U.S. Nuclear Regulatory Commission Operations Center Event Reports For 05/16/94 - 05/17/94 ** EVENT NUMBERS ** 27258 27259 27260 27261 27262 27263 +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27258 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PEACH BOTTOM REGION: 1 |NOTIFICATION DATE: 05/16/94 | |UNIT: [2] [ ] [ ] STATE: PA |NOTIFICATION TIME: 06:12 [ET]| |RX TYPE: [2] GE-4,[3] GE-4 |EVENT DATE: 05/16/94 | +------------------------------------------------+EVENT TIME: 04:23[EDT]| |NRC NOTIFIED BY: C.N. SWENSON |LAST UPDATE DATE: 05/16/94 | |HQ OPS OFFICER: STEVE SANDIN +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |RICHARD CONTE 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 HOT SHUTDOWN | 0 HOT SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | UNIT 2 EXPERIENCED A RHR HIGH PRESSURE ISOLATION DURING FLUSHING DUE TO | | POSSIBLE OUT OF CALIBRATION PRESSURE SWITCHES. | | | | "WITH REACTOR PRESSURE APPROXIMATELY 33 PSIG THE RHR SHUTDOWN COOLING | | PIPING WAS BEING FLUSHED IN PREPARATION FOR RHR SHUTDOWN COOLING MODE. | | REACTOR LEVEL WAS RAISED TO +40 INCHES PER PROCEDURE TO ACCOMMODATE THE | | FLUSH. FOLLOWING THE FIRST FLUSH THE REACTOR LEVEL CONTROLLER OVERSHOT TO | | APPROXIMATELY +50 INCHES. THE COMBINATION OF REACTOR DOME PRESSURE AND THE | | WATER LEG PRESSURE CAUSED BY THE HIGH REACTOR LEVEL CAUSED THE SHUTDOWN | | COOLING HIGH PRESSURE ISOLATION SIGNAL TO ACTUATE. THE ISOLATION WENT TO | | COMPLETION AS EXPECTED. HOWEVER, THE ISOLATION WAS NOT EXPECTED AND THE | | POTENTIAL WAS NOT ADDRESSED IN THE OPERATING PROCEDURE. INVESTIGATION IS | | CONTINUING INTO POSSIBLE PROCEDURE ENHANCEMENT OR POSSIBLE OVERLY | | CONSERVATIVE OR OUT OF CALIBRATION PRESSURE SWITCHES." | | | | THE LICENSEE IS REVIEWING CALIBRATION SHEETS TO VERIFY THAT NORMAL +23 | | INCHES STATIC HEAD IS INCLUDED IN THE PRESSURE SWITCH SETPOINT OF 60.5 | | PSIG. WITH +50 INCHES STATIC HEAD AND A DOME PRESSURE OF 33 PSIG THE | | LICENSEE ESTIMATES THAT THE COMBINED PRESSURE SEEN BY THE HIGH PRESSURE | | SWITCH IS 57.5 PSIG. CURRENT INFORMATION SUGGESTS THAT A PRESSURE SWITCH IS | | OUT OF CALIBRATION. THE LICENSEE NOTED THAT THE LEVEL OVERSHOOT TO +50 | | INCHES HAD NOT BEEN EXPERIENCED IN THE PAST AND ATTRIBUTED THE CAUSE TO | | SLUGGISH CONTROLLER RESPONSE. THE LEVEL CONTROLLER SETPOINT WAS READJUSTED | | TO +33 INCHES WHICH RESULTED IN A LEVEL OVERSHOOT OF +40 INCHES AND THE RHR | | FLUSHES COMPLETED. CURRENTLY RHR LOOP "A" WITH PUMP "C" IS IN SERVICE. | | | | RESIDENT INSPECTOR WILL BE INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27259 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: FARLEY REGION: 2 |NOTIFICATION DATE: 05/16/94 | |UNIT: [1] [2] [ ] STATE: AL |NOTIFICATION TIME: 12:49 [ET]| |RX TYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 05/15/94 | +------------------------------------------------+EVENT TIME: 22:00[CDT]| |NRC NOTIFIED BY: LARRY CARTER |LAST UPDATE DATE: 05/16/94 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |EDWARD MCALPINE RDO | |NINF INFORMATION ONLY |ROBERT DENNIG EO | | |LOREN BUSH IAT | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | POTENTIAL SABOTAGE THREAT | | | | THE DETAILS OF THIS EVENT ARE LOCATED IN THE HOO LOG. THE THREAT HAS NOT | | BEEN SUBSTANTIATED. THE RESIDENT INSPECTOR WAS INFORMED. THE LICENSEE HAS | | NOTIFIED THE LOCAL LAW ENFORCEMENT AGENCY. COMPENSATORY MEASURES ARE IN | | EFFECT. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 27260 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: WELLBORN BAPTIST HOSPITAL |NOTIFICATION DATE: 05/16/94 | | CITY: EVANSVILLE REGION: 3 |NOTIFICATION TIME: 14:45 [ET]| | COUNTY: STATE: IN |EVENT DATE: 03/09/94 | |LICENSE#: 13-01674-01 AGREEMENT: N |EVENT TIME: 00:00[EDT]| | DOCKET: |LAST UPDATE DATE: 05/16/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |ROGER LANKSBURY RDO | | |MIKE BELL EO | +------------------------------------------------+KATHLEEN SCHNEIDER SP | |NRC NOTIFIED BY: MARSHALL MILLER | | |HQ OPS OFFICER: DOUG WEAVER | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MISADMINISTRATION AT WELLBORN BAPTIST HOSPITAL, EVANSVILLE, INDIANA | | | | A 23 YEAR OLD FEMALE RECEIVED 5 MILLICURIES OF I-131 FOR THE TREATMENT OF | | GRAVES DISEASE ON 3/9/94. SUBSEQUENTLY, IT WAS DISCOVERED THAT THE PATIENT | | WAS 22 WEEKS PREGNANT AT THE TIME OF THE ADMINISTRATION. THIS TREATMENT | | WOULD NOT HAVE BEEN PRESCRIBED HAD THE DOCTOR KNOWN THAT THE WOMAN WAS | | PREGNANT. ALTHOUGH AN ULTRA SOUND PERFORMED REVEALED AN APPARENTLY HEALTHY | | FETUS, THE DIRECTOR OF NUCLEAR MEDICINE AT THE HOSPITAL BELIEVES THAT THIS | | DOSAGE ALMOST CERTAINLY DESTROYED THE THYROID GLAND OF THE FETUS. THE | | PATIENT IS AWARE OF THE POTENTIAL HARM TO HER BABY. | | | | THE PATIENT TOLD THE DOCTOR AT THE TIME OF THE ADMINISTRATION THAT SHE | | COULD NOT BE PREGNANT BECAUSE SHE HAD JUST COMPLETED A NORMAL MENSTRUAL | | CYCLE. NO PREGNANCY TEST WAS PERFORMED PRIOR TO THE ADMINISTRATION. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27261 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SOUTH TEXAS REGION: 4 |NOTIFICATION DATE: 05/16/94 | |UNIT: [ ] [2] [ ] STATE: TX |NOTIFICATION TIME: 22:55 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 05/12/94 | +------------------------------------------------+EVENT TIME: 22:10[CDT]| |NRC NOTIFIED BY: JACK GRANT |LAST UPDATE DATE: 05/16/94 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |PHIL HARRELL 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 HOT SHUTDOWN | 0 HOT SHUTDOWN | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | FEEDWATER ISOLATION DUE TO OVERFILLING A STEAM GENERATOR | | | | THIS EVENT OCCURRED ON 5/12/94 AT 2210 CENTRAL TIME. WHILE PERFORMING A | | CALIBRATION OF THE T-HOT AND T-COLD RTD'S, STEAM GENERATOR 2D WAS FILLED TO | | 87.5% NARROW RANGE LEVEL WITH AN AUXILIARY FEEDWATER PUMP. REQUIRED LEVEL | | FOR THIS PROCEDURE IS 70% TO 80% NARROW RANGE. WHEN LEVEL REACHED 87.5% ON | | TWO OUT OF FOUR LEVEL INSTRUMENTS A FEED WATER ISOLATION SIGNAL WAS | | GENERATED. SINCE FEEDWATER WAS ALREADY ISOLATED, NO VALVES REPOSITIONED. | | ALL SYSTEMS FUNCTIONED AS EXPECTED. | | | | LICENSEE MANAGEMENT DETERMINED AT 1935 CENTRAL TIME ON 5/16/94 THAT THIS | | EVENT WAS REPORTABLE. THE CAUSE OF THIS EVENT APPEARS TO BE A POOR | | TURNOVER BETWEEN TWO OPERATORS. ONE OPERATOR COMMENCED FEEDING THE STEAM | | GENERATOR WITH AUX FEED AND WAS RELIEVED WITH THIS EVOLUTION IN PROGRESS. | | THE ONCOMING OPERATOR WAS NOT INFORMED OF THIS EVOLUTION. THE HIGH LEVEL | | ALARMS FOR THE STEAM GENERATORS WERE ALREADY LOCKED IN DUE TO MAINTAINING | | THE 70% TO 80% BAND. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27262 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: FERMI REGION: 3 |NOTIFICATION DATE: 05/17/94 | |UNIT: [2] [ ] [ ] STATE: MI |NOTIFICATION TIME: 03:37 [ET]| |RX TYPE: [2] GE-4 |EVENT DATE: 05/17/94 | +------------------------------------------------+EVENT TIME: 02:29[EDT]| |NRC NOTIFIED BY: STEVE PETERMAN |LAST UPDATE DATE: 05/17/94 | |HQ OPS OFFICER: STEVE SANDIN +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: | | |AINC 50.72(b)(2)(iii)(C) POT UNCNTRL RAD REL | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 2 | N N 0 REFUELING | 0 REFUELING | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | COMBINED LEAKAGE OF ALL FOUR MAIN STEAM LINES EXCEEDED TS ALLOWED LIMIT. | | | | "THE RESULTS OF THE LOCAL LEAK RATE TEST (LLRT) OF THE COMBINED LEAKAGE OF | | ALL FOUR MAIN STEAM LINES WAS 137.3 SCFH. FERMI-2 TECH SPEC SECTION | | 3.6.1.2.C STATES "PRIMARY CONTAINMENT LEAKAGE RATES SHALL BE LIMITED TO | | LESS THAN OR EQUAL TO 100 SCFH FOR ALL FOUR MAIN STEAM LINES". INDIVIDUAL | | MAIN STEAM LINE ISOLATION VALVES WILL BE LEAKRATE TESTED TO DETERMINE THE | | NECESSARY REPAIRS. A FULL REPORT WILL BE PROVIDED PER 10CFR50.73." | | | | THE LICENSEE WILL INFORM THE NRC REGION3(MONTE PHILLIPS). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27263 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: LASALLE REGION: 3 |NOTIFICATION DATE: 05/17/94 | |UNIT: [1] [ ] [ ] STATE: IL |NOTIFICATION TIME: 04:46 [ET]| |RX TYPE: [1] GE-5,[2] GE-5 |EVENT DATE: 05/17/94 | +------------------------------------------------+EVENT TIME: 02:00[CDT]| |NRC NOTIFIED BY: |LAST UPDATE DATE: 05/17/94 | |HQ OPS OFFICER: STEVE SANDIN +-----------------------------+ +------------------------------------------------+ 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 REFUELING | 0 REFUELING | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | UNIT 1 EXPERIENCED A 22 MINUTE LOSS OF SHUTDOWN COOLING DUE TO A PROCEDURAL | | DEFICIENCY IDENTIFIED DURING EDG TESTING. | | | | "WHILE PERFORMING LTS-800-105 "1A D/G 24 HR RUN SURVEILLANCE", AN ISOLATION | | SIGNAL TO THE RHR INBOARD ISOLATION VALVE "1E12-F009" WAS RECEIVED. THIS | | RESULTED IN A TEMPORARY LOSS OF SHUTDOWN COOLING. SHUTDOWN COOLING WAS | | RESTARTED 22 MINUTES LATER (AFTER VERIFYING FILL AND VENT). THE ISOLATION | | SIGNAL IS BELIEVED TO HAVE COME FROM THE LOSS OF, AND SUBSEQUENT RETURN OF | | POWER (FROM THE "1A D/G") TO LEAK DETECTION LOGIC." | | | | THE DIESEL TEST REQUIRED THAT BUS "142Y" BE ENERGIZED FROM THE DIVISION 2 | | EDG "1A". THE DIV 1 TRAIN "A" RHR WAS IN SERVICE AT THE TIME. THE PROCEDURE | | DID NOT ACCOUNT FOR THE LEAK DETECTION LOGIC RECEIVING POWER FROM BOTH DIV | | 1 AND DIV 2. ALL SYSTEMS FUNCTIONED AS REQUIRED. THE DIESEL TEST WAS | | COMPLETED SATISFACTORILY. RCS TEMPERATURE PRIOR TO AND FOLLOWING THE LOSS | | OF SHUTDOWN COOLING REMAINED 82F. THE LICENSEE INFORMED THE NRC RESIDENT | | INSPECTOR. | +------------------------------------------------------------------------------+