U.S. Nuclear Regulatory Commission Operations Center Event Reports For 04/15/94 - 04/18/94 ** EVENT NUMBERS ** 27067 27096 27098 27099 27100 27101 27102 27103 27104 27105 27106 27107 27108 27109 27110 27111 27112 +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27067 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: KEWAUNEE REGION: 3 |NOTIFICATION DATE: 04/09/94 | |UNIT: [1] [ ] [ ] STATE: WI |NOTIFICATION TIME: 11:22 [ET]| |RX TYPE: [1] W-2-LP |EVENT DATE: 04/09/94 | +------------------------------------------------+EVENT TIME: 07:00[CDT]| |NRC NOTIFIED BY: WEBB |LAST UPDATE DATE: 04/16/94 | |HQ OPS OFFICER: TIM McGINTY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BRUCE BURGESS RDO | |ADAS 50.72(b)(2)(i) DEG/UNANALYZED COND | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AN ANALYSIS OF STEAM GENERATOR "A" EDDY CURRENT RESULTS, DETERMINED THAT | | ONE REGION IN STEAM GENERATOR "A" MEETS THE CRITERIA FOR CLASSIFICATION AS | | "C-3". A REGION IS CLASSIFIED AS "C-3" WHEN GREATER THAN 1% OF THE TUBES | | INSPECTED IN THAT REGION ARE DETERMINED TO BE DEFECTIVE. A DEFECTIVE TUBE | | IS ANY TUBE WITH AN INDICATION BELIEVED TO BE MORE THAN 50% THROUGH WALL. | | IN STEAM GENERATOR "A", 7 OF THE 226 (APPROXIMATELY 3.1%) UPPER SLEEVE | | EXPANSION JOINTS INSPECTED, WERE DETERMINED TO BE DEFECTIVE. NO OTHER | | REGIONS OF STEAM GENERATOR "A" HAVE BEEN CLASSIFIED AS "C-3" TO DATE, AND | | INSPECTION OF STEAM GENERATOR "B" HAS NOT COMMENCED. | | | | FOR CORRECTIVE ACTIONS; | | | | 1. THE SCOPE OF THE INSPECTION WILL BE EXPANDED TO INCLUDE THE REMAINING | | UPPER SLEEVE EXPANSION JOINTS (APPROXIMATELY 2000 MORE). | | | | 2. THE DEFECTIVE TUBES WILL BE PLUGGED. | | | | 3. AN ANALYSIS WILL BE PERFORMED TO ENSURE THAT THE PLUGGING RATE DOES NOT | | RESULT IN AN UNANALYZED CONDITION. | | | | A SCHEDULED NRC REGION III INSPECTION OF KEWAUNEE'S STEAM GENERATOR EDDY | | CURRENT METHODOLOGY AND RESULTS IS PLANNED FOR NEXT WEEK. THE DEFINITION | | FOR A DEFECTIVE TUBE IS CONTAINED IN THE TECHNICAL SPECIFICATIONS. THE | | LICENSEE INFORMED THE RESIDENT INSPECTOR. | | | | * * * UPDATE 2100EDT ON 4/16/94 FROM DENNIS ROZELL TO S.SANDIN * * * | | INSPECTIONS COMPLETED AT 1645CDT ON STEAM GENERATOR "B" DETERMINED THAT 24 | | OUT OF 2098 (APPROXIMATELY 1.1%) UPPER SLEEVE EXPANSION JOINTS ARE | | DEFECTIVE. THIS COMPLETES A 100% INSPECTION WITH NO OTHER REGIONS | | CLASSIFIED AS "C-3". THE STEAM GENERATOR WILL NOT BE RETURNED TO SERVICE | | UNTIL ALL DEFECTIVE TUBES ARE PLUGGED, REPAIRED, OR OTHERWISE | | DISPOSITIONED. AN NRC REGION III MEETING IS SCHEDULED FOR 4/19/94 TO | | DISCUSS RESOLUTION OF THE AFFECTED TUBES. THE LICENSEE INFORMED THE NRC | | RESIDENT INSPECTOR. NOTIFIED R3DO(CANIANO). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27096 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: CALVERT CLIFFS REGION: 1 |NOTIFICATION DATE: 04/14/94 | |UNIT: [1] [2] [ ] STATE: MD |NOTIFICATION TIME: 14:05 [ET]| |RX TYPE: [1] CE,[2] CE |EVENT DATE: 04/14/94 | +------------------------------------------------+EVENT TIME: 13:53[EDT]| |NRC NOTIFIED BY: BURGER/SHUMAKER |LAST UPDATE DATE: 04/16/94 | |HQ OPS OFFICER: STEVE SANDIN +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: UNUSUAL EVENT +-----------------------------+ |10 CFR SECTION: |WILLIAM LAZARUS RDO | |AAEC 50.72(a)(1)(i) EMERGENCY DECLARED |AL CHAFFEE EO | | |BERNICE CARR FEMA | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | LICENSEE DECLARED AN UNUSUAL EVENT DUE TO THE METEOROLOGICAL TOWER BEING | | OUT OF SERVICE. | | | | AFTER COMPLETING PREVENTATIVE MAINTENANCE ON THE MET TOWER WIND SPEED AND | | DIRECTION INSTRUMENTATION, THE LICENSEE WAS USING A PULLEY SYSTEM TO | | REPOSITION THE INDICATOR WHEN A BEARING IN THE PULLEY SYSTEM FAILED. THE | | LICENSEE ESTIMATES THAT REPAIRS WILL BE COMPLETED BY 1200EDT ON 4/15/94 AT | | WHICH TIME THE UNUSUAL EVENT WILL BE TERMINATED. DURING THE PERIOD OF TIME | | THAT THE MET TOWER IS OUT OF SERVICE, THE LICENSEE WILL USE MET DATA FROM | | THE PATUXENT NAVAL AIR STATION. THE LICENSEE INFORMED ALL STATE/LOCAL | | AGENCIES PER THEIR EMERGENCY PLAN AND THE NRC RESIDENT INSPECTOR. | | | | * * * UPDATE AT 0606 ON 04/16/94 BY WASEM ENTERED BY HOO JOLLIFFE * * * | | | | AT 2115 ON 04/15/94, LICENSEE RESTORED THE METEOROLOGICAL TOWER TO SERVICE | | AND TERMINATED THE UNUSUAL EVENT. LICENSEE NOTIFIED STATE AND LOCAL | | OFFICIALS AND WILL NOTIFY THE NRC RESIDENT INSPECTOR OF THE TERMINATION OF | | THE UNUSUAL EVENT. HOO NOTIFIED R1DO LAZARUS, NRR EO BRIAN GRIMES, AND | | FEMA CARR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27098 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BROWNS FERRY REGION: 2 |NOTIFICATION DATE: 04/15/94 | |UNIT: [ ] [2] [ ] STATE: AL |NOTIFICATION TIME: 06:10 [ET]| |RX TYPE: [1] GE-4,[2] GE-4,[3] GE-4 |EVENT DATE: 04/15/94 | +------------------------------------------------+EVENT TIME: 02:18[CDT]| |NRC NOTIFIED BY: DAVENPORT |LAST UPDATE DATE: 04/15/94 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |CAUDLE JULIAN RDO | |ARPS 50.72(b)(2)(ii) RPS ACTUATION | | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | |AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | A/R Y 100 POWER OPERATION | 0 HOT SHUTDOWN | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - AUTO Rx SCRAM FROM 100% DUE TO PERSONNEL ERROR & HPCI AREA HIGH TEMP - | | | | WHILE ISOLATING 1 OF 2 REDUNDANT SCRAM AIR HEADER PRESSURE CONTROL VALVES | | DURING MAINTENANCE ACTIVITIES, A CONTROL ROOM OPERATOR INADVERTENTLY CLOSED | | BOTH SCRAM AIR HEADER PRESSURE CONTROL VALVES AT THE SAME TIME CAUSING THE | | SCRAM AIR HEADER PRESSURE TO DROP. | | | | AT 0218 (CDT), THE UNIT 2 REACTOR AUTO SCRAMMED FROM 100% POWER DUE TO | | A LOW SCRAM AIR HEADER PRESSURE SIGNAL. ALL CONTROL RODS INSERTED | | COMPLETELY. STEAM IS BEING DUMPED TO THE MAIN CONDENSER. | | | | REACTOR VESSEL WATER LEVEL DROPPED TO BELOW +11 INCHES, THE LOW | | REACTOR VESSEL WATER LEVEL SETPOINT, CAUSING ISOLATIONS OF PRIMARY | | CONTAINMENT ISOLATION SYSTEMS GROUP 2 (DRYWELL SUMP DISCHARGE VALVES), | | GROUP 3 (REACTOR WATER CLEANUP SYSTEM), GROUP 6 (PRIMARY AND SECONDARY | | CONTAINMENT ISOLATION VALVES), GROUP 8 (TRAVERSING INCORE PROBES), | | REACTOR BUILDING VENTILATION SYSTEM AND THE INITIATION OF THE STANDBY | | GAS TREATMENT SYSTEM AND THE CONTROL ROOM EMERGENCY VENTILATION SYSTEM. | | NORMAL REACTOR VESSEL WATER LEVEL IS +33 INCHES. THE REACTOR VESSEL | | WATER LEVEL DID NOT DROP TO THE LOW LOW LEVEL SETPOINT OF -45 INCHES. | | | | AT 0228 (CDT), CONTROL ROOM OPERATORS MANUALLY CLOSED THE HPCI SYSTEM | | OUTBOARD STEAM ISOLATION VALVE (#2-FCV-73-3) IN ACCORDANCE WITH A PLANT | | EMERGENCY OPERATING INSTRUCTION AFTER RECEIVING A HPCI SYSTEM AREA HIGH | | TEMPERATURE ALARM RENDERING THE HPCI SYSTEM INOPERABLE. THE HPCI SYSTEM | | AREA AMBIENT TEMPERATURE HAD RISEN DUE TO A SLOW PACKING LEAK ON THE | | #73-3 VALVE AND THE ISOLATION OF THE REACTOR BUILDING VENTILATION SYSTEM. | | THE HPCI SYSTEM INITIATION SIGNAL IS LOW LOW REACTOR VESSEL WATER LEVEL | | SETPOINT. | | | | AT 0535 (CDT), LICENSEE RESTORED THE HPCI SYSTEM TO OPERABLE STATUS. | | | | UNIT 2 IS STABLE IN CONDITION 3 (HOT SHUTDOWN) WITH REACTOR VESSEL WATER | | LEVEL BEING MAINTAINED IN THE NORMAL RANGE AND ALL SYSTEMS RESTORED TO | | NORMAL. | | | | LICENSEE IS INVESTIGATING THE CAUSE OF THE SCRAM AND THE HPCI AREA HIGH | | TEMPERATURE ALARM. | | | | LICENSEE WILL SUBMIT AN LER TO THE NRC ON THIS EVENT. | | | | LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27099 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: CRYSTAL RIVER REGION: 2 |NOTIFICATION DATE: 04/15/94 | |UNIT: [3] [ ] [ ] STATE: FL |NOTIFICATION TIME: 10:37 [ET]| |RX TYPE: [3] B&W-L-LP |EVENT DATE: 04/15/94 | +------------------------------------------------+EVENT TIME: 10:00[EDT]| |NRC NOTIFIED BY: STEPHENSON |LAST UPDATE DATE: 04/15/94 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |CAUDLE JULIAN RDO | |DSAF 73.71(b)(1) SECURITY DEGRADATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 3 | N N 0 REFUELING | 0 REFUELING | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | SAFEGUARDS SYSTEM DEGRADATION RELATED TO AN AREA BOUNDARY. IMMEDIATE | | COMPENSATORY ACTIONS WERE TAKEN UPON DISCOVERY. SEE HOO LOG FOR DETAILS. | | THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 27100 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: FOX CHASE CANCER CENTER, PHIL, PA |NOTIFICATION DATE: 04/15/94 | | CITY: PHILADELPHIA REGION: 1 |NOTIFICATION TIME: 11:20 [ET]| | COUNTY: PHILADELPHIA STATE: PA |EVENT DATE: 04/14/94 | |LICENSE#: AGREEMENT: N |EVENT TIME: 14:00[EDT]| | DOCKET: |LAST UPDATE DATE: 04/15/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |WILLIAM LAZARUS RDO | | |BILL BRACH, NMSS EO | +------------------------------------------------+ | |NRC NOTIFIED BY: NANCY MOLDOFSKY | | |HQ OPS OFFICER: DICK JOLLIFFE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - INCORRECT FRACTIONAL RADIATION DOSE ADMINISTERED TO A MALE PATIENT - | | | | ON 08/18/93, A MALE CANCER PATIENT AT THE FOX CHASE CANCER CENTER IN | | PHILADELPHIA, PA WAS GIVEN 2 FRACTIONAL RADIATION DOSES TO HIS ESOPHAGUS: | | 1000 AND 400 CENTIGRAYS; TOTAL DOSE 1400 CENTIGRAYS. THE PRESCRIBED DOSE | | WAS 700 CENTIGRAYS EACH; TOTAL DOSE 1400 CENTIGRAYS. THERE WERE NO ADVERSE | | EFFECTS TO THE PATIENT. | | | | THE LICENSEE IS INVESTIGATING THE CAUSE OF THE MISADMINISTRATION. | | | | THE LICENSEE DETERMINED THIS EVENT TO BE A MEDICAL MISADMINISTRATION EVENT | | AT 1400 ON 04/14/94. | | | | THE LICENSEE WILL NOTIFY THE PATIENT'S PHYSICIAN. | | | | LICENSEE WILL SUBMIT A WRITTEN REPORT TO THE NRC. | | | | SEE HOO LOG FOR LICENSEE'S TELEPHONE NUMBER. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27101 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SEQUOYAH REGION: 2 |NOTIFICATION DATE: 04/15/94 | |UNIT: [1] [2] [ ] STATE: TN |NOTIFICATION TIME: 13:05 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 04/15/94 | +------------------------------------------------+EVENT TIME: 12:20[EDT]| |NRC NOTIFIED BY: CHRIS REEVES |LAST UPDATE DATE: 04/15/94 | |HQ OPS OFFICER: STEVE SANDIN +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |CAUDLE JULIAN RDO | |ANTO 50.72(b)(1)(iii) TORNADO | | |NLCO TECH SPEC LCO A/S | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 1 STARTUP | 1 STARTUP | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | BOTH UNITS ENTERED TS 3.0.3 DUE TO A TORNADO WARNING ISSUED FOR NORTHEAST | | HAMILTON COUNTY, TN. | | | | AT 1220EDT THE SITE ENTERED ABNORMAL OPERATING INSTRUCTION (AOI/8) DUE TO A | | TORNADO WARNING ISSUED BY NOAA FOR NORTHEAST HAMILTON COUNTY, TN. PER THE | | AOI THE LICENSEE HAS BLOCKED CRANES IN THE TURBINE BUILDING, CONDUCTED | | SEARCHES FOR DEBRIS AND PLACED THE EMERGENCY PRESSURIZATION FANS IN THE | | PULL-TO-LOCK POSITION. THIS PLACED BOTH UNITS IN TS 3.0.3 DUE TO BOTH | | TRAINS OF CONTROL ROOM VENTILATION BEING INOPERABLE. IF THE TORNADO WARNING | | IS NOT CANCELED WITHIN THE TIME ALLOWED BY TS 3.0.3 BOTH UNITS WILL ENTER | | AN UNUSUAL EVENT WHEN THEY COMMENCE A TS REQUIRED SHUTDOWN. ALL SAFETY | | EQUIPMENT REMAINS OPERABLE INCLUDING ALL SOURCES OF OFFSITE POWER. THE | | LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | | | | * * * UPDATE 1345EDT ON 4/15/94 BY REEVES TO S.SANDIN * * * | | BOTH UNITS HAVE EXITED TS 3.0.3 DUE TO THE TORNADO WARNING BEING DOWNGRADED | | TO A TORNADO WATCH. THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | | NOTIFIED R2DO(JULIAN). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 27102 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: BECKLEY HOSPITAL, INC. |NOTIFICATION DATE: 04/15/94 | | CITY: BECKLEY REGION: 2 |NOTIFICATION TIME: 14:59 [ET]| | COUNTY: RALEIGH STATE: WV |EVENT DATE: 04/08/94 | |LICENSE#: 47-25188-01 AGREEMENT: N |EVENT TIME: 19:30[EDT]| | DOCKET: |LAST UPDATE DATE: 04/15/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |CAUDLE JULIAN RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: BILL CRAWFORD | | |HQ OPS OFFICER: STEVE SANDIN | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | A PATIENT AT THE BECKLEY HOSPITAL LOCATED IN BECKLEY, WV. RECEIVED THE | | INCORRECT FORM OF TECHNETIUM-99m DUE TO TECHNICIAN ERROR. | | | | A PATIENT WAS INJECTED WITH 4.2 mCi OF Tc-99m DTPA (PENTETATE - RENAL | | FUNCTION) INSTEAD OF DISOFENIN (BILIARY - GALL BLADDER FUNCTION). THE | | LICENSEE ATTRIBUTES CAUSE TO TECHNICIAN ERROR. THE PATIENT AND ATTENDING | | PHYSICIAN WERE NOTIFIED ON 4/8/94. THERE ARE NO EXPECTED ADVERSE EFFECTS. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 27103 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: HAHNEMANN UNIVERSITY |NOTIFICATION DATE: 04/15/94 | | CITY: PHILADELPHIA REGION: 1 |NOTIFICATION TIME: 15:28 [ET]| | COUNTY: PHILADELPHIA STATE: PA |EVENT DATE: 04/15/94 | |LICENSE#: 37-00467-34 AGREEMENT: N |EVENT TIME: 05:00[EDT]| | DOCKET: |LAST UPDATE DATE: 04/15/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |WILLIAM LAZARUS RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: KENT LAMBERT | | |HQ OPS OFFICER: STEVE SANDIN | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AT THE HAHNEMANN UNIVERSITY HOSPITAL LOCATED IN PHILADELPHIA, PA., AN | | IMPLANT CONTAINING THREE Cs-137 SOURCES (STRENGTH NOT AVAILABLE) BECAME | | DISLODGED EXPOSING THE PATIENT'S THIGH. | | | | AT APPROXIMATELY 1200EDT ON 4/14/94 A FEMALE PATIENT HAD A Cs-137 IMPLANT | | PLACED IN POSITION FOR A SCHEDULED 20 HOUR STANDARD TREATMENT PLAN. AT | | 0330EDT ON 4/15/94 THE PATIENT AWOKE AND WAS AWARE THAT THE IMPLANT WAS | | STILL IN PLACE. A FEW MINUTES AFTER 0500EDT THE PATIENT AGAIN AWOKE AND | | CONTACTED THE NURSING STAFF THAT THE IMPLANT WAS DISLODGED ALONGSIDE HER | | THIGH. THE SOURCE WAS IMMEDIATELY RETRIEVED AND STORED PER PROCEDURE. THE | | LICENSEE HAS CONSERVATIVELY CALCULATED THAT THE MAXIMUM DOSE TO THE SKIN ON | | THE THIGH WOULD BE 225 RAD BASED UPON A 1.5 HOUR DIRECT CONTACT WHICH | | SHOULD RESULT IN NO SEVERE ADVERSE HEALTH EFFECTS. THE PATIENT AND | | ATTENDING PHYSICIAN HAVE BOTH BEEN NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27104 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: CLINTON REGION: 3 |NOTIFICATION DATE: 04/15/94 | |UNIT: [1] [ ] [ ] STATE: IL |NOTIFICATION TIME: 15:53 [ET]| |RX TYPE: [1] GE-6 |EVENT DATE: 04/15/94 | +------------------------------------------------+EVENT TIME: 11:15[CDT]| |NRC NOTIFIED BY: GEORGE MOTSEGOOD |LAST UPDATE DATE: 04/15/94 | |HQ OPS OFFICER: STEVE SANDIN +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |ROY CANIANO RDO | |NLTR LICENSEE 24 HR REPORT |BRIAN GRIMES EO | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | LICENSEE IS MAKING A 24 HOUR REPORT PER SECTION 2.G OF THEIR LICENSE FOR | | BRIEFLY EXCEEDING THE LICENSED POWER OF 2894MW. | | | | FOR REASONS UNKNOWN REACTOR RECIRCULATION FLOW CONTROL VALVE (FVC) "A" | | OPENED FROM ITS 57.1% TO 93.3% POSITION INDICATION IN APPROXIMATELY 30 | | SECONDS. THIS CAUSED REACTOR POWER TO INCREASE ABOVE 100% INDICATED FOR | | APPROXIMATELY 34 SECONDS. THE HIGHEST RECORDED POWER WAS 109.8% ON APRM "D" | | [SCRAM SETPOINT IS 111%]. OPERATORS FOLLOWING REACTOR RECIRCULATION | | OPERATING PROCEDURE 3302.01 RESET THE HYDRAULIC POWER UNIT AND MANUALLY | | CLOSED THE AFFECTED FCV IN APPROXIMATELY 6 SECONDS TO A POSITION LESS THAN | | 57.1% CORRESPONDING TO 97% REACTOR POWER. AT THIS TIME THE UNIT BRIEFLY | | ENTERED A TS A/S FOR A LOOP FLOW MISMATCH > 5% BEFORE OPERATORS | | RESTABILIZED FLOW TO LOOP "A" AND TERMINATED THE TRANSIENT AFTER | | APPROXIMATELY 70 SECONDS. THE LICENSEE HAS THE CAUSE OF THE FAILURE UNDER | | INVESTIGATION AND HAS INFORMED THE NRC RESIDENT INSPECTOR. | | | | * * * 1905EDT 4/15/94 FROM CONTROL ROOM TO S.SANDIN * * * | | AT THE TIME OF THE FCV FAILURE OPERATORS WERE PERFORMING AN ADJUSTMENT ON | | THE TEMPERATURE REG VALVE ON THE LOOP "A" HYDRAULIC POWER UNIT. OPERATORS | | TRIPPED THE HYDRAULIC POWER UNIT AFTER RECEIVING AN ALARM. THE LICENSEE | | INTENDS TO TAKE THE UNIT OFFLINE LATE TONIGHT AND SHUTDOWN ON 4/16 FOR A | | MAINTENANCE OUTAGE. NOTIFIED R3DO(CANIANO). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |OTHER NUCLEAR MATERIAL | |EVENT NUMBER: 27105 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: ABBOTT HEALTH PRODUCTS |NOTIFICATION DATE: 04/15/94 | | CITY: ALTA VEGA REGION: 2 |NOTIFICATION TIME: 18:14 [ET]| | COUNTY: STATE: PR |EVENT DATE: 04/15/94 | |LICENSE#: 52-24994-01 AGREEMENT: N |EVENT TIME: 17:25[AT ]| | DOCKET: |LAST UPDATE DATE: 04/15/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |CAUDLE JULIAN RDO | | |CARL PAPERIELLO EO | +------------------------------------------------+ | |NRC NOTIFIED BY: BRUCE MALLETT (REGION 2) | | |HQ OPS OFFICER: STEVE SANDIN | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NINF INFORMATION ONLY | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | ABBOTT HEALTH PRODUCTS LOCATED IN VEGA ALTA, ROAD 690, KM 1.7, PUERTO RICO | | 00762 NOTIFIED REGION 2 THAT AT 1725EDT ON 4/15/94 ONE OF THE TWO CO-60 | | RACKS FAILED TO DROP BACK INTO THE POOL IRRADIATOR AS DESIGNED AFTER | | OPERATORS DEPRESSED THE PUSHBUTTON. LICENSEE TROUBLESHOOTING DETERMINED | | THAT THE SOLENOID VALVE ASSOCIATED WITH THE PNEUMATIC BLEED OFF OF THE LIFT | | HOIST HAD FAILED TO OPERATE. THE PNEUMATIC LINE WAS BROKEN ALLOWING THE | | SOURCE RACK TO FALL INTO THE IRRADIATOR POOL. THE LICENSEE IS PREPARING FOR | | ROOM ENTRY TAKING APPROPRIATE MEASURES TO MONITOR FOR RADIATION. PRIOR TO | | RESTORING OPERATIONS THE LICENSEE HAS AGREED TO CONTACT REGION 2 WITH THE | | RESULTS OF THE INVESTIGATION INTO THE HOIST FAILURE. | | | | * * * 2100EDT 4/15/94 FROM ROYBAS TO MALLETT * * * | | SOLENOIDS REPLACED. THE LICENSEE IS PREPARING TO RESUME OPERATION AND WILL | | PERFORM VERIFICATION TEST FOR OPERABILITY. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27106 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MONTICELLO REGION: 3 |NOTIFICATION DATE: 04/15/94 | |UNIT: [1] [ ] [ ] STATE: MN |NOTIFICATION TIME: 21:40 [ET]| |RX TYPE: [1] GE-3 |EVENT DATE: 04/15/94 | +------------------------------------------------+EVENT TIME: 18:09[CDT]| |NRC NOTIFIED BY: DUANE DISTODEAU |LAST UPDATE DATE: 04/15/94 | |HQ OPS OFFICER: STEVE SANDIN +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |ROY CANIANO RDO | |ARPS 50.72(b)(2)(ii) RPS ACTUATION | | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | A/R Y 100 POWER OPERATION | 0 HOT SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | UNIT SCRAMMED ON LOW CONDENSER VACUUM FOLLOWING AN UNEXPLAINED TRIP OF BOTH | | MAIN CONDENSER CIRCULATING WATER PUMPS. | | | | "AT 1809CDT THE REACTOR SCRAM OCCURRED FROM A LOW MAIN CONDENSER VACUUM. | | THE LOW VACUUM WAS CAUSED BY BOTH MAIN CONDENSER CIRCULATING PUMPS | | TRIPPING. THE MAIN CONDENSER CIRCULATING PUMPS WERE RESTARTED IMMEDIATELY | | AFTER THE REACTOR SCRAM. SECONDARY CONTAINMENT ISOLATION AND STANDBY GAS | | TREATMENT INITIATION OCCURRED. THE REACTOR SCRAM AND SECONDARY CONTAINMENT | | ISOLATION TRIPS HAVE BEEN RESET. FOLLOWUP INVESTIGATION OF THE REACTOR | | SCRAM IS IN PROGRESS." | | | | ALL CONTROL RODS FULLY INSERTED. ALL SAFETY SYSTEMS ARE AVAILABLE WITH | | DECAY HEAT BEING REMOVED VIA THE STEAM DUMPS TO THE MAIN CONDENSER. DURING | | THE TRANSIENT REACTOR VESSEL WATER LEVEL DECREASED TO A MINIMUM OF +8 | | INCHES WHICH RESULTED IN BOTH GROUP 2 AND 3 ISOLATIONS AT +9 INCHES. ALSO, | | THE EMERGENCY FILTRATION TRAINS (EFTs) SWAPPED OVER TO THE HIGH RAD MODE. | | THE LICENSEE SPECULATED THAT THE SWAP OVER WAS DUE TO A POWER SURGE. NORMAL | | REACTOR FEED REMAINED IN SERVICE RECOVERING WATER TO THE NORMAL LEVEL. THE | | CIRCULATING WATER PUMPS ARE POWERED BY SEPARATE NON-VITAL BUSES. THE | | LICENSEE NOTED THAT THE SITE WAS EXPERIENCING HIGH WIND CONDITIONS AND | | RAIN, HOWEVER, NORMAL OFFSITE POWER IS AVAILABLE. THE LICENSEE INFORMED THE | | PRAIRIE ISLAND (BACKUP TO THIS SITE) NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27107 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: DIABLO CANYON REGION: 4 |NOTIFICATION DATE: 04/17/94 | |UNIT: [1] [ ] [ ] STATE: CA |NOTIFICATION TIME: 05:52 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 04/17/94 | +------------------------------------------------+EVENT TIME: 01:35[PDT]| |NRC NOTIFIED BY: ANDERSON |LAST UPDATE DATE: 04/17/94 | |HQ OPS OFFICER: TIM McGINTY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JOHN PELLET RDO | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 REFUELING | 0 REFUELING | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | INADVERTENT AUTO-START OF THE "1-3" EDG. | | | | DURING THE REMOVAL OF A CLEARANCE, AN OPERATOR INADVERTENTLY CLOSED A KNIFE | | SWITCH ON THE VITAL 4 KV BUS "F" STARTUP UNDERVOLTAGE RELAY. AT THE TIME, | | STARTUP POWER WAS NOT AVAILABLE, SO THIS RESULTED IN AN AUTO-START OF | | EMERGENCY DIESEL GENERATOR "1-3". THE OPERATOR WAS ACTUALLY IN THE PROCESS | | OF CLEARING THE TAGOUT WHICH WOULD RESTORE STARTUP POWER TO UNIT 1. | | OPERATORS IMMEDIATELY SECURED THE EDG, AND THE LICENSEE WILL INFORM THE | | RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27108 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SALEM REGION: 1 |NOTIFICATION DATE: 04/17/94 | |UNIT: [1] [2] [ ] STATE: NJ |NOTIFICATION TIME: 12:28 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 04/17/94 | +------------------------------------------------+EVENT TIME: 12:00[EDT]| |NRC NOTIFIED BY: JOE VARGA |LAST UPDATE DATE: 04/17/94 | |HQ OPS OFFICER: STEVE SANDIN +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |WILLIAM LAZARUS RDO | |AOUT 50.72(b)(1)(ii)(B) OUTSIDE DESIGN BASIS | | |NLCO TECH SPEC LCO A/S | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | 2 | N Y 65 POWER OPERATION | 65 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | UNIT 2 DECLARED THE STEAM DRIVEN AUX FEED PUMP INOPERABLE DUE TO A | | MISWIRING OF THE ROOM COOLING DAMPERS WHICH PLACES THE UNIT OUTSIDE ITS | | DESIGN BASIS. | | | | "A REVIEW OF THE AUXILIARY FEED PUMP ROOM COOLER CIRCUIT HAS DISCOVERED A | | CONTACT WIRED INCORRECTLY. THIS MISWIRING RESULTED IN THE ROOM COOLER BEING | | INOPERABLE UNDER NORMAL CONDITIONS AND, UNDER STEAM BREAK CONDITIONS IN THE | | "23" AUX FEED PUMP ROOM, WOULD DUMP STEAM TO THE LOCAL AREAS INSTEAD OF THE | | PENETRATION AREA. ADMINISTRATIVELY AN INOPERABLE ROOM COOLER REQUIRES THE | | APPLICABLE PUMP TO BE DECLARED INOPERABLE. THIS MEANS THE "23" AUX FEED | | PUMP HAS TECHNICALLY BEEN INOPERABLE FOR AN INDETERMINATE PERIOD OF TIME, | | BUT DEFINITELY GREATER THAN THE TIME ALLOWANCE OF 72 HOURS PER TECH SPEC | | 3.7.1.2.D ACTION A. THIS PLACES THE PLANT IN A CONDITION OUTSIDE THE DESIGN | | BASIS." | | | | THIS CONDITION WAS DISCOVERED AT APPROXIMATELY 1500EDT ON 4/16/94 WHILE | | PERFORMING A SURVEILLANCE ON ANOTHER ROOM COOLER. DURING THIS SURVEILLANCE | | DISCREPANCIES WERE FOUND WHICH UPON FURTHER INVESTIGATION IDENTIFIED THE | | MISWIRING. NORMAL SURVEILLANCES WOULD NOT DETECT THIS CONDITION. THE | | MISWIRING CAUSES IMPROPER DAMPER REPOSITIONING DURING A POSTULATED STEAM | | LINE BREAK, i.e., PREVENTS STEAM FROM EXHAUSTING TO OUTSIDE. THE LICENSEE | | IS INVESTIGATING WHETHER UNIT 1 IS AFFECTED (SCHEMATICS SHOW SIGNIFICANT | | DIFFERENCES BETWEEN UNITS). AUX FEED PUMP "23" WAS DECLARED INOPERABLE AT | | 0350EDT ON 4/17. THE LICENSEE ESTIMATES THAT THE MISWIRING WILL BE | | CORRECTED TODAY. THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | | | | * * * UPDATE 1707EDT 4/17/94 FROM VARGA TO SANDIN * * * | | REVIEW OF UNIT 1 DETERMINED THAT THE ROOM COOLER FOR AUX FEED PUMP "13" HAS | | ALSO BEEN MISWIRED. NO TECH SPEC A/S IS APPLICABLE DUE TO THE CURRENT MODE | | OF THE PLANT. THE LICENSEE WILL CORRECT THIS PROBLEM PRIOR TO STARTUP. THE | | LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. NOTIFIED R1DO(LAZARUS) | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27109 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: QUAD CITIES REGION: 3 |NOTIFICATION DATE: 04/17/94 | |UNIT: [ ] [2] [ ] STATE: IL |NOTIFICATION TIME: 12:40 [ET]| |RX TYPE: [1] GE-3,[2] GE-3 |EVENT DATE: 04/17/94 | +------------------------------------------------+EVENT TIME: 10:45[CDT]| |NRC NOTIFIED BY: RONALD K. RUSTICK |LAST UPDATE DATE: 04/17/94 | |HQ OPS OFFICER: STEVE SANDIN +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |ROY CANIANO RDO | |ADEG 50.72(b)(1)(ii) DEGRAD COND DURING OP | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N Y 97 POWER OPERATION | 97 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | UNIT 2 DECLARED AN RCS SAMPLE LINE INOPERABLE DUE TO STICKING SAMPLE LINE | | ISOLATION VALVES DISCOVERED DURING SURVEILLANCE TESTING. | | | | "AT 0850CDT ON 4/17/94, WHILE PERFORMING QCOS 202.12 (QUARTERLY TESTING | | REACTOR RECIRCULATION SYSTEM AIR OPERATED VALVES), THE "220-44" INBOARD | | REACTOR SAMPLE ISOLATION VALVE FAILED TO INDICATE CLOSED ON THE CONTROL | | PANEL. THE COMPUTER INDICATED CLOSED. THE CONTROL SWITCH WAS CYCLED OPEN | | AND THEN CLOSED. THE VALVE THEN INDICATED CLOSED. THE VALVE WAS THEN | | REOPENED AT 0853CDT. THE "220-45" OUTBOARD ISOLATION VALVE WAS TESTED. IT | | DID NOT INDICATE CLOSED IN THE CONTROL ROOM EITHER. AFTER CYCLING THE | | CONTROL SWITCH FOUR TIMES THE CONTROL ROOM LIGHT INDICATION SHOWED CLOSED. | | THE COMPUTER INDICATED THE VALVE WAS CYCLING CORRECTLY. AT 1000CDT IT WAS | | DISCOVERED THAT THE COMPUTER INDICATION IS NOT INDICATIVE OF VALVE | | POSITION. CONTROL ROOM LIGHT INDICATION COMES OFF OF LIMIT SWITCHES | | DIRECTLY MOUNTED TO THE VALVE. AT 1045CDT THE EVENT WAS DETERMINED TO BE 1 | | HOUR REPORTABLE IN ACCORDANCE WITH 10CFR50.72(b)(1)(ii). BOTH ISOLATION | | VALVES WERE CLOSED AT 1000CDT AND THE SAMPLE LINE WAS VERIFIED TO HAVE | | ISOLATED BY EXHIBITING NO FLOW AT THE SAMPLE SINK." | | | | THE COMPUTER RECEIVES DEMANDED VALVE POSITION FROM AUX CONTACTS ON THE | | CONTROL SWITCH AS OPPOSED TO ACTUAL VALVE POSITION FROM A LIMIT SWITCH. THE | | LICENSEE HAS INITIATED A WORK REQUEST TO INVESTIGATE THE CAUSE OF THE | | VALVES STICKING WITH CORRECTIVE ACTION UNDER EVALUATION. THESE VALVES WERE | | LAST EXERCISED APPROXIMATELY 3 MONTHS AGO ON 1/17/94 WITH NO RECORD OF ANY | | PROBLEMS AT THAT TIME. WITH BOTH VALVES CLOSED AND INOPERABLE THIS PLACES | | UNIT 2 IN TS 3.7.D.2. WHICH ALLOWS CONTINUED OPERATION PROVIDED THAT THE | | LINE IS ISOLATED BY AT LEAST ONE VALVE. ALTERNATE RCS SAMPLING IS AVAILABLE | | FROM THE REACTOR WATER CLEANUP (RWCU) SYSTEM. THE LICENSEE WILL INFORM THE | | NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27110 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: RIVER BEND REGION: 4 |NOTIFICATION DATE: 04/17/94 | |UNIT: [1] [ ] [ ] STATE: LA |NOTIFICATION TIME: 18:21 [ET]| |RX TYPE: [1] GE-6 |EVENT DATE: 04/17/94 | +------------------------------------------------+EVENT TIME: 16:43[CDT]| |NRC NOTIFIED BY: GEORGE D. TURNER, JR. |LAST UPDATE DATE: 04/17/94 | |HQ OPS OFFICER: STEVE SANDIN +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JOHN PELLET RDO | |DDDD 73.71 UNSPECIFIED PARAGRAPH | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | LICENSEE DISCOVERED THAT A CONTRACT EMPLOYEE WITH PROTECTED AREA ACCESS HAD | | FALSIFIED EMPLOYMENT APPLICATION. COMPENSATORY MEASURES TAKEN. SEE HOO LOG | | FOR DETAILS. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27111 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SEQUOYAH REGION: 2 |NOTIFICATION DATE: 04/17/94 | |UNIT: [1] [2] [ ] STATE: TN |NOTIFICATION TIME: 20:20 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 04/17/94 | +------------------------------------------------+EVENT TIME: 16:43[EDT]| |NRC NOTIFIED BY: JEFF EPPERSON |LAST UPDATE DATE: 04/17/94 | |HQ OPS OFFICER: STEVE SANDIN +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |CAUDLE JULIAN RDO | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 8 STARTUP | 8 STARTUP | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MALFUNCTIONING IODINE RAD MONITOR CAUSED INITIATION OF BOTH AUXILIARY | | BUILDING GAS TREATMENT TRAINS. | | | | "AT 1643EDT ON 17 APRIL 94 A MALFUNCTION IN THE IODINE MONITOR OF THE | | AUXILIARY BUILDING EXHAUST RADIATION MONITOR RESULTED IN AN AUXILIARY | | BUILDING ISOLATION AND THE ASSOCIATED AUTOMATIC START OF THE AUXILIARY | | BUILDING GAS TREATMENT SYSTEM. ALL SUPPORT SYSTEMS FUNCTIONED AS REQUIRED. | | RADCON SURVEYS INDICATED THAT NO UNUSUAL RADIATION LEVELS EXIST IN THE | | AUXILIARY BUILDING. AT PRESENT BOTH TRAINS OF AUXILIARY BUILDING GAS | | TREATMENT SYSTEM ARE STILL IN SERVICE AS WE AWAIT REMOVAL OF THE | | MALFUNCTIONING RADIATION MONITOR FROM SERVICE." | | | | THE AFFECTED RAD MONITOR IS "0-RM-90-101C". WHEN THE RAD MONITOR IS REMOVED | | FROM SERVICE THE LICENSEE WILL COMPLY WITH THE REQUIREMENTS OF THE OFFSITE | | DOSE CALCULATION (ODC) MANUAL WHICH REQUIRES PERIODIC SAMPLING. THE | | LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27112 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: HATCH REGION: 2 |NOTIFICATION DATE: 04/18/94 | |UNIT: [ ] [2] [ ] STATE: GA |NOTIFICATION TIME: 05:41 [ET]| |RX TYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 04/18/94 | +------------------------------------------------+EVENT TIME: 04:45[CDT]| |NRC NOTIFIED BY: BUTLER |LAST UPDATE DATE: 04/18/94 | |HQ OPS OFFICER: TIM McGINTY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: | | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N N 0 REFUELING | 0 REFUELING | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | PARTIAL GROUP 2 ISOLATION WHEN AN ELECTRICIAN BUMPED A FUSE. | | | | AN ELECTRICIAN WAS RESTORING A CLEARANCE RELATIVE TO THE STROKING AND SETUP | | OF THE MSIVs WHEN HE BUMPED ANOTHER FUSE IN THE PANEL. THIS RESULTED IN A | | PARTIAL GROUP 2 ISOLATION. THE ELECTRICIAN RESEATED THE FUSE IN THE HOLDER | | WHEN HE NOTICED IT WAS LOOSE, WHICH CLEARED THE ISOLATION SIGNAL. OPERATORS | | SUBSEQUENTLY RESTORED THE AFFECTED SYSTEMS TO NORMAL. | | | | THE PARTIAL GROUP 2 ISOLATION CAUSED THE DRYWELL EQUIPMENT AND FLOOR DRAIN | | SUMP OUTBOARD VALVES AND THE "B" HYDROGEN/OXYGEN ANALYZER ISOLATION VALVES | | TO CLOSE. THE LICENSEE PULLED THE PRINTS AND VERIFIED THAT THE ISOLATIONS | | WERE CONSISTENT WITH THAT FUSE BEING BUMPED, AND ALL SYSTEMS OPERATED AS | | DESIGNED. THE ELECTRICIAN WAS IN THE "2H11 P623" PANEL. THE LICENSEE WILL | | INFORM THE RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+