U.S. Nuclear Regulatory Commission Operations Center Event Reports For 09/13/94 - 09/14/94 ** EVENT NUMBERS ** 27778 27779 27780 27781 27782 +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27778 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MCGUIRE REGION: 2 |NOTIFICATION DATE: 09/13/94 | |UNIT: [1] [ ] [ ] STATE: NC |NOTIFICATION TIME: 12:55 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 09/13/94 | +------------------------------------------------+EVENT TIME: 08:00[EDT]| |NRC NOTIFIED BY: RUMFELT |LAST UPDATE DATE: 09/13/94 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |LAWYER RDO | |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 N 0 REFUELING | 0 REFUELING | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | LICENSEE NOTIFIED NC STATE DEPT OF ENVIRONMENTAL HEALTH OF A RELEASE OF | | CHLORINATED WATER VIA A NON-AUTHORIZED PATHWAY. | | | | THE LICENSEE WAS CLEANING CONDENSER TUBES WITH CHLORINATED WATER FROM THE | | FIRE PROTECTION SYSTEM. THIS WATER WAS DRAINED TO THE TURBINE BUILDING | | SUMP, THEN PUMPED TO THE WASTE WATER COLLECTION BASIN, WHICH DRAINS INTO | | THE CATAWBA RIVER. THIS IS NOT AN AUTHORIZED RELEASE PATHWAY FOR | | CHLORINATED WATER ACCORDING TO THE LICENSEE'S STATE ENVIRONMENTAL PERMIT. | | THE STATE DETERMINED THAT THIS RELEASE WAS A DEVIATION FROM THE PERMIT, AND | | NOT A VIOLATION. NO PRESS RELEASE IS PLANNED. THE RI HAS BEEN INFORMED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 27779 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: ST. JOHN'S MEDICAL CENTER |NOTIFICATION DATE: 09/13/94 | | CITY: ANDERSEN REGION: 3 |NOTIFICATION TIME: 16:22 [ET]| | COUNTY: STATE: IN |EVENT DATE: 09/13/94 | |LICENSE#: AGREEMENT: N |EVENT TIME: 12:00[EDT]| | DOCKET: |LAST UPDATE DATE: 09/13/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |BRUCE BURGESS RDO | | | | +------------------------------------------------+VIRGILIO SP | |NRC NOTIFIED BY: DR. CURRIER | | |HQ OPS OFFICER: GREG SCARFO | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | DR. CURRIER OF ST. JOHN'S MEDICAL CENTER OF ANDERSEN, INDIANA, | | INADVERTENTLY PRESCRIBED A PAIN TREATMENT TO THE LEFT HIP OF A CANCER | | PATIENT WHEN THE INTENT WAS TO TREAT THE RIGHT HIP. | | | | APPROXIMATELY 600 CENTIGRAYS OF COBALT-60 TELETHERAPY WAS ADMINISTERED TO | | THE LEFT HIP OF A LUNG CANCER PATIENT. THE PHYSICIAN INTENDED TO TREAT THE | | RIGHT HIP OF THE PATIENT FOR PAIN ASSOCIATED WITH A BONE METASTASIS AND A | | SUBSEQUENT TREATMENT WILL BE PERFORMED. THE PATIENT WAS INFORMED OF THE | | MISADMINISTRATION. NO ADVERSE EFFECTS ARE EXPECTED. THE RADIATION SAFETY | | OFFICER AND REGION III WERE NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27780 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BROWNS FERRY REGION: 2 |NOTIFICATION DATE: 09/13/94 | |UNIT: [ ] [2] [ ] STATE: AL |NOTIFICATION TIME: 19:15 [ET]| |RX TYPE: [1] GE-4,[2] GE-4,[3] GE-4 |EVENT DATE: 09/13/94 | +------------------------------------------------+EVENT TIME: 17:25[CDT]| |NRC NOTIFIED BY: BOOHER |LAST UPDATE DATE: 09/13/94 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |LAWYER 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N Y 89 POWER OPERATION | 89 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | RHR HEAT EXCHANGERS MAY NOT TRANSFER SUFFICIENT HEAT DURING PERIODS OF HIGH | | RIVER WATER TEMPERATURES DUE TO INSUFFICIENT RHR SERVICE WATER FLOW. | | | | THE LICENSEE REPORTED THAT FLOW THROUGH THE RHR HEAT EXCHANGERS MAY NOT BE | | SUFFICIENT TO TRANSFER ACCIDENT HEAT LOADS DURING PERIODS OF OPERATION AT | | THE MAXIMUM DESIGN HEAT EXCHANGER INLET TEMPERATURE OF 95øF. DURING A | | DESIGN REVIEW, THE LICENSEE DETERMINED THAT, DUE TO INSTRUMENT | | INACCURACIES, MEASURED FLOW THROUGH THE A AND C RHR HEAT EXCHANGERS MAY NOT | | MEET THE REQUIRED FLOW OF 7940 GPM. (THIS REQUIREMENT WAS CALCULATED FROM | | THE FSAR REQUIREMENT THAT ACCIDENT HEAT LOADS BE ADEQUATELY TRANSFERRED UP | | TO A RIVER TEMPERATURE OF 95øF.) DURING A FLOW TEST, CONTROL ROOM | | INSTRUMENTS INDICATED A COMBINED FLOW OF 8300 GPM THROUGH THE A AND C HEAT | | EXCHANGERS, WITH A COMBINED INSTRUMENT UNCERTAINTY OF +/- 400 GPM. ASSUMING | | WORST-CASE INSTRUMENT UNCERTAINTY, THE LICENSEE HAS CONCLUDED THAT THE | | ACTUAL FLOW COULD FALL SHORT OF THE REQUIRED FLOW. THE RIVER TEMPERATURE | | IS CURRENTLY 81.4øF. | | | | THE LICENSEE IS ATTEMPTING TO QUANTIFY THE ACTUAL INSTRUMENT INACCURACIES, | | AND MAY RETRACT THIS EVENT. THE RI WILL BE INFORMED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27781 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: CATAWBA REGION: 2 |NOTIFICATION DATE: 09/13/94 | |UNIT: [ ] [2] [ ] STATE: SC |NOTIFICATION TIME: 20:55 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 09/13/94 | +------------------------------------------------+EVENT TIME: 18:54[EDT]| |NRC NOTIFIED BY: CLEMENTS |LAST UPDATE DATE: 09/13/94 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |LAWYER 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | A/R Y 100 POWER OPERATION | 0 HOT STANDBY | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AUTOMATIC REACTOR TRIP DUE TO CLOSURE OF MAIN STEAM ISOLATION VALVE. | | | | AN AUTOMATIC REACTOR/TURBINE TRIP OCCURRED ON OVERPOWER DIFFERENTIAL | | TEMPERATURE AFTER THE "C" MSIV CLOSED UNEXPECTEDLY. THE AUXILIARY | | FEEDWATER SYSTEM AUTOMATICALLY STARTED AS EXPECTED FOLLOWING THE TRIP DUE | | TO LOW STEAM GENERATOR LEVEL. A FULL MSIV ISOLATION ALSO OCCURRED | | FOLLOWING THE TRIP DUE TO LOW TAVE. ALL RODS INSERTED PROPERLY AND ALL | | OTHER SYSTEMS FUNCTIONED AS REQUIRED FOLLOWING THE TRIP. | | | | DURING RECOVERY FROM THE TRIP, THE LICENSEE EXPERIENCED SOME PROBLEMS IN | | RESETTING THE AFW SYSTEM. THE LICENSEE REPORTED THAT THE RESET BUTTON WAS | | DEPRESSED THREE TIMES BEFORE THE PROPER STANDBY INDICATION WAS OBSERVED IN | | THE CONTROL ROOM. ADDITIONALLY, LETDOWN FLOW VARIABLE ORIFICE CONTROL | | VALVE 2NV849 FAILED TO OPEN UPON RESTORATION OF LETDOWN FLOW FROM THE RCS. | | | | THE LICENSEE IS INVESTIGATING THE CAUSE OF THE INITIAL MSIV CLOSURE, BUT | | SUSPECTS A GROUND IN A DC ELECTRICAL BUS. CONCURRENT WITH THE CLOSURE OF | | THE C MSIV, THE PLANT COMPUTER REGISTERED A NUMBER OF ELECTRICAL GROUNDS. | | THE LICENSEE SUSPECTS THAT A SOLENOID VALVE MAY HAVE DEVELOPED AN | | ELECTRICAL GROUND. THE LICENSEE PLANS TO RESTART THE UNIT FOLLOWING | | INVESTIGATION OF THE MSIV CLOSURE AND COMPLETION OF REPAIRS TO THE "B" | | COMPONENT COOLING WATER HEAT EXCHANGER (APPROXIMATELY 24-48 HOURS). THE RI | | HAS BEEN INFORMED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27782 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MILLSTONE REGION: 1 |NOTIFICATION DATE: 09/13/94 | |UNIT: [ ] [ ] [3] STATE: CT |NOTIFICATION TIME: 22:07 [ET]| |RX TYPE: [1] GE-3,[2] CE,[3] W-4-LP |EVENT DATE: 09/13/94 | +------------------------------------------------+EVENT TIME: 21:36[EDT]| |NRC NOTIFIED BY: O'CONNELL |LAST UPDATE DATE: 09/13/94 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |CONTE 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 N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | LICENSEE DECLARED THE "B" EMERGENCY DIESEL GENERATOR INOPERABLE DUE TO A | | FAULTY PRESSURE SWITCH ON 1 OF 2 EDG STARTING AIR COMPRESSORS. | | | | WHILE TROUBLESHOOTING A LOW STARTING AIR PRESSURE ALARM FOR THE "B" EDG, | | THE LICENSEE DISCOVERED THAT THE RELIEF VALVE ON ONE OF THE STARTING AIR | | HEADERS HAD LIFTED. THE LICENSEE OBSERVED THAT THE COMPRESSOR WAS NOT | | SHUTTING OFF AUTOMATICALLY, CAUSING THE RELIEF VALVE TO LIFT AND | | DEPRESSURIZING THE STARTING AIR HEADER. THE LICENSEE HAS SECURED THE AIR | | COMPRESSOR, AND HAS CROSSTIED THE STARTING AIR HEADER TO THE REDUNDANT | | STARTING AIR HEADER. | | | | THE UNIT IS CURRENTLY IN A TECHNICAL SPECIFICATION LIMITING CONDITION OF | | OPERATION WHICH PROHIBITS CORE ALTERATIONS UNTIL THE "B" EMERGENCY DIESEL | | GENERATOR IS DECLARED OPERABLE. THE RI WILL BE INFORMED. | +------------------------------------------------------------------------------+