U.S. Nuclear Regulatory Commission Operations Center Event Reports For 08/19/94 - 08/22/94 ** EVENT NUMBERS ** 27689 27690 27691 27692 27693 +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27689 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MILLSTONE REGION: 1 |NOTIFICATION DATE: 08/19/94 | |UNIT: [1] [ ] [ ] STATE: CT |NOTIFICATION TIME: 12:57 [ET]| |RX TYPE: [1] GE-3,[2] CE,[3] W-4-LP |EVENT DATE: 08/19/94 | +------------------------------------------------+EVENT TIME: 12:37[EDT]| |NRC NOTIFIED BY: DON CLEARY |LAST UPDATE DATE: 08/19/94 | |HQ OPS OFFICER: JOSEPH SEBROSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |RICHARD KEIMIG 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 +------------------------------------------------------------------------------+ | OPENINGS IN THE STANDBY GAS TREATMENT SYSTEM (SGTS) DISCHARGE LINES COULD | | SPREAD CONTAMINATION INTO THE CONTROL ROOM DURING A LOSS OF COOLANT | | ACCIDENT (LOCA). | | | | THE LICENSEE WAS DOING A WALKDOWN OF THE SGTS FOR A PERMANENT DESIGN CHANGE | | TO DOCUMENT THE PLUGGING OF SOME HOLES THAT HAD BEEN PREVIOUSLY IDENTIFIED | | ON 9/24/93 (SEE EVENT # 26115). DURING THIS WALKDOWN FOUR NEW HOLES WERE | | IDENTIFIED IN THE SYSTEM. THE HOLES ARE 0.25 INCH DRAIN HOLES AND THERE ARE | | TWO PER TRAIN. IN THE EVENT THE SGTS OPERATED DURING A LOCA, RADIOACTIVE | | GASES WOULD BE INTRODUCED INTO THE VENTILATION ROOM, WHICH COULD THEN | | MIGRATE INTO THE CONTROL ROOM, MAKING IT UNINHABITABLE. THE PROBLEM IS | | BELIEVED TO HAVE EXISTED SINCE INITIAL PLANT CONSTRUCTION. | | | | DURING THE INITIAL FOLLOWUP OF THE 9/24/93 EVENT (EVENT # 26115) A WALKDOWN | | OF THE SGTS IDENTIFIED THE FOUR DRAIN HOLES, HOWEVER, AT THE TIME THE | | LICENSEE BELIEVED THESE HOLES TO BE PLUGGED. THE LICENSEE BELIEVED THE | | HOLES TO BE PLUGGED BECAUSE THE INDIVIDUAL PERFORMING THE WALKDOWN STUCK AN | | OBJECT INSIDE THE HOLE AND HIT SOMETHING SOLID. THE LICENSEE NOW BELIEVES | | THAT WHAT THE INDIVIDUAL HIT WAS A DIVERTER INSIDE THE FAN HOUSING THAT | | DIVERTS FLOW TOWARDS THE DRAIN HOLE AND NOT A PLUG. | | | | THE LICENSEE WILL PLUG THE DRAIN HOLES. THEY ESTIMATE THAT THIS WILL TAKE | | APPROXIMATELY 2 HOURS. THE LICENSEE IS NOT CURRENTLY IN A TECH SPEC ACTION | | STATEMENT BECAUSE OF THE PROBLEM. | | | | THE LICENSEE HAS INFORMED THE RESIDENT INSPECTOR AND STATE AND LOCAL | | OFFICIALS. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |GENERAL INFORMATION or OTHER | |EVENT NUMBER: 27690 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: WASHINGTON UNIVERSITY MEDICAL CNTR |NOTIFICATION DATE: 08/19/94 | | CITY: SAINT LOUIS REGION: 3 |NOTIFICATION TIME: 16:32 [ET]| | COUNTY: STATE: MO |EVENT DATE: 07/21/94 | |LICENSE#: 24-00167-11 AGREEMENT: N |EVENT TIME: 12:00[CDT]| | DOCKET: |LAST UPDATE DATE: 08/19/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |THOMAS BURDICK RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: JOHN EICHLING | | |HQ OPS OFFICER: JOSEPH SEBROSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |BAB2 20.2201(a)(1)(ii) LOST/STOLEN LNM>10X | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | WASHINGTON UNIVERSITY MEDICAL CENTER OF SAINT LOUIS, MISSOURI IS MAKING A | | REPORT DUE TO THE DISCOVERY OF A LOST SOURCE. | | | | THE SOURCE IS A 20 MICRO CURIE AMERICIUM 241 SOURCE THAT WAS USED TO REMOVE | | STATIC CHARGES ON A MICRO BALANCE IN A RESEARCH LAB. THE SOURCE WAS A | | CIRCULAR PLATED SOURCE THAT WAS 0.5 CENTIMETERS IN DIAMETER AND 0.05 | | CENTIMETERS THICK. THE LICENSEE NOTICED THE SOURCE TO FIRST BEING MISSING | | ON 7/21/94. THE SOURCE WAS USED ALONG WITH SOME COMPANION SOURCES FOR OVER | | 20 YEARS. | | | | THE LICENSEE WILL USE AN ELECTRONIC DEVICE IN THE FUTURE TO CONTROL STATIC | | CHARGES. THE LICENSEE HAS COLLECTED ALL THE OTHER SOURCES USED FOR THIS | | PURPOSE AND HAS TURNED THEM OVER TO THE RADIATION SAFETY DEPARTMENT FOR | | DISPOSAL. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27691 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PALO VERDE REGION: 4 |NOTIFICATION DATE: 08/19/94 | |UNIT: [ ] [ ] [3] STATE: AZ |NOTIFICATION TIME: 17:54 [ET]| |RX TYPE: [1] CE,[2] CE,[3] CE |EVENT DATE: 08/19/94 | +------------------------------------------------+EVENT TIME: 13:19[MST]| |NRC NOTIFIED BY: KATHLEEN ROBERSON |LAST UPDATE DATE: 08/19/94 | |HQ OPS OFFICER: JOSEPH SEBROSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |CHARLES CAIN RDO | |ARPS 50.72(b)(2)(ii) RPS ACTUATION | | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | | | | | 3 | A/R Y 100 POWER OPERATION | 0 HOT STANDBY | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | REACTOR TRIP FROM 100% POWER DUE TO LOW LEVEL IN THE #1 STEAM GENERATOR. | | | | AFTER THE REACTOR TRIP THE #1 STEAM GENERATOR LEVEL CONTINUED TO DECREASE | | TO THE LOW-LOW STEAM GENERATOR LEVEL SETPOINT. THIS CAUSED AN ENGINEERED | | SAFETY FEATURE (ESF) ACTUATION OF THE AUXILIARY FEEDWATER (AFW) SYSTEM. THE | | AFW SYSTEM RESTORED THE STEAM GENERATOR LEVELS TO THEIR NORMAL BAND. THE | | LOWEST STEAM GENERATOR LEVEL REACHED WAS 17% WIDE RANGE. | | | | PRIOR TO THE TRIP OPERATORS NOTICED A RAPID DECREASE IN THE #1 STEAM | | GENERATOR LEVEL. THE SUSPECTED CAUSE OF THE PROBLEM WAS A LOSS OF MAIN | | FEEDWATER TO THE #1 STEAM GENERATOR WHEN THE ECONOMIZER VALVE CLOSED. THE | | LICENSEE IS INVESTIGATING THE CAUSE OF THE CLOSURE OF THE ECONOMIZER VALVE. | | | | THE POST TRIP RESPONSE WAS NORMAL. ALL RODS FULLY INSERTED AND NO PRIMARY | | OR SECONDARY RELIEF VALVES LIFTED. ALL ELECTRICAL BUSSES TRANSFERRED AS | | EXPECTED. THE DIESEL GENERATORS DID START BUT DID NOT LOAD ONTO THE BUS. | | THE DIESEL GENERATOR STARTED ON THE AUTO START OF THE AFW SYSTEM. THE | | DIESEL GENERATORS AND THE AFW SYSTEM HAVE BEEN SECURED AND PLACED IN A | | STANDBY MODE. STEAM GENERATOR LEVELS ARE BEING MAINTAINED BY THE MAIN | | FEEDWATER SYSTEM AND THE MAIN CONDENSER IS AVAILABLE AS A HEAT SINK. | | | | THE LICENSEE HAS INFORMED THE RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27692 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BRUNSWICK REGION: 2 |NOTIFICATION DATE: 08/20/94 | |UNIT: [1] [ ] [ ] STATE: NC |NOTIFICATION TIME: 03:50 [ET]| |RX TYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 08/20/94 | +------------------------------------------------+EVENT TIME: 00:08[EDT]| |NRC NOTIFIED BY: JESTER |LAST UPDATE DATE: 08/20/94 | |HQ OPS OFFICER: GREG SCARFO +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |GEORGE AL BELISLE 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 PRIMARY CONTAINMENT ISOLATION OCCURRED DUE TO A SPURIOUS RELAY ACTUATION. | | | | THE FOLLOWING IS THE TEXT OF A FACSIMILE SUBMITTED BY THE LICENSEE: | | "AT 0008 ON AUGUST 20, 1994, SPURIOUS GROUP 2 AND GROUP 6 "B" DIVISION | | ISOLATION SIGNALS WERE RECEIVED. APPROPRIATE ISOLATION VALVES WERE | | VERIFIED CLOSED. AT 0047, AFTER VERIFYING THAT THE ISOLATIONS WERE NOT DUE | | TO A VALID SIGNAL, THE ISOLATIONS WERE RESET AND SYSTEMS WERE RETURNED TO | | SERVICE TO SUPPORT PLANT OPERATION. THE INITIAL INVESTIGATION SUGGESTS THE | | PCIS 1A71-K18 SPURIOUSLY INITIATED THE ISOLATIONS; TROUBLESHOOTING IS STILL | | IN PROGRESS TO CONFIRM THE CAUSE." END OF TEXT. | | | | THIS EVENT HAD A MINIMAL EFFECT ON PLANT OPERATIONS, ONLY RESULTING IN A | | LOSS OF CONTAINMENT ATMOSPHERIC CONTROL SYSTEMS, CONTAINMENT ATMOSPHERIC | | MONITORING SYSTEMS, AND THE ISOLATION OF SEVERAL DRYWELL SUMP SYSTEM | | VALVES. ALL THE SYSTEMS INVOLVED FAILED TO THE CONDITION REQUIRED TO | | FULFILL THEIR SAFETY FUNCTION. | | | | CORRECTIVE ACTIONS WILL BE DETERMINED PENDING THE COMPLETION OF AN | | INVESTIGATION OF THE PCIS RELAY IN QUESTION. IF THE RELAY IS DETERMINED TO | | BE THE SOURCE OF THE ACTUATION, IT WILL BE REPLACED. THE LICENSEE INFORMED | | THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27693 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: QUAD CITIES REGION: 3 |NOTIFICATION DATE: 08/21/94 | |UNIT: [1] [ ] [ ] STATE: IL |NOTIFICATION TIME: 07:10 [ET]| |RX TYPE: [1] GE-3,[2] GE-3 |EVENT DATE: 08/21/94 | +------------------------------------------------+EVENT TIME: 05:38[CDT]| |NRC NOTIFIED BY: OSELAND |LAST UPDATE DATE: 08/21/94 | |HQ OPS OFFICER: GREG SCARFO +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |THOMAS BURDICK RDO | |ASHU 50.72(b)(1)(i)(A) PLANT S/D REQD BY TS | | |NLCO TECH SPEC LCO A/S | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 0 STARTUP | 0 HOT SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | A TECHNICAL SPECIFICATION (T/S)-REQUIRED SHUTDOWN WAS INITIATED WHEN THE | | HIGH PRESSURE COOLANT INJECTION (HPCI) SYSTEM FAILED DURING STARTUP | | TESTING. | | | | A T/S-REQUIRED SHUTDOWN WAS INITIATED AT 0538CDT (REACTOR SCRAM) AFTER THE | | HPCI SYSTEM FAILED TO PASS ITS STARTUP TEST DUE TO AN UNDETERMINED FLOW | | CONTROLLER PROBLEM. THE SYSTEM WAS DECLARED INOPERABLE AND THE UNIT | | ENTERED T/S ACTION STATEMENT 3.5.C.4 (REQUIRES THE UNIT TO BE LESS THAN 150 | | PSIG WITHIN 24 HOURS). AN INVESTIGATION INTO THE PROBLEM WITH THE FLOW | | CONTROLLER IS UNDERWAY. THE UNIT EXITED THE T/S LCO AT 0620CDT WHEN | | REACTOR PRESSURE WAS REDUCED BELOW 150 PSIG. | | | | THE UNIT IS STABLE IN HOT SHUTDOWN. THE LICENSEE WILL INFORM THE NRC | | RESIDENT INSPECTOR. | | | | * * * UPDATE 08/22/94 0432EDT BY:SCARFO * * * | | THE FAILURE OF THE FLOW CONTROLLER WAS LINKED TO A SOFTWARE PROBLEM. THE | | FLOW CONTROLLER HAS BEEN REPROGRAMMED AND PREPARATIONS ARE UNDERWAY TO | | RETEST THE HPCI SYSTEM. | +------------------------------------------------------------------------------+