U.S. Nuclear Regulatory Commission Operations Center Event Reports For 05/19/94 - 05/20/94 ** EVENT NUMBERS ** 27272 27273 27274 27275 27276 27277 27278 +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27272 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: DIABLO CANYON REGION: 4 |NOTIFICATION DATE: 05/19/94 | |UNIT: [1] [2] [ ] STATE: CA |NOTIFICATION TIME: 05:27 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 05/19/94 | +------------------------------------------------+EVENT TIME: 02:07[PDT]| |NRC NOTIFIED BY: BOB ARROYO |LAST UPDATE DATE: 05/19/94 | |HQ OPS OFFICER: RUDY KARSCH +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |PHIL HARRELL RDO | |DSAF 73.71(b)(1) SECURITY DEGRADATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE LICENSEE IS INVESTIGATING THE ALLEGATION THAT A SECURITY OFFICER WAS | | ASLEEP AT HIS POST ON 4/28/94. THERE IS NO EVIDENCE OF UNAUTHORIZED ENTRY | | AT THE SITE. THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 27273 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: STAMFORD HOSPITAL, STAMFORD, CT |NOTIFICATION DATE: 05/19/94 | | CITY: STAMFORD REGION: 1 |NOTIFICATION TIME: 09:51 [ET]| | COUNTY: FAIRFIELD STATE: CT |EVENT DATE: 05/18/94 | |LICENSE#: 06-06697-02 AGREEMENT: N |EVENT TIME: 12:00[EDT]| | DOCKET: |LAST UPDATE DATE: 05/19/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |GLENN MEYER RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: KARL | | |HQ OPS OFFICER: RUDY KARSCH | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | A SCHEDULING ERROR RESULTED IN A THYROID DOSE TO A PATIENT. | | | | ACCORDING TO PAUL KARL OF STAMFORD HOSPITAL OF STAMFORD, CONNECTICUT, AN | | UNIDENTIFIED HOSPITAL AUTHORITY INADVERTENTLY SCHEDULED A WHOLE-BODY SCAN | | FOR A PATIENT INSTEAD OF A "RED CELL MASS" TEST. A TECHNICIAN ADMINISTERED | | ONE (1) MILLICURIE OF IODINE-131 TO A PATIENT. HOWEVER, THE PATIENT WAS | | PRESCRIBED TO RECEIVE A "RED CELL MASS" TEST WHICH REQUIRES SEVERAL | | MICROCURIES OF I-125. THE "RED CELL MASS" TEST IS NOT PERFORMED IN THE | | NUCLEAR MEDICINE DEPARTMENT AT STAMFORD HOSPITAL. THEREFORE, THE FULL | | EXPOSURE WAS UNWARRANTED. | | | | THE TOTAL BODY DOSE DUE TO THE ONE-MILLICURIE OF IODINE-131 EXPOSURE IS | | 0.47 RADS AND THE THYROID DOSE IS 800 RADS. THE ATTENDING PHYSICIAN DOES | | NOT ANTICIPATE THYROID REPLACEMENT THERAPY OR ANY OTHER ADVERSE EFFECTS. AN | | INVESTIGATION IS ONGOING. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27274 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MILLSTONE REGION: 1 |NOTIFICATION DATE: 05/19/94 | |UNIT: [ ] [2] [ ] STATE: CT |NOTIFICATION TIME: 15:23 [ET]| |RX TYPE: [1] GE-3,[2] CE,[3] W-4-LP |EVENT DATE: 05/19/94 | +------------------------------------------------+EVENT TIME: 14:24[EDT]| |NRC NOTIFIED BY: EMBROSKY |LAST UPDATE DATE: 05/19/94 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |GLENN MEYER RDO | |AINB 50.72(b)(2)(iii)(B) POT RHR INOP | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 THAT THEY COULD HAVE A CONDITION WHERE AUX | | FEEDWATER WOULD NOT AUTOMATICALLY ACTUATE WHEN NEEDED. | | | | THIS WAS DISCOVERED DURING A DESIGN REVIEW WHICH DETERMINED THAT A CABLE | | RUNNING FROM ONE OF THEIR ACTUATION CABINETS TO A CONTROL PANEL CONTAINED | | TWO WIRES WHICH IF THEY HAD POTENTIALLY SHORTED, WOULD HAVE PREVENTED | | DE-ENERGIZATION OF THE RELAYS THAT WOULD HAVE ACTUATED THE AUTO START OF | | THE AUX FEEDWATER SYSTEM. THEY ARE STILL INVESTIGATING CORRECTIVE ACTIONS | | FOR THIS DESIGN ERROR. THE RI WAS NOTIFIED ALONG WITH THE STATE AND LOCAL | | AGENCIES. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |OTHER NUCLEAR MATERIAL | |EVENT NUMBER: 27275 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: SYNCOR INTERNATIONAL CORPORATION |NOTIFICATION DATE: 05/19/94 | | CITY: KANSAS CITY REGION: 3 |NOTIFICATION TIME: 16:12 [ET]| | COUNTY: STATE: MO |EVENT DATE: 05/18/94 | |LICENSE#: 24-16617-01MD AGREEMENT: N |EVENT TIME: 15:00[CDT]| | DOCKET: |LAST UPDATE DATE: 05/19/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |JIM MCCORMICKBARGER RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: DAVID PELLICCIARINI | | |HQ OPS OFFICER: WILLIAM HUFFMAN | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NINF INFORMATION ONLY | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | DELIBERATE MISUSE OF A LICENSED RADIOACTIVE MATERIAL RESULTING IN | | CONTAMINATION OUTSIDE OF RESTRICTED AREA. | | | | THE SYNCOR INTERNATIONAL CORPORATION REPORTED AN INCIDENT WHICH OCCURRED AT | | THEIR NUCLEAR PHARMACEUTICAL MANUFACTURING FACILITY IN KANSAS CITY, | | MISSOURI. A DISGRUNTLED EMPLOYEE TOOK A SYRINGE FULL OF TECHNETIUM-99M | | PERTECNITATE AND SQUIRTED IT ON TWO BUTTERFLIES MATING ON A TREE NEAR THE | | FACILITY. THE INCIDENT WAS WITNESSED BY OTHER EMPLOYEES WHO IMMEDIATELY | | CONTACTED THE RADIATION SAFETY OFFICER (RSO). | | | | THE INDIVIDUAL INVOLVED WAS IMMEDIATELY SUSPENDED BY THE RSO AND | | TERMINATION PROCESSING IS IN PROGRESS. THE AREA WHERE THE BUTTERFLIES WERE | | SQUIRTED WAS SECURED AND SURVEYED. CONTAMINATION WAS FOUND ON A TREE AND IN | | THE DIRT. BECAUSE OF THE DIFFICULTY IN DECONTAMINATING THESE ITEMS, THE | | LICENSEE HAS POSTED A GUARD AND RESTRICTED ACCESS TO THE AREA. THIS | | ARRANGEMENT WILL CONTINUE UNTIL CONTAMINATION LEVELS DECAY TO BACKGROUND. | | THE INCIDENT OCCURRED IN A LOW TRAFFIC AREA BETWEEN THE FACILITY BUILDING | | AND A PARKING LOT. THE CONTAMINATED BUTTERFLIES WERE ALSO CAPTURED AND ARE | | BEING HELD UNTIL THEY REACH BACKGROUND LEVEL. | | | | THE TOTAL AMOUNT OF TC-99M INVOLVED IS BELIEVED TO BE LESS THAN 5 | | MILLICURIES. THE LICENSEE HAS ALREADY INFORMED REGION III (JONES). NO OTHER | | NOTIFICATIONS WERE MADE. | | | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27276 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: COMANCHE PEAK REGION: 4 |NOTIFICATION DATE: 05/19/94 | |UNIT: [ ] [2] [ ] STATE: TX |NOTIFICATION TIME: 17:17 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 05/19/94 | +------------------------------------------------+EVENT TIME: 14:30[CDT]| |NRC NOTIFIED BY: GOODWIN |LAST UPDATE DATE: 05/19/94 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |PHIL HARRELL 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 PLANT DECLARED TRAINS "A" AND "B" OF CONTAINMENT SPRAY INOPERABLE DUE | | TO LEAKS AT WELD JOINTS. | | | | VISUAL OBSERVATION OF LEAKAGE COMING FORM WELD JOINTS ON 3/4" SS PIPING ON | | TRAINS "A" AND "B" PROMPTED A FURTHER INVESTIGATION WHICH REVEALED SEVERAL | | SMALL THROUGH WALL CRACKS ON THE CONTAINMENT SYSTEM. A PRELIMINARY ANALYSIS | | INDICATES THAT THE CRACKS WERE POSSIBLY SYSTEM VIBRATION INDUCED ALTHOUGH | | CONTINUED ANALYSES AND EVALUATIONS ARE UNDERWAY TO DETERMINE THE EXACT | | CAUSE AND TO WHAT EXTENT THESE CONDITIONS COULD IMPACT THE SYSTEMS ABILITY | | TO FULFILL ITS SAFETY FUNCTION TO MITIGATE THE CONSEQUENCES OF AN ACCIDENT. | | HOWEVER, THE LICENSEE HAS CONSERVATIVELY CONSIDERED THIS CONDITION TO BE | | REPORTABLE. THEY ARE NOT IN ANY LCO ACTION STATEMENT IN THIS MODE. THE RI | | WAS INFORMED. | | | | NOTE: UNIT 1 HAS NOT EXPERIENCED ANY VIBRATION INDUCED CRACKING SINCE | | OPERATIONS BEGAN. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 27277 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: GARDEN CITY HOSPITAL |NOTIFICATION DATE: 05/19/94 | | CITY: GARDEN CITY REGION: 3 |NOTIFICATION TIME: 19:00 [ET]| | COUNTY: STATE: MI |EVENT DATE: 05/18/94 | |LICENSE#: 21-04072-01 AGREEMENT: N |EVENT TIME: 20:00[EDT]| | DOCKET: |LAST UPDATE DATE: 05/19/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |JIM MCCORMICKBARGER RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: LEY/LUTSIC | | |HQ OPS OFFICER: CHAUNCEY GOULD | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE GARDEN CITY HOSPITAL IN GARDEN CITY MI. REPORTED A MEDICAL | | MISADMINISTRATION WHEN THEY DISCOVERED A DISCREPANCY IN THE CESIUM 137 | | TREATMENT. | | | | THE PRESCRIBED DOSE IN MILLIGRAM-HRS WAS ALSO THE GIVEN DOSE, BUT ON THE | | ISODOSE CURVES THEY FOUND THAT THERE WAS A DIFFERENCE FROM THE ORIGINAL | | EVALUATION TO A POINT "A" DOSE FROM 1074 RADS TO 1700 RADS. THEREFORE, THE | | PATIENT RECEIVED OVER A 20% VARIATION OF WHAT WAS ORIGINALLY FELT TO BE THE | | DOSAGE BECAUSE OF A 700 RAD DIFFERENCE RESULTING FROM A CALCULATION ERROR | | ON THE TREATMENT PLAN. THERE WERE NO ADVERSE AFFECTS TO THE PATIENT AND THE | | PATIENT WILL BE NOTIFIED. THIS TREATMENT OCCURRED 3/28/94, BUT THE ERROR | | WAS NOT DISCOVERED UNTIL 5/18/94. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27278 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: DUANE ARNOLD REGION: 3 |NOTIFICATION DATE: 05/19/94 | |UNIT: [1] [ ] [ ] STATE: IA |NOTIFICATION TIME: 19:50 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 05/19/94 | +------------------------------------------------+EVENT TIME: 16:30[CDT]| |NRC NOTIFIED BY: VANSICKEL |LAST UPDATE DATE: 05/19/94 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JIM MCCORMICKBARGER RDO | |AINA 50.72(b)(2)(iii)(A) POT UNABLE TO SAFE SD | | |NLCO TECH SPEC LCO A/S | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE PLANT DECLARED THE "A" RPS TRAIN INOPERABLE DUE TO THE PRESSURE | | SWITCHES THAT PROVIDE FOR THE HIGH PRESSURE REACTOR SCRAM FUNCTION BEING | | DECLARED INOPERABLE. | | | | THE TWO PRESSURE SWITCHES ON THE "A" RPS WERE DECLARED INOPERABLE BECAUSE | | THEY HAD NOT BEEN SURVEILLANCE TESTED FOR RESPONSE TIME SINCE THEY HAD BEEN | | INSTALLED('91 & '92). THE SURVEILLANCE REQUIREMENT IS THAT ONE SWITCH BE | | TESTED EVERY 18 MONTHS. THE "B" TRAIN SWITCHES WERE TESTED 2/17/93 AND | | 5/18/94. THE LCO ACTION STATEMENT REQUIRED THEM TO INSERT, WITHIN 1 HR, A | | HALF SCRAM ON THE "A" RPS, WHICH THEY HAD ALREADY DONE. THEY ARE CURRENTLY | | TESTING THE SWITCHES ON THE "A" TRAIN. THE RI WILL BE INFORMED. | +------------------------------------------------------------------------------+