U.S. Nuclear Regulatory Commission Operations Center Event Reports For 08/09/94 - 08/10/94 ** EVENT NUMBERS ** 27646 27647 27648 27649 27650 27651 27652 +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27646 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: DRESDEN REGION: 3 |NOTIFICATION DATE: 08/09/94 | |UNIT: [ ] [2] [ ] STATE: IL |NOTIFICATION TIME: 04:06 [ET]| |RX TYPE: [1] GE-1,[2] GE-3,[3] GE-3 |EVENT DATE: 08/09/94 | +------------------------------------------------+EVENT TIME: 01:34[CDT]| |NRC NOTIFIED BY: STEVE KUCZYNSKI |LAST UPDATE DATE: 08/09/94 | |HQ OPS OFFICER: JOSEPH SEBROSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MARK RING RDO | |AINA 50.72(b)(2)(iii)(A) POT UNABLE TO SAFE SD | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N N 0 HOT SHUTDOWN | 0 HOT SHUTDOWN | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE HIGH PRESSURE COOLANT INJECTION (HPCI) SYSTEM OUTBOARD CONTAINMENT | | ISOLATION VALVE FAILED TO AUTO CLOSE ON AN ISOLATION SIGNAL. | | | | WHILE COOLING DOWN THE PLANT TO REPAIR THE HPCI SYSTEM, IT WAS NOTICED THAT | | THE HPCI OUTBOARD ISOLATION VALVE (#2-2301-5) DID NOT AUTO CLOSE AS | | REQUIRED ON AN ISOLATION SIGNAL. THE VALVE WAS SUPPOSED TO CLOSE | | AUTOMATICALLY WHEN REACTOR VESSEL PRESSURE REACHED APPROXIMATELY 80 PSIG. | | THIS LOW REACTOR PRESSURE ISOLATION SIGNAL IS FOR PROTECTION OF THE HPCI | | TURBINE. THE VALVE COULD NOT BE CLOSED FROM THE CONTROL ROOM EITHER. THE | | VALVE HAD TO BE CLOSED USING THE MANUAL HAND WHEEL. AT THE TIME OF THE | | EVENT THE HPCI SYSTEM WAS INOPERABLE WITH THE INBOARD ISOLATION VALVE IN | | THE CLOSED POSITION. | | | | THE LICENSEE IS INVESTIGATING THE PROBLEM AND AT THIS TIME SUSPECTS AN | | ELECTRICAL MALFUNCTION. IT IS ASSUMED BY THE LICENSEE THAT THE OUTBOARD | | ISOLATION VALVE WOULD NOT HAVE CLOSED ON AN ACTUAL ESF ACTUATION SIGNAL. | | THE INBOARD ISOLATION VALVE ALSO CLOSES ON AN ESF ACTUATION SIGNAL, | | HOWEVER, BECAUSE THE VALVE WAS SHUT PRIOR TO RECEIVING THE SIGNAL THE | | LICENSEE IS NOT SURE IF IT WOULD HAVE OPERATED PROPERLY. THE UNIT IS | | PROCEEDING TO COLD SHUTDOWN AT THIS TIME. | | | | THE LICENSEE WILL INFORM THE RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27647 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: HATCH REGION: 2 |NOTIFICATION DATE: 08/09/94 | |UNIT: [1] [ ] [ ] STATE: GA |NOTIFICATION TIME: 08:15 [ET]| |RX TYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 08/09/94 | +------------------------------------------------+EVENT TIME: 05:45[CDT]| |NRC NOTIFIED BY: JAMES BARNES |LAST UPDATE DATE: 08/09/94 | |HQ OPS OFFICER: THOMAS ANDREWS +-----------------------------+ +------------------------------------------------+ 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 +------------------------------------------------------------------------------+ | THE REACTOR CORE ISOLATION COOLING EXHAUST LINE VACUUM BREAKER VALVE | | "1E51-F105" CLOSED FOR UNKNOWN REASONS. THERE WAS NO ISOLATION SIGNAL | | PRESENT. THE VALVE HAS BEEN REOPENED. | | | | THE EVENT IS UNDER INVESTIGATION. ACCORDING TO THE LICENSEE, THERE WERE | | ELECTRICIANS WORKING IN A CABINET AND THEY MAY HAVE BUMPED A RELAY. | | | | THE NRC RESIDENT INSPECTOR HAS BEEN NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27648 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: GINNA REGION: 1 |NOTIFICATION DATE: 08/09/94 | |UNIT: [1] [ ] [ ] STATE: NY |NOTIFICATION TIME: 15:14 [ET]| |RX TYPE: [1] W-2-LP |EVENT DATE: 08/09/94 | +------------------------------------------------+EVENT TIME: 14:20[EDT]| |NRC NOTIFIED BY: DAN BERRY |LAST UPDATE DATE: 08/09/94 | |HQ OPS OFFICER: WILLIAM HUFFMAN +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JENNY JOHANSEN 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 98 POWER OPERATION | 80 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | SAFETY INJECTION SYSTEM DECLARED INOPERABLE RESULTING IN TECH SPEC REQUIRED | | SHUTDOWN. | | | | WHILE PERFORMING A SURVEILLANCE ON THE "B" SI PUMP, A SMALL LEAK WAS | | OBSERVED ON A WELD ON THE SI PUMP RECIRC LINE FOR MINI-FLOW BACK TO THE | | REFUELING WATER STORAGE TANK (DOWNSTREAM OF VALVE #V-1820C). LEAKAGE WAS | | OBSERVED TO BE ABOUT 30 TO 50 CC/MINUTE. THE LEAKING WATER IS FROM THE | | RWST, NOT FROM THE RCS. SINCE THE RECIRC FLOW PATH IS COMMON TO THE SI | | PUMPS AT GINNA, ALL 3 SI PUMPS WERE DECLARED INOPERABLE. TECH SPEC LCO | | 3.3.1.4 WAS ENTERED WHICH REQUIRES THE PLANT TO BE IN HOT SHUTDOWN IN | | 6 HOURS AND BELOW 350 DEGREES IN THE FOLLOWING 6 HOURS. | | | | THE PLANT WILL REPAIR THE WELD LEAK FOLLOWING SHUTDOWN. ALTHOUGH THE SI | | PUMPS HAVE BEEN DECLARED INOPERABLE, THEY ARE FULLY CAPABLE OF PERFORMING | | THEIR INTENDED FUNCTION. | | | | THE NRC RESIDENT INSPECTOR HAS BEEN NOTIFIED. | | | | *** UPDATE 08/10/94 @ 01:38 BY LINGL TO GOULD *** | | THE PLANT EXITED THE LCO ACTION STATEMENT AT 1:30 WHEN THEY REACHED <350 | | DEGREES F. THEY WILL REMAIN BETWEEN BETWEEN 330 AND 350 DEGREES WHILE THEY | | REPAIR THE LINE. THE RI WILL BE INFORMED. HOO NOTIFIED R1DO JOHANSEN. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 27649 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: V.A. HOSPITAL OF LONG BEACH, CA |NOTIFICATION DATE: 08/09/94 | | CITY: LONG BEACH REGION: 4 |NOTIFICATION TIME: 16:15 [ET]| | COUNTY: STATE: CA |EVENT DATE: 08/09/94 | |LICENSE#: 04-00689-07 AGREEMENT: Y |EVENT TIME: 09:30[PDT]| | DOCKET: |LAST UPDATE DATE: 08/09/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |WILLIAM JOHNSON RDO | | |CARL PAPERIELLO EO | +------------------------------------------------+ | |NRC NOTIFIED BY: STEPHEN MILLS | | |HQ OPS OFFICER: WILLIAM HUFFMAN | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | A STRONTIUM-89 DOSE WAS ADMINISTERED TO THE WRONG PATIENT. | | | | THE RADIATION SAFETY OFFICER FOR THE VA HOSPITAL IN LONG BEACH, CALIFORNIA, | | REPORTS THAT THE WRONG PATIENT WAS ADMINISTERED 4 MILLICURIES OF | | STRONTIUM-89. STRONTIUM-89 IS A BONE SEEKER USED TO TREAT CANCER. THE | | ESTIMATED BONE DOSE TO THE PATIENT IS 250 RAD. | | | | THE PATIENT AND HIS PHYSICIAN HAVE BEEN INFORMED. THERE IS SOME POSSIBLE | | LONG TERM EFFECT TO THE PATIENT'S BONE MARROW WHICH MAY RESULT IN A LOWER | | BLOOD COUNT. THE LICENSEE IS CURRENTLY INVESTIGATING WAYS OF RAPIDLY | | REMOVING THE STRONTIUM FROM THE PATIENT'S SYSTEM. | | | | THE HOSPITAL'S NUCLEAR MEDICINE DEPARTMENT HAS BEEN SHUT DOWN WHILE AN | | INVESTIGATION IS IN PROGRESS. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27650 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SUSQUEHANNA REGION: 1 |NOTIFICATION DATE: 08/09/94 | |UNIT: [1] [2] [ ] STATE: PA |NOTIFICATION TIME: 16:35 [ET]| |RX TYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 08/09/94 | +------------------------------------------------+EVENT TIME: 15:47[EDT]| |NRC NOTIFIED BY: D. J. BOYLE |LAST UPDATE DATE: 08/09/94 | |HQ OPS OFFICER: WILLIAM HUFFMAN +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JENNY JOHANSEN RDO | |AARC 50.72(b)(1)(v) OTHER ASMT/COMM INOP | | |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 | 100 POWER OPERATION | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | SIREN ACTUATION SYSTEM OUT OF SERVICE. | | | | THE FOLLOWING IS THE TEXT OF A FACSIMILE FROM THE LICENSEE REPORTING THIS | | EVENT: | | | | "EMERGENCY SIRENS FOR OFFSITE NOTIFICATIONS ARE INOPERABLE DUE TO A | | TELEPHONE LINE PROBLEM. MANUAL ACTUATION OF THE SIRENS IS POSSIBLE AT THIS | | TIME VIA PERSONNEL STATIONED AT THE TRANSMITTER IN RADIO CONTACT. THE PHONE | | COMPANY IS WORKING ON THE PROBLEM AT THIS TIME. IT IS NOT KNOWN HOW LONG | | THE SYSTEM HAS BEEN INOPERABLE OR HOW LONG IT WILL TAKE TO REPAIR. | | | | THE SHIFT SUPERVISOR WAS NOTIFIED OF THE CONDITION AT 1547 EDT ON 8-9-94. | | EMERGENCY RESPONSE PERSONNEL CONTACTED WERE PEMA; LCEMA; AND CEMA AT 1623 | | EDT ON 8-9-94." | | | | THE NRC RESIDENT INSPECTOR HAS BEEN INFORMED. | | | | *** UPDATE FROM ROLLAND TO HUFFMAN AT 1930 EDT ON 8/9/94 *** | | | | THE SIREN ACTUATION SYSTEM WAS RESTORED TO SERVICE AT 1816 EDT. STATE AND | | LOCAL AUTHORITIES HAVE BEEN INFORMED. THE NRC RESIDENT WILL BE INFORMED. | | R1DO (JOHANSEN) NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27651 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: QUAD CITIES REGION: 3 |NOTIFICATION DATE: 08/09/94 | |UNIT: [1] [2] [ ] STATE: IL |NOTIFICATION TIME: 19:57 [ET]| |RX TYPE: [1] GE-3,[2] GE-3 |EVENT DATE: 08/08/94 | +------------------------------------------------+EVENT TIME: 15:20[CDT]| |NRC NOTIFIED BY: JEFF DAVIS |LAST UPDATE DATE: 08/09/94 | |HQ OPS OFFICER: WILLIAM HUFFMAN +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JAMES CREED RDO | |BAE1 20.2202(b)(1) PERS OVEREXPOSURE |GUS LAINASS EO | | |KEN BROCKMAN ERB | | |ED JORDAN AEOD | | |WILLIAM BEECHER PAO | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | POSSIBLE DELIBERATE RADIATION EXPOSURE INCIDENT. | | | | THE FOLLOWING IS THE TEXT OF A FACSIMILE FROM THE LICENSEE EVENT: | | "THIS NOTIFICATION IS BEING MADE IN ACCORDANCE WITH 10 CFR 20.2202 | | (b)(1)(iii). THERE IS A POTENTIAL THAT AN INDIVIDUAL RECEIVED A DOSE | | EQUIVALENT TO THE SKIN IN EXCESS OF THE 50 REM LIMIT. AN INVESTIGATION IS | | IN PROGRESS TO DETERMINE THE CAUSE OF THE EVENT AND TO ASSESS THE DOSE TO | | AN INDIVIDUAL WHO WAS DISCOVERED WITH A STRONTIUM-90 SOURCE IN THE PANTS | | POCKET. THE INDIVIDUAL'S SHALLOW DOSE EQUIVALENT IS ESTIMATED TO BE | | APPROXIMATELY 60 REM AS CALCULATED AT 1500 HOURS ON 8-9-94. THIS ESTIMATE | | IS BASED ON COMPUTER MODELING USING VARSKIN (MOD.2). THE LICENSEE IS | | PURSUING DIRECT MEASUREMENT OF THE DOSE WITH A NATIONAL LABORATORY TO | | ARRIVE AT THE MOST ACCURATE ESTIMATE OF DOSE, HOWEVER, THIS ACTION WILL | | TAKE SEVERAL DAYS TO COMPLETE." END OF TEXT. | | | | THE STRONTIUM-90 WAS IN A SMALL CALIBRATION SOURCE WHICH WAS APPARENTLY | | PLACED IN THE REAR PANTS POCKET OF A WORKERS UNATTENDED STREET CLOTHING | | WHILE THE WORKER WAS WEARING PLANT ISSUED COVERALLS. THE SOURCE WAS | | DETECTED WHEN THE WORKER HAD CHANGED BACK INTO THEIR STREET CLOTHES AND | | SET OFF A RADIATION MONITOR UPON EXITING A RADIATION CONTROL AREA. | | | | CORPORATE STAFF PERSONNEL ARE INVESTIGATING THE INCIDENT INCLUDING POSSIBLE | | DELIBERATE PLACEMENT OF THE SOURCE INTO THE WORKERS POCKET. LICENSEE ISSUED | | A PRESS RELEASE ON THIS EVENT. | | | | THE RESIDENT INSPECTOR AND REGION III ARE FOLLOWING THE LICENSEE'S | | INVESTIGATION. REGION III ISSUED PRELIMINARY NOTIFICATION #PNO-III-94-62. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27652 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: OCONEE REGION: 2 |NOTIFICATION DATE: 08/10/94 | |UNIT: [ ] [ ] [3] STATE: SC |NOTIFICATION TIME: 05:13 [ET]| |RX TYPE: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP |EVENT DATE: 08/10/94 | +------------------------------------------------+EVENT TIME: 04:57[EDT]| |NRC NOTIFIED BY: GREWE |LAST UPDATE DATE: 08/10/94 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: UNUSUAL EVENT +-----------------------------+ |10 CFR SECTION: |KENNETH BARR RDO | |AAEC 50.72(a)(1)(i) EMERGENCY DECLARED |GUS LAINAS EO | | |BELCHER FEMA | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | | | | | 3 | A/R Y 100 POWER OPERATION | 0 HOT SHUTDOWN | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE PLANT REPORTED A REACTOR TRIP AT 04:25 FROM 100% POWER(DUE TO TRIP OF | | BOTH MAIN FEED PUMPS) FOLLOWED BY THE DECLARATION OF AN NOUE DUE TO | | SECONDARY SIDE DEPRESSURIZATION. | | | | THE MAIN FEED PUMP TRIP WAS DUE TO A BLOWN FUSE(CAUSE WILL BE INVESTIGATED) | | CAUSING THE LOSS OF THE "KI" INVERTER THAT FEEDS THE INTEGRATED CONTROL | | SYSTEM WHICH SENDS AN AUTOMATIC TRIP SIGNAL TO THE PUMPS WHICH RESULTED IN | | THE REACTOR TRIP. ALL RODS FULLY INSERTED AND NO PRIMARY SAFETY RELIEF | | VALVES LIFTED, BUT SECONDARY RELIEF VALVES DID LIFT AND MAY NOT HAVE | | RESEATED PROPERLY. THEY DECLARED THE NOUE DUE TO SECONDARY SIDE | | DEPRESSURIZATION(COULD POSSIBLY BE CAUSED BY A STEAM LINE BREAK, BUT THERE | | WERE NO INDICATIONS OF ONE). THEY ARE INVESTIGATING THE CAUSE OF THE | | SECONDARY SIDE DEPRESSURIZATION. THE "3B" ONCE-THROUGH STEAM GENERATOR WAS | | ISOLATED DUE TO A PRESSURE MISMATCH FOLLOWING THE REACTOR TRIP. THE LEVEL | | IN THE OTSG IS ZERO(ACTUAL LEVEL IS 6" BUT ANYTHING BELOW 15" IS CONSIDERED | | ZERO) AND IS CONSIDERED A DRY S/G. THE HEAT SINK IS THE EMERGENCY | | FEEDWATER AND THE "3A" STEAM GENERATOR. THE PLANT IS STABLE AT THIS TIME | | AND ALL EMERGENCY EQUIPMENT IS OPERABLE. THE RI WILL BE INFORMED. THE STATE | | AND LOCAL AGENCIES HAVE BEEN NOTIFIED. | +------------------------------------------------------------------------------+