U.S. Nuclear Regulatory Commission Operations Center Event Reports For 06/21/94 - 06/22/94 ** EVENT NUMBERS ** 27422 27423 27424 27425 27426 27427 +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27422 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: TURKEY POINT REGION: 2 |NOTIFICATION DATE: 06/21/94 | |UNIT: [3] [4] [ ] STATE: FL |NOTIFICATION TIME: 10:45 [ET]| |RX TYPE: [3] W-3-LP,[4] W-3-LP |EVENT DATE: 06/21/94 | +------------------------------------------------+EVENT TIME: 02:30[EDT]| |NRC NOTIFIED BY: PREVATT |LAST UPDATE DATE: 06/21/94 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |FRANCIS JAPE RDO | |NINF INFORMATION ONLY | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 3 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | 4 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | FIRE IN AN OFF SITE SUBSTATION. | | | | A FIRE THIS MORNING IN THE MACGREGGOR SUBSTATION LOCATED ABOUT ONE HALF | | MILE FROM THE PLANT HAS RECEIVED SOME MEDIA ATTENTION. THE FIRE WAS | | STARTED BY A RACCOON ENTERING THE SUBSTATION AND CAUSING AN ELECTRICAL | | SHORT. NO PLANT SYSTEMS WERE AFFECTED. THE ADMINISTRATIVE BUILDINGS | | POWERED FROM THIS SUBSTATION ARE BEING SUPPLIED FROM ANOTHER SUBSTATION. | | THE FIRE SUBSIDED IN LESS THAN 15 MINUTES, BUT THE LOCAL FIRE DEPARTMENT | | WAS CALLED AS A PRECAUTION. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 27423 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: BACCHUS HOSPITAL OF NORWICH, CT |NOTIFICATION DATE: 06/21/94 | | CITY: NORWICH REGION: 1 |NOTIFICATION TIME: 16:47 [ET]| | COUNTY: STATE: CT |EVENT DATE: 06/21/94 | |LICENSE#: 061173402 AGREEMENT: N |EVENT TIME: 12:00[EDT]| | DOCKET: |LAST UPDATE DATE: 06/21/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |JOHN ROGGE RDO | | |CHARLEY HAUGHNEY EO | +------------------------------------------------+ | |NRC NOTIFIED BY: KORCHIN | | |HQ OPS OFFICER: GREG SCARFO | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE ACTIVITIES OF OVER ONE HUNDRED SEEDS OF IODINE-125 GREATER THAN 10 | | TIMES THE AMOUNT PRESCRIBED WERE IMPLANTED INTO THE PROSTATE OF A CANCER | | PATIENT AT BACCHUS HOSPITAL OF NORWICH, CONNECTICUT. | | | | A DOSIMETRIST, WHO FAILED TO CHECK THE ASSOCIATED ORDER SHEETS PER THE | | HOSPITAL'S QUALITY MANAGEMENT PLAN, ALLOWED A PHYSICIAN TO IMPLANT 112 | | "SEEDS" OF IODINE-125, WHOSE ACTIVITIES WERE TEN-TIMES GREATER THAN | | PRESCRIBED, IN A PATIENT AS BRACHYATHERAPY FOR PROSTATE CANCER. THE | | PHYSICIAN'S PRESCRIPTION WAS FOR THE IMPLANTATION OF 112 "SEEDS" OF I-125 | | OF ACTIVITIES BETWEEN 0.43 AND 0.46 MILLICURIES. THE PRESCRIBED TOTAL | | ACTIVITY WAS FOR APPROXIMATELY 50.288 MILLICURIES TO THE PROSTATE. THE | | IMPLANTED "SEEDS" HAD ACTIVITIES OF APPROXIMATELY 4.49 MILLICURIES PER SEED | | FOR AN EXPECTED TOTAL ACTIVITY OF 502 MILLICURIES TO THE PROSTATE. THESE | | SEEDS WERE IMPLANTED INTO THE PROSTATE OF THE PATIENT AND THE PATIENT WAS | | SENT HOME. | | | | UPON REVIEW OF THE DOSE LOG AND ORDER SHEET AFTER THE IMPLANTATION, THE | | DOSIMETRIST DISCOVERED THE ERROR AND INFORMED THE PHYSICIAN. THE PHYSICIAN | | INFORMED THE PATIENT AND REQUESTED THAT THE PATIENT RETURN IMMEDIATELY FOR | | REMOVAL OF THE SEEDS AND THE PROSTATE GLAND. THAT PROCEDURE IS ONGOING AT | | THIS TIME. | | | | THIS CONSTITUTED A VIOLATION OF THE HOSPITAL'S QUALITY MANAGEMENT PLAN. | | CORRECTIVE ACTIONS ARE UNDER INVESTIGATION AT THIS TIME. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27424 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: QUAD CITIES REGION: 3 |NOTIFICATION DATE: 06/21/94 | |UNIT: [ ] [2] [ ] STATE: IL |NOTIFICATION TIME: 17:13 [ET]| |RX TYPE: [1] GE-3,[2] GE-3 |EVENT DATE: 06/21/94 | +------------------------------------------------+EVENT TIME: 14:05[CDT]| |NRC NOTIFIED BY: BRITZ |LAST UPDATE DATE: 06/21/94 | |HQ OPS OFFICER: GREG SCARFO +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MARTIN FARBER 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 | M/R Y 100 POWER OPERATION | 0 HOT SHUTDOWN | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | A MANUAL REACTOR SCRAM WAS INITIATED WHEN ELECTROHYDRAULIC (EHC) SYSTEM | | PRESSURE DECREASED DUE TO A LEAKING MAIN TURBINE CONTROL VALVE (CV). | | | | AT 1230 EDT, A LOW-LEVEL EHC FLUID ALARM OCCURRED. AN INVESTIGATION FOUND | | THAT A LEAKING MAIN TURBINE CONTROL VALVE CAUSED THE INVENTORY OF EHC FLUID | | TO DECREASE. WHILE ATTEMPTING TO REFILL THE EHC SYSTEM, A SECOND EHC PUMP | | AUTO STARTED ON LOW EHC (FLUID) SYSTEM PRESSURE AND OPERATORS INITIATED A | | MANUAL REACTOR SCRAM. | | | | ALL RODS EXCEPT THE "M-06" CONTROL BLADE FULLY INSERTED ON THE REACTOR | | SCRAM. THE "M-06" CONTROL BLADE "BOUNCED" BACK TO THE "02" POSITION BEFORE | | BEING MANUALLY INSERTED BACK TO THE "00" POSITION. | | | | REACTOR WATER LEVEL DECREASED TO THE LOW-LEVEL SETPOINT OF +8 INCHES WHERE | | AN AUTOMATIC REACTOR SCRAM SIGNAL, GROUP 2 (REACTOR BUILDING VENTILATION | | ISOLATION, CONTROL ROOM VENTILATION ISOLATION, AND STANDBY GAS TREATMENT | | SYSTEM ACTUATION) ISOLATION, AND A GROUP 3 (REACTOR WATER CLEANUP) | | ISOLATION OCCURRED. NO SAFETY-RELIEF VALVES LIFTED DURING THE SCRAM. ALL | | SAFETY LOADS TRANSFERRED PROPERLY TO OFFSITE POWER AS EXPECTED. REACTOR | | PRESSURE REMAINED WITHIN EXPECTED BANDS. NO OTHER ENGINEERED SAFETY | | FEATURES ACTUATIONS OCCURRED. | | | | CURRENTLY, THE UNIT IS STABLE IN HOT SHUTDOWN. A PLANT COOLDOWN IS IN | | PROGRESS UTILIZING THE RWCU SYSTEM INTERFACE WITH THE CONDENSER. BYPASS | | VALVES ARE AVAILABLE BUT NOT IN SERVICE. A REACTOR FEED PUMP IS FEEDING | | THE VESSEL VIA A BYPASS/STARTUP FEEDWATER VALVE. OFFSITE POWER IS | | SUPPLYING ALL PLANT LOADS AND THE GRID IS STABLE. | | | | THE LEAKING CONTROL VALVE IS UNDER INVESTIGATION AND CORRECTIVE ACTIONS | | WILL BE DETERMINED PENDING ITS COMPLETION. THE LICENSEE INFORMED THE NRC | | RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |OTHER NUCLEAR MATERIAL | |EVENT NUMBER: 27425 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: MICROGENESIS OF MERIDEN, CT |NOTIFICATION DATE: 06/21/94 | | CITY: MERIDEN REGION: 1 |NOTIFICATION TIME: 17:37 [ET]| | COUNTY: STATE: CT |EVENT DATE: 06/21/94 | |LICENSE#: 06-20749-01 AGREEMENT: N |EVENT TIME: 16:30[EDT]| | DOCKET: |LAST UPDATE DATE: 06/21/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |JOHN ROGGE RDO | | |CHARLEY HAUGHNEY EO | +------------------------------------------------+CONKLIN EPA | |NRC NOTIFIED BY: GOODRICH | | |HQ OPS OFFICER: GREG SCARFO | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |IBDB 30.50(b)(4)(ii) DAMAGED LNM/CONTAINER | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | A PHOSPHORUS-32 SPILL OCCURRED IN A LABORATORY AT MICROGENESIS OF MERIDEN, | | CONNECTICUT. NO PERSONNEL EXPOSURES OCCURRED. | | | | A TECHNICIAN PREPARING TO PERFORM A DNA TEST INADVERTENTLY SPILLED A | | SOLUTION OF 50 MICROCURIES OF P-32 IN 200 MICRO LITERS OF WATER ON THE | | FLOOR OF THE LABORATORY. THE SPILL WAS REMOVED AND A RADIATION SURVEY WAS | | PERFORMED. THE RESULTS OF THE SURVEY FOUND A "HOT SPOT" ON THE | | TECHNICIAN'S LAB COAT AND BLOUSE. NO OTHER CONTAMINATED AREAS OR PERSONNEL | | CONTAMINATIONS OCCURRED. THE LAB COAT AND BLOUSE WERE STORED AS | | RADIOACTIVE WASTE ALONG WITH THE SPILLED P-32 SOLUTION. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27426 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: LASALLE REGION: 3 |NOTIFICATION DATE: 06/22/94 | |UNIT: [ ] [2] [ ] STATE: IL |NOTIFICATION TIME: 02:39 [ET]| |RX TYPE: [1] GE-5,[2] GE-5 |EVENT DATE: 06/21/94 | +------------------------------------------------+EVENT TIME: 22:30[CDT]| |NRC NOTIFIED BY: J. HENRY |LAST UPDATE DATE: 06/22/94 | |HQ OPS OFFICER: THOMAS ANDREWS +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MARTIN FARBER 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 100 POWER OPERATION | 0 HOT SHUTDOWN | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | WITH THE UNIT AT 100% POWER, A DIVISION 1 - 125 VDC GROUND DETECTOR ALARM | | BEGAN CHATTERING IN THE CONTROL ROOM. BEFORE THE LICENSEE COULD DIAGNOSE | | THE PROBLEM, THE GROUND WENT AWAY AND THERE WAS NO LONGER ANY INDICATION OF | | A PROBLEM. | | | | ABOUT 30 MINUTES LATER, THE DIVISION 1 - 125 VDC GROUND DETECTOR ALARM | | RETURNED, FOLLOWED BY A LOSS OF THE 6.9 KV NON-ESS FEED TO TWO 480 V BUSES. | | THIS RESULTED IN A FEEDWATER TRANSIENT THAT CAUSED A DECREASE IN THE | | SUCTION PRESSURE TO THE TURBINE DRIVEN REACTOR FEED PUMPS. THIS CAUSED AN | | AUTOMATIC REACTOR SCRAM WHEN THE REACTOR WATER LEVEL REACHED THE LEVEL 3 | | SETPOINT. | | | | AN INVESTIGATION WILL BE CONDUCTED. THE CAUSE OF THE GROUND AND ITS | | RELATIONSHIP TO THE LOSS OF THE 480 KV BUSES IS UNKNOWN AT THIS TIME. | | | | ALL RODS HAVE BEEN VERIFIED TO BE FULLY INSERTED. THE LOWEST WATER LEVEL | | OBSERVED WAS -12 INCHES. WATER IS BEING FED TO THE REACTOR USING THE MOTOR | | DRIVEN REACTOR FEED PUMP. THE STEAM IS BEING DUMPED TO THE CONDENSER VIA | | THE BYPASS VALVES. CONDENSER VACUUM IS BEING MAINTAINED BY THE STEAM JET | | AIR EJECTORS AND THE OFF-GAS SYSTEM. | | | | AS A RESULT OF THE LOSS OF POWER, THE "A" REACTOR RECIRC FLOW CONTROL VALVE | | RECEIVED A LOCKOUT SIGNAL. FOLLOWING THE TURBINE TRIP, THE ELECTRO | | HYDRAULIC CONTROL SYSTEM REACHED THE AUTOMATIC START SETPOINT FOR THE | | SECOND PUMP, HOWEVER, THE LOSS OF POWER PREVENTED THE START OF THE SECOND | | PUMP. AT THIS TIME, THE CAUSE OF THE LOW ELECTRO HYDRAULIC PRESSURE IS | | SUSPECTED TO BE A RESULT OF INTERNAL VALVE LEAKAGE. | | | | ALL SYSTEMS FUNCTIONED AS REQUIRED WITH THE EXCEPTIONS OF THE ITEMS LISTED | | ABOVE. THE LICENSEE HAS NOTIFIED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27427 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: DIABLO CANYON REGION: 4 |NOTIFICATION DATE: 06/22/94 | |UNIT: [1] [2] [ ] STATE: CA |NOTIFICATION TIME: 05:56 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 06/22/94 | +------------------------------------------------+EVENT TIME: 02:40[PDT]| |NRC NOTIFIED BY: RAAB |LAST UPDATE DATE: 06/22/94 | |HQ OPS OFFICER: THOMAS ANDREWS +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: UNUSUAL EVENT +-----------------------------+ |10 CFR SECTION: |THOMAS WESTERMAN RDO | |AAEC 50.72(a)(1)(i) EMERGENCY DECLARED |BRUCE BOGER EO | | |CARR FEMA | | |WING | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | UNUSUAL EVENT DECLARED AT 0240 PDT DUE TO A GRASS FIRE OUTSIDE THE | | PROTECTED AREA. | | | | THE FIRE IS APPROXIMATELY 1/3 MILE SOUTHEAST FROM THE PROTECTED AREA. IT | | IS MOVING IN A GENERAL DIRECTION TOWARDS THE NORTH EAST. THE WINDS ARE | | LIGHT AND THE DIRECTION IS VARIABLE. THE FIRE IS MOVING ABOUT 2 MILES PER | | HOUR. THE FIRST ANTICIPATED THREAT TO THE SITE WOULD BE TO THE UNIT 2 - | | 500 KV LINES. THE FIRE IS ABOUT 1/4 MILE FROM THESE LINES. THE FIRE IS | | GENERATING A LARGE AMOUNT OF SMOKE. | | | | THERE ARE NO EQUIPMENT PROBLEMS AT THE PLANT. THE OFFSITE POWER IS | | PRESENTLY STABLE. | | | | THE BASIS FOR TERMINATING THE UNUSUAL EVENT WILL BE WHEN THE FIRE IS EITHER | | OUT OR NO LONGER POSING A THREAT TO THE PLANT. | | | | THE LICENSEE HAS NOTIFIED THE CALIFORNIA DEPARTMENT OF FORESTRY, THE STATE | | AND LOCAL OFFICIALS AND WILL NOTIFY THE NRC RESIDENT INSPECTOR. A PRESS | | RELEASE IS EXPECTED. | | | | **** UPDATE AT 0643 EDT ON 06/24/94 BY RAAB TAKEN BY ANDREWS **** | | THE LICENSEE INDICATED THAT THE THREAT TO THE 500 KV LINES IS SMALL. THIS | | IS BASED ON THE SIZE AND LOCATION OF THE FIRE. CALIFORNIA DEPARTMENT OF | | FORESTRY IS ONSITE WITH FIRE ENGINES AND BULLDOZERS. R4D0 (), EO (). | +------------------------------------------------------------------------------+