Переводы документов. Translations in English

NP-027-10. Regulation on the procedure for investigation and recording of malfunctioning of nuclear research installations

NP-027-10

Approved by

Order of the Ministry

of Natural Resources and Environment

of the Russian Federation

dated May, 31, 2010 No. 185

 

FEDERAL RULES AND REGULATIONS

IN THE AREA OF ATOMIC ENERGY USE "REGULATIONS

ON THE PROCEDURE FOR INVESTIGATION AND RECORDING OF MALFUNCTIONING OF

NUCLEAR RESEARCH INSTALLATIONS"

NP-027-10

 

1. GENERAL PROVISIONS

 

1.1. The Regulation on the procedure for investigation and recording of malfunctioning of nuclear research facilities (hereinafter - the Regulations) establishes the following:

categories of malfunctioning of NRFs;

the procedure for investigation and recording of malfunctioning of NRFs;

the procedure for establishment of commissions for investigation of malfunctioning of NRFs;

the contents and the procedure for submittal of information on any malfunctioning of NRFs;

requirements for the reports on investigation of any malfunctioning of NRFs.

1.2. The purposes of investigation and recording of malfunctioning of NRFs are the following:

to define the causes of malfunctioning;

to determine the categories of malfunctioning in accordance with their characteristics and consequences;

to develop corrective measures in order to prevent recurrence of these malfunctioning in the future.

1.3. The operating organization shall arrange collection, processing, analysis, systematization and storage of information on any NRF malfunctioning within the entire NRF life cycle as well as submittal of this information to any other organizations in accordance with the procedure established in these Regulations and other regulatory documents.

1.4. These Regulations shall be applicable to commissioned, operated and decommissioned nuclear research facilities regardless of their type and departmental subordination.

 

2. CATEGORIES OF NRF MALFUNCTIONING AND THEIR RECORDING

 

2.1. Malfunctioning of NRFs are classified into categories given in Table 1 depending on their characteristics and consequences.

 

Table 1

 

Categories of malfunctioning of NRFs subject to

investigation and recording

 

    Reference   

  designation  

   of category   

            Characteristics and consequences of malfunctioning           

                                 Accident                                 

      А01      

Discharge (release) of radioactive substances into the environment

which has caused radiation exposure for persons from among       

the public in excess of the basic dose limits for      

the public established in the standards of radiation          

safety                                            

      А02      

Exceedance of the basic dose limits for the personnel        

established in the radiation safety standards (in absence of any   

consequences of malfunctioning A01)                  

                              Incident                               

  Incident 

 (radiation)

      P01      

Radiation exposure for the personnel and (or) radioactive contamination   

of the building (NRF room) in excess of the reference levels

but not exceeding the basic dose limits established in the  

radiation safety standards                      

      P02      

Deviation from limits and (or) conditions of safe          

operation                                           

      P03      

Damage of fuel assemblies, fuel elements and            

radiation sources caused by failure of systems and    

equipment (including hoisting one) or         

erroneous actions of the personnel (except for     

any events accompanied with characteristics and consequences  

typical for malfunctioning referred to categories   

А01, А02, P01, P02)                                    

      P04      

Failure in the course of radiation-hazardous works for decommissioning

of safety-related NRF equipment or 

systems                                           

      P05      

NRF shutdown caused by any malfunctioning of             

safety-related process and (or) electrical           

equipment                 

      P06      

NRF power reduction or shutdown caused by errors of

the personnel                                               

      P07      

NRF shutdown caused by any malfunctioning of             

NRF experimental devices without any exceedance of 

safe operation limits                                

      P08      

NRF shutdown caused by any malfunctioning of   

the control and protection system, process protections and interlocks

with the NRF controlled parameter values         

not exceeding the established limits                     

    P09 <*>

NRF shutdown caused by any power supply interruption   

within the operational responsibility <**>

of the operating organization without any deviations from              

operation limits and conditions of safe         

operation                                           

Note. P02 - P09 - non-radiation incidents                     

 

--------------------------------

<*> In case of any event outside the operational responsibility the malfunctioning shall be investigated in accordance with the procedure established by the operating organization with subsequent submittal of the investigation materials to the Federal Environmental, Industrial and Nuclear Supervision Service.

<**> The operational responsibility area shall be defined by the certificate on delineation of balance sheet distribution and the operational responsibility certificate issued within the framework of the agreement with the energy supplier. In the absence of any operational responsibility certificate the boundary of the operational responsibility area shall coincide with the balance sheet attribution boundary.

 

2.2. The following events shall not be classified as NRF malfunctioning:

power reduction or the NRF shutdown in order to perform any maintenance works prescribed in the NRF process regulations, the operation guidelines and operation manuals for the NRF systems (components) and equipment as well as power reduction or the NRF shutdown in the course of experiments in accordance with guidelines, methodological programs and process regulations;

power reduction or the NRF shutdown due to withdrawal of any systems (components) and equipment from service in order to eliminate any malfunctions and defects in accordance with the procedure established in the operation documentation;

withdrawal of individual safety system channels from the state of availability without any deviations from the NRF safe operation conditions not related to restoration of the channel component operability for the period of time permitted in accordance with the operation documentation.

2.3. Recording of the NRF malfunctioning

2.3.1. Recording and investigation of the NRF malfunctioning of all categories specified in Table 1 of these Regulations shall be performed from the day of delivery of nuclear materials, radiation sources and radioactive substances to the NRF.

2.3.2. The operating organization shall arrange registration of all NRF malfunctioning including the malfunction specified in par. 4.9 of the Regulations and events listed in par. 2.2 of the Regulations. The recording form shall be defined by the operating organization.

Information on the NRF malfunctioning and events listed in par. 4.9 and 2.2 of the Regulations shall be submitted to the Federal Environmental, Industrial and Nuclear Supervision Service (hereinafter - Rostechnadzor) upon request and specified in the annual reports of the operating organization on the NRF nuclear and radiation safety.

 

3. CONTENTS AND THE PROCEDURE FOR SUBMITTAL OF INFORMATION ON MALFUNCTIONING

OF NRF

 

3.1. The operating organization administration shall ensure preparation and timely submittal of the following information on malfunctioning of the NRF:

the immediate (primary) notification (for NRF malfunctioning with the characteristics and consequences of malfunctioning referred to any category specified in Table 1 of these Regulations);

the preliminary (updated) notification (only for NRF malfunctioning with the characteristics and consequences of malfunctioning referred to categories A01, A02, P01).

3.2. The immediate and preliminary notifications on the NRF malfunctioning shall be submitted by the officers appointed via the order of the chief executive officer of the operating organization.

3.3. The NRF officers authorized to submit notifications shall have the list of organizations where immediate and preliminary notifications on the NRF malfunctioning are to be submitted at their workplaces; the list shall be approved by the chief executive officer of the operating organization.

This list shall include the details of the organizations particularly telephone numbers or codes of any other communication means ensuring timely submittal of immediate and preliminary notifications. The list shall be reviewed at least once per five years in accordance with the procedure established by the operating organization.

3.4. Immediate notification on the NRF malfunctioning

3.4.1. An immediate notification on the NRF malfunctioning shall contain the following information:

name of the atomic energy use controlling authority;

name of the operating organization;

name of the nuclear research facility;

date and time of the malfunctioning (local/ Moscow);

state of the NRF before malfunctioning;

data on any expected radiation impact on the personnel, the public and the environment;

implemented immediate radiation protection measures for the personnel, the public and the environment;

brief characteristics of the malfunctioning, suspected causes of the malfunctioning;

state of the NRF as of the notification submittal moment;

approximate assessment of the malfunctioning category in accordance with Table 1;

position and full name of the person who has submitted the notification.

3.4.2. The immediate notification on any NRF malfunctioning shall be submitted by the authorized officer of the operating organization via telephone and (or) fax communications or through the use of any other communication means ensuring prompt transmission within the following time limits:

for events with the characteristics and consequences of malfunctioning referred to categories A01, A02, P01 - not later than within 1 hour after registration of any deviation from the established operation limits and conditions by instruments and (or) its detection by the personnel;

for events with the characteristics and consequences of malfunctioning referred to categories P02, P03, P04, P05, P06, P07, P08, P09 - not later than within 24 hours after registration of any deviation from the established operation limits and conditions by instruments and (or) its detection by the personnel.

3.4.3. The immediate notification on any NRF malfunctioning with the characteristics and consequences of malfunctioning referred to categories A01, A02, P01 shall be submitted to:

the duty officer of Rostechnadzor Operating Dispatch Service;

the department of Rostechnadzor Interregional Territorial Administration carrying out direct supervision over nuclear and radiation safety at this NRF;

the duty officer of FSUE "Rosatom CMC";

the duty officer of the SC of the Russian Ministry of Nature (for any malfunctioning of category A01);

the duty officer of the federal executive authority performing the functions for control and supervision in the area of sanitary and epidemiological safety for workers of certain industries with extremely dangerous labor conditions.

3.4.4. The immediate notification on any NRF malfunctioning with the characteristics and consequences of malfunctioning referred to categories P02-P09 shall be submitted to:

the duty officer of Rostechnadzor Operating Dispatch Service;

the department of Rostechnadzor Interregional Territorial Administration carrying out direct supervision over nuclear and radiation safety at this NRF;

the duty officer of FSUE "Rosatom Rescue Coordination Center".

3.5. Preliminary notification on the NRF malfunctioning with the characteristics and consequences of malfunctioning referred to categories А01, А02, P01.

3.5.1. A preliminary notification on the NRF malfunctioning shall contain the following information:

name of the atomic energy use controlling authority;

name of the operating organization;

name of the nuclear research facility;

date and time of the malfunctioning (local/ Moscow);

state of the NRF before malfunctioning;

brief description of the malfunctioning arising and development as well as the progress of its consequences mitigation, suspected causes of the malfunctioning, presence of any deviations from safe operation limits and conditions;

pre-established category of malfunctioning;

damages systems (components) and their basic data, location, nature and causes of damages;

the list of implemented measures for the malfunctioning localization;

state of the NRF as of the preliminary notification submittal moment;

data on any expected radiation impact on the personnel, the public and the environment;

information on the radiation situation in the NRF rooms, at the NRF site and outside it (according to the data of stationary or portable means of the radiological control system or the laboratory control data) with indication of the time of measurement;

sufficiency (insufficiency) of own resources for mitigation of the malfunctioning consequences and implementation of protective measures;

preliminary assessment of the malfunctioning in accordance with INES;

position, full name, signature (for a notification sent by fax) of the person who has submitted the notification.

3.5.2. The preliminary notification on the NRF malfunctioning signed by the authorized officer of the operating organization shall be submitted within 24 h after registration of the malfunctioning by instruments and (or) its detection by the personnel.

3.5.3. The preliminary notification on the NRF malfunctioning shall be submitted to:

the duty officer of Rostechnadzor Operating Dispatch Service;

the department of Rostechnadzor Interregional Territorial Administration carrying out direct supervision over nuclear and radiation safety at this NRF;

the duty officer of FSUE "Rosatom CMC";

the duty officer of the federal executive authority performing the functions for control and supervision in the area of sanitary and epidemiological safety for workers of certain industries with extremely dangerous labor conditions.

3.5.4. The operating organization shall arrange daily submittal of the updated preliminary notification on any NRF malfunctioning with the characteristics and consequences of malfunctioning referred to categories A01, A02 and P01 until complete elimination of any consequences caused by the malfunctioning to the following persons:

the duty officer of Rostechnadzor Operating Dispatch Service;

the department of Rostechnadzor Interregional Territorial Administration supervising over nuclear and radiation safety at this NRF;

the duty officer of FSUE "Rosatom CMC";

the duty officer of the SC of the Russian Ministry of Nature (for any malfunctioning of category A01).

 

4. PROCEDURE FOR INVESTIGATION OF THE NRF MALFUNCTIONING

 

4.1. The NRF malfunctioning investigation commission shall be established within the period of not more than two days after the malfunctioning detection in order to investigate the NRF malfunctioning.

4.2. The investigation commission for NRF malfunctioning with the characteristics and consequences of malfunctioning referred to categories A01, A02 shall be established in accordance with the order of the atomic energy use controlling authority or under the instructions from the head of the atomic energy use controlling authority in accordance with the order of the operating organization

4.3. The investigation commission for NRF malfunctioning with the characteristics and consequences of malfunctioning referred to categories A01, A02 shall include representatives of the atomic energy use controlling authority, Rostechnadzor, the federal executive authority performing the functions for control and supervision in the area of sanitary and epidemiological safety for workers of certain industries with extremely dangerous labor conditions; any other federal executive authorities, the operating organization and (in case of necessity) any organizations performing works and rendering services to the operating organization in relation to the NRF nuclear and radiation safety assurance; the representatives of the constituent entity of the Russian Federation and (or) the local governmental authority of the territory where the NRF is located.

4.4. The investigation commission for NRF malfunctioning with the characteristics and consequences of malfunctioning referred to categories P01-P09 shall be established by the operating organization.

4.5. The investigation commission for NRF malfunctioning with the characteristics and consequences of malfunctioning referred to categories P01-P09 shall include the operating organization representatives, the representatives of the NRF administration, shift supervisors and heads of the NRF services and also (in case of necessity) representative of any organizations performing works and rendering services to the operating organization in relation to the NRF nuclear and radiation safety assurance.

The officer of the operating organization responsible for the NRF nuclear and radiation safety assurance may not be appointed as the chairman of the above-mentioned commission.

4.6. The NRF malfunctioning investigation commission shall be guided by the effective regulations, federal regulations and rules in the area of atomic energy use and the operation documents related to the NRF safety assurance.

The following procedure shall be adhered to in the course of malfunctioning investigation:

1) To familiarize with the documentation necessary for the investigation. To perform visual inspection of the place of malfunctioning, the NRF equipment and rooms.

2) To detect sequences of system (component) failures and human errors in the course of the malfunctioning.

3) To define any actions performed in order to detect the causes of the system (component) failures and human errors.

4) To detect any previous similar malfunctioning.

5) To detect consequences of the malfunctioning:

deviation from safe operation limits and (or) conditions;

release of radioactive substances beyond the established boundaries;

radiation exposure for the persons from among the personnel and the public; any killed and (or) injured persons;

radioactive contamination of the systems (components), rooms, the NRF site, the territory outside the NRF site;

damage of systems (components);

the NRF downtime.

6) To reveal the causes of the malfunctioning:

failures of systems (components), human errors in the course of the malfunctioning;

direct causes of system (component) failures and human errors;

root causes of system (component) failures and human errors.

7) To assess sufficiency of the implemented measures for localization and mitigation of the malfunctioning consequences.

8) To assess malfunctioning from the viewpoint of safety.

9) To reveal any non-conformities:

in the personnel's actions;

in functioning of normal operation systems (components);

in functioning of safety-related systems (components);

in maintenance and repair;

in the documentation;

in the arrangement of works at the NRF;

in operation of experimental devices and radiation sources.

10) To present the proposals for corrective measures in relation to:

repair of systems (components);

replacement of systems (components);

operation of systems (components);

development of systems (components);

design of systems (components);

manufacturing of systems (components);

construction of systems (components);

installation of systems (components);

adjustment of systems (components);

modifications in the regulatory and operation documentation;

the personnel's actions.

4.7. Investigation on any NRF malfunctioning accompanied with or caused by a fire and (or) collapse of the NRF buildings and structures shall be performed with due regard for the effective regulations on investigation of cases with fires and (or) the regulatory documents on investigation of building and structure collapses.

4.8. Investigation of any accidents with the NRF personnel shall be performed in accordance with the requirements of the regulations establishing the procedure for investigation and recording of occupational accidents.

4.9. Investigation of any NRF malfunctioning associated with failures and damages of safety-related systems (components) particularly with damages of the control and protection system actuators, equipment, human errors without any characteristics and consequences specified in Table 1 of these Regulations shall be performed in accordance with the procedure established by the operating organization.

4.10. Duration on any NRF malfunctioning investigation shall not exceed 15 days after its detection. The decision on extension of the NRF malfunctioning investigation period shall be made by the head of the organization which has issued the order on the NRF malfunctioning investigation commission establishment with notification to Rostechnadzor. The maximum extension period for the NRF malfunctioning investigation shall not exceed 15 days.

4.11. The operating organization shall inform Rostechnadzor Interregional Territorial Administration and the department of Rostechnadzor Interregional Territorial Administration supervising over nuclear and radiation safety at this NRF on establishment of the malfunctioning investigation commission and venue and time of its work commencement.

4.12. The operating organization and the NRF malfunctioning investigation commission shall submit to Rostechnadzor Interregional Territorial Administration and the department of Rostechnadzor Interregional Territorial Administration supervising over nuclear and radiation safety at this NRF the required information, documentation and investigation materials.

4.13. The NRF malfunctioning investigation commission shall be entitled to obtain any explanations from the NRF personnel, the representatives of any other organizations that have performed any works at the NRF as per the moment of the malfunctioning registration by instruments and (or) detection by the personnel or as per the moment of the potential malfunctioning cause appearance and to demand any required tests, inspections and expert reviews.

The working regime for the NRF malfunctioning investigation commission shall be defined by the chairman of the commission.

4.14. Prior to establishment of commissions for investigation of any NRF malfunctioning with the characteristics and consequences of malfunctioning referred to categories A01, A02, P01 the operating organization shall implement measures to preserve the scenery at the place of malfunctioning as it has been as per the moment of the malfunctioning detection; stop all works on the plants and equipment where the malfunctioning has taken place; prevent any access of the personnel to the place of malfunctioning provided that it does not pose any life hazards and does not cause further development of the malfunctioning. In case it is impossible to preserve the scenery the existing scenery shall be recorded (schemes, photographs, etc.).

The decision on the need to preserve the scenery till establishment of the investigation commissions for any NRF malfunctioning with the characteristics and consequences of malfunctioning referred to categories P02-P09 shall be made by the operating organization.

4.15. It is strictly prohibited to open any instrumentation, to change the warning and emergency alarm setpoints from detection of the NRF malfunctioning with the characteristics and consequences of malfunctioning referred to categories A01, A02, P01 and till commencement of the NRF malfunctioning investigation commission work.

Opening (disassembly) of any damaged equipment with registration of its state before opening (disassembly) in case of any malfunctioning with the characteristics and consequences of malfunctioning referred to categories A01, A02, P01 may be carried out prior to commencement of the commission work only subject to the written order of the chief executive officer of the operating organization subsequent to approval by the NRF malfunctioning investigation commission chairman.

In case of any NRF malfunctioning with the characteristics and consequences of malfunctioning referred to categories P02-P09 the decision on opening (disassembly) of damaged equipment with registration of its state before opening (disassembly) prior to commencement of the commission work shall be made by the operating organization.

4.16. The operating organization shall ensure the required conditions for the work of the NRF malfunctioning investigation commission particularly:

submit all required information to the commission and grant access to the equipment and documentation related to the malfunctioning investigation;

present any design, operation, factory, regulatory and other documents necessary for the commission work;

perform any necessary technical calculations, laboratory studies, tests and inspections, take photos of the objects, systems (components), equipment;

engage experts for the malfunctioning investigation in case of necessity;

provide rooms for work, communication means and transportation;

arrange duplication of the investigation materials;

ensure free access to the NRF territory, rooms and equipment.

4.17. Prior to commencement of the NRF malfunctioning investigation commission work the operating organization shall implement the following arrangements:

determine the malfunctioning nature and size in order to adjust the commission composition;

prepare the data on the radiation situation at the NRF, its location site, within the NRF sanitary-protective area and on any expected exposure doses for the personnel and the public during the NRF malfunctioning;

invite (in case of necessity) the representatives of the manufacturing plants, design, engineering, research, repair, adjustment and any other organizations;

take any measures in order to preserve diagrams of the recording devices, oscillograph charts, tape records of in-process conversations, in-process log sheets, computer prints;

register the values of neutron and physical characteristics of the NRF nuclear core as per the moment of the malfunctioning detection, the position of the safety-related switching devices, shutoff and control valves, relay drops and cover plates;

collect (in case of necessity) explanatory reports of the shift personnel, the personnel participating in the malfunctioning elimination, its witnesses and the NRF administration immediately after the shift handover;

develop the change curves (on the uniform time scale) for any operating parameters of systems and equipment necessary for the investigation on the basis of the available operational materials with indication of equipment switching and actuation of process protections and interlocks;

prepare and present to the commission design documentation, reports on testing, inspections, verifications, diagrams and operation guidelines, repair documentation and also any information on similar malfunctioning of this NRF;

prepare preliminary proposals for development of the corrective measures in order to prevent any similar malfunctioning in the future.

The operating organization shall present to the commission the proposals for elimination of any malfunctioning causes and development of the recommendations in order to prevent any similar NRF malfunctioning in the future.

4.18. At the first (kickoff) meeting of the NRF malfunctioning investigation commission the report of the operating organization representative on the malfunctioning, the NRF state, the radiation situation in the NRF rooms, at the NRF site and outside it, the implemented measures for mitigation of the malfunctioning consequences, the results of preliminary analysis of the malfunctioning causes shall be listened, and the decision on the commission preparedness for work shall be made with due regard for the obtained information.

4.19. In case more severe consequences of the NRF malfunctioning are detected in the course of investigation giving reasons to  refer it to any other category in accordance with Table 1 of these Regulations, and the commission status does not comply with the requirements of par. 4.3 of these Regulations the decision on continuation of the commission work or establishment of a new commission shall be made by the atomic energy use controlling authority which may establish the investigation commission for the NRF malfunctioning with more severe consequences.

The previously established commission shall continue its work till commencement of the newly established commission work, in this case it should hand over the obtained investigation results to the new commission.

4.20. The decision on resumption of works at the NRF shall be made by:

the atomic energy use controlling authority in cooperation with Rostechnadzor upon completion of investigation with regard to the causes of malfunctioning referred to categories A01, A02 and P01 and their elimination or implementation of any measures for their elimination;

the operating organization subsequent to approval by the department of Rostechnadzor Interregional Territorial Administration supervising over nuclear and radiation safety at this NRF after determination and elimination of any causes of malfunctioning referred to categories P02-P09.

 

5. REPORTING ON INVESTIGATION OF THE NRF MALFUNCTIONING

 

5.1. The NRF malfunctioning investigation commission shall issue the report on the NRF malfunctioning investigation.

The title page format and the structure of the NRF malfunctioning investigation report are given in Appendix 2 to these Regulations and the requirements for the contents of the NRF malfunctioning investigation report are given in Appendix 3.

In this case the NRF malfunctioning investigation commission shall be entitled to include any information not specified in the requirements of these Regulations but important (in the opinion of the commission) for the malfunctioning analysis into the above-mentioned report.

5.2. The final revision of the NRF malfunctioning investigation report shall be signed by all members of the NRF malfunctioning investigation commission.

In case of any disputes the final decision shall be made by the chairman of the commission.

The commission member who disagree with the adopted resolution shall state their specific opinions in written form and attach to the NRF malfunctioning investigation report.

The chief executive officer of the operating organization shall be familiarized with the report against written acknowledgment.

5.3. The original copy of the NRF malfunctioning investigation report signed by the commission members together with all necessary attachments shall be stored in the operating organization till the NRF decommissioning completion.

5.4. The operating organization shall submit copies of the NRF malfunctioning investigation report together with the necessary attachments to the following organizations within 5 days after completion of the NRF malfunctioning investigation commission work:

Rostechnadzor;

Rostechnadzor Interregional Territorial Administration;

the department of Rostechnadzor Interregional Territorial Administration supervising over nuclear and radiation safety at this NRF;

the federal executive authority performing the functions for control and supervision in the area of sanitary and epidemiological safety for workers of certain industries with extremely dangerous labor conditions (for malfunctioning of categories A01, A02, P01);

the territorial agency of the federal executive authority performing the functions for control and supervision in the area of sanitary and epidemiological safety for workers of certain industries with extremely dangerous labor conditions (for malfunctioning of categories A01, A02, P01);

Scientific and Engineering Centre for Nuclear and Radiation Safety;

Center for Collection and Analysis of Information on Safety of Nuclear Research Facilities of JSC SSC NIIAR. Based on the obtained reports the Center for Collection and Analysis of Information on Safety of Nuclear Research Facilities shall present annual consolidated reports on NRF malfunctioning to the federal executive authorities for atomic energy control and to Rostechnadzor;

Rosatom State Atomic Energy Corporation (for malfunctioning of categories A01, A02, P01);

other organizations according to the order established by an operating organization.

5.5. In case any additional information on any circumstances, causes and corrective measures becomes known after signing of the report by the NRF malfunctioning investigation commission the operating organization shall develop a supplementary report (a supplement to the report).

In case any additional investigation of the NRF malfunctioning is necessary the NRF malfunctioning investigation commission shall be established in accordance with the procedure specified in Section 4 of these Regulations.

The requirements for the supplementary report (supplement to the report) and its distribution are similar to the requirements for the NRF malfunctioning investigation report specified in par. 5.3 and 5.4 of these Regulations. The supplementary report shall contain reference to the initial report number.

 

6. CORRECTIVE MEASURES

 

6.1. The operating organization shall develop the action plan for elimination of the malfunctioning causes and prevention of its recurrence for each NRF malfunctioning with due regard for the recommendations of the NRF malfunctioning investigation commission. Particular persons in charge and the time limits for the planned arrangements shall be specified in the plan.

For NRF malfunctioning with the characteristics and consequences of categories A01, A02 and P01 the operating organization shall submit information on the above-mentioned action plan implementation progress to the atomic energy use controlling authority, Rostechnadzor and the department of Rostechnadzor Interregional Territorial Administration supervising over nuclear and radiation safety at this NRF.

For NRF malfunctioning with the characteristics and consequences of categories P02-P09 the operating organization shall submit information on the above-mentioned action plan implementation progress to the department of Rostechnadzor Interregional Territorial Administration supervising over nuclear and radiation safety at this NRF.

6.2. The operating organization shall provide the required arrangements in the quality assurance program for the works at the NRF in order to collect data on the NRF malfunctioning, systematize them and submit any information on the NRF malfunctioning important from the viewpoint of the NRF safety assurance to other operating organizations, any organizations performing works and rendering any services to the operating organization (within the relevant scope) and also to Rostechnadzor.

6.3. When obtaining any information specified in par. 6.2 of these Regulations from other operating organizations the operating organization shall analyze the probability of similar malfunctioning of its NRFs. In case of necessity measures shall be taken to prevent similar malfunctioning of its NRFs.

6.4. The operating organization shall include the materials with the analysis results for any NRF malfunctioning, particularly the malfunctioning specified in par. 4.9 of these Regulations; proposals and recommendations for safety enhancement in the course of works at the NRF and use of corrective measures implemented subsequent to investigation results at other NRFs; the list of implemented measures (administrative, technical, etc.) for elimination and prevention of similar malfunctioning in the course of further works at the NRF; data on implementation and time limits for implementation of the commission's recommendations specified in the NRF malfunctioning investigation reports into the annual report on current nuclear and radiation safety assessment for the NRF.

 

 

 

 

 

Appendix 1

 

ABBREVIATIONS

 

 NRF                    - Nuclear Research Facility

 Rostechnadzor ITA      - Interregional Territorial Administration for Nuclear and Radiation Safety Supervision of the Federal Environmental, Industrial and Nuclear Supervision Service

 ODS                    - Operating Dispatch Service

 JSC SSC NIIAR          - Open Joint Stock Company State Scientific Center Scientific and Research Institute for Nuclear Reactors

FSUE "Rosatom CMC"     - Federal State Unitary Enterprise "Crisis Management Center of the Federal Nuclear Energy Agency"

SC of the Russian Ministry of Nature    - Situation Center of the Ministry of Natural Resources and Environment of the Russian Federation

 FMBA                   - Federal Medical and Biological Agency

 CCAI NRF               - Center for collection and analysis of information on safety

 NRS                    - Nuclear and Radiation Safety

 INES                   - International Nuclear Event Scale

 

 

 

 

 

Appendix 2

 

STANDARD FORM

OF THE TITLE PAGE AND STRUCTURE OF THE NRF MALFUNCTIONING

INVESTIGATION REPORT

 

Title page of the report

 

┌─────────────────────────────────────────────────────────────────────────┐

│    NRF malfunctioning information system                                │

│                                                                         │

│NRF malfunctioning investigation report                                  │

├──────────────────────────────────────┬──────────────────────────────────┤

│    Report No.:                       │Date of issue:                    

│                                      │________________                  │

│                                      │date, month, year                 │

├──────────────────────────────────────┼──────────────────────────────────┤

│Date of malfunction:  _______________ │Time of malfunction: "___" "___"  │

│                    date, month, year │                    h    min.     │

├──────────────────────────────────────┴──────────────────────────────────┤

│Name of malfunctioning:                                                  │

├─────────────────────────────────────────────────────────────────────────┤

│Category of malfunctioning:                                              │

├─────────────────────────────────────────────────────────────────────────┤

│    Level as per INES scale:                                             │

├─────────────────────────────────────────────────────────────────────────┤

│    NRF name:                                                            │

├─────────────────────────────────────────────────────────────────────────┤

│    Operating organization:                                              │

├─────────────────────────────────────────────────────────────────────────┤

│    Atomic energy use controlling authority:                             │

├─────────────────────────────────────────────────────────────────────────┤

│  Distribution of the report:                                            │

├─────────────────────────────────────────────────────────────────────────┤

│    Organizations:                                                       │

├─────────────────────────────────────────────────────────────────────────┤

│    NRF departments (services):                                          │

├─────────────────────────┬───────────────────────────────────────────────┤

│NRF officer              │    Full name                                 

│for further contact:     │    Address:                                   │

│                         │    Telephone:                                 │

│                         │    Fax:                                       │

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└─────────────────────────┴───────────────────────────────────────────────┘

 

Structure of the report

 

1. COMPOSITION OF THE NRF MALFUNCTIONING INVESTIGATION COMMISSION

Organization establishing the commission.

Date and number of the order on the commission establishment.

Chairman of the commission:

full name, position, name of the organization.

Members of the commission:

full names, positions, names of organizations.

 

2. DESCRIPTION OF THE MALFUNCTIONING

2.1. The NRF state before malfunctioning.

2.2. Description of the sequence of events in the course of the malfunctioning development.

2.3. Actions performed in order to detect the malfunctioning causes.

2.4. Previous similar malfunctioning with indication of the malfunctioning date.

2.5. The NRF department (service) in charge of the equipment where failures have taken place or where any human errors have been detected.

2.6. Implemented measures for the malfunctioning localization.

 

3. CONSEQUENCES OF MALFUNCTIONING

3.1. Deviation from safe operation limits and (or) conditions.

3.2. Release of radioactive substances beyond the established NRF boundaries.

3.3. Radiation exposure for the persons from among the personnel and the public; any killed and injured persons.

3.4. Radioactive contamination of the NRF systems (components), equipment, rooms, the NRF site, the territory outside the NRF site.

3.5. Equipment damage.

3.6. The NRF downtime.

 

4. CAUSES OF MALFUNCTIONING

 

5. ASSESSMENT OF MALFUNCTIONING FROM THE VIEWPOINT OF SAFETY

 

6. NON-CONFORMITIES DETECTED IN THE COURSE OF THE MALFUNCTIONING INVESTIGATION

6.1. In the personnel's actions.

6.2. In functioning of normal operation systems (components).

6.3. In functioning of safety-related systems (components).

6.4. In maintenance and repair.

6.5. In the documentation.

6.6. In arrangement of the works at the NRF.

6.7. In operation of experimental devices and radiation sources.

 

7. CORRECTIVE MEASURES

7.1. To be implemented with regard to:

7.1.1. Repair of systems (components).

7.1.2. Replacement of systems (components).

7.1.3. Operation of systems (components).

7.1.4. Development of systems (components).

7.1.5. Design of systems (components).

7.1.6. Manufacturing of systems (components).

7.1.7. Construction of systems (components).

7.1.8. Installation of systems (components).

7.1.9. Adjustment of systems (components).

7.1.10. Documentation.

7.1.11. Personnel.

7.1.12. Procedures for detection and elimination of any defects and damages of systems (components).

7.1.13. Experimental devices and radiation sources.

7.1.14. Procedures for elimination of any revealed non-conformities in the personnel training.

7.2. Recommended for implementation with regard to:

7.2.1. Repair of systems (components).

7.2.2. Replacement of systems (components).

7.2.3. Operation of systems (components).

7.2.4. Development of systems (components).

7.2.5. Design of systems (components).

7.2.6. Manufacturing of systems (components).

7.2.7. Construction of systems (components).

7.2.8. Installation of systems (components).

7.2.9. Adjustment of systems (components).

7.2.10. Operation documentation.

7.2.11. Personnel.

7.2.12. Procedures for detection and elimination of any defects and damages of systems (components).

7.2.13. Experimental devices and radiation sources.

7.2.14. Procedures for elimination of any revealed non-conformities in the personnel training.

 

8. THE LIST OF DOCUMENTS USED BY THE COMMISSION IN THE COURSE OF THE NRF MALFUNCTIONING INVESTIGATION

 

9. APPENDICES TO THE NRF MALFUNCTIONING INVESTIGATION REPORT

 

10. SIGNATURES OF THE COMMISSION CHAIRMAN AND MEMBERS

 

     Chairman of the commission:             (Full name) (signature)

 

     Members of the commission:                     (Full name) (signature)

 

11. THE LIST OF PERSONS FAMILIARIZED WITH THE REPORT

 

 

 

 

 

Appendix 3

 

STANDARD REQUIREMENTS

FOR THE CONTENTS OF THE NRF MALFUNCTIONING INVESTIGATION REPORT

 

Information on all items of the report listed in Appendix 2 to these Regulations shall be provided in the report, or the reason for their absence shall be explained.

 

Title page of the report

 

The number of the NRF malfunctioning investigation report (Report No.).

The reference number of the report assigned in accordance with the procedure established in the operating organization for  the record-keeping purposes shall be indicated on the title page.

The report issuance date shall be specified as per the report signing date.

The malfunctioning date - the date of the malfunctioning detection shall be specified. It should be stated as follows: date, month, year (for example 26.01.2008).

The malfunctioning time - the time (Moscow) of the malfunctioning registration by instruments and (or) detection by the personnel shall be indicated (for example 07:43).

The name of the malfunctioning shall contain indication of the main consequence of the malfunctioning (in accordance with Column 2, Table 2.1 of these Regulations, for example: "Personnel exposure...", "Damage of fuel elements...", "Reactor plant shutdown...", "Power reduction...") used as the basis for its classification and the direct cause of the malfunctioning.

The category of malfunctioning shall be specified in accordance with Column 1, Table 2.1 of these Regulations.

Level as per INES scale - the level in accordance with INES scale shall be indicated.

Note. It is recommended to use the following document for assessment of the malfunctioning level: "INES. International Nuclear Event Scale. User Guide. Revised and expanded edition, IAEA, Vienna, 2001".

The NRF name - the NRF name shall be specified (for example MIR.M1).

The operating organization - the name of the operating organization shall be specified.

The atomic energy use controlling authority - the name of the relevant atomic energy use controlling authority which has recognized the organization (legal entity) as the NRF operating organization shall be specified.

Distribution of the report - abbreviated names of the organizations this report is submitted to (for example Rostechnadzor) including the NRF departments (services) shall be specified.

The NRF officer for further contact - the full name of the NRF officer appointed by the operating organization for the purposes of further contact, his/ her address, telephone number, fax, teletype, e-mail shall be specified for further contacts.

 

1. COMPOSITION OF THE NRF MALFUNCTIONING INVESTIGATION COMMISSION

 

The name of the organization establishing the commission, the date and number of the order on the commission establishment shall be specified.

Names of the organizations appointing the chairman and members of the commission, positions, surnames and initials of the chairman and members of the commissions shall be presented.

 

2. DESCRIPTION OF THE MALFUNCTIONING

 

2.1. The NRF state before malfunctioning

Information on the conditions of works at the NRF, the state of the main and auxiliary systems (components) and equipment (in operation, in stand-by mode, under repair; operating parameters), routine control, inspections and maintenance of the equipment, any performed tests and repairs, existing damages or defects of systems (components) and equipment, deviations from the requirements of the effective operation documentation and substantiation of these deviations shall be provided.

All abbreviated names of the systems (components) and equipment used in the description of the malfunctioning shall be expanded at first reference.

Designation of parameters and their measurement units shall comply with the state standards.

 

2.2. Description of the sequence of events in the course of the malfunctioning development.

The sequence of failures and human errors in the course of the malfunctioning development shall be described (in chronological order) including the following information:

- changes of parameters and modes;

- actuation of protections and interlocks;

- automatic or manual actuation of safety systems and operation of other systems (components) and safety-related equipment;

- failures of any systems (components) and consequences of these failures;

- actions of the personnel in the course of the malfunctioning (both correct and erroneous).

Graphs and diagrams illustrating the dynamic pattern for any parameters important for analysis of this malfunctioning shall be attached to the malfunctioning description. Starting points of the events (moments of failures, human errors, actuation (failure to actuate) of the protections and interlocks) shall be indicated on them.

 

2.3. Actions performed in order to detect the causes of failures and human errors.

Analysis results for operation of systems and equipment as well as the actions of the NRF personnel shall be specified in order to detect the causes of failures and human errors.

 

2.4. Previous similar malfunctioning

Information on any similar malfunctioning that have taken place at the NRF shall be presented with indication of the date of each malfunctioning. Information from the NRF malfunctioning investigation report shall be provided.

The list of implemented corrective measures and brief analysis of any potential causes of recurrent malfunctioning shall be presented.

Information on implementation of corrective measures for these malfunctioning shall be specified. The conclusion should be made on the reason for which the previously implemented measures failed to prevent recurrent malfunctioning.

 

2.5. The NRF department (service) in charge of the equipment where failures have taken place or where any human errors have been detected

The names of the NRF departments (services) in charge of the equipment where failures have taken place or where any human errors have been detected shall be specified.

 

2.6. Implemented measures for the malfunctioning localization

 

3. CONSEQUENCES OF MALFUNCTIONING

 

Information on the consequences of the malfunctioning for safety of works at the NRF including radiological consequences (if any), for the NRF personnel, the public and the environment shall be provided.

 

3.1. Deviation from safe operation limits and (or) conditions

Manifestations of the malfunctioning shall be specified, and reference shall be given to the relevant section of the regulatory document and (or) operation documentation of the NRF.

 

3.2. Release of radioactive substances beyond the established NRF boundaries

Information on the amount and radionuclide composition of the release (discharge) shall be provided.

 

3.3. Radiation exposure for the persons from among the personnel and the public; any killed and injured persons

Information in individual effective and equivalent dose values for the personnel and the public (in mSv) shall be presented. Information on any implemented arrangements for rendering of premedical first aid and medical treatment to the injured persons, planned preventive measures for improvement of health for the persons having suffered from radiation, chemical or any other hazardous effect shall be also specified for malfunctioning referred to categories A01, A02 and P01.  Implementation of the action plan for protection of the personnel and the public in case of any malfunctioning with radiological consequences shall be described.

 

3.4. Radioactive contamination of the NRF systems (components), equipment, rooms, the NRF site, the territory outside the NRF site

Information on contamination of the NRF equipment, rooms and site and the territory outside the NRF site (contaminated areas and gamma radiation dose rates from individual components) shall be presented.

 

3.5. Equipment damage

The list and names of damaged equipment shall be provided, and nature of damage shall be specified.

 

3.6. The NRF downtime

The time period within which no works have been performed at the NRF due to the malfunctioning investigation shall be specified.

 

4. CAUSES OF MALFUNCTIONING

 

Analysis results for all failures and human errors (erroneous actions) that have taken place in the course of the NRF malfunctioning, their direct and root causes shall be presented.

The list of system (component) failures and human errors (erroneous actions) that have taken place in the course of the malfunctioning as well as direct and root causes of each failure and human error shall be presented in the chronological order and in the form of a table (the failure table format is given below).

The direct cause is any phenomenon, process or state which determines disturbance of the normal process.

Typical direct causes of failures (errors) and their codes are given in the classifier in Appendix 4, Section 1. All direct causes of the failure (error) detected in the course of analysis shall be indicated in the table.

The root cause is the circumstance which has created the conditions for appearance or manifestation of the direct cause.

Typical root causes of failures (errors) and their codes are given in the classifier in Appendix 4, Section 2. All root causes of the failure (error) detected in the course of analysis shall be indicated in the table.

In case the analysis of failure (error) causes revealed any drawbacks of the procedures during which any hidden defect in operability of the equipment, applicability of procedures and the personnel preparedness has not been detected and (or) eliminated the root causes related to these procedural drawbacks shall be specified in the list of root causes for failures (human errors). In case any failure (error) became possible due to any non-conformities in the NRF personnel work the category of the personnel shall be specified in description of the relevant root cause.

 

Table format for failures and human errors

 

  Time of failure or personnel error

 Description of failure or personnel error 

 Description and code of the direct cause of failure or personnel error

 Description and code of the root cause of failure or personnel    error 

 

 

 

 

 

5. ASSESSMENT OF MALFUNCTIONING FROM THE VIEWPOINT OF SAFETY

 

This section shall contain analysis of the malfunctioning with regard to potential radiation impacts on the personnel, the public and the environment as well as assessment of the factors affecting the NRF safety.

Consequences for safe operation of the NRF that have or might have taken place in case of any other possible malfunctioning development shall be specified.

Safety-related failures and human errors shall be selected from the list of all failures and human errors specified in the table in Section 4, Appendix 3 to these Regulations. Assessment of significance of each selected failure or human error for safety shall be provided in the text format so that to determine whether the failure (error) consequences could be more severe under any other possible conditions.

The malfunctioning level in accordance with INES scale shall be substantiated.

 

6. NON-CONFORMITIES DETECTED IN THE COURSE OF THE MALFUNCTIONING INVESTIGATION

 

Non-conformities not related directly to the malfunctioning and not associated with its causes shall be specified in this section in case any such non-conformities are detected in the course of the malfunctioning investigation:

- in actions of the NRF personnel;

- in functioning of normal operation systems (components);

- in functioning of safety-related systems (components);

- in maintenance and repair;

- in the documentation;

- in arrangement of the works at the NRF;

- in operation of experimental devices and radiation sources.

 

7. CORRECTIVE MEASURES

 

The relevant corrective measures shall be proposed for each direct and root cause of any failure (human error) as well as for each non-conformity revealed by the NRF malfunctioning investigation commission in the course of investigation in order to eliminate any deviations from the requirements of federal regulations and rules in the area of atomic energy use and to prevent recurrent malfunctioning.

The NRF malfunctioning investigation commission shall formulate the proposals for corrective measures in such a way so that the final objectives and time limits for the arrangements could be clearly understood. Corrective measures may be mandatory for implementation (par. 7.1) and recommended for implementation (par. 7.2). Both types of corrective measures have the same structure presented in par. 7 of Appendix 2.

Corrective measures mandatory for implementation may include the arrangements for resumption of works at the NRF, prevention of any similar malfunctioning, as well as the arrangements for elimination of any non-compliances with the requirements of regulatory documents.

Corrective measures recommended for implementation shall include any arrangements that may be performed by the organizations engaged in development, design, manufacturing, installation, adjustment, repair of systems (components), development of documentation or agreed with these organizations and also any arrangements requiring performance of additional research.

The person in charge and the time limits shall be specified for each arrangement.

Control of implementation and efficiency of corrective measures shall be provided by the operating organization, and the results shall be specified in the annual report of the operating organization on nuclear and radiation safety at the NRF.

 

8. THE LIST OF DOCUMENTS USED BY THE COMMISSION

IN THE COURSE OF THE NRF MALFUNCTIONING INVESTIGATION

 

The list of effective regulations, standards and rules, NRF safety assurance documents used by the commission in the course of the NRF malfunctioning investigation shall be provided.

 

9. APPENDICES TO THE NRF MALFUNCTIONING INVESTIGATION

REPORT

 

In general the following materials shall be attached to the NRF malfunctioning investigation report.

1. Diagrams of the basic NRF parameters changes.

2. The NRF core fuel loading pattern in case of any deviations from safe operation limits and (or) conditions.

3. Change diagrams for the basic parameters of the NRF systems (components), printed results of recording of any changes in the state of the main systems (components) in the course of the malfunctioning development.

4. Radiation situation survey data, information on radiation exposure for the personnel. Medical assessment report on the health state of the injured person (persons) due to any malfunctioning with radiation consequences.

5. Explanatory reports of the personnel.

6. Any required process and electrical diagrams (or their fragments), drawings, sketches, photos of damaged components and damage areas.

7. Post-accident inspection reports and certificates, results of metallographic and any other studies, opening (disassembly) reports for any damaged components.

8. Information sheets from meteorological stations and extracts from the design or calculations (in case of malfunctioning due to external impacts).

9. Any other materials confirming the commission's conclusions on the malfunctioning causes.

10. Opinions of experts (in case of necessity) engaged in the malfunctioning investigation.

11. Data on any faulty, damaged or defective component in accordance with the table.

 

Data on each item of the faulty, damaged

or defective component

 

Name and designation of the faulty component in accordance with  

specifications                                             

 

Brief description of the failure, damage or defect         

 

Type (brand)                                              

 

Manufacturer, serial number                            

 

Date of manufacture                                        

 

Date of commissioning                                

 

Date of failure                                               

 

Time to failure since the date of commissioning, h    

 

Number of the component failures since the date of commissioning

 

Information on any similar failures,           

damages or defects (with indication of the date) of this or    

similar component                                    

 

 

12. Information on the NRF personnel having committed any erroneous actions:

- full name;

- position and grade;

- education and specialty;

- total period of service at the NRF, period of service in this position;

- the number of Rostechnadzor permit for performance of work in the area of atomic energy use;

- medical certificate on occupational fitness;

- results of emergency response drills.

13. Decision on the malfunctioning investigation period extension in case this period exceeds the time limits specified in par. 4.11 of these Regulations.

The list of attachments to the NRF malfunctioning investigation report shall be defined by the commission carrying out the investigation.

14. Specific opinions of the commission members (if any) shall be stated in written form.

 

10. SIGNATURES OF THE COMMISSION CHAIRMAN AND MEMBERS

 

Chairman of the commission:                         (Full name) (signature)

 

Members of the commission:                                (Full name) (signature)

 

 

 

 

 

 

 

 

Appendix 4

 

DIRECT AND ROOT CAUSES

OF COMPONENT FAILURES AND ERRORS OF THE NRF PERSONNEL

 

1. Direct causes of component failures and errors of the NRF personnel [N]

 

N0. Not determined.

N1. Mechanical part malfunctions.

N1.0. Not determined.

N1.1. Other.

N1.2. Corrosion, erosion.

N1.3. Wear, poor lubrication.

N1.4. Fatigue, weld seam defect, internal material defect.

N1.5. Overloading (exceedance of permissible mechanical stress).

N1.6. Vibration.

N1.7. Blockage, motion limitation, seizure, jamming.

N1.8. Deformation, alignment error, shifting, spurious movement, detachment, connection attenuation.

N1.9. Loosening of the fastening to the foundation, building structures, breakage of the foundation or building structures.

N1.10. External mechanical impact.

N1.11. Contamination, ingress of foreign objects (including generation of sludge and scale).

N2. Electrical part malfunctions.

N2.0. Not determined.

N2.1. Other.

N2.2. Short circuit, sparking.

N2.3. Voltage and frequency deviations.

N2.4. Faulty contact, breaking, open circuit.

N2.5. Grounding damage.

N2.6. Insulation damage.

N2.7. Internal damage.

N2.8. Abnormal connection (bridging).

N3. Malfunctions of electronic components.

N3.0. Not determined.

N3.1. Other.

N3.2. Element base defect.

N3.3. Defect of computer hardware.

N3.4. Drawbacks of computer software, impact of malicious programs (viruses).

N3.5. Impact (including electromagnetic interference) of other devices causing a spurious signal.

N4. Environment.

N4.0. Not determined.

N4.1. Other.

N4.2. Lightning strike.

N4.3. Heavy rainfall, flooding.

N4.4. Storm (hurricane), tornado.

N4.5. Earthquake.

N4.6. Air temperature decrease.

N4.7. Air temperature increase.

N4.8. Air shock wave.

N4.9. Airplane crash.

N4.10. Icing.

N5. Human factor.

N5.0. Not determined.

N5.1. Other.

N5.2. Incorrect and low-quality performance of process operations (errors in switching, connections, handling works, dismantling works).

N5.3. Incorrect and unintended impact on protection and automation components.

N5.4. Unauthorized performance of works, switchings, etc.

N5.5. Non-coordinated actions.

N5.6. Installation and commissioning of unchecked defective equipment and components (with faulty devices and assemblies), installation of beyond-design assemblies and parts.

N5.7. Lack of control or poor control of the state of systems (components) and performed process operations.

N5.8. Deliberate intervention to functioning of the automation devices.

N5.9. Work without any program, switching sheet, work permit, deviation from the work program, guidelines and other documents.

N5.10. Low-quality repair, deviations from the repair techniques.

N5.11. Low-quality post-repair testing and trial run.

N5.12. Errors in the course of inspection, maintenance, testing or adjustment.

N6. Malfunctions related to chemical or physical characteristics of the nuclear core

N6.0. Not determined.

N6.1. Other.

N6.2. Chemical contamination, appearance of any depositions.

N6.3. Uncontrolled chemical reaction.

N6.4. Deviations of neutron and physical parameters of the nuclear core.

N6.5. Insufficient chemical control.

N6.6. Fuel problems.

N6.7. Unusual behavior of materials.

N7. Malfunctions related to hydraulic/ pneumatic systems

N7.0. Not determined.

N7.1. Other.

N7.2. Hydraulic shock, irregular pressure, pressure drops, overpressure.

N7.3. Loss of flow.

N7.4. Loss of pressure.

N7.5. Cavitation.

N7.6. Gas block.

N7.7. Moisture in pneumatic systems.

N7.8. Vibration caused by liquid flow

N8. Other.

 

2. Root causes of component failures and errors of the NRF personnel [K]

 

K0. Not determined.

K1. Drawbacks in development, design, manufacturing, construction, installation, adjustment and repair.

K1.1. Engineering drawbacks.

K1.2. Design faults.

K1.3. Manufacturing drawbacks.

K1.4. Construction faults.

K1.5. Installation faults.

K1.6. Adjustment faults.

K1.7. Drawbacks of the repair performed by external organizations.

K2. Non-conformities of operation documentation.

K2.1. Absence of documentation.

K2.2. Incorrect or ambiguous definition of the operation documentation provisions.

K2.3. Untimely introduction of modifications to the documentation.

K3. Procedural drawbacks.

K3.1. Drawbacks in the procedure for admittance to the remedial works and maintenance and the procedure for supervision over these works.

K3.2. Drawbacks in the procedure for maintenance and repair.

K3.3. Drawbacks in the procedures for incoming control of the equipment, acceptance of the equipment for operation after installation or repair.

K4. Failure to implement the necessary measures or their untimely implementation.

K4.1. For provision of working media, spare parts, assemblies and units for the systems, timely replacement of any equipment with expired lifetime.

K4.2. For modification of the circuitry and design of components.

K4.3. For elimination of any revealed defects.

K5. Drawbacks of the personnel training.

K5.1. Operating.

K5.2. Repair.

K5.3. Personnel of divisions and laboratories.

K5.4. Management.

K6. Other.

 

 

 

 


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