Information Notice 1986-42, Improper Maintenance of Radiation Monitoring Systems

Improper Maintenance of Radiation Monitoring Systems

ML031250045
Person / Time
Site:	Beaver Valley, Millstone, Hatch, Monticello, Calvert Cliffs, Dresden, Davis Besse, Peach Bottom, Browns Ferry, Salem, Oconee, Nine Mile Point, Palisades, Palo Verde, Perry, Indian Point, Fermi, Kewaunee, Catawba, Harris, Wolf Creek, Saint Lucie, Point Beach, Oyster Creek, Watts Bar, Hope Creek, Grand Gulf, Cooper, Sequoyah, Byron, Pilgrim, Arkansas Nuclear, Three Mile Island, Braidwood, Susquehanna, Summer, Prairie Island, Columbia, Seabrook, Brunswick, Surry, Limerick, North Anna, Turkey Point, River Bend, Vermont Yankee, Crystal River, Haddam Neck, Ginna, Diablo Canyon, Callaway, Vogtle, Waterford, Duane Arnold, Farley, Robinson, Clinton, South Texas, San Onofre, Cook, Comanche Peak, Yankee Rowe, Maine Yankee, Quad Cities, Humboldt Bay, La Crosse, Big Rock Point, Rancho Seco, Zion, Midland, Bellefonte, Fort Calhoun, FitzPatrick, McGuire, LaSalle, University of Lowell, 05000000, Zimmer, Fort Saint Vrain, Shoreham, Satsop, Trojan, Atlantic Nuclear Power Plant, Skagit, Marble Hill
Issue date:	06/09/1986
From:	Jordan E L NRC/IE
To:
References
IN-86-042, NUDOCS 8606040007
Download: ML031250045 (6)

SSINS No.: 6835IN 86-42UNITED STATESNUCLEAR REGULATORY COMMISSIONOFFICE OF INSPECTION AND ENFORCEMENTWASHINGTON, D.C. 20555June 9, 1986IE INFORMATION NOTICE NO. 86-42: IMPROPER MAINTENANCE OF RADIATIONMONITORING SYSTEMS

Addressees

All nuclear power reactor facilities holding an operating license (OL) or aconstruction permit (CP).

Purpose

and Summary:This notice is issued to alert licensees to the potential for defeating thesafety function associated with radiation monitoring systems by not properlyadhering to established surveillance and maintenance procedures. A recentevent at a BWR, when an electrical jumper was inadvertently left in place aftera planned surveillance, led to failure to maintain secondary containmentintegrity during irradiated fuel movement.It is expected that recipients will review the information for applicability totheir maintenance and surveillance program and consider actions, if appropriate,to preclude similar problems at their facility. However, suggestions containedin this notice do not constitute NRC requirements; therefore, no specific actionor written response is required.Previous Related CorrespondenceIE Information Notice No. 83-23, "Inoperable Containment AtmosphereSensing Systems," April 25, 1983.INPO Significant Event Report, 35-83, "Compromise of Secondary ContainmentIntegrity," June 9, 1983.IE Information Notice No. 83-52, "Radioactive Waste Gas System Events,"August 9, 1983.IE Information Notice No. 84-37, "Use of Lifted Leads and Jumpers DuringMaintenance or Surveillance Testing," May 10, 1984.

Description of Circumstances

On November 18, 1985 the Cooper Nuclear Station was in a shutdown condition(reactor coolant temperature less than 2120F and vented) with acceptancetesting for a plant design change in progress. When this testing failed toprovide for the required Group VI isolation (various containment isolation andCopies to: Withers, Yundt, Lentsch, Orser, Steele, E. Burton, E. Jordan, A. Holm,iLIS;.j. A. Olmstead, S. Hoag, S. Sautter, TNP:GOV REL F:NRC CHRONO,TNiPGOV REL F:NRC IE Information Notice 86-42PGE OAR Action -M. H. Halmros (Due 8/12/86)NSRD Action -M. H. Malmros

IN 86-42June 9, 1986 engineered safety feature (ESF) initiations), the licensee investigated anddiscovered that electrical jumpers were installed in the reactor building (RB)ventilation radiation monitors (VRM) auxiliary trip units. These jumpersprohibited a Group VI isolation by a high radiation signal from the RB VRM.The jumpers were immediately removed and the NRC was promptly notified asrequired by 10 CFR 50.72.The licensee's subsequent investigation revealed that the electrical jumpershad been installed on November 13, 1985 by an instrument and control technicianduring a routine surveillance procedure to functionally test the VRM. Thesejumpers are used to prevent trip and equipment operations during the requiredfunctional/calibration testing. The technician had signed off the proceduralstep requiring jumper removal (before actually removing the electrical jumper)and then started checking control room annunciator and trip signal status. Thetechnician then became involved in other unrelated craft work and forgot to goback and remove the jumpers.On November 18, 1986, before discovery of the jumpers, 18 irradiated fuelbundles were loaded into a spent fuel shipping cask. Failure to properlyimplement the surveillance procedure for operability checks of radiationmonitors rendered inoperable the automatic initiation of the standby gastreatment system (SBGTS) and automatic isolation of the reactor building uponreceipt of a high radiation signal. This degraded condition lasted approxi-mately 5 days. However, control room annunciators and instrumentation thatwould provide warning to operators of any high radiation problems remainedoperational during the 5 days. Manual-start of the SBGTS and reactor buildingisolation capabilities from the control room remained available during theevent.Discussion:This event clearly demonstrates that the level of attention given to theprocedural controls for the maintenance of radioactive monitoring systemsproviding ESF actuation can be significantly improved. While there were noactual radiological consequences of this event, the NRC took escalated enforce-ment actions (issued civil penalty) to emphasize the importance of correctlyperforming surveillance procedures on systems designed to mitigate or preventaccidents. Attachment No. 1 contains 6 summaries of related events taken fromthe Licensee Event Report files. Further examples of how improper maintenancepractices have degraded radiation monitoring systems are provided in the listedPrevious Related Correspondence section.The Cooper Station initiated the following corrective actions to preventrecurrence:1. All temporary modifications (e.g., electrical jumpering, fuse removal)performed by the involved technician since October 5, 1985 were indepen-dently verified.2. Site management stressed the importance of procedural adherence--sign offthe procedural step after completing the required action.

IN 86-42June 9, 1986 . All surveillance procedures requiring temporary modifications to system orplant components were reviewed for deficiencies, and these procedures willbe modified to provide for independent verification to ensure that tempo-rary modifications are removed and the system/component is fully restoredto operational status.No specific action or written response is required by this information notice.If you have any questions about this matter, please contact the RegionalAdministrator of the appropriate regional office or this office.4'-CJ1ward L. Jord, DirectorDivision of Edergency Preparednessand Engineering ResponseOffice of Inspection and EnforcementTechnical Contacts: James E. Wigginton, IE(301) 492-4967Roger L. Pedersen, IE(301) 492-9425Attachments:1. Event Summaries2. List of Recently Issued IE Information Notices

Attachment 1IN 86-42June 9, 1986 EVENT SUMMARIESUnplanned Gaseous Release (Connecticut Yankee, PWR)LER 85-025Event Date: 9/19/85Cause: Personnel Maintenance ErrorAbstract: With the plant operating at 100 percent power, a main stack highradiation alarm was received during routine scheduled maintenanceon a pressure actuated valve in the gaseous waste stream. Theunplanned release occurred through an isolation valve inadvertentlyleft open, allowing the on-line waste gas decay tank a release path.The maintenance tag-out procedure correctly required the isolationvalve to be isolated, but the operator shut the wrong valve. Thetotal noble gas release was approximately 20 curies (about 14 percentof technical specification limit). Licensee corrective actionincluded clearly relabeling associated valves and discussion of theevent with operation staff.Containment Radiation Monitor Isolated (Byron 1, PWR)LER 85-026Event Date: 2/28/85Cause: Improper Valve PositionAbstract: With the reactor at zero percent power, a containment radiationmonitor used for required reactor coolant leakage detection wasinadvertently left isolated for 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> from containment aftermaintenance on an associated valve. Abnormal in-leakage at themonitor caused normal-range readings on RM-li console in the maincontrol room (leakage was later repaired). Licensee correctiveaction included implementing administrative controls to ensuresystem integrity/proper restoration after completion of maintenanceactivities.Liquid Radwaste Effluent Monitor Isolated (Cooper, BWR)LER 84-008Event Date: 6/09/84Cause: Monitor Discharge Valve ShutAbstract: A liquid discharge occurred without required continuousradiation monitoring because the liquid effluent radiation monitorwas isolated. No discharge limits were exceeded. Two days beforethe event, a technician apparently shut the radiation monitor outletvalve during maintenance without permission or knowledge ofoperations personnel. As corrective actions, the licensee revisedcontrolling procedures and informed all plant operators of theevent.

Attachment 1IN 86-42June 9, 1986 Off-Gas Stack Monitor Inoperable (Cooper, BWR)LER 84-006Event Date: 4/18/84Cause: Personnel ErrorAbstract: With the reactor at 70 percent power, the off-gas stack effluentsampler was found inoperable. The sampler was drawing air fromthe surrounding off-gas filter building ambient atmosphere insteadof sampling the plant stack effluent. The event resulted from achemistry technician failing to follow the approved procedure forchanging the inline particulate filter/iodine cartridge (routineoperation). In addition to making appropriate supervisors and allchemistry technicians aware of the event, the licensee revised andclarified the governing procedure to prevent recurrence.Liquid Radwaste Auto-Isolation Valve Inoperative (Hatch 1, BWR)LER 82-093Event Date: 11/07/82Cause: Jumper InstalledAbstract: During a liquid radwaste discharge, the licensee discovered thatthe radiation monitor auto control (provides isolation signal uponhigh radiation) to the discharge isolation valve was inoperable.However, the monitor's alarm function remained operable. Anelectrical jumper used during corrective maintenance had not beenremoved after the work was completed.Containment Atmosphere Radiation Monitors Isolated (FitzPatrick 1, BWR)LER 81-061 (Rev 1Event Date: 8/21/81Cause: Containment Isolation Valve IsolatedAbstract: The NRC resident inspector discovered that during normal 85 percentpower operations the containment isolation valves for the containmentatmosphere gaseous and particulate monitoring system had been shutfor approximately 22 hours2.546296e-4 days <br />0.00611 hours <br />3.637566e-5 weeks <br />8.371e-6 months <br />. With this loss of monitoring capability,the technical specifications require a reactor hot shutdown within12 hours. The event occurred because a surveillance procedure didnot direct the operator to re-open the isolation valves following'the surveillance activities. As a corrective action, the licenseecorrected the subject procedure and reviewed all other surveillanceprocedures for similar deficiencies.

4'Attachment 2IN 86-42June 9, 1986LIST OF RECENTLY ISSUEDIE INFORMATION NOTICESInformation Date ofNotice No. Subject Issue Issued to86-4186-32Sup. 186-4086-3986-3886-3786-3686-3586-34Evaluation Of QuestionableExposure Readings Of LicenseePersonnel DosimetersRequest For Collection OfLicensee RadioactivityMeasurements Attributed ToThe Chernobyl Nuclear PlantAccidentDegraded Ability To IsolateThe Reactor Coolant SystemFrom Low-Pressure CoolantSystems in BWRSFailures Of RHR Pump MotorsAnd Pump InternalsDeficient Operator ActionsFollowing Dual Function ValveFailuresDegradation Of StationBatteriesChange In NRC PracticeRegarding Issuance OfConfirming Letters ToPrincipal Contractors6/9/866/6/866/5/865/20/865/20/865/16/865/16/86All byproductmaterial licenseesAll power reactorfacilities holdingan OL or CPAll power reactorfacilities holdingan OL or CPAll power reactorfacilities holdingan OL or CPAll power reactorfacilities holdingan OL or CPAll power reactorfacilities holdingan OL or CPAll power reactorfacilities holdingan OL or CPAll power reactorfacilities holdingan OL or CPAll power reactorfacilities holdingan OL or CP -Fire In Compressible Material 5/15/86At Dresden Unit 3Improper Assembly, Material 5/13/86Selection, And Test Of ValvesAnd Their ActuatorsOL = Operating LicenseCP = Construction Permit