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Category:REPORTABLE OCCURRENCE REPORT (SEE ALSO AO LER)
MONTHYEARML20205A6551999-03-19019 March 1999 Ro:On 990310,main Ventilation Damper Failed to Close on Receipt of High Radiation Test Signal.Cause Indeterminate. Relays Associated with Main Exhaust Damper/Fans & Main Intake Damper Were Replaced ML20206P5321999-01-0606 January 1999 Ro:On 981229,only One Nuclear Safety Period Scram Channel Was Operable,For Period of Five Minutes.Caused by Placement of Nuclear Safety Sys Channel 1 Input Signal Cable on Wrong Bnc Connector.Placed Channel on Correct Bns Connector ML20217E8071998-03-23023 March 1998 Ro:On 980127,containment Integrity No Longer Existed & Key Switch Was Still 'On' for One of Test & Calibr Procedures. Caused by Retrieving Tool Box from Truck Air Lock.Discussed Occurrence W/Personnel & Will Consider TS Rev Re Key Switch ML20092K8281995-09-22022 September 1995 Corrective Action for RO 50-20/1995-4,re Abnormal Situations Which Occurred on 950711 ML20091K3091995-08-18018 August 1995 Ro:On 950809,malfunction of Shim Blade Drive Mechanism Occurred.Determined That Mechanism Experienced Intermittent Slippage When Blade Being Withdrawn.Blade Drive Mechanism Assembly Procedure PM 7.1.1.1 Will Be Reviewed ML20086T7571995-07-28028 July 1995 RO 50-20/1995-4:on 950720,operated W/One Shim Blade Fully Inserted.Caused by Failure of Licensed Operators to Follow Written Procedure for Investigating Mismatch.Failed Proximity Switches Replaced ML20082B8551995-03-30030 March 1995 RO 50-20/1995-2:on 950320,operation of Reactor in natural- Circulation Mode W/O Required Two Operable Nuclear Safety Level Channels Set to Scram at or Less than 100 Kw,Mitr TS 3.7 ML20078S2241995-02-17017 February 1995 Reportable Occurrence 50-020/95-01:on 950206,voltage & Specific Gravity Measurements of Cell of Emergency Battery Bank Recorded at Less than Specified Weekly SR in TS 4.3.5. C/A Will Modify SR to Monthly ML20058Q2371993-12-17017 December 1993 RO 50-20/1993-1:on 931207,operation W/Fewer than Required Number of 100 Kw Nuclear Safety Sys Level Channels Identified.Caused by Faulty four-segment Relay in low-range Amplifier of Channel 5.Amplifier Replaced ML20094K0721992-03-12012 March 1992 RO 50-020/1992-2:on 911030,three Fission Chambers Missing During Annual Inventory of SNM Matl.Search for Missing Chambers Completed on 920311 W/O Locating Chambers.Snm Inventory for 1991 Has Been Amended ML20090D6661992-03-0202 March 1992 RO 50-20/92-1 on:920218,malfunction Occurred in Reactor Analog Controller Due to Improper Performance of Increase in Reactor Power.Caused by Operator Error.Analog Automatic Control Sys Investigated & Temporarily Repaired ML20082K5911991-08-22022 August 1991 RO 50-20/1991-1:on 910813,fission Product Gas Levels Rose from Normal Operating Levels to Max of 15% of Mpc.Caused by Small Blister on One of Element MIT-17 Fuel Plates. Corrective Action Consisted of Removing MIT-17 from Core ML20248C7111989-08-0404 August 1989 RO 50-20/1989-2:on 890726,console Operator Received Abnormal Bldg Alarm.Leak Test Revealed Crack on Sys Ref Line Which Senses Atmospheric Pressure Outside Containment.All Polyethylene Tubing in Sys Replaced ML20246P3071989-03-17017 March 1989 RO 50-20/1989-1:on 890308,operation W/Fewer than Required Number of Nuclear Safety Channel Level Scrams Due to Lack of High Voltage Power Supply (Hvps) to Channel 5.Reactor Shut Down & Hvps Energized to Supply Channel 5 ML20154M6501988-05-26026 May 1988 RO 50-20/1988-1:on 880511,incipient Fuel Clad Defect Detected.Caused by Small Blister on One Element MIT-12 Fuel Plate.Element MIT-12 Removed from Core ML20236S4931987-11-19019 November 1987 RO 50-20/1987-2:on 871110,improper Performance of Reactor Reshim Resulted in Excessive Power Rise.Caused by Operator Error.Operator Suspended from All Licensed Duties Pending Further Review of Circumstances & Disciplinary Measures ML20213G0601986-11-0606 November 1986 RO 50-20/1986-3:on 861027,shim Blade 6 Could Not Operate at full-out Position Due to Mechanical Interference.Caused by Misalignment of Blade Proximity Switch Tube.Switch Tube Reinstalled Properly ML20214V9001986-10-17017 October 1986 Revised RO 50-20/1986-2:on 861008,elevated Levels of Fission Gases Discovered in Primary Containment.Cause Undetermined. Refueling Initiated & Element MIT-19 Removed.All in-core Elements Sipped.No Abnormalities Found ML20214H9541986-10-17017 October 1986 RO 50-020/86-02:on 861008,elevated Levels of Fission Gases in Primary Containment Observed.Cause Unknown.Element MIT-19 Removed from Core & All in-core Elements Sipped ML20154S4591986-02-28028 February 1986 RO 50-20/1986-1:on 860219,fission Product Gas Levels Rose from Normal Operating Levels.Caused by Blister on Surface of Outer Fuel Plate of Element MIT-11.Element MIT-11 Removed from Core ML20137G3661985-07-23023 July 1985 RO 50-20/1985-2:on 850715,defect in Fuel Element Cladding Observed.Caused by High Rate of Outgassing from Fuel Element MIT-32.Defective Element Removed ML20137G3531985-04-18018 April 1985 RO 50-20/1985-1:on 850408,main Intake Valve Failed Light Test Maint Procedure.Caused by Excessive Wear of Valve Gasket.Gasket Replaced ML20081H8191983-09-15015 September 1983 RO 50-20/1983-2:on 830906,fission Product Gas Levels Rise from 2.8% Max Permissible Concentration in Jul 1983 to 4.57% in Aug Noted.Caused by Excessive Outgassing of Fuel Element MIT-08.Element Removed from Core ML20074A7521983-04-29029 April 1983 RO 50-20/1983-1:on 830419,main Intake Valve Closed & Could Not Be Reopened.Caused by Piston Rod Rupture Near Rod Eye, Leaving Valve in Closed Position.Defective Hydraulic Cylinder Shaft Replaced ML20063B9221982-08-17017 August 1982 Ro:On 820809,slight Increase Found in Levels of Fission Products in Reactor Primary Sys.Cause Under Investigation. Criterion for Operation W/Possible Faulty Core Element Per RO 50-20/79-4 Will Be Observed 1999-03-19
[Table view] Category:TEXT-SAFETY REPORT
MONTHYEARML20209C9331999-07-0808 July 1999 Vols 1 & 2 to SAR for Ma Institute of Technology Nuclear Reactor Lab ML20196K0331999-06-30030 June 1999 Quality Mgt Program for Generation of MITR-II Medical Therapy Facility Beams for Human Therapy, Reflecting Change to Provision 14 ML20205A6551999-03-19019 March 1999 Ro:On 990310,main Ventilation Damper Failed to Close on Receipt of High Radiation Test Signal.Cause Indeterminate. Relays Associated with Main Exhaust Damper/Fans & Main Intake Damper Were Replaced ML20206P5321999-01-0606 January 1999 Ro:On 981229,only One Nuclear Safety Period Scram Channel Was Operable,For Period of Five Minutes.Caused by Placement of Nuclear Safety Sys Channel 1 Input Signal Cable on Wrong Bnc Connector.Placed Channel on Correct Bns Connector ML20199H2371998-12-31031 December 1998 Revised SER for Fission Converter Facility ML20196B7541998-06-30030 June 1998 Mit Research Reactor Nuclear Reactor Lab Ma Inst of Technology,Annual Rept to Us NRC for Period 970701-980630. with ML20217E8071998-03-23023 March 1998 Ro:On 980127,containment Integrity No Longer Existed & Key Switch Was Still 'On' for One of Test & Calibr Procedures. Caused by Retrieving Tool Box from Truck Air Lock.Discussed Occurrence W/Personnel & Will Consider TS Rev Re Key Switch ML20217G2181997-10-0303 October 1997 SER for Fission Converter Facility ML20198P8071997-06-30030 June 1997 Annual Operating Rept for Jul 1996 - June 1997 ML20137L5901997-04-0303 April 1997 Safety Evaluation Supporting Amend 30 to License R-37 ML20129B3201996-06-30030 June 1996 Annual Rept to Us NRC for Period 950701-960630 ML20092K8281995-09-22022 September 1995 Corrective Action for RO 50-20/1995-4,re Abnormal Situations Which Occurred on 950711 ML20091K3091995-08-18018 August 1995 Ro:On 950809,malfunction of Shim Blade Drive Mechanism Occurred.Determined That Mechanism Experienced Intermittent Slippage When Blade Being Withdrawn.Blade Drive Mechanism Assembly Procedure PM 7.1.1.1 Will Be Reviewed ML20086T7571995-07-28028 July 1995 RO 50-20/1995-4:on 950720,operated W/One Shim Blade Fully Inserted.Caused by Failure of Licensed Operators to Follow Written Procedure for Investigating Mismatch.Failed Proximity Switches Replaced ML20092K2301995-06-30030 June 1995 Mit Research Reactor Annual Rept to NRC for Period Jul 1994 - June 1995 ML20082B8551995-03-30030 March 1995 RO 50-20/1995-2:on 950320,operation of Reactor in natural- Circulation Mode W/O Required Two Operable Nuclear Safety Level Channels Set to Scram at or Less than 100 Kw,Mitr TS 3.7 ML20078S2241995-02-17017 February 1995 Reportable Occurrence 50-020/95-01:on 950206,voltage & Specific Gravity Measurements of Cell of Emergency Battery Bank Recorded at Less than Specified Weekly SR in TS 4.3.5. C/A Will Modify SR to Monthly ML20072T3041994-06-30030 June 1994 Annual Rept for Mit Research Reactor for 930701-940630 ML20058Q2371993-12-17017 December 1993 RO 50-20/1993-1:on 931207,operation W/Fewer than Required Number of 100 Kw Nuclear Safety Sys Level Channels Identified.Caused by Faulty four-segment Relay in low-range Amplifier of Channel 5.Amplifier Replaced ML20056G8011993-06-30030 June 1993 Mit Research Reactor Nuclear Reactor Lab Mit,Annual Rept to NRC for Period 920701-930630 ML20128P4371993-02-16016 February 1993 Safety Evaluation Supporting Amend 27 to License R-37 ML20073H1451992-12-0909 December 1992 Study of MITR-II Core Tank Aging for Relicensing Consideration ML20114D9261992-06-30030 June 1992 Mit Research Reactor Nuclear Reactor Lab Mit,Annual Rept to NRC for 910701-920630 ML20094K0721992-03-12012 March 1992 RO 50-020/1992-2:on 911030,three Fission Chambers Missing During Annual Inventory of SNM Matl.Search for Missing Chambers Completed on 920311 W/O Locating Chambers.Snm Inventory for 1991 Has Been Amended ML20090D6661992-03-0202 March 1992 RO 50-20/92-1 on:920218,malfunction Occurred in Reactor Analog Controller Due to Improper Performance of Increase in Reactor Power.Caused by Operator Error.Analog Automatic Control Sys Investigated & Temporarily Repaired ML20082K5911991-08-22022 August 1991 RO 50-20/1991-1:on 910813,fission Product Gas Levels Rose from Normal Operating Levels to Max of 15% of Mpc.Caused by Small Blister on One of Element MIT-17 Fuel Plates. Corrective Action Consisted of Removing MIT-17 from Core ML20082L8451991-06-30030 June 1991 Mit Research Reactor Annual Rept to NRC for Jul 1990 to June 1991 ML20058N5741990-08-10010 August 1990 QA Program for MITR-II Spent Fuel Shipment ML20059G4331990-06-30030 June 1990 Mit Research Reactor Annual Rept to NRC for Jul 1989 - June 1990 ML20012D9651990-03-22022 March 1990 RO 50-20/1990-1:on 900312,incorrect Calculation of Estimated Critical Position (ECP) Attained During Reactor Startup. Caused by Failure to Check Second Portion of ECP Calculation Performed by Individual in Training ML20012C2771990-03-0909 March 1990 SER for BWR Coolant Chemistry Loop to Be Installed & Operated in Mitr ML20248C7111989-08-0404 August 1989 RO 50-20/1989-2:on 890726,console Operator Received Abnormal Bldg Alarm.Leak Test Revealed Crack on Sys Ref Line Which Senses Atmospheric Pressure Outside Containment.All Polyethylene Tubing in Sys Replaced ML20247H7041989-06-30030 June 1989 Mit Research Reactor Annual Rept for Jul 1988 - June 1989 ML20246P3071989-03-17017 March 1989 RO 50-20/1989-1:on 890308,operation W/Fewer than Required Number of Nuclear Safety Channel Level Scrams Due to Lack of High Voltage Power Supply (Hvps) to Channel 5.Reactor Shut Down & Hvps Energized to Supply Channel 5 ML20195K1161988-10-24024 October 1988 Suppl to PWR Loop Ser:Use of Large Circulating Pump ML20154J6221988-08-29029 August 1988 Revised Mit Research Reactor Annual Rept to NRC for Jul 1987 - June 1988 ML20153F5591988-06-30030 June 1988 Mit Research Reactor Annual Rept to NRC for Jul 1987 - June 1988 ML20154M6501988-05-26026 May 1988 RO 50-20/1988-1:on 880511,incipient Fuel Clad Defect Detected.Caused by Small Blister on One Element MIT-12 Fuel Plate.Element MIT-12 Removed from Core ML20151R7341988-04-19019 April 1988 Sser for PWR Coolant Chemistry Loop (Pccl) MITNRL-020 ML20236S4931987-11-19019 November 1987 RO 50-20/1987-2:on 871110,improper Performance of Reactor Reshim Resulted in Excessive Power Rise.Caused by Operator Error.Operator Suspended from All Licensed Duties Pending Further Review of Circumstances & Disciplinary Measures ML20237K6121987-06-30030 June 1987 Mit Research Reactor Annual Rept to NRC for Jul 1986 - June 1987 ML20151R7271987-02-13013 February 1987 SER for PWR Coolant Chemistry Loop (Pccl) MITNRL-020 ML20213G0601986-11-0606 November 1986 RO 50-20/1986-3:on 861027,shim Blade 6 Could Not Operate at full-out Position Due to Mechanical Interference.Caused by Misalignment of Blade Proximity Switch Tube.Switch Tube Reinstalled Properly ML20214V9001986-10-17017 October 1986 Revised RO 50-20/1986-2:on 861008,elevated Levels of Fission Gases Discovered in Primary Containment.Cause Undetermined. Refueling Initiated & Element MIT-19 Removed.All in-core Elements Sipped.No Abnormalities Found ML20214H9541986-10-17017 October 1986 RO 50-020/86-02:on 861008,elevated Levels of Fission Gases in Primary Containment Observed.Cause Unknown.Element MIT-19 Removed from Core & All in-core Elements Sipped ML20148B3011986-06-30030 June 1986 Mit Research Reactor Annual Rept to NRC for Period Jul 1985 - June 1986 ML20154S4591986-02-28028 February 1986 RO 50-20/1986-1:on 860219,fission Product Gas Levels Rose from Normal Operating Levels.Caused by Blister on Surface of Outer Fuel Plate of Element MIT-11.Element MIT-11 Removed from Core ML20214R3811986-01-31031 January 1986 Rept of Educational & Research Activities for Academic/ FY84-85 W/Selected Data from Previous Yrs ML20137G3661985-07-23023 July 1985 RO 50-20/1985-2:on 850715,defect in Fuel Element Cladding Observed.Caused by High Rate of Outgassing from Fuel Element MIT-32.Defective Element Removed ML20133H4081985-06-30030 June 1985 Mit Research Reactor Annual Rept to Us NRC for Jul 1984 - June 1985 1999-07-08
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NUCLEAR REACTOR LABORATORY -
AN INTERDEPARTMENTAL CENTER OF _ ;
MASSACHUSETTS INSTITUTE OF TECHNOLOGY --
l l
JOHN A. BERNARD 138 Albany Street, Cambridge, MA 02139-4296 Activation Analysis Director 9erectorof Reactoroperahons Telefaz No. (617g7g, Coolant Chenpstry Tel. No. (617) Nuclear Medicine Pnncipal Research Engineer Reactor Engineenng 1
January 6,1999 U.S. Nuclear Regulatory Commission Washington, D.C. 20555 l i
Attn.: Document Control Desk
Subject:
Reportable Occurrence 50-20/1998-2, Operation With Fewer than the Required Number of Nuclear Safety Channel Period Scrams Gentlemen:
The Massachusetts Institute of Technology hereby submits a report of an ;
occurrence at the MIT Research Reactor (MITR) in accordance with paragraph 7.13.2(d) !
of the Technical Specifications. An initial report was made by telephone to NRC Region I on December 30,1998.
The format and content of this report are based on Regulatory Guide 1.16, Revision 1.
- 1. Report No.: 50-20/1998-2 2a. Report Date: 6 January 1999-2b. Date of Occurrence: 29 December 1998 \7 .:
- 3. Facility: MfT Nuclear Reactor Laboratory 138 Albany Street Cambridge,MA 02139
- 4. Identification of Occurrence: '
For a period of five minutes, during a startup to low power of the MIT Research Reactor, only one nuclear safety period scram channel was operable.
Technical Specification No. 3.7 requires that there be at least two such operable channels while the reactor is operating.
- 5. Conditions Prior to Occurrence:
. Full power instrumentation and mechanical checklists had been completed prior to the startup. Safety Channels #1-3 provide an automatic shutdown on short reactor period. Channels #1 and #2 consist of both a fission and ion chamber.
Channel #3 is comprised only of an ion chamber. For a reactor startup, the fission chambers of channels #1 and #2 are initially operable. As the startup proceeds, the neutron level in the reactor increases because of subcritical multiplication. As a 9901120137 990106 PDR ADOCK 05000020 S . P OR _
. ' Reportable Occurrence 50-20/1998-2 Page 2 of 3 i
f<
l result, the ion chambers become operable and the instrumentation is shifted by
- adjusting gains / discrimination settings to the ion chambers. The sequence is:
- 1. Channei #1 and #2 fission chambers operable.
- 2. Channel #3 ion chamber on scale. . :
- 3. Shift Channel #1 to ion chamber. (Ch. #2 and #3 operable)
- 4. Channel #1 ion chamber operable.
l
~5. Shift Channel #2 to ion chamber. (Ch. #1 and #3 operable) j 6.- Channel #2 ion chamber operable.
The act of shifting from fission to ion chamber causes the affected channel to be inoperable for a short interval, five minutes or less.
- 6. Descrintion of Occurrence:
At 2233 on December 29,1998, a reactor startup was commenced on d.e MIT Research Reactor. At 2255, channel #3 was declared in service, and channel
- 1 fission chamber was shifted to ion chamber. At that time channels #2 and #3 were operable. At 2256 channel #1 was declared in service and channel #2 fission chamber was shifted to ion chamber. However, channel #1:was'not fully operable in that while it was indicating properly, its scrain function was not functional.
Hence, the reactor was operating with only the channel #3 nuclear safety. system j l period scram. Channel #2 was declared operable at 2301, resulting in two nuclear
- . safety system period channel scrams being operable in accordance with Technical l Specification 3.7. The reactor was operated for a total of 5 minutes (2256 to 2301) l
- with~only one operable period automatic scram. The reactor power was at about 20 1
- kW at the time. l l 1
~7. Descriotion of Apparent Cam of Occurrence: ,
i l
The procedure listed above in section 5 of this report ensures that two
- m. clear safety system period scrams are operable at all times. The switching of input from a fission chamber to an ion chamber may induce a period transient that can be positive and of a high enough magnitude to induce electronic indication of a protective action Accordingly, at 2255, the input to the channel #1 nuclear safety system was temporarily removed by disconnecting the input signal cable from its BNC connector on the back of the chassis. When the induced period transient had decreased to a level below the scram setpoint, the operator reconnected the input signal to an incorrect BNC connector on the same chassis, disabling nuclear safety system channel #1. Thus, the immediate cause of this occurrence was the r placement of the nuclear safety system channel #1 input signal cable on the wrong L BNC connector. This incorrect placement of the mput cable was noticed and I corrected by an operator at 0930 on December 30,1998.
[ The incorrect BNC connector is unused by the chassis. All personnel were j aware that it was unused and the operating crew ho conducted the startup on 4
12/29/98 had in fact discussed the importance of reconnecting the signal to the
[ correct cc,anector and rehearsed the procedure. The root cause of the occurrence
- was therefore a design error in that en unused connector was left installed on the chassis.
(
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.- Reportable Occurrence 50-20/1998-2 Page 3 of 3.
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- 8. Annivsis of Occurrence:
On December 29,1998, the MIT Research Reactor was operated for a total !
of five minutes with only one of two required number of period scram channels l Indication of reactor period was available on two channels at all times. Also, three i other safety channels provided automatic protection against a high power level at all '
times (only two are required).
- 9. Corrective Action: ,
- The immediate corrective action consisted of placing the nuclear safety l system period channel #1 input signal cable on its correct BNC connector and placing a cap on'the incorrect connector. The permanent corrective action will consist of physically removing the unused BNC connection from the nuclear safety system chassiss' o that only the correct connector will be present. This action will be completed during our next maintenance outage, now scheduled for March or April IV)9. In addition, all other safety system channels'have been checked for unused connectors. None were found.
- 10. Failure Data-None.
Since ..
YY Q Lc l
omas H. Newton, Jr., PE Edward S. Lau, NE -
i sst. Superintendent for Engineering Asst. Superinter. int for Operations
- MIT Resean:h Reactor MIT Research Reactor
,(c6/ '
chn A. Bernard, Ph .
Director i MIT Nuclear Reactor Laboratory '
l
- ' JAB /gw . t cc: MITRSC
(
I USNRC - Senior Project Manager,
- NRR/ONDD '
- USNRC - Region I- Project Scientist, I i Effluents Radiation Protection Section (ERPS)
!- FRSSB/DRSS i
I
- -_ . . - . .- , --