U.S. Nuclear Regulatory Commission Operations Center Event Reports For 05/05/94 - 05/06/94 ** EVENT NUMBERS ** 27209 27210 27211 27212 27213 +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27209 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MILLSTONE REGION: 1 |NOTIFICATION DATE: 05/05/94 | |UNIT: [ ] [2] [ ] STATE: CT |NOTIFICATION TIME: 15:46 [ET]| |RX TYPE: [1] GE-3,[2] CE,[3] W-4-LP |EVENT DATE: 05/05/94 | +------------------------------------------------+EVENT TIME: 15:35[EDT]| |NRC NOTIFIED BY: JOHN RESETAR |LAST UPDATE DATE: 05/05/94 | |HQ OPS OFFICER: RUDY KARSCH +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |P. K. EAPEN RDO | |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 | N N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE LICENSEE DISCOVERED A DESIGN DEFICIENCY IN UNDERVOLTAGE MODULES WHICH | | SHORTENS THEIR DESIGN LIFE. | | | | UNDERVOLTAGE MODULES USED IN ACCIDENT MITIGATION EQUIPMENT WERE EXPECTED TO | | HAVE A DESIGN LIFE OF TWENTY YEARS, BUT THE LICENSEE HAS EXPERIENCED RANDOM | | FAILURES WHICH INDICATE A DESIGN LIFE OF 1.5 YEARS. INVESTIGATIONS BY THE | | LICENSEE REVEALED A DESIGN DEFICIENCY WHICH CONTRIBUTES TO ACCELERATED | | AGING. IF THREE OUT OF FOUR MODULES FAILED SIMULTANEOUSLY, ACTIONS TO | | MITIGATE ACCIDENT CONSEQUENCES MIGHT NOT OCCUR. THE LICENSEE HAS A PROGRAM | | IN PLACE TO REPLACE MODULES PERIODICALLY SO MODULES VARY IN AGE. THE | | LICENSEE FEELS THAT THIS REDUCES THE PROBABILITY THAT THREE MODULES WOULD | | FAIL SIMULTANEOUSLY. THE LICENSEE DOES NOT THINK THIS PROBLEM IS GENERIC | | TO OTHER CE PLANTS. THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR AND | | STATE AND LOCAL GOVERNMENT AGENCIES. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 27210 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: MEMORIAL HOSPITAL |NOTIFICATION DATE: 05/05/94 | | CITY: SOUTH BEND REGION: 3 |NOTIFICATION TIME: 17:12 [ET]| | COUNTY: ST. JOSEPH STATE: IA |EVENT DATE: 04/13/92 | |LICENSE#: 13-18881-01 AGREEMENT: Y |EVENT TIME: 14:25[CDT]| | DOCKET: |LAST UPDATE DATE: 05/05/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |MICHAEL J. JORDAN RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: ALEX HASHEMI | | |HQ OPS OFFICER: RUDY KARSCH | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MEMORIAL HOSPITAL, SOUTH BEND, INDIANA. | | AN NRC INSPECTION COMPLETED 5/4/94 REVEALED THAT A DISLODGED THERAPY SOURCE | | EXPOSED UNINTENDED AREAS OF THE PATIENT TO RADIATION. | | | | ON 4/13/92, WHILE LOADING A CANCER PATIENT WITH CESIUM 137 SOURCES, ONE | | SOURCE WAS DISLODGED AND FELL INTO THE PATIENT'S BEDDING. IT WAS | | SUBSEQUENTLY FOUND ON THE FLOOR, RECOVERED, PLACED IN A SHIELDED CONTAINER, | | AND REINTRODUCED INTO THE PATIENT LATER THAT NIGHT. THE ATTENDING | | PHYSICIAN, THE PATIENT AND THE RADIATION SAFETY OFFICER WERE AWARE OF THE | | SITUATION. | | | | THE SOURCE WAS 44.51 mCi OF CESIUM 137. THE UNDER DOSE WAS CALCULATED AT | | 8%. THIS WAS MADE UP IN A LATER TREATMENT. DURING THE APPROXIMATELY SEVEN | | HOURS THE SOURCE WAS UNACCOUNTED FOR IT MAY HAVE SUBJECTED THE PATIENT TO | | AN INDETERMINATE SKIN DOSE. THE PATIENT WAS OBSERVED FOR SYMPTOMS AND NONE | | WERE DETECTED. TWO NURSES IN ATTENDANCE WHO CARED FOR THE PATIENT HAD | | IMMEDIATE PROCESSING OF THEIR FILM BADGES. THE RESULTS SHOWED NO RADIATION | | EXPOSURE. A FOLLOWUP REPORT WILL BE SUBMITTED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27211 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PEACH BOTTOM REGION: 1 |NOTIFICATION DATE: 05/05/94 | |UNIT: [2] [3] [ ] STATE: PA |NOTIFICATION TIME: 17:31 [ET]| |RX TYPE: [2] GE-4,[3] GE-4 |EVENT DATE: 05/05/94 | +------------------------------------------------+EVENT TIME: 16:30[EDT]| |NRC NOTIFIED BY: CHRIS SCHWARZ |LAST UPDATE DATE: 05/05/94 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |P. K. EAPEN RDO | |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 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | 3 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | CONTROL ROOM VENTILATION RADIATION MONITORS MAY NOT HAVE MET DESIGN | | REQUIREMENTS. | | | | THE TRAIN "A" PROGRAM OF THE CONTROL ROOM VENTILATION RADIATION MONITORING | | SYSTEM WAS CHANGED FROM STATISTICAL AVERAGING TO 10 MINUTE AVERAGING. THE | | LICENSEE DID NOT KNOW IF THE 10 MINUTE AVERAGING PROGRAM WOULD HAVE MET | | DESIGN CRITERIA SINCE THE DESIGN HAD NOT BEEN REVIEWED. THE TIME PERIOD OF | | CONCERN IS FROM AN UNSPECIFIED TIME THIS MORNING UNTIL 1645 TODAY. THE | | PROBLEM WAS DISCOVERED AT 1630 TODAY WHEN WORKERS WERE CONDUCTING A ROUTINE | | DEBRIEF OF THE JOB. THE STATISTICAL AVERAGING PROGRAM WAS REINSTALLED IN | | TRAIN "A" AT 1645. TRAIN "B" WAS INOPERABLE DURING THIS ENTIRE TIME. | | | | A MODIFICATION WAS UNDERWAY TO REPLACE ELECTRONIC COMPONENTS IN BOTH TRAINS | | "A" AND "B" OF THE CONTROL ROOM RADIATION MONITORING SYSTEM. THE TRAIN "A" | | MODIFICATION WAS SUCCESSFULLY COMPLETED LAST WEEK. THE TRAIN "B" | | MODIFICATION COMMENCED THIS MORNING. SIGNAL SPIKES ENCOUNTERED DURING THE | | MODIFICATION INSTALLATION ON TRAIN "B" WERE FIXED BY USING THE 10 MINUTE | | AVERAGING PROGRAM. THIS CHANGE WAS NOT INCLUDED IN THE MODIFICATION. THIS | | PROGRAM CHANGE WAS THEN APPLIED TO TRAIN "A". TRAIN "B" WAS STILL | | INOPERABLE AT THE TIME OF THIS NOTIFICATION. THE TECHNICAL SPECIFICATION | | ACTION STATEMENT FOR THIS SYSTEM WAS ENTERED ON 4/30/94 FOR WORK ON | | TRAIN "B". THE LCO EXPIRES ON 5/7/94. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | | | | * * * UPDATE AT 2124 ON 5/5/94 BY SCHWARZ TAKEN BY WEAVER * * * | | A SPIKE ON CHANNEL "C" OF THE MAIN CONTROL ROOM VENTILATION RADIATION | | MONITORING SYSTEM FAILED TO AUTO INITIATE CONTROL ROOM EMERGENCY | | VENTILATION. OPERATORS SUBSEQUENTLY MANUALLY INITIATED EMERGENCY | | VENTILATION. CHANNELS "A" & "C" ARE IN TRAIN "A" AND CHANNELS "B" & "D" | | ARE IN TRAIN "B". THE LOGIC IS NORMALLY ONE OUT OF TWO TAKEN TWICE. TRAIN | | "B" WAS INOPERABLE AT THE TIME OF THIS EVENT DUE TO THE MODIFICATION | | DESCRIBED ABOVE. BECAUSE OF THE WORK ON TRAIN "B" THE LOGIC WAS ALTERED TO | | ALLOW EITHER CHANNEL "A" OR "C" ALONE TO INITIATE EMERGENCY VENTILATION. | | | | THE LICENSEE BELIEVES THE FAILURE OF CHANNEL "C" TO INITIATE EMERGENCY | | VENTILATION WAS CAUSED BY AN INCORRECT INSTALLATION OF THE MODIFICATION | | PREVIOUSLY DESCRIBED. FURTHER, THE LICENSEE BELIEVES OUT OF DATE PRINTS | | WERE USED TO INSTALL THE MODIFICATION. THE USE OF THE OLD PRINTS CAUSED | | CHANNEL "C" TO BE INADVERTENTLY JUMPERED OUT. BASED ON THEIR REVIEW TO | | THIS POINT THE LICENSEE HAS CONCLUDED THAT A TRIP OF CHANNEL "A" WOULD HAVE | | INITIATED EMERGENCY VENTILATION. | | | | THE LICENSEE INTENDS TO EVALUATE THE CHANGES PERFORMED AND RESTORE TRAIN | | "A" TO ITS ORIGINALLY INTENDED CONDITION I.E., EITHER CHANNEL WILL INITIATE | | EMERGENCY VENTILATION. CONTROL ROOM VENTILATION WILL THEN BE RETURNED TO | | ITS NORMAL LINEUP. A ROOT CAUSE INVESTIGATION WILL BE PERFORMED. | | | | THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | | | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |OTHER NUCLEAR MATERIAL | |EVENT NUMBER: 27212 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: KAJIMA ENGRG & CONST INC. |NOTIFICATION DATE: 05/05/94 | | CITY: CHANDLER REGION: 4 |NOTIFICATION TIME: 19:24 [ET]| | COUNTY: MARICOPA STATE: AZ |EVENT DATE: 05/03/94 | |LICENSE#: 7-359 AGREEMENT: Y |EVENT TIME: 11:00[MDT]| | DOCKET: |LAST UPDATE DATE: 05/05/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |GARY SANBORN RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: JOHN WILSON, AZ RAD REG | | |HQ OPS OFFICER: RUDY KARSCH | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |FLOM 20.402(a) THEFT/DIVERSION LNM | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE ARIZONA RADIATION REGULATORY AGENCY (RRA) REPORTED THAT A TROXLER MODEL | | 3440 MOISTURE DENSITY GAGE CONTAINING 10 mCi CESIUM 137 AND 50 mCi | | AMERICIUM 241 BERYLLIUM WAS STOLEN FROM THE KAJIMA ENGINEERING AND | | CONSTRUCTION COMPANY OF CHANDLER, ARIZONA. THE THEFT WAS REPORTED TO THE | | ARIZONA RRA AT 1550 MST. A PRESS RELEASE WAS ISSUED BY THE ARIZONA RRA TO | | ALERT THE PUBLIC. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27213 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: TURKEY POINT REGION: 2 |NOTIFICATION DATE: 05/05/94 | |UNIT: [3] [ ] [ ] STATE: FL |NOTIFICATION TIME: 19:50 [ET]| |RX TYPE: [3] W-3-LP,[4] W-3-LP |EVENT DATE: 05/05/94 | +------------------------------------------------+EVENT TIME: 17:27[EDT]| |NRC NOTIFIED BY: JOE GUYER |LAST UPDATE DATE: 05/05/94 | |HQ OPS OFFICER: RUDY KARSCH +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MARK LESSER RDO | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 3 | N N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | ENGINEERED SAFEGUARDS ACTUATION FOR UNKNOWN REASON. | | | | THE LICENSEE WAS REENERGIZING THEIR SAFEGUARDS ACTUATION RACKS FOLLOWING | | REFUELING MAINTENANCE IN PREPARATION FOR PERIODIC TESTS, WHEN ONE TRAIN OF | | ESF EQUIPMENT SPURIOUSLY ACTUATED. THE EQUIPMENT WAS SECURED PER | | PROCEDURE, AND A ROOT CAUSE INVESTIGATION WAS INITIATED. ALL EQUIPMENT | | EXCEPT ONE HIGH HEAD SAFETY INJECTION PUMP RESPONDED AS EXPECTED. THE 4A | | HIGH HEAD SI PUMP FAILED TO START AS REQUIRED. THE OTHER TWO HIGH HEAD | | PUMPS DID START. SHUTDOWN COOLING WAS MAINTAINED THROUGHOUT THIS EVENT AND | | NO VESSEL INJECTION OCCURRED. THE LICENSEE INFORMED THE NRC RESIDENT | | INSPECTOR. | +------------------------------------------------------------------------------+