Headquarters Daily report DECEMBER 22, 1994 *************************************************************************** REPORT NEGATIVE NO INPUT ATTACHED INPUT RECEIVED RECEIVED HEADQUARTERS X REGION I X REGION II X REGION III X REGION IV X *************************************************************************** PRIORITY ATTENTION REQUIRED MORNING REPORT - HEADQUARTERS DEC. 22, 1994 MR Number: H-94-0116 NRR DAILY REPORT ITEM GENERIC COMMUNICATIONS BRANCH/EVENTS ASSESSMENT BRANCH DIVISION OF OPERATING REACTOR SUPPORT OFFICE OF NUCLEAR REACTOR REGULATION Subject: N/A Revision 1 to NRC Information Notice 89-25, "Unauthorized Transfer of Ownership or Control of Licensed Activities," was issued on December 7, 1994. NRC issued this revised notice to clarify previous guidance concerning information to be submitted to NRC before a change of ownership or control. The notice also incorporates recent information from OGC concerning the transferee's liability for open inspection issues and potential enforcement actions from past violations; and responsibility for decontamination activities and decommissioning of the site. Technical contact: Susan L. Greene, NMSS (301) 415-7843 PRIORITY ATTENTION REQUIRED MORNING REPORT - REGION DECEMBER 22, 1994 MR Number: H-94-0117 NRR DAILY REPORT ITEM SIGNIFICANT EVENTS EVENTS ASSESSMENT BRANCH DIVISION OF OPERATING REACTOR SUPPORT Subject: DEFICIENCY IN THE AUTOMATIC ACTUATION OF EMERGENCY CORE COOLING SYSTEM The NRR/AEOD Events Assessment Panel on December 20, 1994, classified the design deficiency identified in the automatic actuation of emergency core cooling system at Turkey Point Units 3 and 4, as a Significant Event for the Performance Indicator Program. Classification was based on the potential risk from the unavailability of both trains of the Emergency Core Cooling System without operator assistance. Emergency load sequencing systems at Turkey Point units are controlled by Allen-Bradley programmable logic controllers (PLC). The controllers were customized by United Controls Inc., with a capability for a continuous automatic electronic surveillance (auto-test) system. Auto-test is done in 16 different segments each taking one hour at successive intervals. Turkey Point units have jointly four 50% capacity high head injection pumps. Two pumps are assigned to two trains in one unit and the other two to the other unit. All four pumps receive start signal for safety injection (SI) from either unit. On November 3, 1994, during an integrated safeguard testing at train "a" Unit 4, "3A" high-head safety injection pump failed to start. The problem was diagnosed to be an inappropriate "actuation inhibit" signal becoming locked up such that a valid SI signal will not cause actuation while the sequencer is in certain test segments. It affected engineered safety feature (ESF) signals producing safety injection demands when offsite power remained available. Potential unavailability was limited to 1/4 of total time for each train. Manual start capability of individual components remained available in the control room. Both sequencers could be locked up coincidentally for 1/16 of the time. The most limiting accident for this scenario is a large break LOCA in a unit when both its sequencers are locked up. The HPSI pumps on the other unit may provide some flow for core cooling, and certain other safeguards loads would be automatically actuated, depending on the segment under test. The immediate corrective licensee action was to disable the "auto test" and revert to periodic surveillance for complying with Tech. Spec.. This problem existed for approximately 2 years at Unit 3 and 1 1/2 years at Unit 4. The Turkey Point IPE internal events CDF is 1 E-4. SPSB estimated the increase in the CDF to be small (2.4%) using the ASP program. The ASP evaluation indicates that a small break LOCA initiator is the dominant contributor to this increase. The CDF increase from a large break LOCA is very small due to the low initiator frequency. CONTACT: Thomas Koshy, NRR/DOPS/OECB (301) 504-1176 PRIORITY ATTENTION REQUIRED MORNING REPORT - REGION DECEMBER 22, 1994 MR Number: H-94-0118 NRR DAILY REPORT ITEM SIGNIFICANT EVENTS EVENTS ASSESSMENT BRANCH DIVISION OF OPERATING REACTOR SUPPORT Subject: REACTOR TRIP WITH PREMATURE SAFETY VALVE LIFT AND LEAKAGE The NRR/AEOD Events Assessment Panel on December 20, 1994, classified the July 19, 1994, reactor trip with safety valve leakage at Calvert Cliffs Unit 1, as a Significant Event for the Performance Indicator Program. The classification was based upon a reactor scram with complications. On July 19, 1994, at Calvert Cliffs Unit 1, an intermittent failure on the electronic circuit card that controls the #2 turbine stop valve caused all four turbine stop valves to close from 100% power. The #2 stop valve acts as the master stop valve with the other valves slaved to it. The resulting transient caused shrink in the steam generator which caused a reactor trip on low steam generator level. Operators manually initiated auxiliary feedwater to restore steam generator level. Main feed pumps and condenser remained available. The transient also caused a pressure surge in the reactor coolant system which lifted both power-operated relief valves momentarily. Peak pressure was 2410 psig. Also during the transient, safety/relief valve, RV-201, lifted below its setpoint (nominally 2565 psig +/-1%) and failed to fully reseat. The result was an unisolable 25 gpm leak. The leak pressurized the quench tank and blew out the rupture disc at 100 psig. Operators stabilized pressure at 1900 psig and later commenced a cooldown. The safety/relief valve stopped leaking at approximately 1000 psig, 12 hours after the initiating event. Approximately 5000 gallons of RCS was discharged through the safety during this event. The licensee replaced the leaking safety/relief valve and sent it to Wyle Labs for analysis. Wyle Labs confirmed that the valve had fully lifted and found a significant amount of damage to the internal parts of the valve. Most of the damage was in the form of galling and was consistent with a relief valve that has gone into "flutter". "Flutter" is a rapid cycling of the valve in which the disc does not come in contact with the seat, as opposed to chatter where the disc does come in contact with the seat. The licensee concluded that the safety/relief valve, RV 201, lifted due to four concurrent factors: 1) Disc holder was improperly staked to the bellows assembly and fell down on the lower adjusting ring (which in the presence of seat leakage would lower the effective lift pressure); 2) elevated RCS pressure during the transient; 3) flow-related vibration effects from the lift of the associated PORV; and 4) existing seat leakage. The leakage after the transient was associated with damage due to the valve lift and/or flutter. The Probabilistic Safety Assessment Branch modeled this event and calculated a conditional core damage probability of 2.8E-5. The event was briefed July 27, 1994, Operating Reactors Events Briefing 94-26, "Reactor Trip with Safety Valve Leakage." CONTACT: John Tappert, NRR/DOPS/OECB (301) 504-1167 PRIORITY ATTENTION REQUIRED MORNING REPORT - REGION III DECEMBER 22, 1994 Licensee/Facility: Notification: Christian Hospital, N.E. MR Number: 3-94-0245 Christian Hospital Date: 12/22/94 St. Paul,Minnesota telecon from licensee 12/21/94 Dockets: 03002382 License No: 24-13383-01 Subject: patient removes ir-192 endobroncial medical implant Reportable Event Number: N/A Discussion: On Wednesday, December 21, 1994, at approximately 2:00 p.m., the licensee reported to Region III that at 10:25 a.m. (CST), an elderly patient received a 199.4 millicurie iridium-192 endobronchial implant. At 12:43 p.m., the patient removed the implant in the presence of a physician. The source was immediately retrieved and placed in a shielded container. The patient was prescribed to have 2500 cGy, but only received 1400 cGy. At this point, no decision was made as to additional treatment. The licensee does not believe this to be a misadministration because of patient intervention. Regional Action: The State of Missouri and NMSS have been notified. NMSS and Region III concur with the licensee's assessment that the event does not constitute a misadministration and there is no need for a medical consultant. This will be reviewed during the next scheduled inspection. Contact: j. grobe (708)829-9806 d. sreniaswski (708)829-9814