U.S. Nuclear Regulatory Commission Operations Center Event Reports For 07/19/94 - 07/20/94 ** EVENT NUMBERS ** 27550 27551 27552 27553 +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 27550 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: WEST VIRGINIA UNIVERSITY HOSPITAL |NOTIFICATION DATE: 07/19/94 | | CITY: MORGANTOWN REGION: 2 |NOTIFICATION TIME: 16:46 [ET]| | COUNTY: STATE: WV |EVENT DATE: 07/19/94 | |LICENSE#: 47-23066-02 AGREEMENT: N |EVENT TIME: 16:46[EDT]| | DOCKET: |LAST UPDATE DATE: 07/19/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |FLOYD CANTRELL RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: STEVEN SLACK | | |HQ OPS OFFICER: JOSEPH SEBROSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | WEST VIRGINIA UNIVERSITY HOSPITAL OF MORGANTOWN, WEST VIRGINIA, IS MAKING A | | REPORT DUE TO MEDICAL MISADMINISTRATIONS THAT HAVE OCCURRED. | | | | THE MEDICAL MISADMINISTRATIONS OCCURRED OVER A PERIOD OF THE LAST 8 MONTHS | | AND INVOLVED UNDERDOSES TO 7 PATIENTS. THE PATIENTS HAD BEEN PRESCRIBED 4 | | MILLICURIES OF STRONTIUM 89 FOR PALLIATIVE TREATMENT (i.e. A TREATMENT TO | | RELIEVE THE PAIN NOT TO CURE THE DISEASE) OF BONE METASIS. | | | | THE REASON FOR THE UNDERDOSE WAS A MISCOMMUNICATION BETWEEN THE HOSPITAL | | AND THE RADIOPHARMACEUTICAL SUPPLIER. THE SUPPLIER HAD CALIBRATED THE | | DOSES BASED ON A VIAL THEY HAD SENT TO THE LICENSEE, HOWEVER, THE LICENSEE | | EXPECTED THE DOSES TO BE CALIBRATED BASED ON THE VOLUME OF THE SYRINGE THAT | | IS USED TO ADMINISTER THE TREATMENT. THE MISCOMMUNICATION RESULTED IN THE | | LICENSEE ADMINISTERING UNDERDOSES TO 7 OF THE 15 PATIENTS THAT WERE | | PRESCRIBED THE TREATMENT SINCE OCTOBER, 1993. THE 7 PATIENTS WERE | | ADMINISTERED LESS THAN 3.2 MILLICURIES WHICH IS 20% LESS THAN THE | | PRESCRIBED DOSE AND THEREFORE MEETS THE DEFINITION OF A MEDICAL | | MISADMINISTRATION. | | | | THERE WERE NO ADVERSE AFFECTS TO THE PATIENTS. THE LICENSEE INTENDS TO | | NOTIFY AS MANY ATTENDING PHYSICIANS AND PATIENTS AS ARE AVAILABLE. (THE | | TREATMENT IS ADMINISTERED TO TERMINAL PATIENTS AND ONE OF THE PATIENTS HAS | | DIED SINCE THE MISADMINISTRATION). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27551 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PRAIRIE ISLAND REGION: 3 |NOTIFICATION DATE: 07/19/94 | |UNIT: [1] [ ] [ ] STATE: MN |NOTIFICATION TIME: 17:39 [ET]| |RX TYPE: [1] W-2-LP,[2] W-2-LP |EVENT DATE: 07/19/94 | +------------------------------------------------+EVENT TIME: 15:16[CDT]| |NRC NOTIFIED BY: RON HOLTHE |LAST UPDATE DATE: 07/19/94 | |HQ OPS OFFICER: JOSEPH SEBROSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BJ HOLT RDO | |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 Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | INADVERTENT ACTUATION OF A STEAM GENERATOR BLOWDOWN ISOLATION VALVE DUE TO | | IMPROPER MAINTENANCE. | | | | THE ISOLATION WAS CAUSED BY ELECTRICIANS WHO WERE CHANGING WIRE CODES IN | | CONTROL CABLE TERMINAL BOXES IN THE AUXILIARY BUILDING. THE WORK WAS A | | FOLLOWUP TO ELECTRICAL MODIFICATIONS THAT WERE MADE DURING THE LAST | | REFUELING OUTAGE. THE ELECTRICIANS WERE PERFORMING THIS WORK IN A TERMINAL | | BOX FOR STEAM GENERATOR BLOWDOWN ISOLATION VALVE #MV-32044. DURING THEIR | | WORK THE ELECTRICIANS INADVERTENTLY CAUSED THIS VALVE TO CLOSE AND THEN | | APPROXIMATELY 15 MINUTES LATER THE ELECTRICIANS INADVERTENTLY CAUSED THE | | VALVE TO OPEN. | | | | THE LICENSEE HAS STOPPED THE WORK THAT THE ELECTRICIANS WERE PERFORMING AND | | IS INVESTIGATING THE PROBLEM. THE LICENSEE HAS CYCLED #MV-32044 AND TIMED | | THE VALVE. THE VALVE IS CURRENTLY OPEN AND THE LICENSEE CONSIDERS THE | | STEAM GENERATOR BLOWDOWN SYSTEM OPERATIONAL. | | | | THE LICENSEE HAS INFORMED THE RESIDENT INSPECTOR | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27552 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BEAVER VALLEY REGION: 1 |NOTIFICATION DATE: 07/19/94 | |UNIT: [1] [ ] [ ] STATE: PA |NOTIFICATION TIME: 19:05 [ET]| |RX TYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 07/19/94 | +------------------------------------------------+EVENT TIME: 16:10[EDT]| |NRC NOTIFIED BY: RUSS GUMBERT |LAST UPDATE DATE: 07/19/94 | |HQ OPS OFFICER: JOSEPH SEBROSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |WILLIAM LAZARUS 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 | A/R Y 100 POWER OPERATION | 0 HOT STANDBY | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | REACTOR TRIP DUE TO A MAIN TRANSFORMER FAULT. | | | | AT 16:10 UNIT 1 TRIPPED AS A RESULT OF A MAIN TRANSFORMER FAILURE. THE | | FIRST OUT INDICATION FOR THE TRIP WAS A "345 KV LEADS PROTECTION UNIT TRIP" | | WHICH CAUSED THE MAIN TURBINE TO TRIP WHICH IN TURN CAUSED THE REACTOR | | TRIP. | | | | ALL RODS FULLY INSERTED AND NO PRIMARY OR SECONDARY RELIEF VALVES OR PORVS | | OPENED DURING THE POST TRIP RESPONSE. ALL THREE AUXILIARY FEEDWATER (AFW) | | PUMPS AUTO STARTED TO RESTORE LEVEL IN THE STEAM GENERATORS, AS EXPECTED. | | THE AFW PUMPS HAVE BEEN SECURED AND THE LICENSEE IS MAINTAINING STEAM | | GENERATOR WATER LEVELS WITH THE MAIN FEED SYSTEM. THE MAIN CONDENSER IS | | AVAILABLE AS A HEAT SINK. ALL ECCS ARE OPERABLE. ALL BUSSES TRANSFERRED, | | AS EXPECTED. BOTH EDGs DID AUTO START BUT DID NOT LOAD ONTO THE BUS DUE TO | | THE ELECTRICAL TRANSIENT THAT WAS EXPERIENCED. THE EDGS HAVE BEEN SECURED. | | | | THE LICENSEE IS INVESTIGATING THE CAUSE OF THE MAIN TRANSFORMER FAILURE. | | THE MAIN TRANSFORMER THAT FAILED WAS A REPLACEMENT FOR A TRANSFORMER THAT | | HAD PREVIOUSLY FAILED (SEE EVENT #27238). THERE WERE SPARKS AND SMOKE SEEN | | ON TOP OF THE TRANSFORMER AND THE FIRE BRIGADE RESPONDED TO THE AREA. THERE | | WERE NO VISIBLE FLAMES BUT THE LICENSEE DID RECEIVE A MAIN TRANSFORMER FIRE | | ANNUNCIATOR AND AN AUTOMATIC DELUGE VALVE ACTUATION ALARM. THE FIRE BRIGADE | | DID NOT HAVE TO FIGHT A FIRE BECAUSE OF THE AUTOMATIC ACTUATION OF THE | | DELUGE SYSTEM ON THE MAIN TRANSFORMER. UNLIKE EVENT #27239 THERE WAS NO | | AFFECT ON UNIT 2 DUE TO THE ELECTRICAL TRANSIENTS CAUSED BY UNIT 1 | | TRIPPING. | | | | THE LICENSEE HAS INFORMED THE RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27553 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: CALVERT CLIFFS REGION: 1 |NOTIFICATION DATE: 07/19/94 | |UNIT: [1] [ ] [ ] STATE: MD |NOTIFICATION TIME: 19:57 [ET]| |RX TYPE: [1] CE,[2] CE |EVENT DATE: 07/19/94 | +------------------------------------------------+EVENT TIME: 18:24[EDT]| |NRC NOTIFIED BY: ARNOLD SHUMAKER |LAST UPDATE DATE: 07/19/94 | |HQ OPS OFFICER: JOSEPH SEBROSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |WILLIAM LAZARUS RDO | |ARPS 50.72(b)(2)(ii) RPS ACTUATION |JOSE CALVO EO | | |KEN BROCKMAN AEOD | | |LEE SPESSARD AEOD | | |ED JORDAN AEOD | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | A/R Y 100 POWER OPERATION | 0 HOT STANDBY | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | REACTOR TRIP DUE TO HIGH PRESSURIZER PRESSURE. | | | | AT 18:24 THE MAIN TURBINE APPARENTLY TRIPPED FOR UNKNOWN REASONS. SHORTLY | | THEREAFTER THE REACTOR TRIPPED DUE TO HI PRESSURIZER PRESSURE OF 2400 PSIG. | | (NORMALLY A TURBINE TRIP AT 100% POWER WOULD AUTOMATICALLY CAUSE A REACTOR | | TRIP AT THIS PLANT. THAT WAS NOT THE CASE FOR THIS EVENT.) | | | | BOTH PRIMARY PORVS OPENED DURING THE POST TRIP RESPONSE. THE SETPOINT FOR | | THE PORVS IS 2400 PSIG. THE LICENSEE HAD INDICATIONS AFTER THE TRANSIENT | | WAS COMPLETED THAT ONE OF THE PORVS DID NOT RESEAT FULLY. THE INDICATIONS | | WERE AN ACOUSTICAL MONITOR AND THE NEED TO CHARGE AN EXTRA 25 GPM INTO THE | | PRIMARY SYSTEM IN ORDER TO MAINTAIN PRESSURIZER LEVEL CONSTANT. BASED ON | | THESE INDICATIONS THE LICENSEE SHUT BOTH PORV BLOCK VALVES. THIS DID NOT | | STOP THE LEAK. THE LICENSEE NOW SUSPECTS THAT ONE OF THE PRIMARY RELIEF | | VALVES IS NOT FULLY SEATED. (THE PLANT HAS AN ACOUSTICAL MONITOR FOR EACH | | PORV AND RELIEF VALVE, HOWEVER, BECAUSE OF COMMON PIPING IT IS DIFFICULT TO | | DISCERN WHICH VALVE IS LEAKING). THE LICENSEE HAS STABILIZED PLANT | | PRESSURE AT 1880 PSIG (NORMAL PLANT PRESSURE IS 2250 PSIG) AND PLANS TO | | STAY AT THIS PRESSURE BECAUSE ANY ATTEMPT TO INCREASE PLANT PRESSURE HAS | | RESULTED IN A CORRESPONDING INCREASE IN THE LEAK RATE. THE PRESSURE NEVER | | GOT LOW ENOUGH FOR A SAFETY INJECTION SIGNAL. PLANT TEMPERATURE IS | | CURRENTLY 530 DEGREES F. | | | | THE PRIMARY PORVS AND SAFETY RELIEF VALVES RELIEVE TO A QUENCH TANK. THE | | LICENSEE HAS INDICATIONS THAT THE RUPTURE DISK FOR THE QUENCH TANK HAS | | BLOWN. IN THIS CONDITION ANY DISCHARGE TO THE QUENCH TANK WOULD END UP IN | | THE CONTAINMENT SUMP. | | | | ALL RODS FULLY INSERTED AND ALL BUSSES TRANSFERRED AS EXPECTED. ALL ECCS | | AND EDGs ARE OPERABLE. DECAY HEAT IS BEING REMOVED VIA THE TURBINE BYPASS | | VALVES TO THE MAIN CONDENSER. STEAM GENERATOR LEVELS ARE BEING MAINTAINED | | USING THE MAIN FEED SYSTEM. (A MOTOR DRIVEN AUXILIARY FEEDWATER PUMP WAS | | MANUALLY STARTED TO HELP RESTORE STEAM GENERATOR LEVEL AND THEN SECURED.) | | | | THE LICENSEE IS INVESTIGATING THE CAUSE OF THE TRIP AND THE LICENSEE HAS | | INFORMED THE RESIDENT INSPECTOR AND CALVERT COUNTY OFFICIALS. | | | | * * * UPDATE @ 21:30 7/19/94 BY SEBROSKY * * * | | THE LICENSEE GAVE A BRIEF TO NRC MANAGEMENT CONCERNING THIS EVENT. | | ATTENDEES WERE AS FOLLOWS: REGION I(MARTIN, WIGGINS, COWGILL, LANNING, | | WILSON, ABRAHAM, LAZARUS, KANE), AEOD (SPESSARD, BROCKMAN, JOLICOEUR), | | NRR(CALVO). | +------------------------------------------------------------------------------+