Headquarters Daily Report DECEMBER 19, 1996 *************************************************************************** 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 DEC. 18, 1996 MR Number: H-96-0093 NRR DAILY REPORT ITEM GENERIC COMMUNICATIONS Information Notice 96-66, "RECENT MISADMINISTRATIONS CAUSED BY INCORRECT CALIBRATIONS OF STRONTIUM-90 EYE APPLICATORS," was issued on December 13, 1996. This notice is issued to all medical use licensees authorized to use strontium-90 eye applicators to alert them to recent misadministrations caused by incorrect calibration of the applicators. Root causes for two recent events have indicated problems with calibration or determination of the dose rate from the strontium-90 eye applicators. As a result, the administered dose was not within 20% of the prescribed dose. Contacts: Jose M. Diaz-Velez, RII Emilio M. Garcia, RIV (404) 331-7438 (510) 975-0239 E-mail: jxd2@nrc.gov E-mail: emg@nrc.gov James A. Smith, NMSS (301) 415-7904 E-mail: jas4@nrc.gov _ REGION III MORNING REPORT PAGE 2 DECEMBER 18, 1996 Licensee/Facility: Notification: Wisconsin Electric Power Co. MR Number: 3-96-0132 Point Beach 1 2 Date: 12/17/96 Two Rivers,Wisconsin LICENSEE TELEPHONE CALL Dockets: 50-266,50-301 PWR/W-2-LP,PWR/W-2-LP Subject: SENIOR MANAGEMENT RESTRUCTURING AND ADDITIONAL STAFF TO ADDRESS PLANT PROBLEMS Discussion: Responsibilities and reporting relationships for Mr. Richard Grigg, President and Chief Operating Officer, Wisconsin Electric, have been restructured to better support him as he addresses significant performance issues at the Point Beach Nuclear Power Plant. Many of his non-nuclear responsibilities were shifted to Mr. Dave Porter, Senior Vice-President. Messrs. Grigg and Porter will continue to report to Mr. Richard Abdoo, Chairman of the Board, Wisconsin Electric. Mr. Grigg stated that he will augment Point Beach plant staff and the corporate engineering staff with additional operations and engineering personnel from outside groups and from other divisions of his company. The management restructuring and staff augmentation are intended to help Point Beach aggressively address recent issues and improve performance. Contact: J. MCCORMICK-BARGER (630)829-9872 _ REGION II MORNING REPORT PAGE 3 DECEMBER 19, 1996 Licensee/Facility: Notification: MR Number: 2-96-0123 Piedmont Hospital, Atlanta, Ga Date: 12/19/96 Atlanta,Georgia Subject: HIGH DOSE RATE (HDR) BRACHYTHERAPY AFTERLOADER WITH LIMIT SWITCH FAULT Reportable Event Number: 31476 Discussion: Georgia, an Agreement State, notified the NRC on December 18, 1996, that the licensee's Physicist had reported a malfunction of a return limit switch in a GammaMed HDR unit containing 7.5 curies of iridium-192. During an unauthorized attempt to repair the switch, the source was backed out of the device, to an unshielded position. The physicist recovered the source, secured the device, performed surveys, and determined that there was no source leakage. Exposure to the physicist was estimated to be less than 50 millirem whole body. The State is continuing to follow the incident and the mechanical cause of the malfunction will be determined by the device manufacturer and reported to the State. Region II will follow up with the State regarding any generic issues related to the event. Contact: R.Woodruff (404)331-5545 _ REGION III MORNING REPORT PAGE 4 DECEMBER 19, 1996 Licensee/Facility: Notification: Wisconsin Electric Power Co. MR Number: 3-96-0133 Point Beach 1 2 Date: 12/18/96 Two Rivers,Wisconsin LICENSEE TELEPHONE CALL Dockets: 50-266,50-301 PWR/W-2-LP,PWR/W-2-LP Subject: UPDATE - INADVERTENT OPERATIO OF RHR PUMP WITH DISCHARGE VALVES CLOSED. Discussion: The licensee provided RIII with the results of its initial review of the December 16, 1996, event where the Unit 2 "A" Train Residual Heat Removal (RHR) pump was operated for about 38 minutes with the valves in the normal discharge and recirculation (recirc) lines closed. In support of venting air from the RHR recirc line flow instrument after maintenance, an auxiliary operator was aligning the RHR pump for recirculation. Because of lax documentation of valve positioning, the auxiliary operator missed opening an isolation valve between the pump and the recirc line. The control room operator subsequently started the pump, but since dead head (no flow) pump discharge pressure was not significantly different than recirc discharge pressure, and the recirc flow instrument was still unavailable, the control room operator did not have indication that the pump was dead headed. After the auxiliary operator was unable to completely vent the flow instrument (about 38 minutes), the control room operator secured the pump. During a subsequent walkdown, the auxiliary operator discovered that the discharge valve was closed. The licensee removed the shift supervisor, control room operator, and auxiliary operator from operational duties and plans to continue to operate Unit 1 at a reduced power (90 percent) until an in-depth investigation of this event, including identification of all causal factors, has been completed. The power reduction was implemented, in part, to emphasize to the operators the need to operate the facility with a high standard of performance. Regional Action: Resident inspectors and regional management are monitoring the licensee's investigation. Contact: J. MCCORMICK-BARGER (630)829-9872 _