U.S. Nuclear Regulatory Commission Operations Center Event Reports For 06/22/94 - 06/23/94 ** EVENT NUMBERS ** 27423 27426 27427 27430 27431 27432 27433 27434 27435 +----------------------------------+ +-----------------------+ |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: 06/22/94 | | +-----------------------------+ | |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. | | | | * * * COMMISSIONER'S ASSISTANTS' BRIEFING ON 06/22/94 * * * | | BRIEFER: BELLAMY | | | | PARTICIPANTS: BROCKMAN(AEOD) HAYDEN(PAO) DROGGITIS(SP) MITCHELL(EDO) | | STABLIEN(EDO) BATES(SECY) PORTNER(CA) JOHANSON(R1) | | GLENN(R1) HEHL(R1) SCRENCI(R1) | | LUBENAU(DEPLANQUE) | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |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. | | | | HOO NOTIFIED R4D0 (WESTERMAN), EO (CHAFFEE). | | | | **** UPDATE AT 0750 EDT ON 06/24/94 BY RAAB TAKEN BY ANDREWS **** | | THE LICENSEE STATED THAT THE FIRE HAS BEEN CONTAINED. IT IS NOT OUT. THE | | WIND AND WEATHER CONDITIONS ARE SUCH THAT THE FIRE IS NOW MOVING AWAY FROM | | THE PLANT. THE THREAT TO THE PLANT IS DIMINISHING. | | | | HOO NOTIFIED R4D0 (WESTERMAN), EO (CHAFFEE). | | | | **** UPDATE AT 0820 EDT ON 06/22/94 BY RAAB TAKEN BY ANDREWS **** | | LICENSEE TERMINATED THE UNUSUAL EVENT AT 0515 PDT. THE FIRE IS OUT. | | HOO NOTIFIED R4DO (WESTERMAN), EO (CHAFFEE), FEMA (SHULL) | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27430 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SEABROOK REGION: 1 |NOTIFICATION DATE: 06/22/94 | |UNIT: [1] [ ] [ ] STATE: NH |NOTIFICATION TIME: 13:02 [ET]| |RX TYPE: [1] W-4-LP |EVENT DATE: 06/22/94 | +------------------------------------------------+EVENT TIME: 10:00[EDT]| |NRC NOTIFIED BY: STRICKLAND |LAST UPDATE DATE: 06/22/94 | |HQ OPS OFFICER: GREG SCARFO +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |ROGGE RDO | |ADAS 50.72(b)(2)(i) DEG/UNANALYZED COND | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 REFUELING | 0 REFUELING | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | REACTOR COOLANT PUMP (RCP) TURNING VANE CAP SCREWS (TVCS) AND TVCS LOCKING | | CUPS WERE DISLODGED AND FOUND IN THE BOTTOM OF THE REACTOR VESSEL. | | | | THE FOLLOWING IS THE TEXT OF A FACSIMILE SUBMITTED BY THE LICENSEE: | | "NORTH ATLANTIC ENERGY SERVICE CORPORATION CONSERVATIVELY DETERMINED ON | | JUNE 22, 1994, AT 1000AM THAT A REPORTABLE CONDITION PURSUANT TO | | 10CFR50.72(b)(2)(i) EXISTS AT SEABROOK STATION. | | | | NORTH ATLANTIC IS CURRENTLY PERFORMING UNDERWATER INSPECTIONS OF THE 193 | | FUEL ASSEMBLIES WHICH WERE UTILIZED DURING CYCLE 3. THE PURPOSE OF THE | | INSPECTIONS IS TO DETERMINE IF ANY FUEL ASSEMBLIES WERE DEGRADED BY THE RCP | | TURNING VANE CAPSCREW (TVCS) OR TVCS LOCKING CUPS. THE TVCS WAS FOUND IN | | THE BOTTOM OF THE REACTOR VESSEL IN EARLY JUNE DURING REFUELING OUTAGE 3. | | THE LOCKING CUPS WERE FOUND ON THE LOWER CORE SUPPORT PLATE AFTER ECCS FLOW | | TESTING WHICH WAS A REFUELING OUTAGE SURVEILLANCE. TO DATE, 109 OF THE 193 | | FUEL ASSEMBLIES HAVE BEEN INSPECTED IN THE SPENT FUEL POOL WITH THE | | FOLLOWING RESULTS: | | - ONE FUEL ASSEMBLY BOTTOM NOZZLE WAS FOUND TO HAVE MINOR MARKINGS | | - TWO OTHER ADJACENT FUEL ASSEMBLIES WERE FOUND TO HAVE BOTTOM NOZZLE | | DEGRADATION. THIS DEGRADATION APPEARS TO HAVE BEEN CAUSED BY THE | | WEARING ACTION OF THE TVCS AGAINST THE BOTTOM NOZZLES OF THE | | 2 FUEL ASSEMBLIES. THE DEGRADATION IS LIMITED TO THE BOTTOM | | NOZZLES WITH NO DEGRADATION BEING FOUND ON THE FUEL PINS | | THEMSELVES. | | | | NORTH ATLANTIC IS CONSERVATIVELY REPORTING THIS CONDITION UNDER THE | | AFOREMENTIONED REPORTING CRITERIA SINCE THE POTENTIAL EXISTED FOR FURTHER | | DEGRADATION OF THE FUEL ASSEMBLY BOTTOM NOZZLES LEADING TO POSSIBLE FUTURE | | FUEL DEGRADATION." | | END OF TEXT. | | | | NO FUEL CLADDING OR OTHER FUEL ASSEMBLY DAMAGE HAS BEEN DETECTED AT THIS | | TIME. AN INSPECTION OF THE REACTOR COOLANT SYSTEM (RCS) LOOPS IS ONGOING | | TO DETERMINE IF ANY DAMAGE WAS SUSTAINED. THE REACTOR COOLANT PUMPS (RCPs) | | HAVE BEEN REMOVED AND NEW CAP SCREWS WILL BE WELDED ONTO THE TURNING VANE | | BOLTS, AS APPROVED BY WESTINGHOUSE. A PART 21.21 NOTIFICATION ON THESE | | TVCSs AND TVCS LOCKING CUPS FOR THE WESTINGHOUSE STANDARD RCP IS BEING | | CONSIDERED. THE CAUSE OF THE LOOSENED TVCSs AND TVCS LOCKING CUPS IS | | BELIEVED TO BE THERMAL CYCLING. THE LICENSEE WILL INFORM THE NRC RESIDENT | | INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |OTHER NUCLEAR MATERIAL | |EVENT NUMBER: 27431 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: HAPAG-LLOYD AMERICA, INCORPORATED |NOTIFICATION DATE: 06/22/94 | | CITY: PORT ELIZABETH REGION: 1 |NOTIFICATION TIME: 13:21 [ET]| | COUNTY: STATE: NJ |EVENT DATE: 06/22/94 | |LICENSE#: AGREEMENT: N |EVENT TIME: 12:00[EDT]| | DOCKET: |LAST UPDATE DATE: 06/22/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |ROGGE RDO | | |BRACH EO | +------------------------------------------------+ | |NRC NOTIFIED BY: P.O. BRIGHT | | |HQ OPS OFFICER: GREG SCARFO | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NINF INFORMATION ONLY | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | PETTY OFFICER BRIGHT OF THE NATIONAL RESPONSE CENTER (DOT) REPORTED THAT | | APPROXIMATELY 240 MILLICURIES OF CARBON-14 (C-14) IN TRANSIT FROM NORFOLK, | | VIRGINIA, TO ANTWERP, AMSTERDAM, MAY HAVE FROZEN DUE TO A FAILED | | REFRIGERATION CONTROL SYSTEM. THE SUPPLIER OF THE C-14, BECTON-DICKINSON | | OF SPARKS, MARYLAND, HAS REQUESTED THAT THE SHIPPER, HAPAG-LLOYD AMERICA | | INCORPORATED OF PISCATAWAY, NEW JERSEY, REMOVE THE SHIPPING CONTAINER AND | | RETURN IT (AND THE C-14) TO THE SUPPLIER. THE C-14 IS BEING SHIPPED IN | | VIALS HOLDING APPROXIMATELY 2.0 MICROCURIES IN EACH VIAL. THERE ARE 144 | | VIALS IN A CARTON AND 1170 CARTONS IN THE PACKAGE. | | | | THE SUPPLIER REQUESTED THAT THE SHIPPER RETURN THE PACKAGE IN ANTICIPATION | | OF A BREACHED VIAL DUE TO FREEZING OF THE C-14 SOLUTION. THE SHIPPER | | BELIEVES THAT THE VIALS ARE INTACT. THE SHIPMENT IS CURRENTLY LOCATED IN | | PORT ELIZABETH, NEW JERSEY, AND WILL BE TRANSPORTED BY TRUCK TO THE | | SUPPLIER IN MARYLAND. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27432 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MILLSTONE REGION: 1 |NOTIFICATION DATE: 06/22/94 | |UNIT: [ ] [2] [ ] STATE: CT |NOTIFICATION TIME: 15:31 [ET]| |RX TYPE: [1] GE-3,[2] CE,[3] W-4-LP |EVENT DATE: 06/22/94 | +------------------------------------------------+EVENT TIME: 15:25[EDT]| |NRC NOTIFIED BY: DUBAY |LAST UPDATE DATE: 06/22/94 | |HQ OPS OFFICER: GREG SCARFO +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JOHN ROGGE 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 | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | BOTH TRAINS OF THE CONTAINMENT HYDROGEN ANALYZING SYSTEM WERE INOPERABLE | | FOR APPROXIMATELY FOUR HOURS WHILE PERFORMING SURVEILLANCE TESTING OF THE | | SYSTEM. | | | | AFTER COMPLETION OF A MONTHLY SURVEILLANCE TEST ON TRAIN "B" OF THE | | CONTAINMENT HYDROGEN ANALYZER, IT WAS DETERMINED THAT BOTH TRAINS OF THE | | CONTAINMENT HYDROGEN ANALYZER SYSTEM WERE INOPERABLE FOR APPROXIMATELY FOUR | | HOURS (DURING THE TIME WHEN TRAIN "A" WAS BEING TESTED). TRAIN "B" OF THE | | CONTAINMENT HYDROGEN ANALYZER SYSTEM FAILED ITS SURVEILLANCE TEST DUE TO A | | MISPOSITIONED INLET VALVE. IT IS BELIEVED THAT TRAIN "B" WAS INOPERABLE | | FOR APPROXIMATELY TWO WEEKS, SINCE THE LAST TIME THE SYSTEM PASSED A | | MONTHLY SURVEILLANCE TEST. | | | | REPAIRS WERE COMPLETED ON TRAIN "B" AND IT WAS RETURNED TO SERVICE. THE | | CAUSE OF THE MISPOSITIONED VALVE WAS DUE TO A GEAR/LINKAGE PROBLEM. THE | | HYDROGEN ANALYZER SYSTEM IS FULLY OPERABLE AT THIS TIME. THE LICENSEE WILL | | INFORM THE NRC RESIDENT INSPECTOR. STATE AND LOCAL AUTHORITIES WERE ALSO | | NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27433 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: WASHINGTON NUCLEAR REGION: 4 |NOTIFICATION DATE: 06/22/94 | |UNIT: [2] [ ] [ ] STATE: WA |NOTIFICATION TIME: 16:33 [ET]| |RX TYPE: [2] GE-5 |EVENT DATE: 06/22/94 | +------------------------------------------------+EVENT TIME: 13:19[PDT]| |NRC NOTIFIED BY: SWANK |LAST UPDATE DATE: 06/22/94 | |HQ OPS OFFICER: GREG SCARFO +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |THOMAS WESTERMAN RDO | |AOUT 50.72(b)(1)(ii)(B) OUTSIDE DESIGN BASIS | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 2 | N N 0 REFUELING | 0 REFUELING | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AN ENGINEERING ANALYSIS DETERMINED THAT THE FAILURE OF A SINGLE RELAY IN | | THE CONTAINMENT ISOLATION ACTUATION LOGIC COULD PREVENT THE ISOLATION OF | | THE CONTAINMENT (RADIATION) MONITORING SYSTEM. | | | | IN RESPONSE TO AN INPO NOTICE, AN ENGINEERING ANALYSIS WAS PERFORMED ON THE | | CONTAINMENT ISOLATION ACTUATION SYSTEM. THIS ANALYSIS DETERMINED THAT THE | | FAILURE OF A SINGLE RELAY COULD PREVENT SIX CONTAINMENT ISOLATION VALVES | | FROM CLOSING ON A CONTAINMENT ISOLATION SIGNAL. FOUR OF THE SIX VALVES | | OCCUR IN A CONTAINMENT (RADIATION) MONITORING SYSTEM LINE FROM CONTAINMENT | | TO THE RADIATION MONITORS IN SECONDARY CONTAINMENT. DURING A LOCA, THESE | | VALVES WOULD NOT CLOSE AND THIS LINE COULD BECOME A PATH FOR A RADIOLOGICAL | | RELEASE IF THE RACKS SUPPORTING THE RADIATION MONITORS FAIL. THESE RACKS | | ARE NOT ENVIRONMENTALLY-QUALIFIED AND MAY NOT WITHSTAND THE PRESSURES | | GENERATED DURING A LOCA. | | | | CORRECTIVE ACTIONS ARE BEING INVESTIGATED. THE LICENSEE WILL NOT ENTER | | MODES 1, 2, OR 3 BEFORE REPAIRS HAVE BEEN AFFECTED. THE LICENSEE INFORMED | | THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27434 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: FERMI REGION: 3 |NOTIFICATION DATE: 06/22/94 | |UNIT: [2] [ ] [ ] STATE: MI |NOTIFICATION TIME: 20:12 [ET]| |RX TYPE: [2] GE-4 |EVENT DATE: 06/22/94 | +------------------------------------------------+EVENT TIME: 17:00[EDT]| |NRC NOTIFIED BY: STEHULAK |LAST UPDATE DATE: 06/22/94 | |HQ OPS OFFICER: GREG SCARFO +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MARTIN FARBER RDO | |NINF INFORMATION ONLY | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 2 | N N 0 REFUELING | 0 REFUELING | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | A PRESS RELEASE WAS ISSUED REGARDING THE RESTART OF THE UNIT. | | | | A PRESS RELEASE WAS ISSUED WHICH STATES THAT A RESTART OF THE UNIT WOULD | | OCCUR IN THE FALL OF 1994 WITH THE 7TH AND 8TH STAGES OF THE LOW PRESSURE | | TURBINE REMOVED. ALSO, THE LOW PRESSURE TURBINE ROTORS WILL BE REPLACED | | DURING THE NEXT REFUELING OUTAGE IN 1996. THE PRESS RELEASE STATES THAT | | THE DECEMBER 25, 1993 EVENT WAS CAUSED BY THE FAILURE OF ONE 8TH STAGE | | BLADE IN THE #3 LOW PRESSURE TURBINE. THE ROOT CAUSES OF THE EVENT HAVE | | BEEN DETERMINED TO BE A COMBINATION OF METAL FATIGUE AND EXCESS MOISTURE. | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |GENERAL INFORMATION or OTHER | |EVENT NUMBER: 27435 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: BW/IP INTERNATIONAL, INC. |NOTIFICATION DATE: 06/22/94 | | CITY: VERNON REGION: 4 |NOTIFICATION TIME: 13:08 [ET]| | COUNTY: STATE: CA |EVENT DATE: 06/21/94 | |LICENSE#: AGREEMENT: Y |EVENT TIME: 12:00[PDT]| | DOCKET: |LAST UPDATE DATE: 06/22/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | | | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: GIBSON | | |HQ OPS OFFICER: GREG SCARFO | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |CDEG 21.21(c)(3)(i) DEFECTS/NONCOMPLIANCE | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | BW/IP INTERNATIONAL SUPPLIED SEALS MADE FROM AN INCORRECT MATERIAL TO | | ENERTECH COMPANY. | | | | MR. DAVID GIBSON OF BW/IP INTERNATIONAL INCORPORATED OF VERNON, CALIFORNIA, | | IDENTIFIED REPLACEMENT SEALS FOR VALVE HYDRAULIC OPERATOR ACCUMULATORS AND | | CYLINDERS (PART NUMBERS 90433-011, 90433-015, 90433-017, 90433-025, | | 90433-027, 90433-041) MADE OF A MATERIAL (LUBRITHANE, A POLYURETHANE | | DERIVATIVE, WITH A NUTRILE SPRING) THAT ARE NOT QUALIFIED FOR USE WITH | | FYRQUEL 220 MLT OR BRAYCO 853 HYDRAULIC FLUIDS. BOTH MATERIALS DEGRADE | | WHEN IN CONTACT WITH FYRQUEL 220 MLT HYDRAULIC FLUID. THE ACCEPTABILITY OF | | THE BRAYCO 853 FLUID IS UNKNOWN. NEITHER MATERIAL HAS BEEN QUALIFIED FOR | | USE IN HARSH TEMPERATURES OR RADIATION ENVIRONMENTS. THESE SEALS WERE | | DELIVERED TO ENERTECH COMPANY OF BREA, CALIFORNIA. THIS IS THE FOURTH TIME | | THAT SUCH A MATERIALS DISCREPANCY HAS OCCURRED FROM BW/IP INTERNATIONAL TO | | ENERTECH COMPANY. THE SEALS WERE SUBSEQUENTLY INCLUDED IN EQUIPMENT | | DELIVERED BY ENERTECH TO THE FOLLOWING UTILITIES: DUKE POWER (MCGUIRE), | | COMMONWEALTH EDISON (BRAIDWOOD, BYRON), DUQUESNE POWER & LIGHT (BEAVER | | VALLEY). | +------------------------------------------------------------------------------+