U.S. Nuclear Regulatory Commission Operations Center Event Reports For 07/27/94 - 07/28/94 ** EVENT NUMBERS ** 27175 27289 27511 27585 27586 27587 27588 27589 27590 27591 27592 27593 27594 27595 27596 27597 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27175 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PALISADES REGION: 3 |NOTIFICATION DATE: 04/27/94 | |UNIT: [1] [ ] [ ] STATE: MI |NOTIFICATION TIME: 21:40 [ET]| |RX TYPE: [1] CE |EVENT DATE: 04/27/94 | +------------------------------------------------+EVENT TIME: 18:47[EDT]| |NRC NOTIFIED BY: RICHARD MASSA |LAST UPDATE DATE: 07/27/94 | |HQ OPS OFFICER: STEVE SANDIN +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |GARY SHEAR RDO | |ADAS 50.72(b)(2)(i) DEG/UNANALYZED COND | | |AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | LICENSEE IDENTIFIED A POTENTIAL CONDITION WHICH COULD RESULT IN OVERLOADING | | OF THE EMERGENCY DIESEL GENERATOR (EDG) DURING A DESIGN BASIS ACCIDENT. | | | | "UNDER ACCIDENT CONDITIONS (DESIGN BASIS ACCIDENT: LOCA, LOP, 1 EDG | | OPERATING) THE IN SERVICE EMERGENCY DIESEL GENERATOR WOULD EXCEED ITS LOAD | | RATING IF EMERGENCY OPERATING PROCEDURE MANUAL ACTIONS ARE PERFORMED AND | | THE ENGINEERED SAFETY SYSTEM PUMPS ARE ALL OPERATING AT RUNOUT CONDITIONS." | | | | "THE CONTINUOUS LOAD RATING FOR THE EDG IS 2500KW, IT'S 2 HR RATING IS | | 2750KW, AND OPERATION BETWEEN 2750KW AND 3125KW IS LIMITED TO < 30 MINUTES. | | THE TOTAL ELECTRICAL LOAD ON THE OPERATING EDG WOULD EXCEED 2750 KW WHEN A | | SECOND BATTERY CHARGER IS PLACED IN SERVICE FOLLOWING FUNCTIONAL RECOVERY | | PROCEDURE (EOP-9) GUIDANCE." | | | | "IT IS UNLIKELY THAT THE 30 MINUTE RUN TIME ABOVE 2750KW WOULD BE EXCEEDED | | FOR THE FOLLOWING REASONS: | | | | 1. DURING THE DBA IT IS ONLY APPROXIMATELY 32 MINUTES TO THE INITIATION OF | | RECIRCULATION ACTUATION SIGNAL (RAS) WHICH TRIPS THE OPERATING LOW PRESSURE | | SAFETY INJECTION PUMP. REMOVING THIS LOAD FROM THE EDG WOULD ELIMINATE THE | | POSSIBILITY OF EDG OVERLOAD. THUS THE MANUAL ACTION OF PLACING THE BATTERY | | CHARGER IN SERVICE WOULD HAVE TO BE COMPLETED WITHIN THE FIRST 2 MINUTES OF | | THE EVENT TO CHALLENGE THE 30 MINUTE RUN TIME LIMIT. | | | | 2. IT IS PROBABLE THAT THE CONTROL ROOM OPERATORS OR AUXILIARY OPERATORS | | WOULD MONITOR EDG LOADING UNDER THESE CONDITIONS AND TAKE ACTION TO LIMIT | | LOAD." | | | | "HOWEVER, AT THIS TIME DUE TO ONLY HAVING ANALYSIS FOR SMALL AND LARGE | | BREAK LOCAs WE ARE NOT CERTAIN OF THE MAXIMUM TIME TO RAS FOR INTERMEDIATE | | SIZE LOCAs, SO IT MAY BE MORE LIKELY THAN DESCRIBED IN (1) ABOVE THAT THIS | | CONDITION COULD OCCUR." | | | | THIS CONDITION WAS DISCOVERED DURING AN ENGINEERING DESIGN REVIEW ANALYSIS. | | CORRECTIVE ACTIONS WILL INCLUDE REVISIONS TO APPLICABLE EOPs. THE MAXIMUM | | LOADING UNDER THE ABOVE CONDITIONS WOULD BE 2786KW FOR EDG "11" AND 2802KW | | FOR EDG "12". THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | | | | | | * * * UPDATE AT 1010 7/27/94 BY KUEMIN TAKEN BY WEAVER * * * | | | | THE LICENSEE IS RETRACTING THIS EVENT BASED ON IMPROPER ASSUMPTIONS ABOUT | | THE MANUALLY STARTING SEQUENCE OF SOME EDG LOADS. THE HYDROGEN RECOMBINERS | | AND A SECOND BATTERY CHARGER WOULD BE STARTED MUCH LATER THAN ASSUMED IN | | THE ORIGINAL REPORT. THE NEW START TIMES ARE BASED ON A REVIEW OF THE | | PROCEDURES THAT WOULD BE USED DURING A DBA. SINCE OTHER DIESEL LOADS WOULD | | BE SECURED PRIOR TO STARTING THE ABOVE MENTIONED LOADS, THE DIESEL TWO HOUR | | LOAD LIMIT WOULD NOT BE EXCEEDED. THE LICENSEE INFORMED THE RESIDENT | | INSPECTOR. | | | | HOO NOTIFIED R3 RDO (DEFAYETTE) | +------------------------------------------------------------------------------+ !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27289 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PALISADES REGION: 3 |NOTIFICATION DATE: 05/23/94 | |UNIT: [1] [ ] [ ] STATE: MI |NOTIFICATION TIME: 01:27 [ET]| |RX TYPE: [1] CE |EVENT DATE: 05/22/94 | +------------------------------------------------+EVENT TIME: 23:00[EDT]| |NRC NOTIFIED BY: BRUCE DUSTERHOFT |LAST UPDATE DATE: 07/27/94 | |HQ OPS OFFICER: THOMAS ANDREWS +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JIM MCCORMICKBARGER RDO | |ADAS 50.72(b)(2)(i) DEG/UNANALYZED COND | | |AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | WHILE PERFORMING A SPECIAL TEST ON THE SERVICE WATER SYSTEM, THE AS FOUND | | FLOWS TO THE CONTROL ROOM HVAC COOLERS WAS LESS THAN THE MINIMUM REQUIRED | | FLOW. THE REQUIREMENT IS FOR 46 GALLONS PER MINUTE AT 81.5 DEGREES F TO | | EACH COOLER. THIS IS THE NUMBER USED IN THE PLANT ACCIDENT ANALYSES. THESE | | COOLERS ARE DESIGNED TO PROVIDE COOLING TO CONTROL ROOM EQUIPMENT AND | | PERSONNEL DURING ACCIDENT CONDITIONS. | | | | THE MEASURED FLOW FOR ONE COOLER WAS 45 GALLONS PER MINUTE AND 44 GALLONS | | PER MINUTE FOR THE OTHER. THE FLOW WAS ADJUSTED TO ACHIEVE GREATER THAN | | THE MINIMUM FLOW TO EACH COOLER. ALL OTHER FLOW REQUIREMENTS FOR THE | | SERVICE WATER SYSTEM WERE MEASURED SATISFACTORILY. | | | | THE CAUSE OF THE FLOW REDUCTION TO THESE COOLERS IS UNKNOWN AT THIS TIME. | | THE LICENSEE PLANS TO RE-EVALUATE THE FLOW VALUE USED IN THE ACCIDENT | | ANALYSES TO REDUCE THE CHANCES OF THIS EVENT FROM REOCCURRING. | | | | THE NRC RESIDENT INSPECTOR WILL BE NOTIFIED. | | * * * UPDATE AT 1010 ON 7/27/94 BY KUEMIN TAKEN BY WEAVER * * * | | LICENSEE RETRACTED THIS EVENT BASED ON FOLLOWING TWO FACTORS. 1) THE 46 | | GALLONS PER MINUTE AND 81.5 DEGREES F ARE BASED ON MAINTAINING A CONTROL | | ROOM TEMPERATURE OF 75 DEGREES F. THE LOWEST DESIGN TEMPERATURE OF CONTROL | | ROOM EQUIPMENT IS 90 DEGREES F. 2) DURING THE PERIOD WHEN DEGRADED FLOW | | EXISTED, THE LAKE TEMPERATURE WAS NO HIGHER THAN 60 DEGREES F. THE FLOW | | HAS SINCE BEEN RETURNED TO ABOVE 46 GALLONS PER MINUTE. THE LICENSEE | | INFORMED THE RESIDENT INSPECTOR. | | | | HOO NOTIFIED R3RDO (DEFAYETTE) | +------------------------------------------------------------------------------+ !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27511 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: DUANE ARNOLD REGION: 3 |NOTIFICATION DATE: 07/09/94 | |UNIT: [1] [ ] [ ] STATE: IA |NOTIFICATION TIME: 18:01 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 07/09/94 | +------------------------------------------------+EVENT TIME: 15:50[CDT]| |NRC NOTIFIED BY: DAVID SCHUSSLER |LAST UPDATE DATE: 07/27/94 | |HQ OPS OFFICER: JOSEPH SEBROSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JOHN JACOBSON RDO | |AINC 50.72(b)(2)(iii)(C) POT UNCNTRL RAD REL | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | BOTH TRAINS OF THE STANDBY GAS TREATMENT TRAINS WERE DECLARED INOPERABLE | | DUE TO THE DISCOVERY THAT THEY WERE UNABLE TO MEET THEIR TECH SPEC REQUIRED | | FLOW RATES. | | | | THE PROBLEM WAS IDENTIFIED DURING A ROUTINE MONTHLY SURVEILLANCE. THE TECH | | SPEC REQUIRED FLOW RATE IS 3600 SCFM PER TRAIN. THE TRAIN 'A' VALUE | | OBTAINED DURING THE SURVEILLANCE WAS 3400 SCFM WHILE TRAIN 'B' WAS 3460 | | SCFM. THE LICENSEE HAS ENTERED TECH SPEC 3.7.B.2 WHICH REQUIRES THE PLANT | | TO BE IN HOT SHUTDOWN WITHIN 12 HOURS IF THE PROBLEM IS NOT FIXED. | | | | THE LICENSEE IS INVESTIGATING THE CAUSE OF THE PROBLEM AND IS ALSO | | REVIEWING THE BASIS FOR 3600 SCFM LIMIT. THE RESIDENT INSPECTOR HAS BEEN | | NOTIFIED. | | | | * * * UPDATE AT 1048 ON 7/27/94 BY COLLINGSWORTH TAKEN BY WEAVER * * * | | UPON FURTHER REVIEW THE LICENSEE DOES NOT BELIEVE THIS EVENT MEETS THE | | REPORTING CRITERIA OF 50.72 BECAUSE THE SBGT SYSTEM WAS STILL CAPABLE OF | | PERFORMING ITS SAFETY FUNCTION (DRAWING A ONE QUARTER INCH VACUUM IN THE | | REACTOR BUILDING). THE LICENSEE INFORMED THE RESIDENT INSPECTOR. | | | | HOO NOTIFIED THE R3 RDO (DEFAYETTE) | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27585 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MILLSTONE REGION: 1 |NOTIFICATION DATE: 07/27/94 | |UNIT: [1] [ ] [ ] STATE: CT |NOTIFICATION TIME: 07:57 [ET]| |RX TYPE: [1] GE-3,[2] CE,[3] W-4-LP |EVENT DATE: 07/27/94 | +------------------------------------------------+EVENT TIME: 07:55[EDT]| |NRC NOTIFIED BY: RICHARD SCHMIDPKNECHT |LAST UPDATE DATE: 07/27/94 | |HQ OPS OFFICER: JOSEPH SEBROSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |WALTER PASCIAK RDO | |APRE 50.72(b)(2)(vi) OFFSITE NOTIFICATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 100 POWER OPERATION | 85 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | OFFSITE NOTIFICATION DUE TO THE PLANT HAVING TO REDUCE POWER TO LESS THAN | | 40% POWER DUE TO THE ISOLATION CONDENSER BEING DECLARED INOPERABLE. | | | | THE LICENSEE IS REQUIRED BY THEIR EMERGENCY PLANNING IMPLEMENTING | | PROCEDURES (EPIP) TO INFORM STATE OFFICIALS ANYTIME THE PLANT IS DERATED BY | | MORE THAN 50% POWER FOR GREATER THAN 72 HOURS. THE LICENSEE HAS TO REDUCE | | POWER TO LESS THAN 40% DUE TO THE ISOLATION CONDENSER BEING DECLARED | | INOPERABLE. | | | | THE ISOLATION CONDENSER WAS DECLARED INOPERABLE ON 7/26/94 AT 12:22 DUE TO | | THE FAILURE OF A QUARTERLY SURVEILLANCE STROKE TIME TEST. FOUR OF THE | | ISOLATION CONDENSER'S VALVE WERE TESTED AND ONE OF THE VALVES FAILED. THE | | VALVE THAT FAILED IS THE INBOARD CONTAINMENT ISOLATION VALVE TO THE | | CONDENSER. TECH SPECS REQUIRE THE VALVE TO CLOSE IN 24 SECONDS AND THE | | VALVE TOOK 24.22 SECONDS TO CLOSE. | | | | TECH SPEC 3.5.E.2 REQUIRES THE LICENSEE TO REDUCE POWER TO LESS THAN 40% | | POWER WITHIN 24 HOURS OF THE ISOLATION CONDENSER BEING DECLARED INOPERABLE. | | THE LICENSEE COMMENCED POWER REDUCTION AT 07:55 AND THE CURRENT POWER IS | | 85% POWER. THE LICENSEE IS CONTINUING TO INVESTIGATE THE SLOW STROKE TIME. | | THE LICENSEE IS NOT REQUIRED TO SHUTDOWN BY TECH SPECS WITH THE ISOLATION | | CONDENSER INOPERABLE, HOWEVER, IF IT BECOMES NECESSARY TO WORK ON THE VALVE | | THE LICENSEE WILL HAVE TO SHUTDOWN BECAUSE THE VALVE IS LOCATED INSIDE THE | | DRYWELL. | | | | THE LICENSEE HAS INFORMED THE RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 27586 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: SAINT JOSEPH MERCY HOSPITAL |NOTIFICATION DATE: 07/27/94 | | CITY: PONTIAC REGION: 3 |NOTIFICATION TIME: 10:36 [ET]| | COUNTY: STATE: MI |EVENT DATE: 07/26/94 | |LICENSE#: 21-11651-01 AGREEMENT: N |EVENT TIME: 16:30[EDT]| | DOCKET: |LAST UPDATE DATE: 07/27/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |ROBERT DEFAYETTE RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: YOLANDA TAYLOR | | |HQ OPS OFFICER: JOSEPH SEBROSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | SAINT JOSEPH MERCY HOSPITAL OF PONTIAC MICHIGAN IS MAKING A REPORT DUE TO A | | MEDICAL MISADMINISTRATION. | | | | ON 7/26/94 A PATIENT WAS ADMINISTERED 2.5 MILLICURIES OF I-131 FOR A TOTAL | | BODY SCAN. THE PHYSICIAN HAD PRESCRIBED AN IODINE UPTAKE SCAN WHICH WOULD | | TYPICALLY RESULT IN 200 TO 300 MICROCURIES OF I-123 BEING ADMINISTERED TO | | THE PATIENT. | | | | THE PROBLEM WAS DISCOVERED BY A SENIOR TECHNICIAN WHO HAD QUESTIONED THE | | PATIENT AFTER THE I-131 WAS ADMINISTERED. THE SENIOR TECHNICIAN DISCOVERED | | THAT THE PATIENT WAS BEING TREATED FOR A DIFFUSE GOITER CONDITION. THIS | | CONDITION IS NOT TYPICALLY TREATED WITH A I-131 TOTAL BODY SCAN. AFTER | | FURTHER INVESTIGATION IT WAS DETERMINED THAT THE PATIENT SHOULD HAVE | | RECEIVED AN I-123 UPTAKE SCAN. THE ERROR WAS CAUSED BY A NEW TECHNICIAN WHO | | DID NOT REVIEW THE DOCTOR'S ORDERS PROPERLY. | | | | NO ADVERSE AFFECTS ARE EXPECTED TO THE PATIENT AND THE LICENSEE WILL INFORM | | THE PATIENT. THE LICENSEE HAS ALSO INFORMED REGION III (YOUNG) OF THE | | PROBLEM. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27587 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MAINE YANKEE REGION: 1 |NOTIFICATION DATE: 07/27/94 | |UNIT: [1] [ ] [ ] STATE: ME |NOTIFICATION TIME: 11:02 [ET]| |RX TYPE: [1] CE |EVENT DATE: 07/21/94 | +------------------------------------------------+EVENT TIME: 09:00[EDT]| |NRC NOTIFIED BY: MALONEY |LAST UPDATE DATE: 07/27/94 | |HQ OPS OFFICER: JOSEPH SEBROSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |WALTER PASCIAK 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 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | CIRCUMFERENTIAL CRACKS IN EXCESS OF REG GUIDE 1.121 CRITERIA DISCOVERED. | | | | DURING EDDY CURRENT TESTING OF THE #2 STEAM GENERATOR TUBES ON 7/21/94 | | THREE TUBES IN THE HOT LEG WERE IDENTIFIED AS HAVING CIRCUMFERENTIAL CRACKS | | IN THE TUBE WALLS JUST ABOVE THE TUBE SHEET EXPANSION TRANSITION ZONE. THE | | AVERAGE THROUGH WALL DEPTH OF THESE CRACK THROUGH THE 360 DEGREE ARC WAS | | 94%, 94% AND 92% RESPECTIVELY. THIS EXCEED THE REG GUIDE 1.121 CRITERIA | | FOR MAINE YANKEE OF 59% THROUGH WALL CRACKING. IT ALSO EXCEEDS A MAINE | | YANKEE ANALYSIS WHICH PREDICTS A SAFE BEHAVIOR OF TUBES WITH A THROUGH WALL | | CRACK OF UP TO 75%. BASED ON THE ABOVE THE LICENSEE HAS DETERMINED THAT | | THEY HAVE A PRIMARY SAFETY BARRIER THAT IS SERIOUSLY DEGRADED. | | | | THE LICENSEE ORIGINALLY SHUTDOWN ON 7/16/94 DUE TO PRIMARY TO SECONDARY | | LEAKAGE OF APPROXIMATELY 35 GALLONS PER DAY (GPD). THE TECH SPEC LIMIT FOR | | ANY ONE STEAM GENERATOR WAS 216 GPD. THE LICENSEE SUSPECTED THAT THE LEAK | | WAS FROM THE #2 STEAM GENERATOR BASED ON N-16 ANALYSIS. ON 7/20/94 THE | | LICENSEE INSPECTED THE #2 STEAM GENERATOR VISUALLY THROUGH THE MAN WAYS ON | | THE HOT AND COLD LEGS OF THE STEAM GENERATOR. THE VISUAL INSPECTION SHOWED | | 4 LEAKING TUBES IN THE HOT LEG BUT NO LEAKING TUBES ON THE COLD LEG. | | | | THE LICENSEE FOLLOWED UP WITH EDDY CURRENT TESTING ON 7/21/94 AND GOT THE | | ABOVE RESULTS. THE LICENSEE HAD A CONFERENCE CALL WITH NRC REGION 1 AND | | NRR CONCERNING THE PROBLEM. THE LICENSEE DETERMINED TODAY THAT IN ADDITION | | TO INFORMING THE NRC REGION 1 AND NRR A 4 HOUR CALL (50.72(B)(2)(I)) SHOULD | | HAVE BEEN MADE ON 7/21/94. THE LICENSEE IS CONTINUING TO PERFORM EDDY | | CURRENT TESTING ON ALL 3 STEAM GENERATORS. THE LICENSEE HAS INFORMED THE | | RESIDENT INSPECTOR AND MAY ISSUE A PRESS RELEASE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27588 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: OYSTER CREEK REGION: 1 |NOTIFICATION DATE: 07/27/94 | |UNIT: [1] [ ] [ ] STATE: NJ |NOTIFICATION TIME: 12:09 [ET]| |RX TYPE: [1] GE-2 |EVENT DATE: 07/27/94 | +------------------------------------------------+EVENT TIME: 11:00[EDT]| |NRC NOTIFIED BY: HUTTON |LAST UPDATE DATE: 07/27/94 | |HQ OPS OFFICER: THOMAS ANDREWS +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |WALTER PASCIAK RDO | |NONR OTHER UNSPEC REQMNT | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 96 POWER OPERATION | 96 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AT 1930 EDT ON 07/26/94, THE LICENSEE DECLARED CONTROL ROD "06-19" | | INOPERABLE BECAUSE OF NITROGEN LEAKAGE FROM THE HYDRAULIC CONTROL UNIT. THE | | ROD WAS LEFT IN THE FULL OUT AT POSITION 48. AT APPROXIMATELY 2330 EDT, | | THE LICENSEE REALIZED THAT THE TECHNICAL SPECIFICATION REQUIREMENT TO | | MAINTAIN ADEQUATE SHUTDOWN MARGIN WITH THE MOST REACTIVE ROD STUCK OUT OF | | THE CORE WAS NOT BEING MET WITH CONTROL ROD "06-19" BEING INOPERABLE AND | | WITHDRAWN FROM THE CORE. AT 2334 EDT, CONTROL ROD "06-19" WAS FULLY | | INSERTED TO POSITION 00. | | | | THE LICENSEE HAS DETERMINED THAT FOR THE TIME BETWEEN 1930 EDT AND 2334 | | EDT, THEY WERE IN VIOLATION OF THE SHUTDOWN MARGIN TECHNICAL SPECIFICATION. | | THIS REPORT IS BEING MADE AS A 24 HOUR REPORT AS REQUIRED BY THEIR | | LICENSING CONDITIONS. | | | | THE NRC RESIDENT INSPECTOR WILL BE NOTIFIED OF THIS EVENT. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27589 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MILLSTONE REGION: 1 |NOTIFICATION DATE: 07/27/94 | |UNIT: [ ] [2] [ ] STATE: CT |NOTIFICATION TIME: 12:10 [ET]| |RX TYPE: [1] GE-3,[2] CE,[3] W-4-LP |EVENT DATE: 07/27/94 | +------------------------------------------------+EVENT TIME: 11:57[EDT]| |NRC NOTIFIED BY: MULLIN |LAST UPDATE DATE: 07/27/94 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |WALTER PASCIAK RDO | |APRE 50.72(b)(2)(vi) OFFSITE NOTIFICATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N Y 70 POWER OPERATION | 62 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | OFFSITE NOTIFICATION FOR AN UNPLANNED SHUTDOWN GREATER THAN 48 HOURS | | | | THE PLANT IS CURRENTLY REDUCING POWER AND EXPECTS TO BE SHUTDOWN BY 3:00 PM | | TODAY. THERE IS A SMALL OIL LEAK FROM THE UPPER OIL RESERVOIR ON THE A | | REACTOR COOLANT PUMP. THE A PUMP IS OPERATING AND OPERATORS EXPECT NO | | PROBLEMS WITH THE RCP DURING THE SHUTDOWN. THE REPAIR IS EXPECTED TO TAKE | | MORE THAN 48 HOURS, HOWEVER, NO ESTIMATED TIME OF COMPLETION WAS GIVEN. | | | | THE LICENSEE NOTIFIED THE STATE DEPARTMENT OF ENVIRONMENTAL PROTECTION AND | | THE NRC RESIDENT INSPECTOR | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27590 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MILLSTONE REGION: 1 |NOTIFICATION DATE: 07/27/94 | |UNIT: [ ] [2] [ ] STATE: CT |NOTIFICATION TIME: 12:28 [ET]| |RX TYPE: [1] GE-3,[2] CE,[3] W-4-LP |EVENT DATE: 07/27/94 | +------------------------------------------------+EVENT TIME: 12:20[EDT]| |NRC NOTIFIED BY: MULLIN |LAST UPDATE DATE: 07/27/94 | |HQ OPS OFFICER: THOMAS ANDREWS +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |WALTER PASCIAK 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 Y 50 POWER OPERATION | 50 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | WHILE INSPECTING A KNOWN OIL LEAK ON REACTOR COOLANT PUMP "A", THE LICENSEE | | NOTED THAT THERE WAS OIL THAT WAS LEAKING FROM THE PUMP AND NOT BEING | | COLLECTED BY THE OIL COLLECTION SYSTEM. THE LICENSEE HAS DETERMINED THAT | | THE APPENDIX "R" OIL COLLECTION SYSTEM FOR REACTOR COOLANT PUMP "A" IS NOT | | OPERATING AS DESIGNED AND THEREFORE THE PLANT IS OPERATING OUTSIDE ITS | | DESIGN BASIS. | | | | THE LICENSEE IS IN THE PROCESS OF SHUTTING DOWN THE PLANT TO FIX THE OIL | | LEAK AND WILL INVESTIGATE THE PROBLEM WITH THE OIL COLLECTION SYSTEM. | | | | STATE OFFICIALS AND THE NRC RESIDENT INSPECTOR HAS BEEN NOTIFIED. | | | | HOO NOTE: SEE EVENT NUMBER 27589 FOR A RELATED NOTIFICATION. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27591 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SAN ONOFRE REGION: 4 |NOTIFICATION DATE: 07/27/94 | |UNIT: [ ] [ ] [3] STATE: CA |NOTIFICATION TIME: 15:39 [ET]| |RX TYPE: [1] W-3-LP,[2] CE,[3] CE |EVENT DATE: 07/27/94 | +------------------------------------------------+EVENT TIME: 02:00[PDT]| |NRC NOTIFIED BY: CALVIN MEDDINGS |LAST UPDATE DATE: 07/27/94 | |HQ OPS OFFICER: THOMAS ANDREWS +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |IAN BARNES RDO | |NINF INFORMATION ONLY |CHRIS GRIMES EO | | |KEN BROCKMAN ERB | | |JOE GIITTER ERB | | |HENRY BAILEY ERB | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | | | | | 3 | N Y 98 POWER OPERATION | 98 POWER OPERATION | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | DURING PERFORMANCE OF A SEMI-ANNUAL EMERGENCY DIESEL GENERATOR TEST ON THE | | "A" DIESEL FOR UNIT 3, A DIESEL GENERATOR ELECTRICAL TROUBLE ALARM | | ANNUNCIATED. ABNORMAL VAR INDICATIONS WERE OBSERVED. THE DIESEL WAS | | STOPPED. | | | | SMOKE AND OVERHEATING OF ELECTRICAL COMPONENTS WITH A SMALL FLAME WAS | | OBSERVED UNDERNEATH AND BEHIND THE CONTROL ROOM DIESEL GENERATOR PANEL. THE | | FLAMES WERE PUT OUT USING A HAND-HELD HALON EXTINGUISHER WITHIN TWO | | MINUTES. BECAUSE THE FLAMES WERE EXTINGUISHED WITHIN 2 MINUTES, A | | DECLARATION OF AN UNUSUAL EVENT WAS NOT REQUIRED. | | | | A SPURIOUS TOXIC GAS ISOLATION SIGNAL "A" ACTUATION OCCURRED. THIS SIGNAL | | WAS VERIFIED AND RESET. THE ACTUATION WAS RELATED TO THE EQUIPMENT FAILURE | | AND THEREFORE IS DETERMINED TO BE INVALID AND NOT REPORTABLE. | | | | ALARMS WERE RECEIVED THAT WERE CONSISTENT WITH A MOMENTARY FAILURE OF THE | | CORE PROTECTION CALCULATOR CHANNEL #1. | | | | QUALIFIED SAFETY PARAMETER DISPLAY SYSTEM CHANNEL "A" WAS LOST DURING THE | | EVENT AND WAS RESTORED AFTER THE EVENT. | | | | DC BUS "3D1" HAD A GROUND CONDITION THAT HAS BEEN ISOLATED. | | | | DIESEL GENERATOR AND DC BUS "3D1" INDICATIONS ARE NOT AVAILABLE ON THE | | CONTROL PANEL BUT BACKUP INDICATIONS ARE AVAILABLE. | | | | CURRENTLY, THE LICENSEE IS IN A 72 HOUR ACTION STATEMENT TO RESTORE TWO | | OFFSITE POWER SOURCES PER TECHNICAL SPECIFICATION 3.8.1.1. INVESTIGATIONS | | ARE ONGOING AND REPAIR PLANS ARE BEING FORMULATED AT THIS TIME. | | | | THE NRC RESIDENT INSPECTOR HAS BEEN NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |FUEL CYCLE FACILITY | |EVENT NUMBER: 27592 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BABCOCK & WILCOX CO. |NOTIFICATION DATE: 07/27/94 | | RXTYPE: URANIUM FUEL FABRICATION |NOTIFICATION TIME: 16:23 [ET]| |COMMENTS: HEU FABRICATION & SCRAP RECOVERY |EVENT DATE: 07/26/94 | | NAVAL REACTOR FUEL |EVENT TIME: 19:00[EDT]| | |LAST UPDATE DATE: 07/27/94 | | CITY: LYNCHBURG REGION: 2 +-----------------------------+ | COUNTY: CAMPBELL STATE: VA |PERSON ORGANIZATION| |LICENSE#: SNM-42 AGREEMENT: N |CHARLES CASTO RDO | | DOCKET: 07000027 |CARL PAPERIELLO EO | +------------------------------------------------+ | |NRC NOTIFIED BY: ARNE OLSEN | | |HQ OPS OFFICER: THOMAS ANDREWS | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NBNL RESPONSE-BULLETIN | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | FACILITY OR ORGANIZATION: BABCOCK & WILCOX COMPANY | | NAVY NUCLEAR FUEL DIVISION | | LYNCHBURG, VIRGINIA | | CAMPBELL COUNTY | | | | PORTION OF PLANT AFFECTED: URANIUM RECOVERY | | EVENT CLASSIFICATION: OTHER EVENT | | EVENT TYPE: FUEL CYCLE | | INCIDENT REPORT: CRITICALITY CONTROL 24 HOUR (BL 91-01) | | | | SAFETY SIGNIFICANCE: ONE OF THREE BARRIERS FOR CRITICALITY | | WERE LOST (MASS). SPACING AND GEOMETRY | | BARRIERS WERE NOT AFFECTED | | | | SAFETY EQUIPMENT STATUS: NOT AFFECTED | | STATUS OF CORRECTIVE ACTIONS: IN PROGRESS | | | | LICENSEE NOTIFICATIONS: GENERAL MANAGER | | NRC RESIDENT INSPECTOR | | --------------------------------------------------------------------------- | | DESCRIPTION OF EVENT: | | | | AT APPROXIMATELY 1900, JULY 26, 1994, AN OPERATOR REPORTED TO THE SHIFT | | FOREMAN THAT ENRICHED URANIUM SCRAP WAS ADDED TO TWO TRAYS IN THE HIGH | | LEVEL DISSOLVER SECTION OF URANIUM RECOVER THAT EXCEEDED THE MASS LIMIT OF | | 500 GRAMS U-235 PER TRAY. | | | | TYPICALLY, MATERIAL IS REMOVED FROM A STORAGE CONTAINER, PLACED IN A | | TRANSFER CONTAINER, WEIGHED, AND PLACED IN A DISSOLVER TRAY. THE OPERATION | | IS REPEATED UNTIL SUFFICIENT MATERIAL IS CONTAINED IN THE TRAY WITHOUT | | EXCEEDING THE LIMIT. THE AMOUNT OF MATERIAL ADDED TO A TRAY IS TRACKED BY | | THE OPERATOR USING A COMPUTER. WHEN ADDITIONS TO A TRAY WILL RESULT IN THE | | LIMIT BEING EXCEEDED, THE COMPUTER WARNS THE OPERATOR WITH A RED COLORED | | MESSAGE CAUSING THE OPERATOR TO ACKNOWLEDGE THE STATUS. THIS EVENT | | OCCURRED WHEN THE OPERATOR FAILED TO PROPERLY RESPOND TO THE MESSAGE AND | | ADDED THE MATERIAL TO THE TRAYS EXCEEDING THE 500 GRAM LIMIT. | | | | THE IMMEDIATE CORRECTIVE ACTION WAS THAT THE FOREMAN WAS NOTIFIED, THE | | TRAYS WERE CLEANED, AND THE MATERIAL WAS REMEASURED. THE REMEASUREMENT | | INDICATED THAT ONE TRAY ACTUALLY CONTAINED 320.0 GRAMS U-235 AND THE OTHER | | CONTAINED 243.2 GRAMS U-235. THIS INDICATED THAT THE LIMITS WERE NOT | | ACTUALLY EXCEEDED. | | | | THE EVENT IS STILL UNDER INVESTIGATION. ADDITIONAL CORRECTIVE ACTIONS TO | | PREVENT REOCCURRENCE ARE BEING STUDIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27593 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MONTICELLO REGION: 3 |NOTIFICATION DATE: 07/27/94 | |UNIT: [1] [ ] [ ] STATE: MN |NOTIFICATION TIME: 16:35 [ET]| |RX TYPE: [1] GE-3 |EVENT DATE: 07/27/94 | +------------------------------------------------+EVENT TIME: 15:00[CDT]| |NRC NOTIFIED BY: DAVID DILLEY |LAST UPDATE DATE: 07/27/94 | |HQ OPS OFFICER: THOMAS ANDREWS +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |ROBERT DEFAYETTE 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 97 POWER OPERATION | 97 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE LICENSEE HAS CONCLUDED THAT THE CABLE SPREADING ROOM FLOOR HAS NOT BEEN | | CORRECTLY ANALYZED TO CONSIDER DIFFERENTIAL PRESSURES THAT RESULT FROM A | | POSTULATED HALON SYSTEM ACTUATION OR TORNADO EVENT. THE FLOOR MEETS | | OPERABILITY LIMITS UNDER ALL OTHER REQUIRED LOAD COMBINATIONS. | | | | COMPENSATORY ACTIONS HAVE BEEN IMPLEMENTED TO MAINTAIN DIFFERENTIAL | | PRESSURE WITHIN LIMITS BY DEFEATING THE LATCH ON THE ROOM ACCESS DOOR TO | | PROVIDE A VENT PATH. | | | | THE NRC RESIDENT INSPECTOR HAS BEEN NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27594 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: GRAND GULF REGION: 2 |NOTIFICATION DATE: 07/27/94 | |UNIT: [1] [ ] [ ] STATE: MS |NOTIFICATION TIME: 17:03 [ET]| |RX TYPE: [1] GE-6 |EVENT DATE: 07/27/94 | +------------------------------------------------+EVENT TIME: 15:30[CDT]| |NRC NOTIFIED BY: WALTER CADE |LAST UPDATE DATE: 07/27/94 | |HQ OPS OFFICER: THOMAS ANDREWS +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |CHARLES CASTO 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE LICENSEE DISCOVERED CONDUIT AND PULL BOX CONTAINING POWER CABLES FOR | | EMERGENCY SWITCHGEAR AND BATTERY ROOM VENTILATION FANS WITH IMPROPERLY | | INSTALLED THERMOLAG. THIS DEFICIENCY IS CONSIDERED A VIOLATION OF | | SEPARATION REQUIREMENTS UNDER REG GUIDE 1.775ES-02. IT IS NOT CLEAR IF THE | | MISSING THERMOLAG PRESENTS A SIGNIFICANT CONDITION AT THIS TIME. | | | | BECAUSE OF GENERIC CONCERNS REGARDING THERMOLAG, FIRE WATCHES HAVE BEEN | | POSTED SINCE JULY 1992. THESE FIRE WATCHES ARE CONTINUING. HOWEVER, PRIOR | | TO JULY 1992, A FIRE WATCH WAS NOT POSTED WHICH CREATES A CONDITION WHERE | | THE PLANT WAS OUTSIDE THE DESIGN BASIS FOR THE PLANT. | | | | THE NRC RESIDENT INSPECTOR HAS BEEN NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 27595 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: MEDICAL CENTER HOSPITAL |NOTIFICATION DATE: 07/27/94 | | CITY: CHILLICOTHE REGION: 3 |NOTIFICATION TIME: 17:07 [ET]| | COUNTY: ROSS STATE: OH |EVENT DATE: 07/27/94 | |LICENSE#: 3411852-02 AGREEMENT: N |EVENT TIME: 00:00[EDT]| | DOCKET: |LAST UPDATE DATE: 07/27/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |ROBERT DEFAYETTE RDO | | |CARL PAPERIELLO EO | +------------------------------------------------+ | |NRC NOTIFIED BY: JOSEPH KOWALSKI | | |HQ OPS OFFICER: THOMAS ANDREWS | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MEDICAL CENTER HOSPITAL | | CHILLICOTHE, OHIO | | (614) 225-5390 | | | | DURING ADMINISTRATION OF TREATMENT FOR ESOPHAGUS CANCER, A PATIENT WAS | | SCHEDULED TO RECEIVE AN INITIAL TREATMENT OF 4500 RADS WHICH WAS | | ADMINISTERED WITH NO PROBLEMS. | | | | BOOST TREATMENTS USING OBLIQUE FIELDS OF 1400 RADS WERE ALSO PRESCRIBED. | | THE DOSE ADMINISTRATION IS SIMULATED IN A COMPUTER TO DETERMINE THE OBLIQUE | | ANGLES NEEDED. DURING THE ACTUAL ADMINISTRATION OF THE DOSE FOR THE FIRST | | AND HALF OF THE SECOND TREATMENT, THE WRONG ANGLES WERE USED. | | | | THE LICENSEE RECALCULATED THE DOSE AND THE ANGLES CHANGED SO THAT THE DOSE | | VOLUME WILL RECEIVE THE PROPER DOSE WITHIN THE 20% LIMITS DURING THE | | REMAINING TREATMENTS. | | | | THE LICENSEE IS IMPLEMENTING A CHANGE TO PROCEDURES WHERE INDIVIDUALS WHO | | ARE FAMILIAR WITH THE ASSUMPTIONS USED IN THE SIMULATION PROCESS ARE EITHER | | PRESENT OR CONTACTED PRIOR TO THE ADMINISTRATION OF A DOSE TO ENSURE | | CONSISTENCY WITH EQUIPMENT PLACEMENT AND SIMULATION RESULTS. | | | | THE RADIATION SAFETY OFFICER HAS NOT BEEN NOTIFIED, HOWEVER, THE | | TELETHERAPY PHYSICIST AND HOSPITAL ADMINISTRATION HAVE BEEN. THE PATIENT | | WILL BE INFORMED OF THIS EVENT. THE LICENSEE HAS INFORMED REGION III | | (HOLT) OF THIS EVENT. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27596 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: OCONEE REGION: 2 |NOTIFICATION DATE: 07/28/94 | |UNIT: [ ] [2] [ ] STATE: SC |NOTIFICATION TIME: 03:52 [ET]| |RX TYPE: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP |EVENT DATE: 07/28/94 | +------------------------------------------------+EVENT TIME: 01:19[EDT]| |NRC NOTIFIED BY: OTTO KOHLER |LAST UPDATE DATE: 07/28/94 | |HQ OPS OFFICER: JOSEPH SEBROSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |CHARLES CASTO 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 N 0 HOT SHUTDOWN | 0 HOT SHUTDOWN | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | REACTOR TRIP SIGNAL WITH ALL RODS ALREADY INSERTED. | | | | THE FOLLOWING IS A TEXT OF A FACSIMILE FROM THE LICENSEE: | | | | "UNIT 2 WAS PROCEEDING TO COLD SHUTDOWN FOR A STEAM GENERATOR TUBE LEAK | | OUTAGE. RCS PRESSURE HAD BEEN REDUCED TO BELOW 1700 PSIG AND THE SHUTDOWN | | BYPASS HIGH PRESSURE TRIP WAS RESET TO 1710 PSIG. JUST AFTER THE CRD | | BREAKERS WERE RESET IN PREPARATION FOR WITHDRAWING CONTROL ROD GROUP 1 TO | | 50% AND BEFORE ANY ROD MOTION WAS INITIATED, AN AUTOMATIC ACTUATION OF THE | | RPS OCCURRED AT 0119 DUE TO AN INCREASE IN RCS PRESSURE. THIS INCREASE IN | | RCS PRESSURE WAS DUE TO A SLOW INCREASE IN PRESSURIZER LEVEL. RCS PRESSURE | | WAS REDUCED BELOW THE RPS ACTUATION SETPOINT, PRESSURIZER LEVEL WAS | | STABILIZED AND THE RPS WAS RESET." END OF TEXT. | | | | THE UNIT WAS JUST ABOVE COLD SHUTDOWN CONDITIONS WHEN THE TRIP OCCURRED. IN | | PREPARATION FOR COOLING THE PLANT DOWN THE LICENSEE'S PROCEDURES REQUIRE | | THAT CONTROL ROD GROUP 1 BE AT 50% TO ENSURE ADEQUATE SHUTDOWN MARGIN | | DURING THE COOLDOWN. | | | | THE LICENSEE WILL INFORM THE RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |GENERAL INFORMATION or OTHER | |EVENT NUMBER: 27597 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: BW/IP INTERNATIONAL, INC. |NOTIFICATION DATE: 07/27/94 | | CITY: VERNON REGION: 4 |NOTIFICATION TIME: 16:01 [ET]| | COUNTY: STATE: CA |EVENT DATE: 07/27/94 | |LICENSE#: AGREEMENT: Y |EVENT TIME: 16:01[PDT]| | DOCKET: |LAST UPDATE DATE: 07/27/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | | | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: KENT HUBER | | |HQ OPS OFFICER: JOSEPH SEBROSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |CCCC 21.21 UNSPECIFIED PARAGRAPH | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | BW/IP INTERNATIONAL INC OF VERNON CALIFORNIA IS MAKING A PRELIMINARY REPORT | | IN ACCORDANCE WITH 10 CFR PART 21 DUE TO A POTENTIAL PROBLEM WITH THE STEM | | THRUST FOR A MOTOR OPERATED VALVE (MOV). | | | | ON 1/6/94 BW/IP NOTIFIED THE NRC THAT A BORG-WARNER, 6-INCH, MOTOR | | OPERATED, 900# Y-GLOBE VALVE WAS SHOWN, BY TEST, TO REQUIRE A CLOSING STEM | | THRUST GREATER THAN THE DESIGN VALUE. THESE DATA WERE OBTAINED AS PART OF | | THE ELECTRIC POWER RESEARCH INSTITUTE (EPRI) COMPREHENSIVE MOV TEST PROGRAM | | IN RESPONSE TO GENERIC LETTER 89-10. | | | | BW/IP INTERNATIONAL, INC., PUMP DIVISION, HAS NOT COMPLETED THE EVALUATION | | OF THIS ISSUE. THE EVALUATION IS EXPECTED TO BE COMPLETED BY 9/30/94. | +------------------------------------------------------------------------------+