ML20216H745

Ro:On 980224,SRO Left CR Leaving Key Unattended in Console. Caused by Personnel Error.Rso Was Reprimanded for Failing to Follow Procedures & Operators Participated in Special Training Class

ML20216H745
Person / Time
Site:	Armed Forces Radiobiology Research Institute
Issue date:	03/12/1998
From:	Eng R, Miller S ARMED FORCES RADIOBIOLOGICAL RESEARCH INSTITUTE
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
5106.6, NUDOCS 9803230161
Download: ML20216H745 (4)

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• ARMED FORCES RADIO"lOLOGY RECEARCH INSTITUTE 8901 WISCONSIN AVENUE BETHESDA, MARYLAND 20889-6603 5106.6 9 March 1998 U.S. Nuclear Regulatory Commission Document Control Desk Washington,i)C 20555 Gentlemen:

Attached is the Licensee Event Report (LER) for the reportable event that occurred on 24 February 1998 at the AFRRI Reactor Facility, Docket Number 50-170, License Number R84. The event was telephonically reported on that day to appropriate NRC 00 ices. The event was investigated and corrective action was completed by 27 February 1998.

The point of contact for further information is Stephen Miller, Reactor Facility Director, at 301-295-9245.

Sincerely, f .

I R. E C LTC(P), MS, USA Director

Attachment:

As stated Copy to:

USNRC Region 1 Attn: Mr. Thomas Dragoun 475 Allendale Road King of Prussia, PA 19406-1415 [.,),

J I USNRC Attn: Mr. Marvin Mendonca Mail Stop 11B20 Washington, DC 20555 b!$fblllfllf$f5!lllll 9803230161 9003120i DR ADOCK 0500

Licensee Event Report for the l AFRRI TRIGA Reactor Facility Docket 50-170 Prepared by:

Robert George Stephen Miller Apprm'ed:

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ST 'N fMILLER Date i R or Fa:ility Director l i

Approved for Release:

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UT ROIfERT s

R. ENG ' ] Date An ,

LTC(P), MS, USA j l Director, AFRRI t

l Abstract A Senior Reactor Operator (SRO) unlocked the console and moved the reactor core assembly across the pool. The SRO then left the control room leaving the key unattended in the console. A few minutes later, the fire alarm sounded, the control room was locked, and the entire AFRR1 complex was evacuated. When the reactor staff returned at the conclusion of the fire alarm, the key was discovered in the console and removed. The SRO was reprimanded for failing to follow procedures, and the operators participated in a special training class on control of the reactor key and the importance of following procedures.

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Narrative Descrintion of the Event On 24 Feb 1998, an operator moved the reactor core across the pool and closed the lead shield doors to allow for an entry into exposure room 2 (ER2). The operator, then distracted while locating opening information and arranging the opening with the safety and health department, left the control room without removing the key from the console. The operator was then called down to the exposure room to deal with a lighting problem in ER2. Before the operator returned to the control room, the AFRRI fire alarm sounded and the building was evacuated. The control room was locked when the remaining staff left the reactor office area for the fire alarm. Upon completion of the fire alarm, approximately 50 minutes after the console was left unattended, the key was discovered and removed by a member of the reactor staff. The RFD was notified upon his return from the fire alarm. The event was considerri to be a reportable occurrence under the Reactor Technical Specification 6.1.3.2[a.3].

Assessment of Safetv Conscauences Non-licensed members of the staff are trained that they are not to manipulate the controls of the console without an SRO/RO's supervision. A review of the console's historical record (a computer recording of events occurring on the console) and chart recorders, which continuously record reactor power when the key is in the console, verified that the console had not changed power during the time the key was left unattended. Magnet power had not been activated for the core movement or during the time the console was unlocked and unattended. Magnet power is not required for movement of the reactor core and therefore had never bxn activated by the operator. Magnet power is required to bring the reactor to power.

Security of the console was not an issue during the time the key was Icft unattended. Access to AFRRI is controlled by security guards and an electronic card key system. Access to the reactor facility is controlled by an additional, independent card key system. Visitors allowed l

in to the reactor area are escorted by reactor staff. When the fire alarm sounded, the door to the control room was locked with a key and all personnel were evacuated from within AFRRI. All doors to the facility were kept locked to control access to the facility. ,

Description of Corrective Actions J

Facility management investigated the circumstances of the event, and concluded that an operator error occurred. The following actions were taken and completed by 27 February 1998,

1. The operator was reprimanded and cautioned that future failure to follow procedures would result in enhanced disciplinary action.

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2. All operators and trainees were required to attend a training class on the importance of maintaining control of the reactor key and following procedures.

Reference to Any Previous Similar Events A review of records found a similar incident in March 1993. A different operator in that incident was distracted by a phone call for information which was in his office next to the control room.

Point of Contact for Any Ouestions Points of contact for further information are Stephen Miller, Reactor Facility Director, 301-295-9245, or Robert George, Reactor Operations Supervisor, 301-295-1221.

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