ! and schedule.

Please call me with any comments or questions on this matter.

Sincerely, bN Richard Myser, Associate Director c Don W. Miller, Director n

Couege of Engineering

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i APPENDIX B f'

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i AGENDA  :

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14 February 1995 0800 - Arrive at Facility ,

r, 0830 Tour Facility.  ;

1030 - Begin Review ,

t 1700 I

f 15 February 1995 l

0800 Meet with RSC Members 1000 Summarize Review Results f 1300 Outbrief with Reactor Administrator

- 1400 Depart Facility ,

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APPENDIX C f

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~ OSU NRL " ,' ~ 614 823 82$@ @.63

, MAR-24-5995.14244 ~

)

i Engineering Administration and Reactor Operations Conunittee Mr. Joseph P. Allgeier University Radiation Safety Officer Mr. Brian K. Hajek Research Scientist, Mechanical Engmeeting Mr. Richard D. Myser Amwie Director Nuclear ReactorLab Dr. Don W. Miller Duector, Nuclear Re ictor Lab Dr. William A. Baeslack, HI Associate Dean, Engiwring Admuustration Dr. Albert H. Soloway Professor, Pharmac Dr. Thomas E. Blue Associate Professor,yMechanicalEngineering OSU Nuclear Reactor Lab Staff Richard D. Myser Asweiste Duector Joseph W.Talnagi Sr.Research Assoc: ate Kevin R. Herminghuysen Research Assocsate MichaelJ. Davis Research Assistant I

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TOTAL P.02