U.S. Nuclear Regulatory Commission Operations Center Event Reports For 04/22/94 - 04/25/94 ** EVENT NUMBERS ** 27029 27134 27135 27136 27137 27138 27139 27140 27141 27142 27143 27144 27145 27146 27147 27148 27149 27150 27151 27152 27153 27154 27155 27156 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27029 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PRAIRIE ISLAND REGION: 3 |NOTIFICATION DATE: 03/31/94 | |UNIT: [1] [ ] [ ] STATE: MN |NOTIFICATION TIME: 23:14 [ET]| |RX TYPE: [1] W-2-LP,[2] W-2-LP |EVENT DATE: 03/31/94 | +------------------------------------------------+EVENT TIME: 18:59[CST]| |NRC NOTIFIED BY: RON HOLPHE |LAST UPDATE DATE: 04/22/94 | |HQ OPS OFFICER: RUDY KARSCH +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |GARY SHEAR 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 100 POWER OPERATION | 100 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | COOLING WATER PUMP "121" AUTO-STARTED DUE TO A NEGATIVE PRESSURE SPIKE | | WHILE SECURING THE "12" EDG COOLING PUMP FOLLOWING POST MAINTENANCE | | TESTING. THE "121" PUMP WAS NOT LINED UP FOR SAFEGUARDS OPERATION AT THE | | TIME OF THE AUTO-START. THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | | | | ****UPDATE @ 1042EDT 04/22/94 BY TERRY SILVERBERG TAKEN BY MACKINNON**** | | LICENSEE IS RETRACTING THIS EVENT. AFTER DISCUSSIONS WITH THE SENIOR | | RESIDENT INSPECTOR & REGION 3, STAFF ENGINEERING HAS DETERMINED THAT THIS | | EVENT WAS NOT REPORTABLE AND THEY ARE RETRACTING THIS EVENT. COOLING WATER | | PUMP "121" WAS UPGRADED SO IT COULD BE ALIGNED AND USED AS A SAFEGUARDS | | PUMP WHEN ONE OF THEIR TWO SAFEGUARDS PUMPS WAS INOPERABLE. AT THE TIME | | WHEN COOLING WATER PUMP "121" AUTO-STARTED DUE TO A NEGATIVE PRESSURE SPIKE | | IT WAS NOT ALIGNED FOR SAFEGUARDS OPERATION. LICENSEE SAID THAT BOTH OF | | THEIR SAFEGUARDS PUMPS WERE PROPERLY ALIGNED & FULLY OPERABLE IF NEEDED | | WHEN COOLING WATER PUMP "121" AUTO-STARTED. R3DO (JEFF WRIGHT) NOTIFIED. | | | | RESIDENT INSPECTOR WAS INFORMED OF THIS RETRACTION BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27134 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PERRY REGION: 3 |NOTIFICATION DATE: 04/22/94 | |UNIT: [1] [ ] [ ] STATE: OH |NOTIFICATION TIME: 01:20 [ET]| |RX TYPE: [1] GE-6 |EVENT DATE: 04/21/94 | +------------------------------------------------+EVENT TIME: 22:25[EDT]| |NRC NOTIFIED BY: MIKE NEMCEK |LAST UPDATE DATE: 04/22/94 | |HQ OPS OFFICER: RUDY KARSCH +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |GEOFFREY WRIGHT 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 +------------------------------------------------------------------------------+ | ENGINEERED SAFETY FEATURES ACTUATION, BALANCE OF PLANT (BOP) ISOLATION, DUE | | TO HUMAN ERROR. | | | | SEVEN BOP ISOLATION VALVES HAD BEEN OPENED AND DEENERGIZED. WHEN THE | | DIVISION 2 13.8KV BUS, "EH12", WAS REENERGIZED THE 120 VAC INSTRUMENTATION | | BUS FED BY "EH12" DID NOT REENERGIZED BECAUSE REQUIRED FUSES HAD NOT BEEN | | REPLACED. PROCEDURAL PAPER WORK HAD BEEN SIGNED OFF INDICATING THAT THE | | FUSES HAD BEEN REPLACED. WHEN THE SEVEN BOP ISOLATION VALVES WERE | | REENERGIZED THEY CLOSED BECAUSE OF THE DEENERGIZED 120 VAC INSTRUMENTATION | | BUS. THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27135 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: COMANCHE PEAK REGION: 4 |NOTIFICATION DATE: 04/22/94 | |UNIT: [ ] [2] [ ] STATE: TX |NOTIFICATION TIME: 02:52 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 04/22/94 | +------------------------------------------------+EVENT TIME: 00:15[CDT]| |NRC NOTIFIED BY: TRAVIS BROUGHTON |LAST UPDATE DATE: 04/22/94 | |HQ OPS OFFICER: RUDY KARSCH +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |LAWRENCE YANDELL 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 N 0 HOT STANDBY | 0 HOT STANDBY | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | RPS ACTUATION DUE TO A NOISE SPIKE ON A SOURCE RANGE NUCLEAR | | INSTRUMENTATION CHANNEL. | | | | WHILE PERFORMING SOLID STATE PROTECTION (SSPS) CHANNEL "B" TESTING WITH | | SHUTDOWN BANKS WITHDRAWN, SOURCE RANGE CHANNEL "N-32" SPIKED HIGH | | GENERATING A TRIP SIGNAL ON TRAIN "A". THE CAUSE OF THE SPIKE IS BEING | | INVESTIGATED BECAUSE "N-32" SHOULD HAVE BEEN DEENERGIZED DURING THIS PHASE | | OF THE TEST. ALL RODS FULLY INSERTED. THE RCS HAD PREVIOUSLY BEEN BORATED | | TO COLD SHUTDOWN CONDITIONS. THE LICENSEE ELECTED TO INVOKE 10CFR50.54X BY | | NOT OPENING REACTOR TRIP BREAKER "B" AS REQUIRED BY EOP 00, STEP 1, TO | | ALLOW SSPS TO REMAIN UNCHANGED TO FACILITATE TROUBLE SHOOTING. THE | | FEEDWATER PREHEATER BYPASS VALVES WERE OPEN AND CLOSED ON THE REACTOR TRIP | | DUE TO P4. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | | | | * * * UPDATE 04/22/94 1202EDT FROM:MOORE BY:SCARFO * * * | | THE LICENSEE IS RETRACTING THE PORTION OF THIS NOTIFICATION RELATING TO | | 10CFR50.54X ON THE BASIS THAT NO DEVIATION FROM LICENSE CONDITIONS OR | | TECHNICAL SPECIFICATIONS OCCURRED. THE LICENSEE CONTENDS THAT A MINOR | | DEVIATION FROM A TECHNICAL PROCEDURE OCCURRED AND THIS DEVIATION DID NOT | | WARRANT THE INVOCATION OF 50.54X. REACTOR TRIP BREAKER "B" WAS NOT OPENED | | TO FACILITATE TROUBLESHOOTING OF THE RPS SIGNAL. R4DO(YANDELL) NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27136 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BRUNSWICK REGION: 2 |NOTIFICATION DATE: 04/22/94 | |UNIT: [1] [ ] [ ] STATE: NC |NOTIFICATION TIME: 04:56 [ET]| |RX TYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 04/22/94 | +------------------------------------------------+EVENT TIME: 02:19[EDT]| |NRC NOTIFIED BY: GLEN LONG |LAST UPDATE DATE: 04/22/94 | |HQ OPS OFFICER: RUDY KARSCH +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |PAUL FREDRICKSON 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 100 POWER OPERATION | 100 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | ISOLATION OF THE REACTOR WATER CLEANUP (RWCU) SYSTEM AND SECONDARY | | CONTAINMENT AND INITIATION OF STANDBY GAS TREATMENT SYSTEM (SBGTS) DUE TO | | REFERENCE LEG PERTURBATION. | | | | THE FOLLOWING IS THE TEXT OF A LICENSEE FAX: | | "WHILE PERFORMING A VALVE LINE UP ON AN INSTRUMENT RACK FOR REACTOR WATER | | LEVEL AND PRESSURE INSTRUMENTS A DIVISION 1 RWCU ISOLATION, SECONDARY | | CONTAINMENT ISOLATION AND A SBGTS INITIATION OCCURRED. | | | | "DURING A HANDS ON VERIFICATION OF AN INSTRUMENT VALVE, THE AUXILIARY | | OPERATOR ATTEMPTED TO MOVE THE VALVE IN THE CLOSED DIRECTION PER PROCEDURE. | | THIS APPARENTLY CREATED A PERTURBATION IN THE REFERENCE LEG AND CAUSED A | | MOMENTARY FALSE LOW LEVEL 2 (112 INCHES) SIGNAL WHICH RESULTED IN THE ABOVE | | ACTUATIONS. | | | | "VERIFIED THE SIGNAL TO BE FALSE USING MULTIPLE INDICATIONS, RESET THE | | ACTUATIONS AND RETURNED RWCU, SBGTS AND THE REACTOR BUILDING VENTILATION | | SYSTEM TO NORMAL OPERATION. FOLLOW UP INVESTIGATION WILL BE IN ACCORDANCE | | WITH THE PLANT'S CORRECTIVE ACTION PROGRAM." | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27137 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: LIMERICK REGION: 1 |NOTIFICATION DATE: 04/22/94 | |UNIT: [ ] [2] [ ] STATE: PA |NOTIFICATION TIME: 05:39 [ET]| |RX TYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 04/22/94 | +------------------------------------------------+EVENT TIME: 03:45[EDT]| |NRC NOTIFIED BY: GREGORY COLLINS |LAST UPDATE DATE: 04/22/94 | |HQ OPS OFFICER: RUDY KARSCH +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |HAROLD GRAY 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 Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | ISOLATION OF THE DRYWELL H2/O2 ANALYZER DUE TO A BLOWN FUSE. | | | | THE FOLLOWING IS THE TEXT OF A LICENSEE FAX: | | "AT 0345 HOURS ON 04/22/94, A U/2 INADVERTENT ESF ACTUATION OCCURRED WHEN | | FUSE C71A-F32A IN FUSE PANEL 20C609 BLEW, CAUSING A 6C ISOLATION. VALVES | | SV-57-233, 283, & 291 CLOSED ISOLATING 20S206 DRYWELL H2/02 ANALYZER. ALSO | | AS A RESULT, U/2 RECEIVED AN A-1 HALF SCRAM. NO TESTING WAS IN PROGRESS AT | | THIS TIME. THE BLOWN FUSE WAS FOUND APPROXIMATELY 0410 HOURS. ALL | | EXPECTED ACTIONS DID OCCUR. I&C TECHNICIANS ARE INVESTIGATING TO PIN POINT | | THE CAUSE." | | | | THE FUSE WAS REPLACED. A BAD CARD FOR HIGH DRYWELL PRESSURE WAS FOUND. | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27138 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SOUTH TEXAS REGION: 4 |NOTIFICATION DATE: 04/22/94 | |UNIT: [1] [ ] [ ] STATE: TX |NOTIFICATION TIME: 12:13 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 04/22/94 | +------------------------------------------------+EVENT TIME: 10:30[CDT]| |NRC NOTIFIED BY: KEEN |LAST UPDATE DATE: 04/22/94 | |HQ OPS OFFICER: GREG SCARFO +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |LAWRENCE YANDELL RDO | |KFIS 70.52(b) LOSS OF SNM/FISSILE | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | 0.64 NANOGRAMS OF PLUTONIUM-238 WAS LOST. | | | | FOUR RADIATION MONITOR CHECK SAMPLES OF PLUTONIUM-238 WERE DISCOVERED | | MISSING FROM THEIR STORAGE CABINET. EACH CHECK SAMPLE CONTAINED | | APPROXIMATELY 0.16 NANOGRAMS OF PLUTONIUM-238 (TOTAL OF 0.64 NANOGRAMS OF | | PU-238) IN A FILTER CARTRIDGE. THESE SAMPLES WERE PROCURED TO ENSURE THE | | FUNCTIONALITY OF RADIATION MONITORS BUT WERE NOT INCORPORATED INTO THE | | PLANT'S SPECIAL NUCLEAR MATERIAL CONTROL PROGRAM. | | | | THE LICENSEE BELIEVES THAT THE CHECK SAMPLES MAY HAVE BEEN DISPOSED OF IN A | | SOLID RADIOACTIVE WASTE SHIPMENT. AN INVESTIGATION INTO THE WHEREABOUTS OF | | THE SAMPLES IS ONGOING. THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |GENERAL INFORMATION or OTHER | |EVENT NUMBER: 27139 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: DEPARTMENT OF THE NAVY |NOTIFICATION DATE: 04/22/94 | | CITY: WASHINGTON REGION: 1 |NOTIFICATION TIME: 12:31 [ET]| | COUNTY: STATE: DC |EVENT DATE: 04/22/94 | |LICENSE#: 45-23645-01NA AGREEMENT: N |EVENT TIME: 09:30[EDT]| | DOCKET: |LAST UPDATE DATE: 04/22/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |PAUL FREDRICKSON RDO | | |PAPIERELLO EO | +------------------------------------------------+ | |NRC NOTIFIED BY: MALINOSKI | | |HQ OPS OFFICER: GREG SCARFO | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |MAAI 36.83(a)(9) ABNOR WATER LOSS | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MR. MALINOSKI OF THE NAVAL RESEARCH LABORATORY OF WASHINGTON, DC, REPORTED | | THAT THE COBALT-60 POOL IRRADIATOR WEEKLY CONDUCTIVITY MEASUREMENT WAS | | OUTSIDE OF THE ACCEPTABLE LIMIT OF 10CFR36.83. | | | | MR. MALINOSKI OF THE NAVAL RESEARCH LABORATORY OF WASHINGTON, DC, REPORTED | | THAT THE COBALT-60 POOL IRRADIATOR WEEKLY CONDUCTIVITY MEASUREMENT WAS 400 | | MICROSIEMENS, ABOVE THE 100 MICROSIEMENS 10CFR36.83 LIMIT. THIS CONDITION | | WAS ATTRIBUTED TO A SPENT ION-EXCHANGE RESIN COLUMN USED TO FILTER THE POOL | | WATER. IRRADIATOR ACTIVITIES WERE SECURED AND PROCUREMENT OF A NEW | | ION-EXCHANGE RESIN COLUMN WAS INITIATED. A POOL SAMPLE WAS TAKEN FOR A | | RADIATION SURVEY AND THE RESULTS INDICATE ACTIVITY LEVELS BELOW THE MINIMUM | | DETECTABLE ACTIVITY LEVEL OF 1E-8 MICROCURIE PER MILLILITER. REGION II | | PERSONNEL HAVE BEEN NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27140 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MILLSTONE REGION: 1 |NOTIFICATION DATE: 04/22/94 | |UNIT: [1] [ ] [ ] STATE: CT |NOTIFICATION TIME: 14:20 [ET]| |RX TYPE: [1] GE-3,[2] CE,[3] W-4-LP |EVENT DATE: 04/22/94 | +------------------------------------------------+EVENT TIME: 13:55[EDT]| |NRC NOTIFIED BY: CHUNIS |LAST UPDATE DATE: 04/22/94 | |HQ OPS OFFICER: GREG SCARFO +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |HAROLD GRAY RDO | |KFIS 70.52(b) LOSS OF SNM/FISSILE | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | TWO INTERMEDIATE RANGE MONITOR (IRM) SOURCES WERE LOST FROM THE DRYWELL | | SUMP. | | | | PRIOR TO 1985, IT WAS A COMMON PRACTICE TO STORE SPENT IRMs IN THE DRYWELL | | SUMP. THIS PRACTICE WAS STOPPED IN 1985. CURRENT DOCUMENTATION INDICATES | | THAT FOUR IRMs SHOULD BE STORED IN THE DRYWELL SUMP. DURING A RECENT | | CLEANING OF THE DRYWELL SUMP, ONLY TWO OF THE FOUR IRMs COULD BE LOCATED. | | THE TWO RECOVERED IRMs REGISTERED A DOSE RATE OF 500 MILLIREM PER HOUR ON | | CONTACT. IT IS ASSUMED THAT THE TWO MISSING IRMs WOULD BE EQUIVALENT IN | | DOSE RATE. AT 1355EDT, DRYWELL SUMP CLEANING WAS COMPLETED. | | | | THE LICENSEE BELIEVES THAT THERE ARE THREE POSSIBILITIES FOR THE MISSING | | IRMs: STILL IN THE SUMP BUT UNRECOVERABLE; IN THE SPENT FUEL POOL FROM A | | PREVIOUS DRYWELL SUMP CLEANING; DISPOSED OF WITH OTHER RADIOACTIVE DEBRIS | | FROM THE DRYWELL CLEANING. AN INVESTIGATION IS ONGOING. | | | | THE TWO REMAINING IRMs WILL BE STORED IN THE SPENT FUEL POOL. THE LICENSEE | | INFORMED THE NRC RESIDENT INSPECTOR. THE CONNECTICUT ENVIRONMENTAL | | PROTECTION AGENCY (EPA) AND LOCAL AUTHORITIES WERE NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 27141 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: JEWISH HOSPITAL OF ST. LOUIS, MO |NOTIFICATION DATE: 04/22/94 | | CITY: ST. LOUIS REGION: 3 |NOTIFICATION TIME: 16:32 [ET]| | COUNTY: STATE: MO |EVENT DATE: 04/22/94 | |LICENSE#: AGREEMENT: N |EVENT TIME: 11:00[CDT]| | DOCKET: |LAST UPDATE DATE: 04/22/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |GEOFFREY WRIGHT RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: KLEIN | | |HQ OPS OFFICER: GREG SCARFO | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MR. KLEIN OF THE JEWISH HOSPITAL OF ST. LOUIS, MISSOURI, REPORTED THAT THE | | LEFT EYE OF A PATIENT WAS EXPOSED TO AN UNPRESCRIBED COBALT-60 DOSE DURING | | WHOLE-BRAIN RADIOTHERAPY. | | | | MR. KLEIN OF THE JEWISH HOSPITAL OF ST. LOUIS, MISSOURI, REPORTED THAT A | | PATIENT BEING TREATED FOR A METASTATIC DISEASE INADVERTENTLY RECEIVED A | | COBALT-60 EXPOSURE TO THE LEFT EYE. THIS OCCURRED WHEN A TECHNICIAN | | MISTAKENLY PLACED THE COBALT-60 GANTRY IN A 15-DEGREE ANTERIOR OBLIQUE | | POSITION INSTEAD OF THE PRESCRIBED 15-DEGREE POSTERIOR OBLIQUE POSITION. | | THE PRESCRIPTION ASSUMED THAT THE WHOLE-BRAIN AND THE LEFT EYE WOULD BE | | EXPOSED, HOWEVER, THE RIGHT EYE ALSO RECEIVED A MINIMUM OF EXPOSURE. NO | | MEASUREMENTS OF THE PARTICULAR DOSES RECEIVED BY THE EYES WERE AVAILABLE. | | AN INVESTIGATION IS ONGOING. | | | | THE COBALT-60 IRRADIATOR UTILIZED AT THE JEWISH HOSPITAL IS A 5500-CURIE | | SOURCE. NO ADVERSE AFFECTS ARE ANTICIPATED. THE PATIENT WILL BE NOTIFIED. | | | | | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27142 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PALO VERDE REGION: 4 |NOTIFICATION DATE: 04/22/94 | |UNIT: [1] [ ] [ ] STATE: AZ |NOTIFICATION TIME: 16:53 [ET]| |RX TYPE: [1] CE,[2] CE,[3] CE |EVENT DATE: 04/22/94 | +------------------------------------------------+EVENT TIME: 12:00[MST]| |NRC NOTIFIED BY: ROGALSKI |LAST UPDATE DATE: 04/22/94 | |HQ OPS OFFICER: GREG SCARFO +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |LAWRENCE YANDELL RDO | |AUNA 50.72(b)(1)(ii)(A) UNANALYZED COND OP | | |ACNC 50.72(b)(1)(ii)(C) COND OUTSIDE EOPS | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 86 POWER OPERATION | 86 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AN ENGINEERING ANALYSIS DETERMINED THAT IT IS NECESSARY TO MAINTAIN CORE | | PROTECTION CALCULATORS (CPCs) AND THE MAXIMUM BORON CONCENTRATION TO ASSURE | | PROTECTION FROM ALL POSTULATED ROD-WITHDRAWAL ACCIDENTS DURING SUBCRITICAL | | PLANT CONDITIONS. | | | | AN ENGINEERING ANALYSIS PERFORMED IN JUNE, 1991, BY COMBUSTION ENGINEERING | | FOUND THAT THE SUBCRITICAL SOURCE TERM WAS MORE SIGNIFICANT THAN PREVIOUSLY | | ASSUMED. THESE RESULTS INDICATED THAT BOTH THE CPCs AND THE HOT, FULL- | | POWER, ALL-RODS-OUT, MAXIMUM-ZENON, BORON CONCENTRATION WERE REQUIRED TO | | ASSURE THAT NO THERMAL LIMITS WOULD BE VIOLATED DURING ALL POSTULATED ROD- | | WITHDRAWAL ACCIDENTS WHEN THE PLANT IS SUBCRITICAL. ON 03/03/94, | | ADMINISTRATIVE CONTROLS ESTABLISHED THESE AS NORMAL OPERATING CONDITIONS | | VIA REVISION OF THE NORMAL OPERATING PROCEDURES. THE LICENSEE IS PREPARING | | A 50.59 SUBMISSION TO REVISE THE UPDATED FINAL SAFETY ANALYSIS REPORT | | (UFSAR). THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27143 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MILLSTONE REGION: 1 |NOTIFICATION DATE: 04/22/94 | |UNIT: [1] [ ] [ ] STATE: CT |NOTIFICATION TIME: 17:41 [ET]| |RX TYPE: [1] GE-3,[2] CE,[3] W-4-LP |EVENT DATE: 04/22/94 | +------------------------------------------------+EVENT TIME: 16:35[EDT]| |NRC NOTIFIED BY: KNOLL |LAST UPDATE DATE: 04/22/94 | |HQ OPS OFFICER: GREG SCARFO +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |HAROLD GRAY 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 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | SEVERAL GROUP ISOLATIONS OCCURRED DUE TO A TECHNICIAN ERROR DURING | | MAINTENANCE OF A CONTROL ROOM BACK PANEL. | | | | WHILE PERFORMING IN THE "AREA TEMPERATURE" BACK PANEL, A TECHNICIAN | | INADVERTENTLY SHORTED A FUSE HOLDER TO A BRACE DURING THE REMOVAL OF THE | | ENCLOSURE COVER. THIS RESULTED IN A VOLTAGE DIP IN THE INSTRUMENT AC POWER | | SYSTEM AND GROUP 2 (PRIMARY CONTAINMENT ISOLATION VALVES AND ATMOSPHERIC | | VALVES), GROUP 3 (SHUTDOWN COOLING SYSTEM), AND GROUP 5 (REACTOR WATER | | CLEANUP) ISOLATIONS. SHUTDOWN COOLING WAS OUT OF SERVICE FOR APPROXIMATELY | | 15 MINUTES WITH A RCS TEMPERATURE INCREASE OF TWO DEGREES FROM 174 DEGREES | | F (AS MEASURE BY TEMPERATURE INDICATORS IN THE RECIRCULATION LOOPS). | | | | OPERATORS RESET THE ISOLATION LOGIC AND RESTORED THE SYSTEMS TO THEIR | | NORMAL CONFIGURATION. THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | | THE STATE OF CONNECTICUT AND LOCAL AUTHORITIES WERE NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27144 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: OYSTER CREEK REGION: 1 |NOTIFICATION DATE: 04/22/94 | |UNIT: [1] [ ] [ ] STATE: NJ |NOTIFICATION TIME: 18:05 [ET]| |RX TYPE: [1] GE-2 |EVENT DATE: 04/22/94 | +------------------------------------------------+EVENT TIME: 17:30[EDT]| |NRC NOTIFIED BY: AMES |LAST UPDATE DATE: 04/22/94 | |HQ OPS OFFICER: GREG SCARFO +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |HAROLD GRAY RDO | |AOUT 50.72(b)(1)(ii)(B) OUTSIDE DESIGN BASIS | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | AN ENGINEERING ANALYSIS DETERMINED THAT THE ISOLATION CONDENSERS' ISOLATION | | VALVES WILL NOT CLOSE WITHIN THE 60-SECOND TIME REQUIRED BY THE FINAL | | SAFETY ANALYSIS REPORT (FSAR). THIS CONDITION IS OUTSIDE THE DESIGN BASIS | | OF THE PLANT. | | | | AN ENGINEERING ANALYSIS DETERMINED THAT ISOLATION OF THE ISOLATION | | CONDENSERS WILL NOT OCCUR WITHIN THE 60-SECOND TIME ASSUMED IN THE FSAR. | | UTILIZING WORST-CASE ASSUMPTIONS (LOCA WITH DEGRADED GRID VOLTAGE AND TIME | | DELAY TIMER DRIFT), THE LONGEST POSSIBLE TIME FOR CLOSURE OF THE ISOLATION | | CONDENSER ISOLATION VALVES IS 82 SECONDS ACCORDING TO ANOTHER ANALYSIS. A | | THIRD ANALYSIS PERFORMED IN 1991 FOUND THAT ENVIRONMENTAL CONDITIONS ARE | | STILL CONDUCIVE TO EQUIPMENT OPERATION UP TO 95 SECONDS AFTER THE LOCA | | OCCURS. THEREFORE, THE SAFETY FUNCTION OF THE ISOLATION VALVES ON THE | | ISOLATION CONDENSERS WILL STILL BE FULFILLED EVEN THOUGH THIS CURRENT | | CONDITION IS OUTSIDE THE PLANT'S DESIGN BASIS. | | | | CORRECTIVE ACTIONS INCLUDE PERFORMING A CONFIRMATORY ANALYSIS AND AMENDING | | OF THE FSAR. THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27145 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PALISADES REGION: 3 |NOTIFICATION DATE: 04/22/94 | |UNIT: [1] [ ] [ ] STATE: MI |NOTIFICATION TIME: 18:26 [ET]| |RX TYPE: [1] CE |EVENT DATE: 04/22/94 | +------------------------------------------------+EVENT TIME: 16:30[EDT]| |NRC NOTIFIED BY: MASSA |LAST UPDATE DATE: 04/22/94 | |HQ OPS OFFICER: GREG SCARFO +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |GEOFFREY WRIGHT 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 +------------------------------------------------------------------------------+ | A REVIEW OF THE CLASS 1E ELECTRICAL SYSTEM FOUND INADEQUATE SEPARATION | | BETWEEN CLASS 1E AND NON-CLASS 1E LOADS. THE FAILURE OF A NON-CLASS 1E | | LOAD COULD DEGRADE THE CLASS 1E ELECTRICAL SYSTEM AND DISABLE SAFETY LOADS. | | | | DURING A REVIEW OF THE CLASS 1E ELECTRICAL SYSTEM, SOME NON-CLASS 1E LOADS | | ARE SUPPLIED BY THE CLASS 1E (SAFETY-GRADE) SYSTEM. IN PARTICULAR, CLASS | | 1E PANELS "EY-10", "EY-20", "EY-30", AND "EY-40" SUPPLY SEVERAL NON-SAFETY | | LOADS SUCH AS VALVES AND FANS. DURING A SEISMIC EVENT, ALL FOUR OF THESE | | PANELS COULD FAIL (DUE TO THE FAILURE OF A NON-CLASS 1E LOAD) AND RESULT IN | | A SIGNIFICANT REDUCTION OF BUS VOLTAGE AND DEGRADED EQUIPMENT OPERATION. | | | | THE CORRECTIVE ACTION WILL BE TO ESTABLISH A FUSE SYSTEM TO PROVIDE THE | | NECESSARY ISOLATION OF THE NON-CLASS 1E LOADS FROM THE CLASS 1E, SAFETY- | | RELATED SYSTEM. THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27146 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MILLSTONE REGION: 1 |NOTIFICATION DATE: 04/22/94 | |UNIT: [ ] [2] [ ] STATE: CT |NOTIFICATION TIME: 20:07 [ET]| |RX TYPE: [1] GE-3,[2] CE,[3] W-4-LP |EVENT DATE: 04/22/94 | +------------------------------------------------+EVENT TIME: 20:00[EDT]| |NRC NOTIFIED BY: NELSON |LAST UPDATE DATE: 04/22/94 | |HQ OPS OFFICER: GREG SCARFO +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |HAROLD GRAY RDO | |APRE 50.72(b)(2)(vi) OFFSITE NOTIFICATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | NOTIFIED THE STATE AND LOCAL AUTHORITIES OF THE SHUTDOWN OF THE UNIT TO | | REPLACE A FAILED SEAL IN REACTOR COOLANT PUMP "D". NO EXCESSIVE LEAKAGE | | HAS OCCURRED. THE SHUTDOWN WILL BE LONGER THAN 72 HOURS SO A NOTIFICATION | | TO THE STATE IS REQUIRED. THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27147 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MILLSTONE REGION: 1 |NOTIFICATION DATE: 04/23/94 | |UNIT: [ ] [2] [ ] STATE: CT |NOTIFICATION TIME: 03:05 [ET]| |RX TYPE: [1] GE-3,[2] CE,[3] W-4-LP |EVENT DATE: 04/23/94 | +------------------------------------------------+EVENT TIME: 02:55[EDT]| |NRC NOTIFIED BY: JOHN RESETAR |LAST UPDATE DATE: 04/23/94 | |HQ OPS OFFICER: RUDY KARSCH +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: UNUSUAL EVENT +-----------------------------+ |10 CFR SECTION: |HAROLD GRAY RDO | |ARPS 50.72(b)(2)(ii) RPS ACTUATION |GUS LAINAS EO | |AAEC 50.72(a)(1)(i) EMERGENCY DECLARED |JIM MUSE FEMA | |NLCO TECH SPEC LCO A/S | | |ASHU 50.72(b)(1)(i)(A) PLANT S/D REQD BY TS | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | M/R Y 0 STARTUP | 0 HOT STANDBY | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MANUAL REACTOR TRIP FROM 10 EXP -5 DURING A PLANT SHUT DOWN DUE TO AN | | IMMOVABLE CONTROL ROD. | | | | THE LICENSEE WAS SHUTTING DOWN FOR AN 18-DAY OUTAGE TO REPAIR THEIR "D" | | REACTOR COOLANT PUMP SEAL. POWER HAD BEEN REDUCED TO 10 EXP -5 BY BORATION | | WITH CONTROL RODS STILL FULLY WITHDRAWN. THE NEXT OPERATION WAS TO DRIVE | | RODS IN AND OPEN THE REACTOR TRIP CIRCUIT BREAKERS. WHILE DRIVING IN GROUP | | SEVEN RODS THE OPERATORS RECEIVED A "ROD DEVIATION" ALARM AND OBSERVED NON- | | UNIFORM AXIAL NEUTRON FLUX. INVESTIGATION REVEALED THAT ROD 65 HAD NOT | | MOVED IN RESPONSE TO THE "RODS IN" COMMAND. POWER TO THIS ROD WAS THEN | | INTERRUPTED, THE ROD DROPPED INTO THE REACTOR CORE AND THE ROD BOTTOM LIGHT | | CAME ON. THE REACTOR WAS THEN MANUALLY TRIPPED AND THE REMAINING RODS FULLY | | INSERTED. THE LICENSEE SUSPECTS A PROBLEM WITH THE ROD CONTROL CIRCUITRY | | AND WILL INVESTIGATE DURING THE OUTAGE. THE LICENSEE INFORMED THE NRC | | RESIDENT INSPECTOR. | | | | * * * UPDATE AT 0604 EDT FROM RESETAR TAKEN BY WEAVER * * * | | | | LICENSEE DECLARED AN UNUSUAL EVENT AT 0550 BASED ON A TECH SPEC REQUIRED | | SHUTDOWN. THE UNUSUAL EVENT WAS IMMEDIATELY TERMINATED. TECH SPECS | | REQUIRE A SHUTDOWN TO HOT STANDBY WITHIN SIX HOURS WHEN A CEA IS MORE THAN | | 10 STEPS FROM ITS GROUP. CEA #65 WAS 70 STEPS FROM ITS GROUP (GROUP 7). | | THIS DECLARATION WAS MADE AFTER THE FACT BECAUSE WHEN THE T/S ACTION | | STATEMENT WAS ENTERED, A REACTOR SHUTDOWN WAS ALREADY IN PROGRESS. THE T/S | | WAS EXITED AT 0255 EDT WHEN THE REACTOR WAS TRIPPED AND ALL RODS INSERTED. | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. THE STATE AND LOCAL | | GOVERNMENTS WERE INFORMED, AND A PRESS RELEASE MIGHT BE ISSUED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |OTHER NUCLEAR MATERIAL | |EVENT NUMBER: 27148 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: ROSEMOUNT INCORPORATED |NOTIFICATION DATE: 04/23/94 | | CITY: MOUNT PLEASANT REGION: 3 |NOTIFICATION TIME: 12:34 [ET]| | COUNTY: STATE: IL |EVENT DATE: 04/21/94 | |LICENSE#: AGREEMENT: Y |EVENT TIME: 18:00[CDT]| | DOCKET: |LAST UPDATE DATE: 04/23/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |GEOFFREY WRIGHT RDO | | |PIERSON EO | +------------------------------------------------+GREENMAN RIII | |NRC NOTIFIED BY: CANIANO (RIII) |MALLET RII | |HQ OPS OFFICER: GREG SCARFO |CANIANO RIII | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NINF INFORMATION ONLY | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | ROSEMOUNT INCORPORATED, MOUNT PLEASANT, IL. | | ROY CANIANO OF REGION III REPORTED THAT A LEAKING ROSEMOUNT LEVEL GAGE, | | WHICH UTILIZES A GAMMA SOURCE, EXPOSED THREE INDIVIDUALS IN ILLINOIS AND | | POSSIBLY OTHERS IN GEORGIA. | | | | ROY CANIANO OF REGION III REPORTED THAT ON 04/21/94, ROSEMOUNT INCORPORATED | | OF MOUNT PROSPECT, ILLINOIS, RECEIVED A GAMMA LEVEL GAGE FROM GEORGIA | | PACIFIC OF CEDAR SPRINGS, GEORGIA, FOR UNKNOWN REASONS (POSSIBLY FOR | | DISPOSAL). UPON RECEIPT OF THE GAGE, ROSEMOUNT INCORPORATED PERSONNEL | | PERFORMED A RADIATION (SMEAR) SURVEY OF THE GAGE. RESULTS OF THIS TEST WERE | | NEGATIVE AND THEY PROCEEDED TO REMOVE THE 2-CURIE CESIUM SOURCE FROM THE | | GAGE. A SMEAR SURVEY ASSOCIATED WITH THIS PROCEDURE DETECTED CESIUM-137 | | CONTAMINATION OF 150 mR/HOUR. ROSEMOUNT PERSONNEL CONTACTED THEIR HEALTH | | PHYSICS CONSULTANTS, STAN HUBER & ASSOCIATES, FOR TECHNICAL ASSISTANCE. ON | | 04/22/94, THE ILLINOIS DEPARTMENT OF NUCLEAR SERVICES (IL-DNS) WAS INFORMED | | AND RESPONDED WITH PERSONNEL AT THE SITE. THE ILLINOIS INCIDENT RESPONSE | | CENTER HAS BEEN ACTIVATED AND MANNED. | | | | THREE PEOPLE HAVE BEEN CONTAMINATED. TWO INDIVIDUALS' FINGERTIPS WERE | | CONTAMINATED AND REGISTERED BETWEEN 1.1-1.5 mR/HOUR ON CONTACT. THEY HAVE | | SINCE BEEN DECONTAMINATED. THE REMAINING INDIVIDUAL' HAND WAS CONTAMINATED | | AND REGISTERED 10 mR/HOUR ON CONTACT. DECONTAMINATION EFFORTS ON THIS | | PERSON HAVE BEEN UNSUCCESSFUL. THIS INDIVIDUAL HAS BEEN TRANSPORTED TO | | SAINT JOSEPH'S HOSPITAL IN JOLIET, ILLINOIS FOR MEDICAL OBSERVATION AND | | FURTHER DECONTAMINATION EFFORTS. ISOLATED CONTAMINATED SPOTS WERE FOUND AT | | THE HUBER & ASSOCIATES FACILITY (0.1-0.2 mR/HOUR) AND IN MR. HUBER' VEHICLE | | (0.1-2mR/HOUR). THE ONLY CONTAMINATED AREA AT THE ROSEMOUNT FACILITY IS | | THE ROOM WHERE THE GAGE WAS DISMANTLED. | | | | ROSEMOUNT INCORPORATED WILL ACQUIRE A WHOLE-BODY COUNTER TO ASSESS ANY | | POSSIBLE INTERNAL DOSES RECEIVED BY ANY PERSONNEL AND ARGONNE NATIONAL | | LABORATORY WILL CONDUCT THE TESTING. IL-DNS IS AT BOTH THE ROSEMOUNT | | FACILITY AND THE HUBER FACILITY AT THIS TIME. ALL ROSEMOUNT PERSONNEL IN | | THE FACILITY AT THE TIME OF THIS EVENT WILL BE SURVEYED FOR CONTAMINATION. | | THE STATE OF GEORGIA HAS BEEN INFORMED AND WILL BE AT THE GEORGIA PACIFIC | | FACILITY AS SOON AS LATER TODAY. GEORGIA OFFICIALS WILL ATTEMPT TO | | DETERMINED HOW THE GAGE WAS PACKAGED AND TRANSPORTED. | | | | REGION II(MALLET) WAS NOTIFIED. NO PRESS RELEASE HAS BEEN ISSUED. | | | | * * * 04/23/94 1400EDT COMMISSIONERS' ASSISTANTS BRIEFING * * * | | BRIEFER: ROY CANIANO | | PARTICIPANTS: HOLAHAN(AEOD) BROCKMAN(IRB) BROCK(NMSS) | | INGRAM(PAO) BANGART(SP) McCREE(EDO) | | PIERSON(EO) HILL(SECY) KEELING(CA) | | SORENSON(ROGERS)WINSBERG(SELIN) CROCKETT(REMICK) | | McKENNA(DEPLANQUE) STRASMA(RIII) | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27149 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MILLSTONE REGION: 1 |NOTIFICATION DATE: 04/23/94 | |UNIT: [ ] [2] [ ] STATE: CT |NOTIFICATION TIME: 14:39 [ET]| |RX TYPE: [1] GE-3,[2] CE,[3] W-4-LP |EVENT DATE: 04/23/94 | +------------------------------------------------+EVENT TIME: 01:15[EDT]| |NRC NOTIFIED BY: NELSON |LAST UPDATE DATE: 04/23/94 | |HQ OPS OFFICER: GREG SCARFO +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: UNUSUAL EVENT +-----------------------------+ |10 CFR SECTION: |HAROLD GRAY RDO | |AAEC 50.72(a)(1)(i) EMERGENCY DECLARED |GUS LAINAS EO | |NLCO TECH SPEC LCO A/S |MOSTELLER FEMA | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N Y 50 POWER OPERATION | 0 HOT STANDBY | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AN NOUE WAS DECLARED WHEN IT WAS DETERMINED THAT A SHUTDOWN MARGIN | | CALCULATION REQUIRED BY TECHNICAL SPECIFICATION (T/S) COULD NOT BE | | PERFORMED WITHIN THE SPECIFIED TIME. THE NOUE WAS TERMINATED WHEN THE | | STUCK ROD WAS DE-ENERGIZED AND FELL INTO THE CORE. | | | | AT 0115EDT, AN NOUE WAS DECLARED WHEN IT WAS DETERMINED THAT A SHUTDOWN | | MARGIN CALCULATION REQUIRED BY T/S ACTION STATEMENT 3.1.3.1 COULD NOT BE | | PERFORMED WITHIN THE ASSOCIATED 1-HOUR TIMEFRAME. THIS T/S ACTION | | STATEMENT REQUIRES A VERIFICATION OF THE SHUTDOWN MARGIN PRIOR TO ENTERING | | HOT STANDBY (MODE 3). THE LICENSEE DOES NOT HAVE THE CAPABILITY TO PERFORM | | SUCH A CALCULATION AT THIS TIME AND NEVER HAS HAD SUCH A CAPABILITY DURING | | THE OPERATION HISTORY OF THE PLANT. TO PERFORM THE CALCULATION, TWO RODS | | ARE ASSUMED STUCK OUT OF THE CORE. THIS NOUE OCCURRED DURING THE PREVIOUS | | NOUE (REFERENCE EVENT # 27147) ASSOCIATED WITH THE SINGLE, STUCK-ROD | | CONDITION. | | | | THE LICENSEE TERMINATED THE NOUE AT 0115EDT. HOWEVER, THE T/S WAS NOT | | EXITED UNTIL 0248EDT WHEN THE ROD MECHANISM WAS DE-ENERGIZED AND THE ROD | | FELL INTO THE CORE. AN INVESTIGATION INTO ESTABLISHING A SHUTDOWN MARGIN | | CALCULATION CAPABILITY IS BEING PERFORMED. THE LICENSEE INFORMED THE NRC | | RESIDENT INSPECTOR. THE STATE OF CONNECTICUT WAS NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27150 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SAINT LUCIE REGION: 2 |NOTIFICATION DATE: 04/23/94 | |UNIT: [ ] [2] [ ] STATE: FL |NOTIFICATION TIME: 15:50 [ET]| |RX TYPE: [1] CE,[2] CE |EVENT DATE: 04/23/94 | +------------------------------------------------+EVENT TIME: 13:18[EDT]| |NRC NOTIFIED BY: LYONS |LAST UPDATE DATE: 04/23/94 | |HQ OPS OFFICER: GREG SCARFO +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |PAUL FREDRICKSON RDO | |ARPS 50.72(b)(2)(ii) RPS ACTUATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | A/R Y 29 POWER OPERATION | 0 HOT STANDBY | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | A REACTOR TRIP OCCURRED DURING NUCLEAR INSTRUMENTATION CALIBRATION. | | | | WHILE PERFORMING NUCLEAR INSTRUMENTATION CALIBRATION WITH CHANNEL "B" IN | | THE TRIPPED CONDITION, AN I&C TECHNICIAN PLACED CHANNEL "D" IN THE BYPASS | | CONDITION AND RECEIVED A REACTOR TRIP SIGNAL. ALL RODS FULLY INSERTED ON | | THE REACTOR TRIP. NO ENGINEERED SAFETY FEATURES (ESF) ACTUATIONS OR ECCS | | ACTUATIONS OCCURRED. ALL PLANT PARAMETERS REMAINED WITHIN EXPECTED BOUNDS. | | NO PORVs OR SAFETY VALVES LIFTED DURING THE TRIP. ALL LOADS TRANSFERRED | | PROPERLY TO OFFSITE POWER. NO AUXILIARY FEEDWATER SYSTEM ACTUATION | | OCCURRED AND NONE WAS EXPECTED. | | | | THE TRIP LOGIC IS NORMALLY TWO-OUT-OF-FOUR LOGIC. WITH CHANNEL "B" IN THE | | TRIPPED CONDITION, THE LOGIC BECAME ONE-OUT-OF-THREE LOGIC. HOWEVER, | | PLACING CHANNEL "D" IN THE BYPASS CONDITION SHOULD NOT HAVE RESULTED IN A | | REACTOR TRIP ACCORDING TO THE LICENSEE. AN INVESTIGATION IS BEING | | CONDUCTED. | | | | THE UNIT IS STABLE IN HOT STANDBY. THE MAIN FEED SYSTEM CONTINUES TO | | SUPPLY THE STEAM GENERATORS. DECAY HEAT IS BEING DISSIPATED TO THE | | CONDENSER. ALL PLANT LOADS ARE BEING SUPPLIED FROM OFFSITE POWER. THE | | LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27151 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: HATCH REGION: 2 |NOTIFICATION DATE: 04/23/94 | |UNIT: [ ] [2] [ ] STATE: GA |NOTIFICATION TIME: 16:53 [ET]| |RX TYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 04/23/94 | +------------------------------------------------+EVENT TIME: 15:50[CDT]| |NRC NOTIFIED BY: BIENKE & BUTLER |LAST UPDATE DATE: 04/23/94 | |HQ OPS OFFICER: GREG SCARFO +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |PAUL FREDRICKSON 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 N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | A TECHNICIAN ERROR CAUSED AN INSTRUMENT ISOLATION VALVE TO LEAK-BY AND | | RESULTED IN REACTOR SCRAM SIGNAL AND CONTAINMENT ISOLATION SIGNAL. | | | | I&C PERSONNEL, PERFORMING A REACTOR VESSEL LEVEL INDICATION PURGE, | | INADVERTENTLY BUMPED INSTRUMENT ISOLATION VALVE "IV-1" FOR "2B21-NO-93A" | | (WHICH IS THE LEVEL SENSOR FOR THE RCIC SYSTEM) CAUSING THE VALVE TO | | PARTIALLY OPEN. THIS LEAK-OFF CAUSED LEVEL AND DIFFERENTIAL PRESSURE | | INSTRUMENTS "2B21-NO-80C & D" (THE LEVEL SENSORS FOR THE RPS SYSTEM), WHICH | | USE THE SAME REFERENCE LEG, TO TRIP ON LOW-LOW REACTOR WATER LEVEL AND | | GENERATE A REACTOR SCRAM SIGNAL AND CONTAINMENT ISOLATION SIGNAL. NO ROD | | MOVEMENT OR CHANGES IN PLANT CONDITIONS OCCURRED DUE TO THE SCRAM SIGNAL. | | ONLY A PARTIAL CONTAINMENT ISOLATION OCCURRED DUE TO JUMPERS INSTALLED (TO | | PREVENT CONTAINMENT ISOLATION VALVE MOVEMENT) IN PREPARATION FOR A PRIMARY | | CONTAINMENT ISOLATION LOGIC SYSTEM FUNCTIONAL TEST. THE SHUTDOWN COOLING | | SYSTEM WAS ISOLATED PRIOR TO THE CONTAINMENT ISOLATION SIGNAL. | | | | THE INSTRUMENT ISOLATION VALVE WAS CLOSED, REACTOR PROTECTION LOGIC RESET, | | AND ALL SYSTEMS WERE RETURNED TO THEIR ORIGINAL CONFIGURATION. THE | | LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | | | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27152 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: FT CALHOUN REGION: 4 |NOTIFICATION DATE: 04/23/94 | |UNIT: [1] [ ] [ ] STATE: NE |NOTIFICATION TIME: 23:37 [ET]| |RX TYPE: [1] CE |EVENT DATE: 04/23/94 | +------------------------------------------------+EVENT TIME: 21:45[CDT]| |NRC NOTIFIED BY: REISDORFF |LAST UPDATE DATE: 04/23/94 | |HQ OPS OFFICER: GREG SCARFO +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |LAWRENCE YANDELL RDO | |APRE 50.72(b)(2)(vi) OFFSITE NOTIFICATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | THE STATE OF NEBRASKA WILL BE NOTIFIED OF A 1500 POUND RELEASE OF 98% | | SULFURIC ACID FROM A DAY TANK INTO A NEUTRALIZATION BASIN ON SITE. | | | | THE STATE OF NEBRASKA WILL BE NOTIFIED OF A RELEASE OF 1500 POUNDS OF 98% | | SULFURIC ACID FROM A DAY TANK INTO A BERM THAT DRAINS INTO A NEUTRALIZATION | | BASIN. THE DAY TANK WAS OVERFILLED WHEN A TRANSFER PUMP WAS NOT | | AUTOMATICALLY SECURED DUE TO A STUCK SWITCH. THE RELEASE IS ABOVE THE | | STATE LIMIT OF 10 POUNDS AND NPDES LIMIT OF 1000 POUNDS WHICH WARRANTED THE | | NOTIFICATION. THE PUMP WAS SECURED BY OPENING ITS POWER SUPPLY BREAKER. | | | | THE ACID WILL BE NEUTRALIZED THEN RELEASED TO THE RIVER. THE LICENSEE | | INFORMED THE NRC RESIDENT INSPECTOR. DOT-NRC WILL BE NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27153 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SALEM REGION: 1 |NOTIFICATION DATE: 04/24/94 | |UNIT: [1] [2] [ ] STATE: NJ |NOTIFICATION TIME: 14:52 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 04/24/94 | +------------------------------------------------+EVENT TIME: 14:00[EDT]| |NRC NOTIFIED BY: GWIRTZ |LAST UPDATE DATE: 04/24/94 | |HQ OPS OFFICER: GREG SCARFO +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |HAROLD GRAY RDO | |AARC 50.72(b)(1)(v) OTHER ASMT/COMM INOP | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 75 POWER OPERATION | 75 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE TECHNICAL SUPPORT CENTER (TSC) WAS FOUND TO BE UNAVAILABLE WHEN THE | | BACKUP DIESEL GENERATOR COULD NOT AUTOMATICALLY SUPPLY POWER TO THE | | FACILITY AFTER PRIMARY POWER WAS LOST. | | | | WHILE ATTEMPTING TO RE-ENERGIZE THE TSC, IT WAS DETERMINED THAT THE BACKUP | | DIESEL GENERATOR WOULD NOT AUTOMATICALLY SUPPLY LOADS IN THE TSC. PRIMARY | | POWER TO THE TSC WAS LOST WHEN ARCING OCCURRED IN A SUBSTATION WHICH | | NORMALLY SUPPLIES THE FACILITY. THE BACKUP DIESEL COULD BE MANUALLY TIED | | INTO THE TSC LOADS WITHIN THIRTY MINUTES. THE BACKUP DIESEL GENERATOR IS | | NOT A VITAL EMERGENCY DIESEL GENERATOR. AN INVESTIGATION INTO THE CAUSE OF | | THE FAILURE OF THE AUTOMATIC LOADING SYSTEM AND THE LOSS OF THE SUBSTATION | | IS UNDERWAY. THE SUBSTATION MAY BE REPAIRED WITHIN 24 HOURS. | | | | THE EMERGENCY OFFSITE FACILITY IS AVAILABLE AS A BACKUP TO THE TSC. THE | | LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27154 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: QUAD CITIES REGION: 3 |NOTIFICATION DATE: 04/24/94 | |UNIT: [1] [2] [ ] STATE: IL |NOTIFICATION TIME: 19:14 [ET]| |RX TYPE: [1] GE-3,[2] GE-3 |EVENT DATE: 04/24/94 | +------------------------------------------------+EVENT TIME: 02:01[CDT]| |NRC NOTIFIED BY: NORTON |LAST UPDATE DATE: 04/24/94 | |HQ OPS OFFICER: GREG SCARFO +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |GEOFFREY WRIGHT RDO | |HFIT 26.73 FITNESS FOR DUTY |GUS LAINAS EO | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 REFUELING | 0 REFUELING | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | A SENIOR-LEVEL MANAGER FAILED A RANDOM DRUG TEST FOR ALCOHOL. | | | | AFTER BEING CALLED IN TO THE PLANT, A SENIOR-LEVEL MANAGER FAILED A RANDOM | | DRUG TEST FOR ALCOHOL. THE MANAGER HAD BEEN CALLED IN TO ATTEND TO A | | TRANSIENT (LOSS OF COOLING TO THE MAIN TRANSFORMER). A BREATHALYZER TEST | | YIELDED A READING OF 0.075. AT THAT TIME, HE WAS ESCORTED FROM THE | | PROTECTED AREA AND HIS ACCESS WAS REVOKED. HE HAD BEEN ON SITE FOR ABOUT | | TWO HOURS TO OBSERVE PLANT RECOVERY OPERATIONS IN THE CONTROL ROOM BEFORE | | BEING TESTED AND HE DID NOT AFFECT THE STATUS OF ANY SAFETY EQUIPMENT. THE | | MANAGER DID NOT ISSUE ANY ORDERS WHILE IN THE CONTROL ROOM. A BLOOD SAMPLE | | WAS TAKEN TO PERFORM A CONFIRMATORY BLOOD-ALCOHOL TEST. THE LICENSEE | | INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27155 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: CALVERT CLIFFS REGION: 1 |NOTIFICATION DATE: 04/24/94 | |UNIT: [ ] [2] [ ] STATE: MD |NOTIFICATION TIME: 19:21 [ET]| |RX TYPE: [1] CE,[2] CE |EVENT DATE: 04/24/94 | +------------------------------------------------+EVENT TIME: 17:08[EDT]| |NRC NOTIFIED BY: SHUMAKER |LAST UPDATE DATE: 04/24/94 | |HQ OPS OFFICER: GREG SCARFO +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |HAROLD GRAY RDO | |AESF 50.72(b)(2)(ii) ESF ACTUATION |GUS LAINAS EO | |NLCO TECH SPEC LCO A/S | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | A PARTIAL LOSS OF OFFSITE POWER OCCURRED DUE TO A GROUND-FAULT IN THE | | SWITCHYARD. | | | | WHILE TESTING A NEWLY-INSTALLED VOLTAGE REGULATOR BETWEEN 13KV SERVICE BUS | | "11" AND SERVICE TRANSFORMER "U-4000-11", A GROUND-FAULT OCCURRED WHICH | | CAUSED FEEDER-BREAKER "252-1103" TO OPEN AND TRANSFORMER "U-4000-12" TO | | DE-ENERGIZE. THIS DE-ENERGIZED 4160V SAFETY BUS "21" AND ITS ASSOCIATED | | SAFETY EQUIPMENT. NO REACTOR TRIP OCCURRED. EMERGENCY DIESEL GENERATOR | | (EDG) "12" STARTED ON THE UNDERVOLTAGE CONDITION BUT DID NOT LOAD. NO | | OTHER ESF ACTUATIONS OCCURRED. ONE OF THE TWO OFFSITE POWER LINES WAS | | DECLARED INOPERABLE AND THE UNIT ENTERED TECHNICAL SPECIFICATION (T/S) | | ACTION STATEMENT 3.8.1.1 (72-HOUR LCO, PROCEED TO SHUTDOWN). | | | | THE LOSS OF THE SAFETY BUS RESULTED IN THE LOSS OF A COMPONENT COOLING | | WATER PUMP, SERVICE WATER PUMP, AND A SALT WATER PUMP. ALTERNATES TO THESE | | PUMPS WERE STARTED BY OPERATORS. 4160V BUS "21" WAS RE-ENERGIZED FROM 13KV | | SERVICE BUS "21" SHORTLY AFTER THE INCIDENT. EDG "12" RAN FOR AN | | UNSPECIFIED TIME BEFORE BEING SECURED. | | | | TWO TURBINE INTERCEPT VALVES CLOSED FOR UNKNOWN REASONS. ALSO, A LOSS OF | | "SPEED PROBE" SIGNAL OCCURRED TO ONE OF THE FEEDWATER PUMPS RESULTING IS A | | SWITCH FROM AUTOMATIC TO MANUAL OPERATION. | | | | CURRENTLY, THE UNIT IS STABLE AT 100% POWER. THE GRID IS STABLE AND ALL | | SAFETY LOADS ARE BEING SUPPLIED BY THE SINGLE OFFSITE POWER LINE THAT IS | | AVAILABLE. BOTH EDGs ARE OPERABLE. AN INVESTIGATION WILL BE INITIATED TO | | DETERMINE THE CAUSE OF THIS EVENT AND THE REASON FOR THE INTERCEPT VALVE | | CLOSURE. THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27156 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MILLSTONE REGION: 1 |NOTIFICATION DATE: 04/24/94 | |UNIT: [ ] [2] [ ] STATE: CT |NOTIFICATION TIME: 23:20 [ET]| |RX TYPE: [1] GE-3,[2] CE,[3] W-4-LP |EVENT DATE: 04/24/94 | +------------------------------------------------+EVENT TIME: 22:22[EDT]| |NRC NOTIFIED BY: BONNER |LAST UPDATE DATE: 04/24/94 | |HQ OPS OFFICER: GREG SCARFO +-----------------------------+ +------------------------------------------------+ 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 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | A CONTAINMENT PURGE ISOLATION OCCURRED ON A RADIATION MONITOR LOW-FAIL | | SIGNAL. | | | | WHILE PERFORMING A CONTAINMENT PURGE, ONE OF FOUR RADIATION MONITORS | | REGISTERED DECREASING RADIATION LEVELS AND ISSUED A LOW-FAIL SIGNAL. THIS | | RESULTED IN A CONTAINMENT PURGE ISOLATION. ALL RADIATION MONITORS' LOW- | | FAIL SETPOINTS ARE BEING RESET IN PREPARATION FOR RESUMPTION OF THE PURGE. | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. STATE AND LOCAL | | AUTHORITIES WERE NOTIFIED. | +------------------------------------------------------------------------------+