U.S. Nuclear Regulatory Commission Operations Center Event Reports For 08/11/94 - 08/12/94 ** EVENT NUMBERS ** 27649 27659 27660 27661 27662 27663 +----------------------------------+ +-----------------------+ |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: 08/11/94 | | +-----------------------------+ | |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. | | | | **** COMMISSIONER'S ASSISTANT'S BRIEFING **** | | TIME: 1730 EDT | | DATE: AUGUST 11, 1994 | | SUBJECT: POTENTIAL MEDIA INTEREST IN THIS EVENT | | BRIEFER: LINDA KASNER, REGION IV | | | | NOTIFIED: R4DO (JOHNSON), AEOD (JORDAN), ERB (BAILEY), | | NMSS (GLENN, PAPERIELLO), PA (BEECHER), SP (BANGART), | | IP (FAULKNER), EDO (THOMPSON), SECY (HART), CA (CALLAHAN), | | NRR-EO (C. GRIMES), NMSS-EO (COMBS), de Planque (McKENNA), | | SELIN (VIETTI-COOK), ROGERS (SORENSEN) | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27659 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BRAIDWOOD REGION: 3 |NOTIFICATION DATE: 08/11/94 | |UNIT: [1] [ ] [ ] STATE: IL |NOTIFICATION TIME: 12:34 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 08/11/94 | +------------------------------------------------+EVENT TIME: 10:28[CDT]| |NRC NOTIFIED BY: CHERYL GAYHEART |LAST UPDATE DATE: 08/11/94 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: UNUSUAL EVENT +-----------------------------+ |10 CFR SECTION: |MARK RING RDO | |AAEC 50.72(a)(1)(i) EMERGENCY DECLARED |ED GOODWIN EO | |AESF 50.72(b)(2)(ii) ESF ACTUATION |MOSTELLER FEMA | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | A/R Y 100 POWER OPERATION | 0 HOT STANDBY | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | REACTOR TRIP AND MAIN STEAM ISOLATION RESULTED IN A UNUSUAL EVENT BEING | | DECLARED. | | | | "AT 1028 CDT AN INADVERTENT STEAM LINE ISOLATION (TRAIN A) OCCURRED CAUSING | | AN AUTOMATIC REACTOR TRIP ON LO-2 STEAM GENERATOR LEVELS. STEAM RELEASE | | THROUGH THE S/G PORVs AND S/G SAFETIES DISPLACED A GALLERY WHICH DAMAGED | | THE TURBINE BUILDING ROOF. NO DAMAGE WAS DONE TO EQUIPMENT IN THE TURBINE | | BUILDING UPON INITIAL INVESTIGATION. A GSEP (UE) WAS CLASSIFIED BASED ON A | | FAILURE THAT IMPARTS SIGNIFICANT ENERGY TO NEARBY STRUCTURES. | | | | DECAY HEAT IS BEING REMOVED BY THE STEAM GENERATOR PORVs. ALL CONTROL RODS | | FULLY INSERTED INTO THE CORE. THE STEAM GENERATOR SAFETIES HAVE RESEATED. | | THE GSEP (UE) CLASSIFICATION HAS BEEN TERMINATED AT 1125 CDT BASED ON NO | | FURTHER POTENTIAL FOR STRUCTURAL DAMAGE. THE UNIT IS BEING STABILIZED IN | | MODE 3 FOR FURTHER INVESTIGATION OF THE EVENT." | | | | THE UNUSUAL EVENT WAS DECLARED AT 1054 CDT. THE ILLINOIS DEPARTMENT OF | | NUCLEAR SAFETY, THE ILLINOIS SAFETY AND DISASTER AGENCY AND THE NRC | | RESIDENT INSPECTOR WERE NOTIFIED BY THE LICENSEE. | | | | | | * * * UPDATE BY GRAHAM AT 2004 EDT ON 8/11/94 TAKEN BY WEAVER * * * | | | | AT 1555 CDT, AN INADVERTENT STEAM LINE ISOLATION (TRAIN A) OCCURRED, | | CLOSING THE MSIV BYPASS VALVES. PLANT COOLDOWN ON STEAM DUMPS WAS IN | | PROGRESS. THE COOLDOWN WAS TERMINATED UPON RECEIVING THE STEAM LINE | | ISOLATION SIGNAL. PLANT COOLDOWN WAS CONTINUED ON THE STEAM GENERATOR | | PORVs. THIS IS THE SAME SIGNAL WHICH CAUSED THE ORIGINAL EVENT. | | THE CAUSE IS STILL UNDER INVESTIGATION. | | | | THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | | | | HOO NOTIFIED RDO (RING). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27660 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PEACH BOTTOM REGION: 1 |NOTIFICATION DATE: 08/11/94 | |UNIT: [ ] [3] [ ] STATE: PA |NOTIFICATION TIME: 13:22 [ET]| |RX TYPE: [2] GE-4,[3] GE-4 |EVENT DATE: 08/11/94 | +------------------------------------------------+EVENT TIME: 10:04[EDT]| |NRC NOTIFIED BY: MARK ALDERFER |LAST UPDATE DATE: 08/11/94 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JENNY JOHANSEN 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 3 | N Y 79 POWER OPERATION | 79 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | HPCI DECLARED INOPERABLE DUE TO OPERATOR ERROR. | | | | AT 1004 EDT A REACTOR OPERATOR PLACED THE HPCI AUX OIL PUMP IN PULL TO | | LOCK. THIS MAKES HPCI INOPERABLE. HE DID THIS AFTER RECEIVING REPEATED | | RED WARNING LIGHTS AND THE ANNUNCIATOR "HPCI AUX OIL PUMP RUNNING". | | | | AT 1025 A REACTOR OPERATOR RESTORED THE HPCI AUX OIL PUMP TO AUTO AND HPCI | | WAS DECLARED OPERABLE. A 7 DAY LCO (3.5.C.2) WAS ENTERED AND EXITED. | | | | INVESTIGATION REVEALED IDENTIFIED MAINTENANCE PERSONNEL ERRONEOUSLY WORKING | | ON THE HPCI AUX OIL PUMP RELAY INSTEAD OF THE HPCI GLAND SEAL CONDENSER | | VACUUM PUMP RELAYS. THE VACUUM PUMP RELAYS WERE SCHEDULED WORK AND WERE | | BLOCKED (TAGGED OUT). THE WORKER EXERCISED THE HPCI AUX OIL PUMP CONTROL | | RELAY WHICH DID NOT START THE AUX OIL PUMP, YET GAVE THE RED RUNNING LIGHT | | AND THE HPCI AUX OIL PUMP RUNNING ALARM. WORK WAS STOPPED. | | | | BOTH RELAYS ARE LOCATED IN A COMMON PANEL AND ARE SIDE BY SIDE. IT WAS NOT | | KNOWN WHETHER THE RELAYS WERE CLEARLY LABELED. INVESTIGATION INTO TO THIS | | EVENT HAS NOT BEEN COMPLETED. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27661 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SOUTH TEXAS REGION: 4 |NOTIFICATION DATE: 08/11/94 | |UNIT: [1] [2] [ ] STATE: TX |NOTIFICATION TIME: 15:32 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 08/10/94 | +------------------------------------------------+EVENT TIME: 16:45[CDT]| |NRC NOTIFIED BY: PINZON |LAST UPDATE DATE: 08/11/94 | |HQ OPS OFFICER: THOMAS ANDREWS +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |WILLIAM JOHNSON RDO | |NONR OTHER UNSPEC REQMNT | | |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 | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AT APPROXIMATELY 1645 ON AUGUST 10, 1994, THE LICENSEE DETERMINED THAT THE | | ENGINEERED SAFETY FEATURES DIESEL GENERATOR STARTING AIR COMPRESSOR CHECK | | VALVES WERE NOT BEING TESTED IN ACCORDANCE WITH THE REQUIREMENTS OF ASME | | SECTION XI AND TECHNICAL SPECIFICATION 4.0.5. | | | | ALL ENGINEERED SAFETY FEATURES DIESELS WERE DECLARED INOPERABLE. WITH ALL | | THREE ENGINEERED SAFETY DIESEL GENERATORS INOPERABLE, TECHNICAL | | SPECIFICATION 3.8.1.1.F WAS ENTERED WHICH REQUIRES INITIATION OF A PLANT | | SHUTDOWN WITHIN TWO HOURS. HOWEVER, TECHNICAL SPECIFICATION 4.0.3 WAS | | INVOKED TO ALLOW SUSPENSION OF THE REQUIRED ACTIONS FOR 24 HOURS TO ALLOW | | PERFORMANCE OF THE MISSED SURVEILLANCES. | | | | THE VALVES HAVE BEEN SATISFACTORILY TESTED IN BOTH UNITS AND THE ENGINEERED | | SAFETY FEATURES DIESEL GENERATORS HAVE BEEN DECLARED OPERABLE AT 1301 HOURS | | FOR UNIT 1 AND 1357 HOURS FOR UNIT 2 ON AUGUST 11, 1994. | | | | FAILURE TO PERFORM A REQUIRED TECHNICAL SPECIFICATION SURVEILLANCE IS | | REPORTABLE AS A VIOLATION OF THE PLANT OPERATING LICENSES NUMBER NPF-76 AND | | NPF-80 (2G) SECTION 2.C(2) (24 HOUR REPORT). | | | | THE NRC RESIDENT INSPECTOR WILL BE NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27662 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MAINE YANKEE REGION: 1 |NOTIFICATION DATE: 08/11/94 | |UNIT: [1] [ ] [ ] STATE: ME |NOTIFICATION TIME: 18:46 [ET]| |RX TYPE: [1] CE |EVENT DATE: 08/11/94 | +------------------------------------------------+EVENT TIME: 18:15[EDT]| |NRC NOTIFIED BY: WILLOUGHBY |LAST UPDATE DATE: 08/11/94 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JENNY JOHANSEN 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 N 0 HOT STANDBY | 0 HOT STANDBY | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - CABLE SEPARATION REQUIREMENTS NOT MET - | | | | CONTROL CABLES FOR SEVERAL CONTAINMENT ISOLATION VALVES OF DIFFERENT TRAINS | | WERE FOUND IN THE SAME CONDUIT. HOWEVER, NO CABLES TO REDUNDANT EQUIPMENT | | WERE ROUTED TOGETHER IN THIS CONDUIT. | | | | THE LICENSEE IS STILL EVALUATING A COURSE OF ACTION. | | | | THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27663 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: OCONEE REGION: 2 |NOTIFICATION DATE: 08/12/94 | |UNIT: [ ] [ ] [3] STATE: SC |NOTIFICATION TIME: 06:04 [ET]| |RX TYPE: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP |EVENT DATE: 08/12/94 | +------------------------------------------------+EVENT TIME: 04:47[EDT]| |NRC NOTIFIED BY: STASNY |LAST UPDATE DATE: 08/12/94 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |KENNETH BARR 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 42 POWER OPERATION | 0 HOT SHUTDOWN | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE PLANT HAD A REACTOR TRIP FROM 42% POWER DUE TO LOSS OF MFW PUMP "3B". | | | | THIS OCCURRED WHILE THEY WERE INCREASING POWER FROM STARTUP AND THE "3B" | | MAIN FEEDWATER PUMP TRIPPED, CAUSE UNKNOWN AND IS BEING INVESTIGATED(THE | | "3A" MFW PUMP WAS NOT IN SERVICE AT THE TIME). THIS IN TURN RESULTED IN AN | | ANTICIPATORY TRIP OF THE MAIN TURBINE/GENERATOR AND REACTOR. ALL RODS FULLY | | INSERTED, NO SI OCCURRED AND NO PRIMARY SAFETY RELIEF VALVES LIFTED. THEY | | DID HAVE SECONDARY STEAM SAFETY RELIEF VALVES LIFT AND THEY FULLY RESEATED | | AT THE APPROPRIATE PRESSURE. THE HEAT SINK IS BOTH STEAM GENERATORS USING | | THE EMERGENCY FEEDWATER. ALL EMERGENCY EQUIPMENT IS OPERABLE. THE RI WAS | | INFORMED. | +------------------------------------------------------------------------------+