Headquarters Daily Report SEPTEMBER 07, 1995 *************************************************************************** REPORT NEGATIVE NO INPUT ATTACHED INPUT RECEIVED RECEIVED HEADQUARTERS û REGION I û REGION II û REGION III û REGION IV û PRIORITY ATTENTION REQUIRED MORNING REPORT - HEADQUARTERS SEP. 07, 1995 MR Number: H-95-0119 NRR DAILY REPORT ITEM SIGNIFICANT EVENTS Subject: POTENTIAL FOR PRESSURE LOCKING OF SAFETY INJECTION AND OTHER VALVES AT HADDAM NECK The NRR/AEOD/RES Events Assessment Panel on September 5, 1995, classified the Haddam Neck report that the LPSI, HPSI and other safety-related valves were susceptible to the pressure-locking phenomenon, as a Significant Event for the Performance Indicator Program. This classification was made based on the degradation of important safety equipment. On March 9, 1995, the Connecticut Yankee Atomic Power Company reported that seven motor-operated gate valves in the safety injection systems at the Haddam Neck Nuclear Power Plant were susceptible to pressure-locking. These valves included the four high-pressure safety injection admission valves and the two low-pressure safety injection admission valves. On March 15, 1995, and in later reviews, the licensee identified more valves that were susceptible to pressure-locking, including two charging system injection valves and two cross connect valves from the RHR to the high pressure safety injection system. The four high-pressure safety injection admission valves and the two low-pressure safety injection admission valves were susceptible to pressure-locking following a postulated LOCA in which the pressure in the reactor coolant system (RCS) drops substantially before the safety injection actuation signal initiates the opening of the valve. In addition the high-pressure safety valves are also susceptible to pressure-locking caused by the heating of fluid captured in the valve bonnet when the valves are stroked during the start up of the plant. These susceptibilities provided a common mode failure potential that could have prevented both high-pressure and low-pressure coolant from being injected into the reactor during a LOCA and represented most of the risk associated with this event. The Haddam Neck plant was shut down for refueling January 28, 1995, before the identification of the pressure-locking concerns. The licensee modified all of the susceptible valves, before restarting the plant, by venting the valve bonnet space back to the high pressure side of the valve. Information Notice 95-18 and its Supplement 1 have been written discussing these events. Technical contact: John R. Tappert, NRR/DRPM/PECB (301) 415-1167 _ HEADQUARTERS MORNING REPORT PAGE 2 SEPTEMBER 7, 1995 Licensee/Facility: Notification: Part 21 Database MR Number: H-95-0120 Henry Pratt Company Date: 09/07/95 Subject: HENRY PRATT MOTORIZED BUTTERFLY VALVES Discussion: VENDOR: HENRY PRATT COMPANY PT21 FILE NO: 95152 DATE OF DOCUMENT: 06/08/95 ACCESSION NUMBER: 9506130287 SOURCE DOCUMENT: Part 21 REVIEWER: PECB: R. BENEDICT NRC Information Notice 94-67: PROBLEM WITH HENRY PRATT MOTOR-OPERATED BUTTERFLY VALVES was issued September 26, 1994. It described a potential problem in which the valve stem could become uncoupled from the motor operator. The only valves addressed in the Information Notice were 12 inch model 1400 valves that Duquesne Light Company (DLC) had reported to be subject to the problem. By letter dated June 8, 1995, DLC reported to the NRC that two additional Henry Pratt valves, 14 inch model 1100, had been discovered with the same problem. DLC also noted that adaptor plates obtained last year, for the 12 inch valves, were again provided with the wrong size stem holes. Contact: Robert A. Benedict, NRR/DRPM/PECB (301) 415-1157 _ REGION II MORNING REPORT PAGE 3 SEPTEMBER 7, 1995 Licensee/Facility: Notification: MR Number: 2-95-0077 Babcock & Wilcox Co. Date: 09/07/95 Lynchburg,Virginia Dockets: 07000027 License No: SNM-42 URANIUM FUEL FABRICATION Subject: NCS MASS AND/OR MODERATION LIMITS EXCEEDED IN STORAGE CONTAINERS Reportable Event Number: 29275 Discussion: On Friday, September 1, 1995 the licensee reported a situation where Uranium-235 was stored on a rack in excess of the Nuclear Criticality Safety (NCS) limits (Event No. 29275). The licensee's investigation has found three other similar situations in which mass and/or moderation limits in stored containers have not complied with the posted NCS limits. In response to the identification of these additional findings, the licensee has suspended all Special Nuclear Material (SNM) transfer operations to areas or storage racks controlled by mass and/or moderation limits until such areas can be walked-down by supervision to ensure compliance with all posted NCS limits. After NCS limit compliance has been assured, the transfer operations will be allowed to continue only with verification by two operators that stored containers are within the posted NCS limits. Regional Action: The Senior Resident Inspector is independently assessing the licensee's activities. The Region and NMSS are holding a conference call on September 7, with the licensee to discuss the results of the investigation and actions to prevent recurrence. Contact: M. P. Elliott (804)847-7343 _ REGION II MORNING REPORT PAGE 4 SEPTEMBER 7, 1995 Licensee/Facility: Notification: Department Of The Navy MR Number: 2-95-0078 Naval Medical Center San Diego Date: 09/07/95 San Diego,California Dockets: 03029462 License No: 45-23645-01NA Subject: MEDICAL MISADMINISTRATION Discussion: On September 5, 1995, the licensee notified the NRC that a brachytherapy misadministration occurred at the Naval Medical Center, in San Diego, California on August 29, 1995. The written directive called for the patient to receive a treatment for cancer of the cervix using an applicator loaded with four 15 milligram-Radium-equivalent (mg-Ra-eg) Cesium-137 sources. Inadvertently, the medical physicist loaded the applicator with four 10 mg-Ra-eg sources and the patient was treated for 30.6 hours. During removal of the implant the physician in charge of treatment determined that incorrect sources were loaded into the applicator. The original prescribed dose was 2016 centiGray (cGy) but the patient received 1349 cGy. The licensee has begun the investigation of the incident. The patient was notified of the event. Regional Action: Region II will conduct a followup inspection the week of September 11, 1995. The State of California will be informed. Contact: J. Diaz-Velez (404)331-7438 J. D. Ennis (404)331-1587 _ REGION II MORNING REPORT PAGE 5 SEPTEMBER 7, 1995 Licensee/Facility: Notification: MR Number: 2-95-0079 Veteran's Affairs Medical Center Date: 09/07/95 Lexington,Kentucky Dockets: 03010027 License No: 16-08896-04 Subject: BRACHYTHERAPHY MISADMINISTRATION Discussion: On September 7, 1995, the licensee's Radiation Safety Officer notified NRC Region II of a brachytherapy misadministration. The licensee stated that eleven iridium-192 seeds totaling 58.9 millicuries (mCi) were implanted at 4:45 p.m., September 6, 1995, for a bronchial treatment. The seeds were checked and in-place at 7:08 p.m. on September 6, 1995. At 8:00 a.m., on September 7, the catheter containing the seeds was found on a nightstand near the patient's bed. The licensee believes the patient apparently removed the catheter and placed it on the nightstand. The licensee is assessing the dose received by the patient and hospital staff. The patient and referring physician have been informed of the event. Regional Action: Region II is evaluating the potential radiation doses to individuals. Region II will conduct followup inspection on September 13, 1995. The State of Kentucky has been notified. Contact: C. M. Hosey (404)331-5614 J. D. Ennis (404)331-5787 _ REGION IV MORNING REPORT PAGE 6 SEPTEMBER 7, 1995 Licensee/Facility: Notification: Pacific Gas & Electric Co. MR Number: 4-95-0109 Diablo Canyon 1 Date: 09/07/95 Avila Beach,California Resident Inspector and Licensee Dockets: 50-275 PWR/W-4-LP Subject: REACTOR TRIP Discussion: On Wednesday, September 6, 1995, at 3:55 p.m. (PDT), Diablo Canyon, Unit 1, experienced a reactor trip resulting from a turbine trip caused by a loss of electrohydraulic oil pressure to the turbine controls. During the post trip investigation, an auto-stop oil system solenoid valve (SV-171) was found stuck open. SV-171 normally opens on a turbine trip to depressurize the auto-stop oil system and cause the interface valve (PCV-23) to open and depressurize the electrohydraulic system. No other problems have been noted. The licensee is continuing the investigation of the root cause of the reactor trip. The plant response to the trip was normal and uncomplicated with the following exceptions: pressurizer heater Group 4 breaker would not close from the control room due to the DC toggle switch on the front of the breaker being incorrectly positioned, two moisture separator reheater steam control valves failed to close, and EDG 1-1 autostarted. The EDG 1-1 autostart has occurred previously during the transfer to startup power and has been attributed to the slow voltage decrease on the 4 kV bus (Bus F) due to minimal bus loads. EDG 1-1 receives a start signal on low Bus F voltage after a short time delay and then subsequently receives a second signal to load onto Bus F. The startup transformer is designed to fast transfer to Bus F at a lower voltage than the EDG 1-1 start signal voltage, but before the relay times out to block the EDG 1-1 start signal. With the minimal Bus F loads, the slow voltage decrease causes the fast transfer to the startup transformer after the EDG 1-1 start signal times out. Regional Action: The Senior Resident and Resident Inspectors were onsite at the time of the trip. The Resident Inspectors continue to monitor the licensee's root cause evaluation and actions for plant restart. Contact: G. Johnston (510)975-0304 M. Tschiltz (805)595-2354 _