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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of Shim Blade Drive Mechanism Occurred.Determined That Mechanism Experienced Intermittent Slippage When Blade Being Withdrawn.Blade Drive Mechanism Assembly Procedure PM 7.1.1.1 Will Be Reviewed ML20086T7571995-07-28028 July 1995 RO 50-20/1995-4:on 950720,operated W/One Shim Blade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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Text
N -o O
oS1!124 P 5 [
h NUCLEAR REACTOR LABORATORY.
AN INTERDEPARTMENTAL CENTER OF MASSACHUSETTS INSTITUTE OF TECHNOLOGY k
%g Eli O.K. HARLING 138 Albany Street, Cambridge, Mass. 02139 J.A. BERNARD, JR.
Director Telefax No. (617)253-7300 Director of Reactor Operations Telex No. 92-1473-MIT-CAM Tel. No. (617) 253-4202 March 17, 1989 U.S. Nuclear Regulatory Commission Washington, D.C. 20555 Attn Document Control Desk l
I Subj ect: Reportable Occurrence 50-20/1989-1, Operation with Fewer than ]
the Required Number of Nuclear Safety Channel Level Scrams '
Gentlemen:
Massachusetts Institute of Technology hereby submits this ten-day i report of an occurrence at the MIT Research Reactor in accordance with paragraph 7.13.2(d) of the Technical Specifications. An initial re-port was made by telephone to Region I (Mr. J. Lyash) ' on March 9, 1989.
The format and content of this report - are based. on Regulatory Guide 1.16, Revision 1.
- 1. Report No.: 50-20/1989-1 1
2a. Report Date 17 March 1989 2b. Date of Occurrence: 8 March 1989
- 3. Facility: MIT Nuclear Reactor Laboratory 138 Albany Street-Cambridge, MA 02139
- 4. Identification of Occurrence:
A startup of the MIT Research Reactor was conducted on 8 March 1989 with only one operable nuclear safety channel level scram. Technical Specification No. 3.7 requires that there be at least two such operable channels prior to the reactor's being brought critical. Although not satisfying the technical specifi-cation requirement, additional protection was available. In par-ticular, there was an alarmed level channel that was operable.
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,0 j Reportable Occurrence 50-20/1989-1 Page 2
- 5. Conditions Prior to Occurrence:
Full power instrumentation and mechanical checklists had been completed in preparation for a scheduled reactor startup.
Nuclear safety channel No. 4, which is one of three channels that provide an automatic shutdown signal on high reactor power, had been serviced during the maintenance period that preceeded the startup. Accordingly, this channel was considered out-of-com-mission pending observation of its performance .during both the reactor startup and subsequent full-power operation. The other safety level channels are designated as No. 5'and No. 6. (Notes Safety Channels No. 1 - No. 3 are the period safety channels.)
- 6. Description of Occurrence:
The reactor startup was commenced at 1138 on 8 March 1989 and the reactor attained criticality (50 kW on a 50 second period) at 1209. The reactor power was then raised to 250 kW and held at that power until 1315 when . the cooling towers were shifted to the spray mode of operation. A stepwise increase in power was then begun. As part of this process, operators are required to monitor the readings on the safety level channels.
While doing this, it was noted that channel No. 5 was not responding properly. Accordingly, the reactor was immediately shut down. The maximum power attained prior to the shut down was not more than 4.0 MW. The reactor was operating in the power range (>l MW) for 28 minutes. Level safety channel No. 6 was observed to have been operating properly during the entire time.
- 7. Description of Apparent Cause of Occurrence: !
Following the shut down, channel No. 5 was inspected and it I was found that its high voltage power supply was_ switched off.
The channel's voltage had been checked and recorded as part of the instrumentation checklist. Hence, it is known that the loss of voltage occurred after completion of the checklist. It is believed that this loss was inadvertent. The switch in question is unique in that it and an associated meter are located within a small recessed panel that is part of the reactor instrument cabinets. Hence, the switch might have been unknowingly tripped by personnel working exterior to those cabinets. The low voltage condition was corrected and the channel was then verified to be operable through performance of the standard checks for nuclear instrumentation. Thus, the immediate cause of this occurrence i was the lack of the high voltage power supply to channel No. 5.
j A root cause analysis was performed subsequent to the repair j of channel No. 5. The purpose in conducting this analysis was to assess the adequacy of the ' low voltage protection' circuit that causes an automatic shutdown in the event of a loss of chamber I
high voltage or lack of continuity on the chamber signal cables !
in any of the nuclear safety channels. This circuit was verified
Reportable Occurrence 50-20/1989-1 Page 3 P
to be operational . However, it was found that the power supply for channel No. 5 was not connected to this circuit. An examina-
! tion of quality assurance records was then undertaken and it was found that, as part of an approved maintenance action conducted on 24 June 1980, the signal cables for channel No. 5 and another level channel had been interchanged. At the time of the change, it was verified that the detector serving channel No. 5 was neutron sensitive and that cable paths for the various safety channels avoided the possibility of a single failure mode. How-ever, the high voltage power supplies for the two channals were not switched and, as a result, channel No. 5's power supply was not connected to the low voltage protection circuit. (Note: At the time that the original telephone report of this occurrence was made to Region I, it was thought that there was a design deficiency in the low voltage protection circuit. This was not the case.)
- 8. Analysis of Occurrence:
Level safety channel No. 4 had been declared out-of-commis-sion prior to the reactor startup. Channels No. 5 and No. 6 had been set to provide automatic scrams at the proper setpoint, 5.5 MW. As noted above, channel.No. 5 was not cap'able of performing its intended function. Safety channel No. 6 was observed to be operating properly and would have caused a scram if reactor power had exceeded the setpoint of 5.5 MW. .In addition to the safety level channels, there is an alarmed level channel (channel No. 8) that was observed to be operating properly and which would have caused an audible / visual alarm had the reactor power exceeded 5.1 MW. Also, there are tripply redundant scrams on tne core outlet temperature, all of which were operable.
It should be noted that it can be shown from the instrumen-tation checklists and the instrument readings that are taken hourly whenever the reactor is operating, that at no time while the reactor was operating did a low voltage condition exist on channel No. 5 between 1980 and the present occurrence.
- 9. Corrective Action:
The immediate corrective action consisted of shutting down the reactor and energizing the high voltage power supply to the chamber of safety channel No. 5. The long range corrective action consisted of:
(1) Calibrating level channel No. 4 and returning it to service.
(Action completed, 9 March 1989.)
(2) Reconfiguring channel No.5 so that it was properly inter-faced with the low voltage protection circuit. (Action com- L pleted 13 March 1989.)
!m : , )
- . . ,. j l
. i Reportable Occurrence 50-20/1989-1 J Page 4 "
(3) Examining the power supplies for both of the other level channels and the three period safety channels. Several were found to be improperly connected to the low voltage protec-tion circuit. These defiencies were corrected. .It should be noted that the ' low voltage protection' circuit is not a-technical - specification requirement and is not a primary means of providing reactor protection. (Action completed 15 March 1989.)
(4) Instituting a requirement to document the proper interfacing of safety channel power supplies to the low voltage protec-tion circuit whenever a detector or associated cabling is serviced. (Action to be completed 31 March 1989.)
This occurrence was reported to and discussed with a subcommittee of the MIT Reactor Safeguards Committee on March 15, 1989.
- 10. Failure Datas l A related occurrence occurred in October 1979. Refer to ROR 50-20/1979-5 dated-19 October 1979.
Sincerely, W
Kwan S. Kwok Superintendent Y [L John A. Bernard, Ph D I Director of Reactor Operations JAB /gw l
cc MITRSC USNRC - Region I - Chief, Reactor Projects Section IB USNRC - Region I - Project Inspector, Reactor Projects Section IB USNRC - Senior Resident Inspector, Pilgrim Nuclear Station 1
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