U.S. Nuclear Regulatory Commission Operations Center Event Reports For 08/03/94 - 08/04/94 ** EVENT NUMBERS ** 27619 27621 27622 27623 27624 +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27619 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: ROBINSON REGION: 2 |NOTIFICATION DATE: 08/02/94 | |UNIT: [2] [ ] [ ] STATE: SC |NOTIFICATION TIME: 06:35 [ET]| |RX TYPE: [2] W-3-LP |EVENT DATE: 08/02/94 | +------------------------------------------------+EVENT TIME: 05:54[EDT]| |NRC NOTIFIED BY: JAMES CONDER |LAST UPDATE DATE: 08/03/94 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: UNUSUAL EVENT +-----------------------------+ |10 CFR SECTION: |CHARLES CASTO RDO | |AAEC 50.72(a)(1)(i) EMERGENCY DECLARED |JOHN ZWOLINSKI EO | | |RIGHT FEMA | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 2 | M/R Y 100 POWER OPERATION | 0 HOT STANDBY | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | UNUSUAL EVENT DECLARED DUE TO THE FAILURE OF A PORV TO CLOSE AFTER | | ACTUATION | | | | A LOAD REJECTION CAUSED A TURBINE RUNBACK. OPERATORS MANUALLY TRIPPED THE | | REACTOR WHEN THEY OBSERVED THE TURBINE RUNBACK AND LOAD REJECTION. THE | | SUBSEQUENT RISE IN REACTOR PRESSURE CAUSED ONE PORV (RC 455C) TO LIFT. THIS | | PORV CURRENTLY INDICATES INTERMEDIATE. OPERATORS CLOSED THE BLOCK VALVE | | WHEN THEY NOTICED THE ABNORMAL POSITION INDICATION. OPERATORS ARE UNSURE | | WHETHER THE REACTOR COOLANT SYSTEM PRESSURE DROP WAS ALREADY TERMINATED | | WHEN THEY SHUT THE BLOCK VALVE. A REVIEW OF THE PLANT COMPUTER LOGS WILL | | BE CONDUCTED TO PROVIDE THIS INFORMATION. | | | | ALL RODS FULLY INSERTED DURING THE TRIP. ONE ROD BOTTOM LIGHT DID NOT | | ENERGIZE, HOWEVER THE INDIVIDUAL ROD POSITION INDICATION FOR THAT ROD | | INDICATED THAT IT IS FULLY INSERTED. THE STEAM GENERATORS ARE BEING FED ON | | THE BYPASS BY MAIN FEEDWATER AND THE MAIN CONDENSER IS AVAILABLE AS A HEAT | | SINK. | | | | THE CAUSE OF THE LOAD REJECTION IS NOT KNOWN. THE LICENSEE INTENDS TO | | BORATE TO HOT SHUTDOWN. THE UNUSUAL EVENT WILL BE TERMINATED WHEN THE PORV | | IS VERIFIED TO BE SHUT. THE PORV PROBLEM IS SUSPECTED TO BE AN INDICATION | | PROBLEM AND NOT A PROBLEM WITH THE ACTUAL OPERATION OR POSITION OF THE | | VALVE. | | | | THE LICENSEE INFORMED THE RESIDENT INSPECTOR AND THE APPROPRIATE STATE AND | | LOCAL OFFICIALS. | | | | | | * * * UPDATE AT 0717 ON 8/2/94 BY CONDER TAKEN BY WEAVER * * * | | | | SITE MANAGEMENT DECIDED TO TERMINATE THE UNUSUAL EVENT BASED ON THE BLOCK | | VALVE BEING SHUT AND NO LEAKAGE TO THE PRT. | | | | HOO NOTIFIED FEMA (BECLCHER), EO (GOODWIN), RDO (CASTO) | | | | **** UPDATE AT 1122 EDT ON 08/03/94 BY CROOK TAKEN BY ANDREWS **** | | LICENSEE HAS DETERMINED THAT THE CAUSE OF THE ERRONEOUS POSITION INDICATION | | WAS A FAULTY LIMIT SWITCH. THE PORV ACTUALLY CLOSED AS REQUIRED. THE | | LICENSEE HAS NOTIFIED THE NRC RESIDENT INSPECTOR. | | | | HOO NOTIFIED R2DO (BLAKE). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27621 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PILGRIM REGION: 1 |NOTIFICATION DATE: 08/03/94 | |UNIT: [1] [ ] [ ] STATE: MA |NOTIFICATION TIME: 12:04 [ET]| |RX TYPE: [1] GE-3 |EVENT DATE: 08/03/94 | +------------------------------------------------+EVENT TIME: 11:22[EDT]| |NRC NOTIFIED BY: PERITO |LAST UPDATE DATE: 08/03/94 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |ROBERT BORES RDO | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | |AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION | | |NLCO TECH SPEC LCO A/S | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 PLANT ENTERED A 7 DAY LCO ACTION STATEMENT DUE TO RCIC BEING DECLARED | | INOPERABLE. | | | | THIS OCCURRED WHILE THEY WERE PERFORMING THEIR QUARTERLY SURVEILLANCE | | (8.5.5.1) FOR RCIC. UPON THE INITIAL START OF THE RCIC TURBINE THEY | | RECEIVED A RCIC ISOLATION (GP 5 ISOLATION) ON STEAM LINE HIGH DELTA | | PRESSURE (HIGH STEAM FLOW). THE ISOLATION GIVES THEM A RCIC TURBINE TRIP, | | BUT IN THIS CASE IT APPEARS THAT THEY RECEIVED AN OVERSPEED TURBINE TRIP | | DUE TO THE GOVERNOR NOT TAKING CONTROL AS THEY INCREASED TURBINE SPEED. | | RCIC WAS DECLARED INOPERABLE, PUTTING THEM IN THE 7 DAY LCO WHICH REQUIRES | | THEM TO VERIFY OPERABILITY OF HPCI(WHICH HAS BEEN DONE). THEY ARE | | INVESTIGATING THE CAUSE OF THE GROUP 5 ISOLATION TO DETERMINE THE CAUSE. | | THE RI HAS BEEN NOTIFIED AND THE STATE CIVIL DEFENSE AGENCY WILL BE | | NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 27622 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: SINAI HOSPITAL DETROIT, MICHIGAN |NOTIFICATION DATE: 08/03/94 | | CITY: DETROIT REGION: 3 |NOTIFICATION TIME: 13:22 [ET]| | COUNTY: STATE: MI |EVENT DATE: 08/03/94 | |LICENSE#: 21-00299-06 AGREEMENT: N |EVENT TIME: 10:00[EDT]| | DOCKET: |LAST UPDATE DATE: 08/03/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |MARTIN FARBER RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: MR. PRAVEENDALMA | | |HQ OPS OFFICER: JOSEPH SEBROSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | SINAI HOSPITAL LOCATED IN DETROIT MICHIGAN CALLED TO REPORT A POSSIBLE | | MEDICAL MISADMINISTRATION. | | | | BETWEEN 10:00 AND 10:30 AM A PATIENT WAS TREATED WITH 2 BEAMS FOR THERAPY. | | ONE BEAM WAS A RIGHT POSTERIOR OBLIQUE (RPO) THE OTHER BEAM USED WAS A LEFT | | ANTERIOR OBLIQUE (LAO). THE THERAPIST SET THE WRONG COLLIMATOR ANGLE ON THE | | RPO BEAM. THE BLOCK THAT WAS USED WAS A HALF BEAM BLOCK. THIS RESULTED IN | | THE WRONG AREA BEING TREATED WITH THE RPO BEAM. THE RIGHT SHOULDER AREA WAS | | SUPPOSED TO BE TREATED, HOWEVER, THE RIGHT LUNG AREA WAS TREATED. THE | | RIGHT LUNG AREA OF THE PATIENT RECEIVED AN APPROXIMATE DOSE OF 100 | | CENTIGRAY. | | | | THE ERROR WAS CAUGHT BECAUSE A PORT FILM WAS TAKEN AND IT SHOWED THE WRONG | | AREA BEING TREATED. (A PORT FILM IS AN X-RAY THAT IS TAKEN AT THE TIME OF | | THE TREATMENT USING THE TREATMENT BEAM.) THE THERAPIST DID NOT VERIFY THE | | COLLIMATOR ANGLE OR VERIFY THE LIGHT FIELD BEFORE TREATING THE PATIENT. | | THIS VIOLATES THE LICENSEE'S QUALITY MANAGEMENT PROGRAM. | | | | THE LICENSEE WILL INFORM THE PATIENT AND NO ADVERSE AFFECTS ARE EXPECTED TO | | THE PATIENT. THE LICENSEE WILL INFORM THE REGION. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |OTHER NUCLEAR MATERIAL | |EVENT NUMBER: 27623 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: NATIONAL INSTITUTES OF HEALTH |NOTIFICATION DATE: 08/03/94 | | CITY: BETHESDA REGION: 1 |NOTIFICATION TIME: 13:45 [ET]| | COUNTY: MONTGOMERY STATE: MD |EVENT DATE: 07/13/94 | |LICENSE#: 19-00296-10 AGREEMENT: Y |EVENT TIME: 00:00[EDT]| | DOCKET: |LAST UPDATE DATE: 08/03/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |ROBERT BORES RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: WALKER | | |HQ OPS OFFICER: JOSEPH SEBROSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |BAB2 20.2201(a)(1)(ii) LOST/STOLEN LNM>10X | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | NATIONAL INSTITUTES OF HEALTH | | BETHESDA, MD | | | | ON JULY 13, 1994, THE LICENSEE DISCOVERED THAT A SHIPMENT OF 70 MICROCURIES | | OF I-125 COMPOUND WAS MISSING. | | | | THE MATERIAL WAS SENT FROM NEW ENGLAND NUCLEAR - DUPONT (THE MANUFACTURER) | | LOCATED IN MASSACHUSETTS AND DELIVERED TO THE RADIATION SAFETY BRANCH IN | | BUILDING 21. THESE MATERIALS WERE THEN PROCESSED IN AND THEN DELIVERED BY | | CONTRACT COURIER TO THE END-USER LABORATORY ON THE LICENSEE'S FACILITY. | | | | THE PROBLEM AROSE AFTER THE MATERIALS WERE DELIVERED TO THE RESEARCHER ON | | JULY 12, 1994 AND THE MATERIALS WERE NOT IMMEDIATELY SECURED. THE | | RESEARCHER LEFT THE PACKAGE UNATTENDED FOR A SHORT TIME. UPON THEIR | | RETURN, THE PACKAGE WAS NO LONGER WHERE IT HAD BEEN LEFT, SO THE RESEARCHER | | ASSUMED THAT SOMEONE WORKING IN THE LABORATORY HAD SECURED THE PACKAGE. | | | | THESE MATERIALS WERE TO BE USED ON JULY 13, 1994. AT THAT TIME, THE | | PACKAGE COULD NOT BE LOCATED AND IT WAS LEARNED THAT NO ONE HAD SECURED THE | | PACKAGE THE PREVIOUS DAY AS HAD BEEN ASSUMED. THE RADIATION SAFETY OFFICER | | WAS NOTIFIED OF THE MISSING MATERIAL. THE LICENSEE HAS CONDUCTED A SEARCH | | FOR THE MATERIAL BUT IT HAS NOT BEEN FOUND. THEY SPECULATED THAT THE | | MATERIAL WAS PICKED UP BY HOUSEKEEPING AND DISPOSED OF AS ROUTINE WASTE. | | | | THE LICENSEE HAS NOT PERFORMED A SPECIFIC SURVEY TO CHECK FOR CONTAMINATION | | FROM THIS PACKAGE, HOWEVER THESE LABORATORIES ARE ROUTINELY CHECKED FOR | | CONTAMINATION. THE PACKAGE WAS CHECKED FOR CONTAMINATION / LEAKAGE PRIOR | | TO DELIVERY TO THE END-USER LABORATORY. | | | | THE MATERIAL IS A BOLTON-HUNTER CHOLECYSTOKININ-8 SULFATE COMPOUND USED IN | | TRACER RESEARCH WORK. | | | | ACCORDING TO THE LICENSEE THIS EVENT IS BEING REPORTED UNDER PART | | 20.2201.A.II WHICH REQUIRES VERBAL NOTIFICATION WITHIN 30 DAYS AND A | | WRITTEN REPORT 30 DAYS AFTER THE VERBAL NOTIFICATION. | | | | THE LICENSEE HAS DISCUSSED THIS EVENT WITH REGION 1. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27624 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: COOPER REGION: 4 |NOTIFICATION DATE: 08/03/94 | |UNIT: [1] [ ] [ ] STATE: NE |NOTIFICATION TIME: 20:37 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 07/23/94 | +------------------------------------------------+EVENT TIME: 04:45[CDT]| |NRC NOTIFIED BY: SMALLFOOT |LAST UPDATE DATE: 08/03/94 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: | | |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 +------------------------------------------------------------------------------+ | THE LICENSEE DISCOVERED A CONDITION WHERE THE MINIMUM FLOW VALVE IN THE | | MINIMUM FLOW PATH FOR THE CORE SPRAY PUMP "A" COULD FAIL POST ACCIDENT IN A | | NON-CONSERVATIVE POSITION. | | | | THIS WAS DETERMINED WHEN DURING THE PERFORMANCE OF A REVISED CORE SPRAY | | SURVEILLANCE PROCEDURE THE CORE SPRAY PUMP "A" MINIMUM RECIRCULATION VALVE | | CYCLED CLOSED. THE SURVEILLANCE PROCEDURE WAS REVISED TO DEMONSTRATE THAT | | THE CORE SPRAY PUMPS WOULD CONTINUOUSLY OPERATE ON THE MINIMUM FLOW PATH | | PRIOR TO SWITCH OVER TO THE TEST FLOW PATH. THE INVESTIGATION OF THE ROOT | | CAUSE OF THE PROBLEM HAS DETERMINED THAT THE MINIMUM FLOW VALVE COULD CYCLE | | CONTINUOUSLY OPEN/CLOSED DURING THIS MODE OF OPERATION. THE VALVE OPERATOR | | IS NOT DESIGNED FOR CONTINUOUS CYCLING OPERATION, CONSEQUENTLY IT COULD | | FAIL POST ACCIDENT IN A NON-CONSERVATIVE POSITION. | | | | A MODIFICATION OF INSTALLING A TIME DELAY CIRCUIT INTO THE SYSTEM HAS BEEN | | IMPLEMENTED TO MITIGATE THE CONSEQUENCES OF THE OSCILLATING FLOW SIGNAL, | | WHICH WAS THE CAUSE OF THIS CONDITION. EXTENSIVE TESTING HAS DEMONSTRATED | | THAT THIS CONDITION ONLY AFFECTS THE "A" TRAIN OF CORE SPRAY. THIS EVENT | | WAS DETERMINED TO BE REPORTABLE AT 16:30 @ 8/3/94. THE RI WILL BE | | INFORMED. | +------------------------------------------------------------------------------+