Headquarters Daily report OCTOBER 31, 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 - REGION III OCTOBER 31, 1994 Licensee/Facility: Notification: Providence Medical Center MR Number: 3-94-0196 Dept Of Nuclear Radiology Date: 10/27/94 Southfield,Michigan Dockets: 03002022 Subject: NOTIFICATION OF POTENTIAL EXTREMITY OVEREXPOSURE Reportable Event Number: N/A Discussion: On October 27, 1994, the licensee notified the NRC of an extremity TLD radiation dosimeter that recorded in excess of 88.5 rem dose. The licensee's investigation began on September 9, 1994, when the licensee's dosimetry vendor notified the licensee of an individual's July 1994 TLD extremity radiation dose of 11.4 rem. That individual had previously reported the extremity dosimeter missing. Since that date the licensee suspended the nuclear medicine technologist from activities in the department that required a TLD to be worn, i.e. elution of the molybdenum-99/technetium-99m generator, or preparation, assay, and administration of patient dosages. The extremity monitors for August and September were processed disclosing 32.2 rem for the month of August and 88.5 rem for the first 9 days of September. The licensee's physicist and departmental supervisor initiated an investigation of the event. The licensee's investigation considered the possibilities of personnel radiation exposure, contamination of the TLD, and deliberate exposure of the TLD. The investigation included interviews of departmental personnel and comparison of monthly personnel radiation dose reports and monthly workload for the department. The individual is a certified nuclear medicine technologist with 11 years experience, the last 3 years at Providence Medical Center. No contamination was present on the TLD. Also, the patient dosages that were handled by the individual in September 1994, in the manner that was described by the individual, were not sufficient to reasonably produce the radiation dose of 88.5 rems. Other technologists in the department confirmed that no abnormal occurrences in September 1994. This individual's extremity doses for the previous six months averaged approximately 100 millirem and a cumulative whole body dose of 80 millirem for the period beginning January 1994 through September 9, 1994. The licensee concluded that the recorded radiation dose was most likely to the TLD only and does not represent extremity exposure to the individual. The TLD was most likely exposed to a vial containing technetium-99m by an individual with malicious intent. The licensee has identified some difficult personal relationships that may be the root cause of this event. To minimize the recurrence of this specific problem, the licensee is requiring that dosimetry be turned in at the end of each work period and secured. Regional Action: Region III has notified the Michigan Division of Radiological Health and will review this event during a future inspection. Contact: TOM YOUNG (708)829-9835 JOHN A. GROBE (708)829-9837 PRIORITY ATTENTION REQUIRED MORNING REPORT - REGION IV OCTOBER 31, 1994 Licensee/Facility: Notification: Nebraska Public Power District MR Number: 4-94-0128 Cooper 1 Date: 10/27/94 Brownsville,Nebraska Resident Inspector Dockets: 50-298 BWR/GE-4 Subject: FOLLOWUP ON LOSS OF EMERGENCY COMMUNICATIONS CAPABILITY Reportable Event Number: 27953 Discussion: On October 26, 1994, the licensee reported a loss of emergency communications capability. During a test of the in-plant communications system (Gaitronics), the system failed because of a loss of power. The system was transferred to its backup power supply and again failed. The immediate cause was found to be blown fuses in both the normal and backup power supplies. The fuses were replaced and the system functioned normally. The electrical system for the Gaitronics system also provides power to the fire alarm and onsite emergency notification systems. The loss of power caused these systems to be inoperable. While these systems were without power, operations and select maintenance personnel were issued hand-held radios so appropriate information could be transmitted in the event of an emergency. On October 27 the resident inspector was informed by the licensee that there had been recent vandalism associated with the communications system. Licensee security indicated that 11 Gaitronics stations had received damage to either the ear or mouthpiece. Corporate security was notified and an investigation was initiated on October 31. Presently, there is no known connection between the vandalism and the failure of the Gaitronics system on October 26, 1994. The plant has been in a cold shutdown condition since May 25, 1994, and restart is several months away. The Region apprised the NRC IAT of the situation on October 27, 1994. Regional Action: The Region will monitor the licensee's corporate security investigation and review the licensing basis of the communications system. Contact: T. Reis (817)860-8185 P. H. Harrell (817)860-8250 PRIORITY ATTENTION REQUIRED MORNING REPORT - REGION IV OCTOBER 31, 1994 Licensee/Facility: Notification: Arizona Public Service Co. MR Number: 4-94-0129 Palo Verde 2 Date: 10/31/94 Wintersburg,Arizona Resident Inspector Dockets: 50-529 PWR/CE80 Subject: REACTOR TRIP Reportable Event Number: 27968 Discussion: On October 29, 1994, at approximately 8:44 p.m. MST, Unit 2, when operating at 100 percent power, sustained a reactor trip on low departure from nucleate boiling as a result of an equipment failure when Control Element Assembly Calculator (CEAC) 1 inserted large penalty factors into the core protection calculator. Two minutes prior to the reactor trip, numerous CEAC trouble alarms were received in the control room. The reactor trip was uncomplicated, and the unit was stabilized in Mode 3. The licensee investigated the cause of the equipment failure and repaired CEAC 1 by replacing the main processor. Unit 2 started up on October 30, entered Mode 1 on October 31, and is currently making preparations to return to the grid. At the time of the event, Unit 1 was operating at 98 percent power and Unit 3 was operating at 100 percent power. Regional Action: The NRC resident inspector responded to the plant and will continue to follow plant startup and power ascension. Contact: H. Wong (510)975-0296 K. Johnston (602)386-3638