U.S. Nuclear Regulatory Commission Operations Center Event Reports For 05/02/94 - 05/03/94 ** EVENT NUMBERS ** 27199 27200 27201 +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27199 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: NINE MILE POINT REGION: 1 |NOTIFICATION DATE: 05/02/94 | |UNIT: [ ] [2] [ ] STATE: NY |NOTIFICATION TIME: 04:39 [ET]| |RX TYPE: [1] GE-2,[2] GE-5 |EVENT DATE: 05/02/94 | +------------------------------------------------+EVENT TIME: 03:52[EDT]| |NRC NOTIFIED BY: WILLIS |LAST UPDATE DATE: 05/02/94 | |HQ OPS OFFICER: GREG SCARFO +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |PETER ESELGROTH 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 +------------------------------------------------------------------------------+ | A REACTOR WATER CLEANUP (RWCU) ISOLATION OCCURRED WHEN A RWCU PUMP SEAL | | FAILED DURING OPERATION. | | | | THE FOLLOWING IS THE TEXT OF A FACSIMILE SUBMITTED BY THE LICENSEE: | | "THE REACTOR WATER CLEANUP SYSTEM AUTOMATICALLY ISOLATED DUE TO SEAL | | FAILURE ON THE "A" REACTOR WATER CLEANUP PUMP AND SUBSEQUENT HIGH PUMP ROOM | | TEMPERATURE. THE ISOLATION SYSTEM RESPONDED AS DESIGNED (I.E. BOTH INBOARD | | AND OUTBOARD ISOLATION VALVES CLOSED WHEN THEIR RESPECTIVE DIVISIONAL | | ISOLATIONS OCCURRED). IN ADDITION, BOTH RWCU PUMPS TRIPPED OFF AS | | DESIGNED. AFTER SEVERAL MINUTES, REACTOR WATER CLEANUP PUMP ROOM | | TEMPERATURES DECREASED BELOW THEIR SETPOINTS AND PRESENTLY ARE WITHIN THEIR | | NORMAL BAND." | | END OF TEXT. | | | | RWCU PUMP "A" SEAL FAILED CAUSING REACTOR WATER (400 DEGREES F) TO BE | | SPILLED INTO THE RWCU PUMP ROOM. THIS RESULTED IN A SEAL FAILURE ALARM, | | HIGH TEMPERATURE ALARM, RWCU ISOLATION, AND AN AUTOMATIC TRIP OF BOTH RWCU | | PUMPS. WITHIN SEVERAL MINUTES OF THE ISOLATION, THE HIGH TEMPERATURE ALARM | | CLEARED. CONTAINMENT AREA RADIATION MONITORS DID NOT ALARM OR ACTUATE ANY | | REACTOR BUILDING VENTILATION EQUIPMENT. NO OTHER ESF ACTUATIONS OCCURRED. | | | | OPERATORS WERE MONITORING THE TEMPERATURE OF THE RWCU PUMP "A" SEAL FOR | | SEVERAL DAYS AS AN INDICATION OF POTENTIAL FAILURE. SEAL TEMPERATURE HAD | | REACHED THE 185 DEGREE F ALARM SETPOINT WHEN THE SEAL FAILURE OCCURRED | | (LESS THAN TEN MINUTES). OPERATORS ARE NOT REQUIRED TO TAKE THE RWCU PUMP | | OUT OF SERVICE UNTIL SEAL TEMPERATURE REACHES 240 DEGREES F. | | | | THE SYSTEM REMAINS ISOLATED AT THIS TIME. HEALTH PHYSICS IS SURVEYING THE | | RWCU PUMP ROOM AT THIS TIME. WHEN THE RADIATION SURVEYS ARE COMPLETED, | | CLEANUP AND SEAL REPLACEMENT WILL BEGIN. THE LICENSEE WILL INFORM THE NRC | | RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27200 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: LASALLE REGION: 3 |NOTIFICATION DATE: 05/02/94 | |UNIT: [ ] [2] [ ] STATE: IL |NOTIFICATION TIME: 08:41 [ET]| |RX TYPE: [1] GE-5,[2] GE-5 |EVENT DATE: 05/02/94 | +------------------------------------------------+EVENT TIME: 00:00[CDT]| |NRC NOTIFIED BY: IRENE M. JOHNSON |LAST UPDATE DATE: 05/02/94 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: | | |CCCC 21.21 UNSPECIFIED PARAGRAPH | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | LICENSEE IS MAKING A PART 21 NOTIFICATION OF DEFECTIVE NAMCO CONTROLS | | CORPORATION LIMIT SWITCHES SERIES "EA740-86700" INSTALLED ON MAIN STEAM | | ISOLATION VALVES (MSIV) "2B1-F022A/B/C/D" and "2B21-F028A/B/C/D" TO PROVIDE | | THE MSIV POSITION INDICATION TO THE CONTROL ROOM AND AN AUTOMATIC TRIP | | SIGNAL TO THE REACTOR PROTECTION SYSTEM (RPS). | | | | FAILURE OF THE SWITCHES TO RETURN THE OPERATING LEVER IMMEDIATELY TO THE | | NEUTRAL POSITION WAS DUE TO ONE OR ALL OF THE FOLLOWING: | | | | -EXCESSIVE AMOUNT OF GREASE ON THE CONTACT BLOCK AND CONTACT CARRIER, | | -WRONG MATERIAL OF THE O-RING, AND | | -A WEAK TORSION SPRING. | | | | CORRECTIVE ACTIONS INCLUDE REPLACEMENT OF UNIT 2 DEFECTIVE LIMIT SWITCHES | | (TOTAL OF 8) IN JUNE 1994 AND REPLACEMENT OF UNIT 1 (NO DEFECTS FOUND) | | LIMIT SWITCHES DURING THE FALL OF 1995. | | | | HOONOTE: SEE EVENT #26728 AND #26866 FOR ADDITIONAL INFORMATION. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 27201 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: QUEENS MEDICAL CENTER |NOTIFICATION DATE: 05/02/94 | | CITY: HONOLULU REGION: 4 |NOTIFICATION TIME: 20:37 [ET]| | COUNTY: HONOLULU STATE: HI |EVENT DATE: 05/02/94 | |LICENSE#: 53-16533-02 AGREEMENT: N |EVENT TIME: 20:00[AH ]| | DOCKET: |LAST UPDATE DATE: 05/02/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |GARY SANBORN RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: DUBE | | |HQ OPS OFFICER: TIM McGINTY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE RSO OF THE QUEENS MEDICAL CENTER, LOCATED IN HONOLULU, HI, CALLED WITH | | A MEDICAL MISADMINISTRATION. | | | | THE PRESCRIPTION FOR 1000 CENTIGRAY OF SR-90 VIA A HAND HELD APPLICATOR WAS | | TO BE DELIVERED TO THE PATIENTS EYE IN 18 SECONDS. THE APPLICATOR WAS HELD | | IN PLACE FOR A TOTAL OF 30 SECONDS INSTEAD, RESULTING IN A DOSE OF 1667 | | CENTIGRAY. THE PHYSICIAN HOLDS THE SURFACE APPLICATOR TO THE EYE, AND THE | | NURSE USES A STOPWATCH TO COUNT OFF THE TIME ELAPSED. INEXPLICABLY, THE | | PHYSICIAN CONTINUED TO APPLY THE TREATMENT UP TO THE 30 SECOND MARK, | | WAITING FOR THE NURSE TO SAY STOP. THE SR-90 IS USED AT THE INCISION SITE | | AFTER EYE SURGERY IS PERFORMED TO REMOVE A FIBROUS GROWTH, TO PREVENT A | | FURTHER RECURRENCE. | | | | THE LICENSEE ANTICIPATES NO ADVERSE EFFECTS TO THE PATIENT, AND THE | | REFERRING PHYSICIAN WILL BE DISCUSSING IT WITH THE PATIENT. | +------------------------------------------------------------------------------+