U.S. Nuclear Regulatory Commission Operations Center Event Reports For 07/15/94 - 07/18/94 ** EVENT NUMBERS ** 27537 27538 27539 27540 27541 27542 27543 27544 +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27537 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: FERMI REGION: 3 |NOTIFICATION DATE: 07/15/94 | |UNIT: [2] [ ] [ ] STATE: MI |NOTIFICATION TIME: 08:51 [ET]| |RX TYPE: [2] GE-4 |EVENT DATE: 07/15/94 | +------------------------------------------------+EVENT TIME: 08:51[EDT]| |NRC NOTIFIED BY: LYNN GOODMAN |LAST UPDATE DATE: 07/15/94 | |HQ OPS OFFICER: JOSEPH SEBROSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: | | |CCCC 21.21 UNSPECIFIED PARAGRAPH | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 2 | N N 0 REFUELING | 0 REFUELING | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE LICENSEE IS ISSUING A 10CFR21 REPORT DUE TO A PROBLEM WITH THERMOLAG | | FIRE BARRIERS AT THE SITE. | | | | THE PROBLEMS WITH THE FIRE BARRIERS WERE DISCOVERED DURING REMOVAL AND | | REPLACEMENT OF THESE BARRIERS IN THE ONGOING FOURTH REFUELING OUTAGE. | | DETAILS OF THE DISCREPANCIES ARE PROVIDED IN THE REPORT, HOWEVER, THEY ARE | | GENERALLY RELATED TO THE FOLLOWING: | | | | - PANELS WERE NOT INSTALLED CORRECTLY | | | | - CABLE TRAY WRAPS DID NOT HAVE ENOUGH PROTECTIVE MATERIAL INSTALLED | | | | - INTERFERENCES / HEAT TRANSFER SURFACES SUCH AS PIPES, CONDUITS, CABLE | | TRAY AND PIPE SUPPORTS WERE NOT ADEQUATELY PROTECTED WITH SUFFICIENT | | AMOUNT OF THERMOLAG MATERIAL. | | | | IT IS NOT KNOWN TO DETROIT EDISON WHETHER THE CONTRACTOR WHO PERFORMED THE | | INSTALLATION AT THE SITE INSTALLED THERMOLAG AT ANY OTHER NUCLEAR POWER | | PLANT. | | | | NOTE: SEE EVENT #27534 FOR A RELATED 10CFR50.72 EVENT. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27538 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: CALVERT CLIFFS REGION: 1 |NOTIFICATION DATE: 07/15/94 | |UNIT: [1] [2] [ ] STATE: MD |NOTIFICATION TIME: 14:00 [ET]| |RX TYPE: [1] CE,[2] CE |EVENT DATE: 07/15/94 | +------------------------------------------------+EVENT TIME: 09:00[EDT]| |NRC NOTIFIED BY: BURCE MONTGOMERY |LAST UPDATE DATE: 07/15/94 | |HQ OPS OFFICER: THOMAS ANDREWS +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MOHAMED SHANBAKY RDO | |NLTR LICENSEE 24 HR REPORT | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | THE LICENSEE IS MAKING THIS SPECIAL REPORT NOTIFICATION PER TECHNICAL | | SPECIFICATION 3.7.11.1 ACTION STATEMENT (B) ASSOCIATED WITH THE FIRE | | PROTECTION SYSTEM. THEY ARE IN THE PROCESS OF ADDING ADDITIONAL FIRE MAINS | | TO THE FIRE SUPPRESSION SYSTEM. THEY ARE SHUTTING DOWN A PORTION OF THIS | | SYSTEM TO TIE IN THE NEW PORTION TO THE EXISTING SYSTEM. THIS WORK IS | | EXPECTED TO TAKE ABOUT 3 DAYS. | | | | TECHNICAL SPECIFICATION 3.7.11.1 ACTION STATEMENT (B) REQUIRES THEM TO | | NOTIFY THE NRC AND TO PROVIDE A BACKUP METHOD OF FIRE SUPPRESSION DURING | | THIS TIME. THE BACKUP METHOD OF FIRE SUPPRESSION IS FIRE HOSES. THE | | LICENSE HAS POSTED FIRE WATCHES. | | | | THE NRC RESIDENT INSPECTOR HAS BEEN NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27539 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SEQUOYAH REGION: 2 |NOTIFICATION DATE: 07/15/94 | |UNIT: [1] [ ] [ ] STATE: TN |NOTIFICATION TIME: 15:37 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 07/15/94 | +------------------------------------------------+EVENT TIME: 13:52[EDT]| |NRC NOTIFIED BY: ROBERT HAYS |LAST UPDATE DATE: 07/15/94 | |HQ OPS OFFICER: THOMAS ANDREWS +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JACK CRLENJAK 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | M/R Y 25 POWER OPERATION | 0 HOT STANDBY | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE UNIT DECREASED POWER TO 25% RATED THERMAL POWER TO ALLOW SECURING OF | | THE MAIN GENERATOR TO PERFORM ELECTRICAL MAINTENANCE. WHILE REMOVING | | PRIMARY LINE FUSES TO PERFORM THE MAINTENANCE, THE UNIT BOARD "1D" BUS | | POTENTIAL TRANSFORMER FUSES WERE INADVERTENTLY REMOVED, RESULTING IN AN | | INDICATED LOSS OF VOLTAGE TO THE UNIT BOARD "1D" CAUSING A SUBSEQUENT TRIP | | OF ALL MOTOR BREAKERS ON THE "1D" UNIT BOARD, INCLUDING THE "1D" REACTOR | | COOLANT PUMP MOTOR. | | | | PER DESIGN, WITH THE UNIT BELOW 35% RATED THERMAL POWER (P8), ONE REACTOR | | COOLANT PUMP TRIP DOES NOT AUTOMATICALLY CAUSE A REACTOR TRIP. HOWEVER, | | PER AOI-5, THE UNIT SENIOR REACTOR OPERATOR AND UNIT OPERATOR PERFORMED | | IMMEDIATE OPERATOR ACTIONS TO MANUALLY TRIP THE REACTOR BECAUSE THE REACTOR | | WAS GREATER THAN 10% RATED THERMAL POWER AND ONE REACTOR COOLANT PUMP HAD | | TRIPPED. | | | | DURING THE TRANSIENT THAT FOLLOWED, AN UNUSUAL OCCURRENCE WAS A UNIT | | COOLDOWN OF THE REACTOR COOLANT SYSTEM TO APPROXIMATELY 535 DEGREES F AND | | MANUAL CLOSURE OF THE MAIN STEAM ISOLATION VALVES DUE TO LOW DECAY HEAT AND | | RAPID INJECTION OF AUXILIARY FEED WATER TO THE STEAM GENERATORS. EMERGENCY | | BORATION WAS INITIATED PER AOI-34 AS A RESULT OF THE COOLDOWN. | | APPROXIMATELY 250 GALLONS OF BORIC ACID WERE INJECTED TO ENSURE THAT | | ADEQUATE SHUTDOWN MARGIN WOULD BE AVAILABLE FOR A REACTOR COOLANT SYSTEM | | TEMPERATURE OF 521 DEGREES F. | | | | AUXILIARY FEEDWATER AUTOMATICALLY STARTED ON LO-LO STEAM GENERATOR LEVEL. | | STEAM GENERATOR LEVEL HAS BEEN RETURNED TO NORMAL PROGRAM LEVEL. | | | | THE PLANT IS STABLE IN MODE 3. ALL CONTROL RODS FULLY INSERTED. THE OTHER | | 3 REACTOR COOLANT PUMPS REMAINED RUNNING DURING THE EVENT PROVIDING FORCED | | CIRCULATION THROUGH THE REACTOR. THE REACTOR IS BEING COOLED VIA THE STEAM | | GENERATORS. THE STEAM IS BEING RELEASED TO THE ATMOSPHERE THROUGH THE | | STEAM GENERATOR ATMOSPHERIC RELIEF VALVES. THERE IS NO INDICATION OF ANY | | STEAM GENERATOR TUBE LEAKAGE. | | | | ALL SAFETY RELATED SYSTEMS ARE OPERABLE. THE GRID IS PRESENTLY STABLE. | | | | THE NRC RESIDENT INSPECTOR HAS BEEN NOTIFIED. | | | | **** UPDATE AT 1703 EDT ON 07/15/94 BY HAYS TAKEN BY ANDREWS **** | | | | THE LICENSEE WAS RECOVERING FROM THE REACTOR TRIP WITH REACTOR COOLANT | | SYSTEM T-AVG GREATER THAN 550 DEGREES F AND THE FEEDWATER ISOLATION SIGNAL | | RESET TO SECURE THE TURBINE DRIVEN AUXILIARY FEEDWATER PUMP. ONE OF THE | | MAIN FEED PUMPS WAS STARTED AND THE TURBINE DRIVEN AUXILIARY FEEDWATER PUMP | | WAS SECURED. | | | | FOLLOWING THE SECURING OF THE TURBINE DRIVEN FEEDWATER PUMP, THE LOOP 4 | | ATMOSPHERIC RELIEF VALVE OPENED TO RELIEVE PRESSURE AND CAUSED THE REACTOR | | COOLANT SYSTEM TEMPERATURE TO FALL BELOW 550 DEGREES F ON 2 OUT OF 4 T-AVG | | CHANNELS CAUSING ANOTHER FEEDWATER ISOLATION AND AUTOMATIC START OF THE | | TURBINE DRIVEN AUXILIARY FEEDWATER PUMP. THE LOOP 4 ATMOSPHERIC RELIEF | | APPEARED TO BE OPENING MORE THAN IT SHOULD AND WAS OPERATING ERRATICALLY. | | THE OPERATORS MANUALLY CLOSED THE LOOP 4 ATMOSPHERIC RELIEF VALVE. | | | | REACTOR COOLANT SYSTEM TEMPERATURE STABILIZED AT ABOUT 545 DEGREES F AND IS | | BEING RESTORED TO NO-LOAD TEMPERATURE (547) DEGREES. | | | | THE NRC RESIDENT INSPECTOR HAS BEEN NOTIFIED OF THIS UPDATE. | | | | HOO NOTIFIED R2DO (CRLENJAK). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27540 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SAN ONOFRE REGION: 4 |NOTIFICATION DATE: 07/15/94 | |UNIT: [ ] [2] [3] STATE: CA |NOTIFICATION TIME: 19:14 [ET]| |RX TYPE: [1] W-3-LP,[2] CE,[3] CE |EVENT DATE: 07/15/94 | +------------------------------------------------+EVENT TIME: 14:30[PDT]| |NRC NOTIFIED BY: B. GIBSON |LAST UPDATE DATE: 07/15/94 | |HQ OPS OFFICER: THOMAS ANDREWS +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BLAINE MURRAY RDO | |APRE 50.72(b)(2)(vi) OFFSITE NOTIFICATION |FRANK CONGEL EO | | |JOHN DAVIDSON - NMSS IAT | | |LOREN BUSH - NRR IAT | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N Y 97 POWER OPERATION | 97 POWER OPERATION | | 3 | N Y 97 POWER OPERATION | 97 POWER OPERATION | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE LICENSEE HAS NOTIFIED THE FBI OF A NON-CREDIBLE BOMB THREAT. SEE HOO | | LOG FOR DETAILS. THE NRC RESIDENT INSPECTOR HAS BEEN INFORMED BY THE | | LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27541 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: WASHINGTON NUCLEAR REGION: 4 |NOTIFICATION DATE: 07/15/94 | |UNIT: [2] [ ] [ ] STATE: WA |NOTIFICATION TIME: 20:51 [ET]| |RX TYPE: [2] GE-5 |EVENT DATE: 07/15/94 | +------------------------------------------------+EVENT TIME: 00:00[PDT]| |NRC NOTIFIED BY: FASCIMILE |LAST UPDATE DATE: 07/15/94 | |HQ OPS OFFICER: THOMAS ANDREWS +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: | | |CCCC 21.21 UNSPECIFIED PARAGRAPH | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 2 | N N 0 | 0 | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | --- MATERIAL DEFECTS IN WESTINGHOUSE CONTAINMENT PENETRATION MODULES --- | | | | THIS IS AN INITIAL 10CFR21 NOTIFICATION TO THE NRC OPERATIONS CENTER. | | | | ON MAY 9, 1994, INVESTIGATION INTO ELECTRICAL PROBLEMS (OPEN WIRES AND LOW | | RESISTANCE) FOR THE ROD POSITION INDICATION SYSTEM (RPIS) AT WNP-2 | | IDENTIFIED A DEGRADED CONDITION DUE TO CORROSION OF CONDUCTORS INTERNAL TO | | THE STRAIN RELIEF MATERIAL IN PRIMARY CONTAINMENT ELECTRICAL PENETRATION | | MODULES. THE PENETRATION MODULES PROVIDE BOTH THE ELECTRICAL CONTINUITY | | AND CONTAINMENT INTEGRITY FUNCTIONS. THE DEGRADED CONDITION POTENTIALLY | | AFFECTS ELECTRICAL CONTINUITY BUT NOT CONTAINMENT INTEGRITY. | | | | THE DESIGN AND CONSTRUCTION OF THE RPIS PENETRATION MODULE ARE SIMILAR TO | | SAFETY RELATED MODULES. INITIAL OPERABILITY ASSESSMENTS LIMIT THIS PROBLEM | | TO THE RPIS MODULES. SIX OF THE 12 RPIS MODULES HAVE BEEN REPLACED DURING | | THIS REFUELING OUTAGE (R-9). THE REMAINING RPIS MODULES WHICH ARE NOT | | REPLACED ARE OPERABLE. | | | | CONTAINMENT PENETRATION MODULES WERE SUPPLIED BY WESTINGHOUSE AND INSTALLED | | IN WNP-2 DURING INITIAL CONSTRUCTION. IMAGING AND SENSING TECHNOLOGY (IST) | | PURCHASED THE MANUFACTURING FACILITY FOR THE MODULES FROM WESTINGHOUSE IN | | MAY 1988. | | | | THE IST CONTACT IS: | | | | PHIL PONZI, CHAIRMAN | | IMAGING AND SENSING TECHNOLOGY | | 300 WESTINGHOUSE CIRCLE | | HORSEHEADS, NY 14845 | | (607) 796-4433 | | | | THE WESTINGHOUSE CONTACT IS: | | | | R.B. MILLER, ENGINEER, NUCLEAR SAFETY DEPARTMENT | | WESTINGHOUSE ELECTRIC CORP., ENERGY SYSTEMS BUSINESS UNIT | | ENERGY CENTER | | PITTSBURGH, PA 15230 | | (412) 374-5953 | | | | WESTINGHOUSE/IST INDICATE THAT THEY HAVE INFORMED THE ONLY OTHER DOMESTIC | | UTILITY TO WHICH PENETRATIONS CONTAINING SCOTCHCAST HAVE BEEN SUPPLIED OF | | THE PRESENCE SCOTCHCAST IN ONE OF THEIR MODULES. THE MODULE USES INSULATED | | AND JACKETED CABLE BUT NOT VARGLAS. THE UTILITY INFORMED THE VENDOR THAT | | THEY HAVE NOT HAD ANY PROBLEMS WITH THE MODULE. | | | | IF THE IDENTIFIED CONDITION HAD GONE UNDETECTED IN CERTAIN SAFETY RELATED | | APPLICATIONS, IT COULD HAVE RESULTED IN A SUBSTANTIAL SAFETY HAZARD DUE TO | | THE LOSS OF ELECTRICAL CONTINUITY. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27542 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MAINE YANKEE REGION: 1 |NOTIFICATION DATE: 07/16/94 | |UNIT: [1] [ ] [ ] STATE: ME |NOTIFICATION TIME: 05:36 [ET]| |RX TYPE: [1] CE |EVENT DATE: 07/16/94 | +------------------------------------------------+EVENT TIME: 02:07[EDT]| |NRC NOTIFIED BY: MALONEY |LAST UPDATE DATE: 07/16/94 | |HQ OPS OFFICER: WILLIAM HUFFMAN +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MOHAMED SHANBAKY RDO | |ARPS 50.72(b)(2)(ii) RPS ACTUATION | | | |KARL ABRAHAM R1PA | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | M/R Y 2 STARTUP | 0 HOT SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MANUAL REACTOR TRIP WHILE SHUTTING DOWN DUE TO HIGH REACTOR COOLANT PUMP | | VIBRATIONS. | | | | AN UNSCHEDULED PLANT SHUTDOWN WAS IN PROGRESS DUE TO AN INCREASING TREND IN | | STEAM GENERATOR TUBE LEAKAGE IN THE #2 STEAM GENERATOR. WHEN POWER WAS LESS | | THAN 2%, A HIGH VIBRATION ALARM WAS RECEIVED ON THE #2 RCP IN THE RANGE OF | | 26 MILS. PER PLANT ABNORMAL OPERATING PROCEDURES, RCP VIBRATIONS IN EXCESS | | OF 20 MILS REQUIRE THAT THE REACTOR BE MANUALLY TRIPPED FOLLOWED BY | | TRIPPING THE AFFECTED REACTOR COOLANT PUMP. | | | | THE REACTOR WAS TRIPPED WITHOUT COMPLICATIONS AND THEN RCP #2 WAS TRIPPED. | | ALL RODS FULLY INSERTED AND ALL SYSTEMS FUNCTIONED AS REQUIRED. | | | | AN ENGINEERING ANALYSIS OF THE RCP INDICATIONS IS IN PROGRESS. ALL RCP | | PARAMETERS BESIDES VIBRATION APPEARED NORMAL BEFORE THE PUMP TRIP. A | | CONTAINMENT ENTRY WAS MADE FOR VISUAL INSPECTION OF THE PUMP. NO | | ABNORMALITIES WERE OBSERVED. THE LICENSEE PLANS TO REMAIN IN HOT SHUTDOWN | | UNTIL IT IS DETERMINED WHAT ADDITIONAL PUMP TESTING MAY BE NEEDED. | | | | THE NRC RESIDENT INSPECTOR WILL BE NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 27543 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: HAMOT MEDICAL CENTER |NOTIFICATION DATE: 07/16/94 | | CITY: ERIE REGION: 1 |NOTIFICATION TIME: 11:44 [ET]| | COUNTY: STATE: PA |EVENT DATE: 07/15/94 | |LICENSE#: AGREEMENT: N |EVENT TIME: 16:00[EDT]| | DOCKET: |LAST UPDATE DATE: 07/16/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |MOHAMED SHANBAKY RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: DAVID HOWELL | | |HQ OPS OFFICER: WILLIAM HUFFMAN | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | BRACHYTHERAPY TREATMENT FOR CERVIX CANCER TERMINATED PREMATURELY. | | | | THE HAMOT MEDICAL CENTER AT 201 STATE STREET IN ERIE, PA. 16505, REPORTED A | | POTENTIAL UNDEREXPOSURE MISADMINISTRATION. A BRACHYTHERAPY RADIATION | | IMPLANT FOR CERVIX CANCER USING CESIUM-137 SEEDS WAS PRESCRIBED TO BE | | ADMINISTERED FOR A 61.75 HOUR EXPOSURE (3540 RADS TOTAL). DURING THE | | TREATMENT, THE PATIENT WAS COMPLAINING OF DISCOMFORT. AN ULTRASOUND | | REVEALED THAT THE IMPLANT TANDEM HAD PERFORATED THE UTERUS. THE RADIATION | | IMPLANT WAS REMOVED AND THE TREATMENT TERMINATED AFTER ONLY 23 HOURS OF | | EXPOSURE (1375 RADS). | | | | THIS REPORT IS BEING MADE BECAUSE THE PRESCRIBED DOSE DIFFERED FROM THE | | ACTUAL DOSE BY MORE THAN 20% (UNDEREXPOSURE). THE LICENSEE IS | | CONSERVATIVELY REPORTING IT EVEN THOUGH IT WAS TERMINATED PREMATURELY DUE | | TO ADVERSE CIRCUMSTANCES UNRELATED TO THE RADIATION TREATMENT. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27544 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BYRON REGION: 3 |NOTIFICATION DATE: 07/17/94 | |UNIT: [ ] [2] [ ] STATE: IL |NOTIFICATION TIME: 08:54 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 07/17/94 | +------------------------------------------------+EVENT TIME: 05:27[CDT]| |NRC NOTIFIED BY: SCOTT SWANSON |LAST UPDATE DATE: 07/17/94 | |HQ OPS OFFICER: WILLIAM HUFFMAN +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |CYNTHIA PEDERSON RDO | |AARC 50.72(b)(1)(v) OTHER ASMT/COMM INOP | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N Y 99 POWER OPERATION | 99 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | LOSS OF SAFETY PARAMETER DISPLAY SYSTEM (SPDS). | | | | THE FOLLOWING IS THE TEXT OF A FACSIMILE REPORTING THIS EVENT: | | "AT 0527, ON 7/17/94, ONE OF FOUR OFFSITE 345 KV LINES (LO621) TRIPPED OPEN | | AND RECLOSED. THE DIVISION LOAD DISPATCHER IS INVESTIGATING THE CAUSE, | | HOWEVER, LIGHTNING IS SUSPECTED. THE ELECTRICAL TRANSIENT CAUSED A SPIKE ON | | A RADIATION MONITOR (OPR32J) WHICH AUTOSTARTED A CONTROL ROOM MAKE-UP FAN | | (OVC03CA) AND CAUSED THE FAILURE OF THE UNIT 2 PLANT PROCESS COMPUTER. LOSS | | OF THE PROCESS COMPUTER DEFEATS INPUTS TO SAFETY PARAMETER DISPLAY SYSTEM | | WHICH IS PART OF THE EMERGENCY ASSESSMENT DISPLAY AND IS REPORTABLE UNDER | | 10CFR50.72(b)(1)(v). RESTORATION OF THE COMPUTER IS IN PROGRESS." | | END OF TEXT. | | | | WHILE THIS EVENT WAS BEING REPORTED, THE PROCESS COMPUTER WAS RETURNED TO | | SERVICE AND SPDS CAPABILITY RESTORED. | | | | THE NRC RESIDENT INSPECTOR HAS BEEN INFORMED. | +------------------------------------------------------------------------------+