U.S. Nuclear Regulatory Commission Operations Center Event Reports For 04/18/94 - 04/19/94 ** EVENT NUMBERS ** 27112 27113 27114 27115 27116 27117 27118 +----------------------------------+ +-----------------------+ |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: 03:45[CDT]| |NRC NOTIFIED BY: BUTLER |LAST UPDATE DATE: 04/18/94 | |HQ OPS OFFICER: TIM McGINTY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 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. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27113 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BROWNS FERRY REGION: 2 |NOTIFICATION DATE: 04/18/94 | |UNIT: [ ] [2] [ ] STATE: AL |NOTIFICATION TIME: 07:22 [ET]| |RX TYPE: [1] GE-4,[2] GE-4,[3] GE-4 |EVENT DATE: 04/18/94 | +------------------------------------------------+EVENT TIME: 03:55[CDT]| |NRC NOTIFIED BY: SMITH |LAST UPDATE DATE: 04/18/94 | |HQ OPS OFFICER: TIM McGINTY +-----------------------------+ +------------------------------------------------+ 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 | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | A/R Y 14 STARTUP | 0 HOT SHUTDOWN | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | DURING A STARTUP, THE UNIT 2 REACTOR SCRAMMED ON AN MSIV CLOSURE IN | | RESPONSE TO LOWERING REACTOR PRESSURE DUE TO ALL 9 BYPASS VALVES FAILING | | OPEN. | | | | WHILE PERFORMING A UNIT STARTUP, ALL NINE BYPASS VALVES FAILED OPEN AND THE | | RESULTING MAIN STEAM ISOLATION VALVES SHUT ON MAIN STEAM LINE LOW PRESSURE. | | THE UNIT 2 REACTOR RESPONDED AS EXPECTED, WITH ALL RODS FULLY INSERTED AND | | NO OTHER COMPLICATIONS. ADDITIONALLY, ON THE SHRINK AFTER THE SCRAM, THE | | FOLLOWING PCIS ISOLATIONS OCCURRED AT +11" (LOWEST LEVEL REACHED WAS -10"); | | -GROUP 2 (DRYWELL SUMP DISCHARGE VALVES) | | -GROUP 3 (RWCU) | | -GROUP 6 (PRIMARY AND SECONDARY CONTAINMENT) | | -GROUP 8 (TRAVERSING IN-CORE PROBES). | | | | STANDBY GAS TREATMENT AND CONTROL ROOM EMERGENCY VENTILATION ALSO | | AUTO-INITIATED. THE PLANT IS STABLE IN HOT SHUTDOWN, AND AN INVESTIGATION | | INTO THE BYPASS VALVE FAILURE HAS BEEN INITIATED. | | | | AT THE TIME OF THE EVENT, ABOUT 3.5 BYPASS VALVES WERE ALREADY OPEN | | (CAPACITY OF EACH IS ABOUT 3.5%), WHEN THE REMAINING BYPASSES WENT FULL | | OPEN. THE LICENSEE INFORMED THE RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 27114 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: SAINT JOHN'S MERCY MEDICAL CENTER |NOTIFICATION DATE: 04/18/94 | | CITY: ST. LOUIS REGION: 3 |NOTIFICATION TIME: 09:44 [ET]| | COUNTY: STATE: MO |EVENT DATE: 04/15/94 | |LICENSE#: 24-00794-03 AGREEMENT: N |EVENT TIME: 23:30[CDT]| | DOCKET: |LAST UPDATE DATE: 04/18/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |GEOFFREY WRIGHT RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: QUINT | | |HQ OPS OFFICER: TIM McGINTY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | 20% UNDERDOSE DURING BRACHYTHERAPY AT SAINT JOHN'S MERCY MEDICAL CENTER, | | LOCATED IN SAINT LOUIS, MO.. | | | | THE LICENSEE REPORTED A MISADMINISTRATION DURING A BRACHYTHERAPY PROCEDURE | | THIS WEEKEND. THE PATIENT WAS UNDERDOSED BY ABOUT 24% IN THIS CASE. THE | | PATIENT WAS TO RECEIVE OVOIDS IN TANDEM (ABOUT 63 mg EQUIVALENT Cs-137), | | HOWEVER THE TANDEM WAS INADVERTENTLY NOT ADMINISTERED (LEFT IN THE SAFE). | | IT APPEARS THAT THE ADMINISTRATING PHYSICIAN SIMPLY OVERLOOKED THE TANDEM | | (3 SOURCES) AFTER HAVING PUT IN THE TWO OVOIDS (AT 12.8 mg EQUIVALENT | | Cs-137 EACH). THERE ARE NOT EXPECTED TO BE ANY ADVERSE EFFECTS TO THE | | PATIENT, AND THE RSO WILL BE INFORMING THE PATIENTS PHYSICIAN. THE RSO | | WILL ALSO BE NOTIFYING THE REGION. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 27115 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: GEISINGER MEDICAL CENTER |NOTIFICATION DATE: 04/18/94 | | CITY: DANVILLE REGION: 1 |NOTIFICATION TIME: 14:07 [ET]| | COUNTY: STATE: PA |EVENT DATE: 04/18/94 | |LICENSE#: 3701421-01 AGREEMENT: N |EVENT TIME: 11:45[EDT]| | DOCKET: |LAST UPDATE DATE: 04/18/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |GENE KELLY RDO | | |BRACH EO | +------------------------------------------------+ | |NRC NOTIFIED BY: ANDERKO | | |HQ OPS OFFICER: CHAUNCEY GOULD | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE LICENSEE REPORTED A MEDICAL MISADMINISTRATION WHEN A PATIENT RECEIVED A | | HIGHER DOSE OF IODINE 131 THAN WHAT WAS INTENDED DUE TO PERSONNEL ERROR. | | | | THE PATIENT WAS TO RECEIVE AN INTENDED DOSE OF 157 MICROCURIES OF IODINE | | 131 FOR A DIAGNOSTIC TEST FOR NEUROBLASTOMA, BUT INSTEAD RECEIVED 430 | | MICROCURIES. THE TECHNOLOGIST HAD THE CORRECT WRITTEN DIRECTIVE FOR 157 | | MICROCURIES, BUT FOR SOME REASON HE DREW UP THE INCORRECT AMOUNT, ASSAYED | | IT AND INJECTED THE INCORRECT AMOUNT. THE REFERRING PHYSICIAN WAS NOTIFIED | | IMMEDIATELY AND THEY DO NOT EXPECT ANY ADVERSE EFFECTS TO THE PATIENT. THIS | | EVENT WAS REPORTED BY GEISINGER MEDICAL CENTER, DANVILLE, Pa. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27116 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BRUNSWICK REGION: 2 |NOTIFICATION DATE: 04/18/94 | |UNIT: [1] [ ] [ ] STATE: NC |NOTIFICATION TIME: 15:06 [ET]| |RX TYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 04/18/94 | +------------------------------------------------+EVENT TIME: 11:11[EDT]| |NRC NOTIFIED BY: LONG |LAST UPDATE DATE: 04/18/94 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |CAUDLE JULIAN RDO | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | |NLCO TECH SPEC LCO A/S | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | RCIC INBOARD STEAM SUPPLY ISOLATION VALVE INADVERTENTLY CLOSED DUE TO | | PERSONNEL ERROR. THIS MADE RCIC INOP AND PUT THEM IN A 30 DAY LCO ACTION | | STATEMENT. | | | | THIS OCCURRED DURING RCIC TURBINE EXHAUST DIAPHRAGM HIGH PRESSURE | | INSTRUMENT CHANNEL CALIBRATION. THE PROCEDURE REQUIRES VERIFICATION THAT | | EACH PRESSURE CHANNEL RELAY WILL PICKUP AT A NOMINAL PRESSURE OF 5LBS. EACH | | DIVISION HAS TWO CONTACTS IN SERIES OFF OF DIFFERENT PRESSURE SWITCHES. | | BOTH OF THESE SERIES CONTACTS MUST CLOSE TO PICKUP THE RELAY TO GIVE EITHER | | A DIVISION "1" OR "2" ISOLATION WHICH CLOSES STEAM ISOLATION VALVE. | | | | THE FIRST THING VERIFIED DURING TESTING IS THAT THERE IS NO VOLTAGE ON THE | | TWO CONTACTS THAT GO AROUND THE SWITCH BEING CHECKED. LACK OF VOLTAGE | | MEANS THE SECOND TWO CONTACTS FOR THE OTHER PRESSURE SWITCHES ARE OPEN AND | | IT IS OK TO TEST THE SWITCH THAT IS ISOLATED. AFTER THE LICENSEE PERFORMED | | THIS INITIAL CONTACT VOLTAGE VERIFICATION THEY WENT BACK TO CHECK THE SAME | | TWO CONTACTS. WHEN THEY DID THIS, HOWEVER, THEY WENT ONE CONTACT TOO | | FAR(SHOULD HAVE GONE BETWEEN 1 & 2, NOT BETWEEN 1 & 3) AND THE OHM METER | | JUMPERED AROUND BOTH SETS OF CONTACTS AND PICKED UP THE RELAY RESULTING IN | | THE ISOLATION. THEY HAD BOTH HPCI AND ADS OPERABLE AS REQUIRED BY THE TS | | LCO, AND WHEN THEY DETERMINED THE CAUSE AND RETURNED TO INITIAL CONDITIONS, | | THEY EXITED THE LCO AT 12:58. THE RI WAS INFORMED. | | | | | | HOO NOTE: SEE EVENT #27117. DIFFERENT TECHNICIANS WERE INVOLVED IN THESE | | EVENTS. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27117 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BRUNSWICK REGION: 2 |NOTIFICATION DATE: 04/18/94 | |UNIT: [1] [ ] [ ] STATE: NC |NOTIFICATION TIME: 20:28 [ET]| |RX TYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 04/18/94 | +------------------------------------------------+EVENT TIME: 17:18[EDT]| |NRC NOTIFIED BY: ATKINSON |LAST UPDATE DATE: 04/18/94 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |CAUDLE JULIAN RDO | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | |NLCO TECH SPEC LCO A/S | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | RCIC OUTBOARD STEAM SUPPLY ISOLATION VALVE INADVERTENTLY CLOSED DUE TO | | PERSONNEL ERROR. THIS MADE RCIC INOP AND PUT THEM IN A 30 DAY LCO ACTION | | STATEMENT. | | | | THIS OCCURRED DURING RCIC STEAM LINE LOW PRESSURE INSTRUMENT CHANNEL | | CALIBRATION. IT APPEARS THAT AFTER THE I & C TECHNICIAN HAD CONNECTED A DVM | | TO MEASURE VOLTAGE TO VERIFY CONTACTS HAD CLOSED AS PER PROCEDURE. THE | | TECHNICIAN APPARENTLY STEPPED BACK FROM THE PANEL TO REVIEW THE PROCEDURE | | AND INADVERTENTLY PULLED THE LEADS LOOSE. THE UNLANDED LEADS (WHICH WERE | | ASSUMED TO HAVE BEEN PULLED FROM THE PANEL TERMINALS, WERE IN FACT PULLED | | LOOSE FROM THE DVM) WERE RECONNECTED TO THE CABINET TERMINALS LISTED IN THE | | NEXT STEP IN THE PROCEDURE. THIS CONNECTION PROVIDED A CLOSED CIRCUIT TO | | POWER THE ISOLATION RELAY WHICH CAUSED THE VALVE TO CLOSE. THEY ARE STILL | | IN THE LCO SINCE THEY HAVE NOT OPENED THE ISOLATION VALVE AND RETURNED RCIC | | TO OPERABLE STATUS. THE RI WAS NOTIFIED. | | | | | | HOO NOTE: SEE EVENT # 27116. DIFFERENT TECHNICIANS WERE INVOLVED IN THESE | | EVENTS. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27118 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: DRESDEN REGION: 3 |NOTIFICATION DATE: 04/18/94 | |UNIT: [ ] [2] [ ] STATE: IL |NOTIFICATION TIME: 21:36 [ET]| |RX TYPE: [1] GE-1,[2] GE-3,[3] GE-3 |EVENT DATE: 04/18/94 | +------------------------------------------------+EVENT TIME: 17:41[CDT]| |NRC NOTIFIED BY: LIZALEK |LAST UPDATE DATE: 04/18/94 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |GEOFFREY WRIGHT RDO | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | |NLCO TECH SPEC LCO A/S | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N Y 99 POWER OPERATION | 99 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE PLANT ENTERED A 24 HR LCO ACTION STATEMENT TO BE IN COLD SHUTDOWN DUE | | TO THE "2/3" EMERGENCY DIESEL AND THE "2A" CORE SPRAY SYSTEM BEING INOP. | | | | THIS CONDITION WAS IDENTIFIED WHEN THEY RECEIVED THE FOLLOWING ALARMS, | | LPCI/CORE SPRAY PUMP AT PRESSURE, CORE SPRAY PUMP RUNNING, CORE SPRAY PUMP | | TRIP AND CORE SPRAY PUMP HEADER LEAK. IMMEDIATE ATTENTION WAS GIVEN TO THE | | CORE SPRAY SYSTEM AND IT WAS DETERMINED THAT THE "2A" CORE SPRAY PUMP HAD | | AUTO STARTED. IT WAS IMMEDIATELY NOTED THAT DRYWELL PRESSURE AND REACTOR | | WATER LEVEL AS WELL AS ELECTRICAL POWER WERE ALL NORMAL. THE PUMP WAS THEN | | IMMEDIATELY PLACED IN PULL-TO-LOCK, SINCE IT WAS DETERMINED TO BE A | | SPURIOUS INITIATION. AN INVESTIGATION WAS STARTED TO DETERMINE THE CAUSE OF | | THE SPURIOUS INITIATION AND IT WAS REVEALED TO BE RELATED TO WORK BEING | | DONE IN THE "2/3" EDG CUBICLE OF BUS "23-1". THEY WERE WORKING ON | | DETERMINING AUXILIARY CONTACTS IN THE CUBICLE, WITH MANY OF THE WIRE LEADS | | BEING ENERGIZED DURING THE PERFORMANCE OF THE TASK. ONE OF THESE ENERGIZED | | LEADS WAS REMOVED FROM ITS TERMINAL STRIP AND ACCIDENTALLY CONTACTED | | MULTIPLE OTHER CONNECTIONS. AT THIS POINT THE WORKER NOTICED AN ELECTRICAL | | SPARK AND HEARD THE CORE SPRAY PUMP BREAKER ACTUATE. THE LIVE WIRE WAS | | TAPED AND INSULATED, AND AT 20:09 THE PUMP WAS TAKEN OUT OF PULL-TO-LOCK | | AND RETURNED TO NORMAL. OPERABILITY SURVEILLANCES FOR THE PUMP WILL BE | | PERFORMED IMMEDIATELY, SO THAT THEY CAN EXIT THE LCO. THEIR OTHER EMERGENCY | | SYSTEMS ARE OPERABLE AND THEY ARE CONTINUING THE INVESTIGATION TO DETERMINE | | IF IT'S DUE TO PERSONNEL ERROR. THE RI WAS INFORMED. | +------------------------------------------------------------------------------+