Headquarters Daily report JULY 18, 1995 *************************************************************************** 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 I JULY 18, 1995 Licensee/Facility: Notification: Frank Barker Associates, Inc. MR Number: 1-95-0092 Frank Barker Associates, Inc. Date: 07/17/95 Pequannock,New Jersey Dockets: 03032912 License No: 29-28783-01 Subject: Licensee Exposed to Apparent High Extremity Dose Reportable Event Number: N/A Discussion: On July 13, 1995, at about 8:30 p.m., a 10 curie, iridium 192 source, in a Gammamed, Model 12i, High Doserate Afterloader (HDR), became jammed in an unshielded position. At about 1:30 p.m., on July 14, 1995, the Radiation Safety Officer (RSO) from York Hospital notified the NRC Region I office staff that the licensed byproduct material became stuck during acceptance testing (no patients present). The tests were being conducted by the manufacturers U.S. service representatives, an NRC Region I licensee, Frank Barker Associates, Inc. On July 13, 1995, the York RSO was called back to the hospital and arrived at about 9:30 p.m. Shortly after her arrival, an attempt was made by the Barker RSO to free the source by tapping the clamp adapter area with his hand. The total entry time was 16 seconds. The York RSO estimated the Barker RSO right hand exposure to be a maximum of 2 seconds to his right hand which she estimated to be about 1 cm from the stuck source. He had an extremity badge on his right hand. His pocket ionization chamber (PIC) read 20 mR after this (it was at chest level). The source remained stuck. According to the York RSO, at about 10:30 p.m. the Barker RSO and one of the three Barker service engineers present made another attempt to free the source. This time the Barker RSO used the manual crank to retract the source while the engineer loosened the clamp with a broom handle. They both spent a total of 8 seconds in the room and were successful in freeing the source and retracting it to the safe storage position. An additional 1 mR was noted on the RSO's PIC. The other engineer had only a Whole Body (WB) badge. The York RSO estimated a maximum exposure rate of 13 R/sec at 1 cm and assigned a dose of 26 Rem to the extremity for the Barker RSO. She had the Barker RSO agree to process the extremity dosimeter immediately. In addition, the York RSO mentioned that a similar source jam had occurred at the Lahey Clinic in Massachusetts on November 16, 1994. The jaws of the clamping adapter had partially closed preventing the source from fully retracting. Barker Associates had filed a Part 21 report at that time. Regional Action: The NRC plans a reactive inspection to reconstruct the incident and validate the dose estimation as well as to examine the actions taken by the licensee to correct the problem. NRC will continue to follow-up on corrective measures as long as is necessary. Contact: Anthony Kirkwood (610)337-5050 Walter Pasciak (610)337-5258 PRIORITY ATTENTION REQUIRED MORNING REPORT - REGION II JULY 18, 1995 Licensee/Facility: Notification: Virginia Power Co. MR Number: 2-95-0060 North Anna 1 Date: 07/18/95 Richmond,Virginia Dockets: 50-338 PWR/W-3-LP Subject: ENTRY INTO TS 3.0.3. DUE TO BOTH SAFEGUARDS AREA VENTILATION TRAINS BEING INOPERABLE Reportable Event Number: 29074 Discussion: On July 16, 1995, with the Unit 1 at 100 percent power, Technical Specification (TS) 3.0.3 action was entered for approximately 30 minutes when it was discovered that a maintenance activity on the Unit 1 Safeguards Area Ventilation System A train also affected the B train. In response to a resident inspector's observation, the licensee confirmed that an inadvertent suction pathway from the Auxiliary Building had been established when an inspection port had been opened on the A train fan discharge duct. Air flowed through the open port, approximately 13 by 18 inches, backwards through the idle A fan into the A and B trains' common suction line. Operating the B train with a suction from both the Auxiliary and Safeguards Buildings appeared to reduce the B train flow from the Safeguards Building below the TS limit. With both trains considered inoperable, TS 3.0.3 was entered until the inspection port was replaced. The Safeguards Building contains the outside recirculation and the low head safety injection pumps. The inspection port in the A train was removed to permit the capturing of rivet heads that were being cut to allow removal and replacement of a leaking rubber boot between two duct sections. Furthermore, removal of the rubber boot would have created an even larger suction path from the Auxiliary Building. The event was attributed to inadequate work planning, in that, the impact of performing the work was not properly assessed. Regional Action: Routine followup. Contact: G. BELISLE (404)331-4196 PRIORITY ATTENTION REQUIRED MORNING REPORT - REGION III JULY 18, 1995 Licensee/Facility: Notification: Commonwealth Edison Co. MR Number: 3-95-0124 La Salle 2 Date: 07/18/95 Marseilles,Illinois RI VIA TELEPHONE. Dockets: 50-374 BWR/GE-5 Subject: RECENT EVENTS AT LASALLE Reportable Event Number: N/A Discussion: Maintenance personnel cut into a pressurized instrument line apparently due to a deficient out of service (OOS). On July 17, 1995, ComEd was in the process of replacing (by cutting and welding) an instrument root valve in the MSIV leakage control system (LCS). The LCS is a 2-inch drain line between the inboard and outboard MSIVs. Main steam was isolated to the system using a single root valve upstream of the valve to be replaced. When hanging the OOS, the line was not vented or verified to be depressurized. When ComEd cut into the line, high pressure steam was released. Operations personnel tightened down on the root valve used for isolation and successfully isolated the steam leakage. In another incident, equipment failures and plugged floor drains caused 15,000 gallons of water to be spilled in the heater bay. On July 15, 1995, the gasket on the second stage reheater normal level control valve inlet check valve blew, causing the spill. ComEd initiated an emergency load drop to 900 MW and isolated second stage reheat to the 2B MSR which stopped the leak. ComEd entered the heater bay and discovered that all the floor drains in the heater bay were plugged with debris. This prevented the water from draining to radwaste. No injuries or personnel contaminations occurred in either incident. Regional Action: The residents will continue to monitor ComEd's investigations and corrective actions. Contact: BRENT CLAYTON (708)829-9602 PRIORITY ATTENTION REQUIRED MORNING REPORT - REGION IV JULY 18, 1995 Licensee/Facility: Notification: Arizona Public Service Co. MR Number: 4-95-0093 Palo Verde 2 Date: 07/18/95 Wintersburg,Arizona Phone Call from Resident Inspectors Dockets: 50-529 PWR/CE80 Subject: REACTOR TRIP Reportable Event Number: 29079 Discussion: On July 17, 1995, at 11:31 p.m., Palo Verde Unit 2 tripped from 100 percent power due to low steam generator water level. The low steam generator water level occurred after power for feedwater pump control was lost and the feedwater pumps ran back to minimum speed. This event is described in Event Notification 29079, and this Morning Report provides supplemental information. Circuit breaker indication at the control board for operation of the normal and alternate startup transformers was "frozen" as a result of a multiplexer failure which apparently occurred on July 14, 1995. The licensee is investigating the cause of the multiplexer failure and apparent lack of operator awareness. The multiplexer provides control room position indication for switchyard breakers. The licensee is also investigating whether it was appropriate for the operator to reset the alternate circuit breaker which resulted in the loss of power to the SO5 bus. The power supply for the feedwater control system and the steam bypass control system did not automatically transfer from the 4.16kV class "1E" power supply when power was initially lost. The failure to transfer to a nonvital power supply caused the feedwater pumps to run back to minimum speed. Two reactor coolant pumps deenergized after the main turbine and main generator tripped. The fast transfer for the bus powering the reactor coolant pumps was blocked due to the planned startup transformer maintenance; however, the blocked transfer had no impact on this event as the reactor coolant pumps would not have transferred to a dead bus. The plant was stabilized in Mode 3. Palo Verde Units 1 and 3 are operating at 100 percent power. Regional Action: The NRC resident inspectors responded to the site following the reactor trip. Regional and resident personnel will follow the licensee's investigation of the reactor trip. Contact: R. Huey (510)975-0342 A. MacDougall (602)386-3638