U.S. Nuclear Regulatory Commission Operations Center Event Reports For 08/05/94 - 08/08/94 ** EVENT NUMBERS ** 27598 27622 27626 27631 27632 27633 27634 27635 27636 27637 27638 27639 +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 27598 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: SINAI HOSPITAL, DETROIT, MI |NOTIFICATION DATE: 07/28/94 | | CITY: DETROIT REGION: 3 |NOTIFICATION TIME: 11:26 [ET]| | COUNTY: STATE: MI |EVENT DATE: 07/28/94 | |LICENSE#: 21-00299-06 AGREEMENT: N |EVENT TIME: 08:30[EDT]| | DOCKET: |LAST UPDATE DATE: 08/07/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |ROBERT DEFAYETTE RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: PRAVEEN DALMIA, RSO | | |HQ OPS OFFICER: TIM McGINTY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - POSSIBLE MEDICAL MISADMINISTRATION AT SINAI HOSPITAL, DETROIT, MI - | | | | A POSSIBLE MEDICAL MISADMINISTRATION OCCURRED FOR A PATIENT THAT WAS | | TO BE TREATED BY A Co-60 SOURCE IN THE AREA OF THE LEFT NECK. FOR THE | | TREATMENT, THREE-QUARTERS OF THE FIELD WAS BLOCKED BY A BEAM BLOCK. | | THE TREATMENT WAS SET UP CORRECTLY ACCORDING TO THE TREATMENT PLAN; | | HOWEVER, THE COLLIMATOR WAS TURNED TO 270 DEGREES INSTEAD OF THE REQUIRED | | 90 DEGREES. THIS RESULTED IN A DOSE TO THE RIGHT ANTERIOR SUPERCLAV | | (SHOULDER AREA JUST BELOW THE NECK) INSTEAD OF THE LEFT ANTERIOR NECK. | | | | A TOTAL DOSE OF 90 CENTIGRAYS WAS DELIVERED, AS EXPECTED. THE AREA | | THAT WAS TREATED OVERLAPPED 50% OF THE AREA THAT WAS MEANT TO BE TREATED. | | THE NORMAL COLLIMATOR ANGLE FOR THIS TYPE OF TREATMENT IS 270 DEGREES; | | HOWEVER, THIS PARTICULAR APPLICATION CALLED FOR AN ANGLE OF 90 DEGREES. THE | | ANGLE OF THE COLLIMATOR WAS HIGHLIGHTED ON THE PAPERWORK FOR THE PURPOSES | | OF CALLING ATTENTION TO THE COLLIMATOR ANGLE TO THE THERAPIST, | | BUT THE THERAPIST FAILED TO NOTE THIS. THIS WAS THE FIRST TIME THAT THE | | THERAPIST HAD TREATED THIS PARTICULAR PATIENT. | | | | THERE ARE NO EXPECTED ADVERSE MEDICAL AFFECTS TO THE PATIENT. | | | | THE RSO WILL NOTIFY THE PATIENT AND THE ATTENDING PHYSICIAN TODAY. | | | | THE RSO WILL NOTIFY REGION 3 AND SUBMIT A WRITTEN REPORT TO THE NRC WITHIN | | 15 DAYS. | | | | NOTE: SEE EVENTS #27622 AND #27639 FOR RELATED EVENTS. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 27622 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: SINAI HOSPITAL, DETROIT, MI |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: 08/07/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |MARTIN FARBER RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: PRAVEEN DALMA, RSO | | |HQ OPS OFFICER: JOSEPH SEBROSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - POSSIBLE MEDICAL MISADMINISTRATION AT SINAI HOSPITAL, DETROIT, MI - | | | | BETWEEN 1000 AND 1030, 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 RSO WILL NOTIFY REGION 3. | | | | | | ** UPDATE AT 1216 ON 08/07/94 BY RSO PRAVEEN DALMIA ENTERED BY JOLLIFFE ** | | | | UPON FURTHER INSPECTION OF THE PORT FILM FOR THIS EVENT, THE HOSPITAL | | RADIATION SAFETY OFFICER, PRAVEEN DALMIA, OBSERVED THAT IN ADDITION | | TO THE INCORRECT AREA OF THE PATIENT'S BODY THAT WAS TREATED, THE | | FOLLOWING INCORRECT AREAS OF THE PATIENT'S BODY WERE ALSO TREATED | | WITH THE 100 CENTIGRAY DOSE FROM THE RIGHT POSTERIOR OBLIQUE BEAM: | | - PART OF THE MEDIA STERNUM (CENTER OF THE BREAST BONE) | | - PART OF THE FACE | | - PART OF THE RIGHT UPPER ARM. | | | | THIS INCORRECT TREATMENT POSES NO ADVERSE MEDICAL AFFECTS TO THE PATIENT. | | | | THE PATIENT'S REFERRING PHYSICIAN AND THE PATIENT HAVE BEEN NOTIFIED OF | | THIS UPDATE. | | | | THE RSO WILL NOTIFY REGION 3 AND SUBMIT A WRITTEN REPORT TO THE NRC | | WITHIN 15 DAYS. | | | | HOO NOTIFIED R3DO JIM CREED AND R3 ROY CANIANO. | | | | NOTE: SEE EVENTS #27598 AND #27639 FOR RELATED EVENTS. | +------------------------------------------------------------------------------+ !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27626 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: ARKANSAS NUCLEAR REGION: 4 |NOTIFICATION DATE: 08/04/94 | |UNIT: [1] [ ] [ ] STATE: AR |NOTIFICATION TIME: 13:07 [ET]| |RX TYPE: [1] B&W-L-LP,[2] CE |EVENT DATE: 08/04/94 | +------------------------------------------------+EVENT TIME: 11:10[CDT]| |NRC NOTIFIED BY: SCHEIDE |LAST UPDATE DATE: 08/05/94 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |PHIL HARRELL 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 +------------------------------------------------------------------------------+ | -VALID SURVEILLANCE TEST NEVER PERFORMED ON UNIT 1 HYDROGEN ANALYZER SYSTEM | | | | AT 1110 (CDT) ON 08/04/94, LICENSEE DETERMINED THAT THE PIPING | | CONFIGURATION OF BOTH TRAINS OF THE UNIT 1 HYDROGEN ANALYZERS WAS SUCH THAT | | IT COULD NOT BE ASSURED THAT A VALID SURVEILLANCE OF THIS EQUIPMENT HAD | | EVER BEEN PERFORMED. | | | | THE RECIRCULATION LINES AROUND THE ANALYZERS AND THEIR ASSOCIATED FLOW | | SWITCHES MIGHT BE CAPABLE OF PASSING SUFFICIENT FLOW TO INDICATE THAT THE | | SYSTEM WAS FUNCTIONING PROPERLY IF PIPING DOWNSTREAM OF THE ANALYZERS WERE | | TO BECOME BLOCKED, OR IF A VALVE WERE TO BE MISPOSITIONED. | | | | UNIT 1 TECH SPEC LCO A/S 4.0.3 REQUIRES THE LICENSEE TO PERFORM AN ADEQUATE | | SURVEILLANCE TEST ON THIS SYSTEM WITHIN 24 HOURS OR, WITH BOTH SYSTEM | | TRAINS INOPERABLE, ENTER TECH SPEC LCO A/S 3.0.3 WHICH REQUIRES LICENSEE TO | | BEGIN SHUTTING UNIT 1 DOWN WITHIN 1 HOUR AND TO PLACE UNIT 1 IN AT LEAST | | HOT STANDBY MODE WITHIN THE FOLLOWING 6 HOURS. | | | | LICENSEE EXPECTS TO SATISFACTORILY PERFORM AN ADEQUATE SURVEILLANCE TEST OF | | THIS SYSTEM WITHIN 24 HOURS. | | | | LICENSEE DETERMINED THAT UNIT 2 DOES NOT HAVE THIS CONDITION. | | | | LICENSEE NOTIFIED THE NRC RESIDENT INSPECTOR AND WILL NOTIFY STATE | | OFFICIALS. | | | | | | * * * UPDATE AT 2145 ON 08/04/94 BY KILBY ENTERED BY HOO JOLLIFFE * * * | | | | AT 1751 (CDT) ON 08/04/94, LICENSEE PERFORMED AN ADEQUATE SURVEILLANCE | | TEST OF BOTH TRAINS OF UNIT 1 HYDROGEN ANALYZER AND DECLARED THE SYSTEM | | OPERABLE. | | | | LICENSEE WILL NOTIFY THE NRC RESIDENT INSPECTOR. | | | | HOO NOTIFIED R4DO HARRELL. | | | | | | * * * UPDATE AT 1343 ON 08/05/94 BY SCHEIDE ENTERED BY HOO JOLLIFFE * * * | | | | LICENSEE DESIRES TO RETRACT THIS EVENT SINCE BOTH TRAINS OF THE HYDROGEN | | ANALYZER SYSTEM HAD BEEN OPERABLE THROUGHOUT THIS EVENT AND THAT UNIT 1 | | TECH SPECS DO NOT REQUIRE THE PERFORMANCE OF THE SURVEILLANCE TEST | | DESCRIBED IN THIS EVENT. | | | | LICENSEE WILL NOTIFY THE NRC RESIDENT INSPECTOR. | | | | HOO NOTIFIED R4DO HARRELL. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27631 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SALEM REGION: 1 |NOTIFICATION DATE: 08/04/94 | |UNIT: [ ] [2] [ ] STATE: NJ |NOTIFICATION TIME: 22:55 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 08/04/94 | +------------------------------------------------+EVENT TIME: 22:33[EDT]| |NRC NOTIFIED BY: GALLAHER |LAST UPDATE DATE: 08/05/94 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |ROBERT BORES RDO | |ASHU 50.72(b)(1)(i)(A) PLANT S/D REQD BY TS | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | - TECH SPEC REQUIRED PLANT SHUTDOWN DUE TO INOPERABLE Rx TRIP BREAKER - | | | | AT 1955, LICENSEE REMOVED THE 'B' REACTOR TRIP BREAKER FROM SERVICE IN | | ORDER TO PERFORM A TECH SPEC SURVEILLANCE TEST OF THE BREAKER. | | | | AT 2205, LICENSEE DECLARED THE BREAKER INOPERABLE DUE TO THE BREAKER | | EXCEEDING ITS TECH SPEC TRIPPING TIME DURING THE SHUNT TRIP PORTION OF | | THE TEST. | | | | AT 2233, LICENSEE ENTERED TECH SPEC LCO A/S 3.3.1.1, ACTION 1, WHICH | | REQUIRES UNIT 2 TO BE PLACED IN HOT STANDBY MODE WITHIN 6 HOURS WITH | | ONE RECTOR TRIP BREAKER INOPERABLE. LICENSEE BEGAN TO REDUCE POWER. | | | | LICENSEE PLANS TO INSTALL THE 'A' BYPASS BREAKER IN THE 'B' REACTOR TRIP | | BREAKER POSITION AND THEN TEST IT. | | | | LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | | | | * * * UPDATE AT 0254 ON 08/05/94 BY GALLAHER TAKEN BY ANDREWS * * * | | | | LICENSEE EXITED THE TECHNICAL SPECIFICATION REQUIRED SHUTDOWN ACTION | | STATEMENT AT 0150 WHEN THE 'B' REACTOR TRIP BREAKER WAS DECLARED OPERABLE. | | THE SHUTDOWN WAS TERMINATED AT 44% POWER. LICENSEE PLANS TO RETURN TO FULL | | POWER. | | | | LICENSEE NOTIFIED THE NRC RESIDENT INSPECTOR. HOO NOTIFIED R1DO BORES. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27632 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: VOGTLE REGION: 2 |NOTIFICATION DATE: 08/05/94 | |UNIT: [1] [ ] [ ] STATE: GA |NOTIFICATION TIME: 10:43 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 08/05/94 | +------------------------------------------------+EVENT TIME: 06:54[EDT]| |NRC NOTIFIED BY: WILLIAMS |LAST UPDATE DATE: 08/05/94 | |HQ OPS OFFICER: GREG SCARFO +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JEROME BLAKE 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 +------------------------------------------------------------------------------+ | A CONTAINMENT VENTILATION ISOLATION OCCURRED WHILE RESTORING A RADIATION | | MONITOR TO SERVICE. | | | | THE FOLLOWING IS THE TEXT OF A FACSIMILE SUBMITTED BY THE LICENSEE: | | "WHILE RESTORING FROM THE I&C SURVEILLANCE (24626-1) ON CONTAINMENT | | RADIATION MONITOR "1RE2565", A CONTAINMENT VENTILATION ISOLATION WAS | | RECEIVED. ALL EQUIPMENT ACTUATED AS REQUIRED. NO CHANGES IN CONTAINMENT | | RADIATION WAS OBSERVED BY CONTROL ROOM OR CHEMISTRY PERSONNEL. THE CVI | | SIGNAL WAS RESET AND ALL EQUIPMENT RESTORED TO NORMAL BY 0751. THE CAUSE | | OF THE ACTUATION IS UNKNOWN AND PRESENTLY UNDER INVESTIGATION." END OF | | TEXT. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |GENERAL INFORMATION or OTHER | |EVENT NUMBER: 27633 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: DRESSER-RAND |NOTIFICATION DATE: 08/05/94 | | CITY: WELLSVILLE REGION: 1 |NOTIFICATION TIME: 10:50 [ET]| | COUNTY: STATE: NY |EVENT DATE: 08/05/94 | |LICENSE#: AGREEMENT: Y |EVENT TIME: 10:00[EDT]| | DOCKET: |LAST UPDATE DATE: 08/05/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | | | | | | +------------------------------------------------+WALTER HAASS NRR | |NRC NOTIFIED BY: ROBERT M. LOUGHLIN | | |HQ OPS OFFICER: DICK JOLLIFFE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |CCCC 21.21 UNSPECIFIED PARAGRAPH | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - AFW PUMP TURBINE TRIP THROTTLE VALVE STEM UNTHREADED FROM ITS COUPLING - | | | | DURING TESTING OF THE #1 AUXILIARY FEEDWATER PUMP TURBINE AT DAVIS BESSE, | | THE GIMPEL TRIP THROTTLE VALVE WOULD NOT OPEN. THE VALVE INDICATED 28% | | OPEN IN THE TRIPPED POSITION, BUT IN REALITY THE VALVE WAS CLOSED AND | | THE VALVE STEM HAD UNTHREADED ITSELF FROM ITS COUPLING. THIS CONDITION | | PREVENTED THE VALVE FROM OPENING. IN THIS CONDITION, THE TURBINE IS | | UNABLE TO OPERATE AS REQUIRED TO PERFORM ITS INTENDED SAFETY FUNCTION. | | | | THIS CONDITION IS PROBABLY AN ISOLATED INCIDENT AT DAVIS BESSE. | | | | GIMPEL IS THE TRIP VALVE MANUFACTURER. | | | | DRESSER-RAND STEAM TURBINE, MOTOR & GENERATOR DIVISION IS THE TRIP VALVE | | SUPPLIER. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |GENERAL INFORMATION or OTHER | |EVENT NUMBER: 27634 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: ABBOTT LABS, ROSS PRODUCTS DIVISION |NOTIFICATION DATE: 08/05/94 | | CITY: ALTA VISTA REGION: 2 |NOTIFICATION TIME: 16:15 [ET]| | COUNTY: STATE: VA |EVENT DATE: 07/26/94 | |LICENSE#: AGREEMENT: N |EVENT TIME: 12:00[EDT]| | DOCKET: |LAST UPDATE DATE: 08/05/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |JEROME BLAKE RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: DENNIS JANIAK | | |HQ OPS OFFICER: DICK JOLLIFFE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NINF INFORMATION ONLY | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - A SEALED RADIOACTIVE SOURCE FROM A LEVEL GAUGE MISSING IN A SCRAP YARD - | | | | ON ABOUT 07/26/94, A PICO (BRAND NAME) LEVEL GAUGE, USED TO DETERMINE THE | | FILL HEIGHT OF METAL OR PLASTIC CONTAINERS, CONTAINING A 100 MILLICURIE | | AM-241 SEALED RADIOACTIVE SOURCE, WAS INADVERTENTLY THROWN INTO A RECYCLE | | BIN BY AN EMPLOYEE OF ABBOTT LABORATORIES, ROSS PRODUCTS DIVISION | | (A GENERAL LICENSEE), IN ALTA VISTA, VA. | | | | THE CONTENTS OF THE RECYCLE BIN WAS THEN TAKEN BY CYCLE SYSTEMS, INC | | TO THEIR SCRAP METAL RECYCLE SITE IN LYNCHBURG, VA, ABOUT 20 MILES AWAY. | | | | AT APPROXIMATELY 1430 ON 08/05/94, THE GAUGE HOUSING HAD BEEN FOUND IN THE | | SCRAP YARD WITHOUT THE SOURCE. THE GAUGE HAD BEEN PROCESSED THROUGH A | | "SHEARER" MACHINE. | | | | A CONSULTANT FOR THE GENERAL LICENSEE HAS COMPLETED SURVEYS OF SITE | | PERSONNEL AND FOUND NO CONTAMINATION. THE CONSULTANT AND OTHERS ARE | | SEARCHING THE SCRAP YARD FOR THE SOURCE. | | | | NRC REGION 2 PERSONNEL HAVE NOTIFIED COMMONWEALTH OF VIRGINIA OFFICIALS | | WHO ARE RESPONDING TO THE SCENE. | | | | THE NRC RESIDENT INSPECTOR FROM THE NEARBY BABCOCK AND WILCOX FUEL FACILITY | | IS RESPONDING TO THE SCENE. | | | | REGION 2 ISSUED PRELIMINARY NOTIFICATION #PNO-II-94-041 ON 08/05/94. | | | | SEE HOO LOG FOR TELEPHONE NUMBERS. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27635 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: ARKANSAS NUCLEAR REGION: 4 |NOTIFICATION DATE: 08/05/94 | |UNIT: [1] [2] [ ] STATE: AR |NOTIFICATION TIME: 16:50 [ET]| |RX TYPE: [1] B&W-L-LP,[2] CE |EVENT DATE: 04/07/94 | +------------------------------------------------+EVENT TIME: 12:00[CDT]| |NRC NOTIFIED BY: SCHEIDE |LAST UPDATE DATE: 08/05/94 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |LARRY YANDELL RDO | |DDDD 73.71 UNSPECIFIED PARAGRAPH | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | CONTRACTOR WHO HAD A PREVIOUS FELONY CONVICTION WAS GRANTED UNESCORTED | | PLANT ACCESS. COMPENSATORY ACTIONS HAVE BEEN TAKEN UPON DISCOVERY. | | | | LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | | | | SEE HOO LOG FOR DETAILS. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27636 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: FARLEY REGION: 2 |NOTIFICATION DATE: 08/05/94 | |UNIT: [ ] [2] [ ] STATE: AL |NOTIFICATION TIME: 17:05 [ET]| |RX TYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 08/05/94 | +------------------------------------------------+EVENT TIME: 14:59[CDT]| |NRC NOTIFIED BY: HAWKINS |LAST UPDATE DATE: 08/05/94 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JEROME BLAKE 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 | M/R Y 100 POWER OPERATION | 0 HOT STANDBY | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - MANUAL Rx TRIP FROM 100% POWER DUE TO LOSS OF MAIN CONDENSER VACUUM - | | | | IMMEDIATELY AFTER PLACING THE #4 GLAND SEAL PRESSURE REGULATOR IN SERVICE, | | THE REGULATOR FAILED TO MAINTAIN PROPER GLAND SEAL PRESSURE CAUSING THE | | MAIN CONDENSER TO LOSE VACUUM. | | | | CONTROL ROOM OPERATORS MANUALLY TRIPPED THE REACTOR FROM 100% POWER DUE TO | | THE MAIN CONDENSER REACHING ITS BACKPRESSURE LIMIT. | | | | ALL CONTROL RODS INSERTED COMPLETELY AND STEAM IS BEING DUMPED TO THE MAIN | | CONDENSER. | | | | UNIT 2 IS STABLE IN MODE 3 (HOT STANDBY). | | | | LICENSEE IS INVESTIGATING THE CAUSE AND IS DETERMINING CORRECTIVE ACTIONS. | | | | LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27637 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MAINE YANKEE REGION: 1 |NOTIFICATION DATE: 08/05/94 | |UNIT: [1] [ ] [ ] STATE: ME |NOTIFICATION TIME: 19:57 [ET]| |RX TYPE: [1] CE |EVENT DATE: 08/05/94 | +------------------------------------------------+EVENT TIME: 17:00[EDT]| |NRC NOTIFIED BY: EBERT |LAST UPDATE DATE: 08/05/94 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |ROBERT BORES 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 +------------------------------------------------------------------------------+ | - SHUT IN-SERIES S/G EFW ISOLATION & CONTROL VALVES LEAKING BY (IN-LINE) - | | | | THE PLANT IS IN MODE 5 (COLD SHUTDOWN) IN A MAINTENANCE OUTAGE TO REPAIR | | STEAM GENERATOR TUBE LEAKS. | | | | ON 08/04/94, WHILE REFILLING #1 S/G USING AN EMERGENCY FEEDWATER PUMP, | | LICENSEE OBSERVED THAT THE ASSOCIATED EMERGENCY FEEDWATER ISOLATION VALVE | | #EFW-A-338 AND THE IN-SERIES ASSOCIATED EMERGENCY FEEDWATER CONTROL VALVE | | #EFW-A-101 LEAKED BY (IN-LINE) WHEN SHUT. BOTH VALVES ARE DESIGNED TO SHUT | | @ 400 PSI TO PREVENT AN UNCONTROLLED COOLDOWN OF A FAULTED STEAM GENERATOR. | | | | LICENSEE DETERMINED THAT THE ISOLATION VALVE HAD BEEN IMPROPERLY INSTALLED | | IN SUCH A MANNER THAT WHEN THE PLANT HAD PREVIOUSLY BEEN AT POWER, IT WOULD | | NOT HAVE PERFORMED ITS SAFETY FUNCTION. | | | | AT 1700 ON 08/05/94, LICENSEE DETERMINED THAT THE STEAM LINE BREAK SAFETY | | ANALYSIS ASSUMES ZERO IN-LINE LEAKAGE BY THESE 2 VALVES. | | | | LICENSEE CONCLUDED THAT A CONDITION WHEREBY A FAILURE OF THE CONTROL VALVE | | ALONG WITH THE ISOLATION VALVE LEAKING BY AND UNABLE TO PERFORM ITS SAFETY | | FUNCTION TOGETHER WOULD CONSTITUTE AN UNANALYZED CONDITION. | | | | LICENSEE IS CONTINUING TO INVESTIGATE THIS CONDITION. | | | | LICENSEE WILL REPAIR/REPLACE & TEST BOTH VALVES AND TEST THE CORRESPONDING | | VALVES ASSOCIATED WITH THE OTHER 2 STEAM GENERATORS PRIOR TO PLANT RESTART. | | | | LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | | | | * * * UPDATE AT 1151 ON 08/06/94 BY MABEN ENTERED BY HOO JOLLIFFE * * * | | | | LICENSEE TESTED THE CORRESPONDING VALVES ASSOCIATED WITH THE OTHER 2 STEAM | | GENERATORS WITH THE FOLLOWING RESULTS: | | | | - #3 S/G EMERGENCY FEEDWATER ISOLATION VALVE #EFW-A-340 LEAKED BY WHEN SHUT | | AND WAS UNABLE TO PERFORM ITS SAFETY FUNCTION. | | - THE FOLLOWING VALVES TESTED SATISFACTORY; | | - #3 S/G EMERGENCY FEEDWATER CONTROL VALVE | | - #2 S/G EMERGENCY FEEDWATER CONTROL VALVE | | - #2 S/G EMERGENCY FEEDWATER ISOLATION VALVE. | | | | LICENSEE WILL REPAIR/REPLACE & TEST THE #340 VALVE PRIOR TO PLANT RESTART. | | | | LICENSEE WILL SUBMIT AN LER TO THE NRC ON THIS EVENT. | | | | LICENSEE INFORMED THE NRC RESIDENT INSPECTOR ABOUT THIS EVENT AND WILL | | INFORM HIM ABOUT THIS UPDATE. | | | | HOO NOTIFIED R1DO BORES. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27638 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: DRESDEN REGION: 3 |NOTIFICATION DATE: 08/06/94 | |UNIT: [ ] [ ] [3] STATE: IL |NOTIFICATION TIME: 10:15 [ET]| |RX TYPE: [1] GE-1,[2] GE-3,[3] GE-3 |EVENT DATE: 08/06/94 | +------------------------------------------------+EVENT TIME: 07:40[CDT]| |NRC NOTIFIED BY: LARRY COYLE |LAST UPDATE DATE: 08/06/94 | |HQ OPS OFFICER: JOSEPH SEBROSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JAMES CREED RDO | |ARPS 50.72(b)(2)(ii) RPS ACTUATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | | | | | 3 | A/R Y 3 STARTUP | 0 HOT SHUTDOWN | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | REACTOR SCRAM FROM 3% POWER DUE TO LOW REACTOR VESSEL LEVEL. | | | | DURING UNIT 3 STARTUP THE LICENSEE RECEIVED A LOW LEVEL SCRAM. THE REACTOR | | WAS AT APPROXIMATELY 300 PSIG WHEN THIS OCCURRED. THE LICENSEE ALSO | | RECEIVED A GROUP 2 AND GROUP 3 ISOLATION ON LOW LEVEL. THE LOWEST LEVEL THE | | REACTOR VESSEL DROPPED TO WAS +6 INCHES. THE SCRAM SIGNAL, AND THE GROUP 2 | | AND GROUP 3 ISOLATION SIGNALS WERE RESET. THE REACTOR VESSEL LEVEL IS | | CURRENTLY AT +30 INCHES AND IS BEING MAINTAINED BY THE CONDENSATE AND FEED | | SYSTEM. | | | | THE LICENSEE WAS STARTING UP FROM A REFUELING OUTAGE SO THERE IS NO | | APPRECIABLE DECAY HEAT. ALL RODS FULLY INSERTED ON THE SCRAM, AND ALL ECCS | | ARE OPERABLE. THE LICENSEE IS INVESTIGATING THE CAUSE OF THE SCRAM. AT | | THE TIME OF THE SCRAM THE LICENSEE WAS PREPARING TO START ANOTHER | | CONDENSATE PUMP AND REACTOR VESSEL WATER LEVEL CONTROL WAS IN AUTOMATIC | | WITH LEVEL BEING MAINTAINED AT +30 INCHES. | | | | THE LICENSEE WILL INFORM THE RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 27639 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: SINAI HOSPITAL, DETROIT, MI |NOTIFICATION DATE: 08/07/94 | | CITY: DETROIT REGION: 3 |NOTIFICATION TIME: 12:16 [ET]| | COUNTY: STATE: MI |EVENT DATE: 07/14/94 | |LICENSE#: 21-00299-06 AGREEMENT: N |EVENT TIME: 12:00[EDT]| | DOCKET: |LAST UPDATE DATE: 08/07/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |JAMES CREED RDO | | | | +------------------------------------------------+ROY CANIANO R3 | |NRC NOTIFIED BY: PRAVEEN DALMIA, RSO | | |HQ OPS OFFICER: DICK JOLLIFFE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - POSSIBLE MEDICAL MISADMINISTRATION AT SINAI HOSPITAL, DETROIT, MI - | | | | AN INSPECTION BY THE SINAI HOSPITAL RADIATION SAFETY OFFICER, PRAVEEN | | DALMA, OF THE PORT X-RAY FILM FROM A TELETHERAPY MACHINE USED TO TREAT A | | FEMALE CANCER PATIENT WITH A 1OO CENTIGRAY Co-60 SOURCE ON 07/14/94, | | REVEALED THE FOLLOWING: THE INCORRECT COLLIMATOR FIELD SIZE SETTING | | (SIMILAR TO A CAMERA APERTURE OPENING) WAS USED DURING THE TREATMENT. | | THE SETTING USED WAS 24 CM X 32 CM OR LARGER; THE CORRECT SETTING WAS | | 15 CM X 24 CM. | | | | THIS ERROR RESULTED IN THE FOLLOWING INCORRECT PORTIONS OF THE PATIENT'S | | BODY BEING TREATED: | | - ENTIRE RIGHT LUNG | | - PART OF THE MEDIA STERNUM (CENTER OF THE BREAST BONE) | | - PART OF THE FACE | | - PART OF THE UPPER RIGHT ARM. | | | | THE TECHNICIAN ADMINISTERING THIS TREATMENT AND THE PATIENT INVOLVED IN | | THIS EVENT ARE THE SAME INDIVIDUALS INVOLVED IN EVENT #27622 ON 08/03/94. | | | | THE ERROR IN THIS EVENT POSED NO ADVERSE MEDICAL AFFECTS TO THE PATIENT. | | THE COMBINATION OF THE ERROR IN THIS EVENT AND THE ERROR SPECIFIED IN | | EVENT #27622 POSED NO ADVERSE MEDICAL AFFECTS TO THE PATIENT. | | | | THE RSO NOTIFIED THE PATIENT AND HER REFERRING PHYSICIAN AND WILL NOTIFY | | REGION 3 AND SUBMIT A WRITTEN REPORT TO THE NRC WITHIN 15 DAYS. | | | | NOTE: SEE EVENTS #27598 AND #27622 FOR RELATED EVENTS. | +------------------------------------------------------------------------------+