U.S. Nuclear Regulatory Commission Operations Center Event Reports For 12/28/94 - 12/29/94 ** EVENT NUMBERS ** 28188 28192 28193 28194 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 28188 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: DRESDEN REGION: 3 |NOTIFICATION DATE: 12/27/94 | |UNIT: [ ] [ ] [3] STATE: IL |NOTIFICATION TIME: 13:30 [ET]| |RX TYPE: [1] GE-1,[2] GE-3,[3] GE-3 |EVENT DATE: 12/27/94 | +------------------------------------------------+EVENT TIME: 11:20[CST]| |NRC NOTIFIED BY: WELCH |LAST UPDATE DATE: 12/28/94 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JOHN MADERA RDO | |AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | | | | | 3 | N Y 100 POWER OPERATION | 100 POWER OPERATION | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - ELECTRICAL RELAYS IN BOTH ATWS LOGIC TRAINS FAILED DURING A TEST - | | | | DURING A REFUELING OUTAGE, LICENSEE WAS PERFORMING A TECH SPEC SURVEILLANCE | | TEST OF THE ANTICIPATED TRANSIENT WITHOUT SCRAM (ATWS) SYSTEM FROM 03/11/94 | | TO 06/20/94. ON 03/11/94 DURING THE TEST, THE ATWS TIME DELAY RELAY #K101C | | FAILED TO TRIP AND THE ATWS TIME DELAY RELAY #K101D FAILED TO TRIP WITHIN | | THE REQUIRED TECH SPEC TIME TOLERANCE. THESE RELAYS PROVIDE A TRIP SIGNAL | | TO THE RECIRCULATION MOTOR-GENERATOR SET FIELD BREAKERS UPON RECEIPT OF | | A LOW-LOW REACTOR VESSEL WATER LEVEL SIGNAL. FAILURE OF THESE RELAYS | | RENDERED BOTH ATWS LOGIC TRAINS 'A' & 'B' INCAPABLE OF INITIATING THE | | RECIRCULATION M-G SET FIELD BREAKER TRIPS. LICENSEE REPLACED BOTH RELAYS | | AND BOTH TESTED SATISFACTORILY TO WITHIN THE REQUIRED TOLERANCES PRIOR TO | | THE UNIT 3 STARTUP FROM THE REFUELING OUTAGE. | | | | AT 1120 (CST) ON 12/27/94, LICENSEE DETERMINED THAT THIS EVENT HAD NOT | | BEEN REPORTED TO THE NRC. LICENSEE IS INVESTIGATING THE REASON FOR THEIR | | FAILURE TO REPORT THIS MULTIPLE FAILURES OF REDUNDANT TRAINS OF A SAFETY | | RELATED SYSTEM EVENT TO THE NRC AT THE TIME OF OCCURRENCE ON 03/11/94. | | | | LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | | | | * * * UPDATE AT 1442 ON 12/28/94 BY WELCH ENTERED BY HOO JOLLIFFE * * * | | | | LICENSEE DESIRES TO RETRACT THIS EVENT SINCE IT HAD ALREADY BEEN REPORTED | | TO THE NRC. SEE EVENT #26925 ON 03/11/94 AND LER #94-008. | | | | LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. HOO NOTIFIED R3DO MADERA. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 28192 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: SYNCOR INTERNATIONAL CORPORATION |NOTIFICATION DATE: 12/28/94 | | CITY: TULSA REGION: 4 |NOTIFICATION TIME: 16:33 [ET]| | COUNTY: STATE: OK |EVENT DATE: 12/26/94 | |LICENSE#: 35-19583-01MD AGREEMENT: N |EVENT TIME: 08:00[CST]| | DOCKET: |LAST UPDATE DATE: 12/28/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |LINDA HOWELL RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: DAVID PELLICCIARINI | | |HQ OPS OFFICER: DICK JOLLIFFE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |IBBF 30.50(b)(2)(ii) EQUIP DISABLED/FAILS | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - FAILED EXHAUST SYSTEM FOR FUME HOOD CONTAINING IODINE-131 & XENON-133 - | | | | AT 0800 (CST) ON 12/26/94, THE FUME HOOD EXHAUST SYSTEM AT THE SYNCOR | | INTERNATIONAL CORPORATION NUCLEAR PHARMACEUTICAL FACILITY IN TULSA, | | OKLAHOMA FAILED TO OPERATE DUE TO A FAILED EXHAUST FAN MOTOR. THIS FUME | | HOOD IS USED TO STORE AND HANDLE IODINE-131 LIQUID AND XENON-133 GAS. | | | | IODINE-131 LIQUID IS STORED IN SEALED CONTAINERS INSIDE THE HOOD AND ANY | | CONTAMINATED OBJECTS ARE ALSO STORED IN SEALED CONTAINERS INSIDE THE HOOD. | | THESE STEPS ARE TAKEN TO MINIMIZE THE RELEASE OF VOLATILE IODINE-131. | | | | THE TULSA FACILITY HAS AN INSTALLED AIR SAMPLING SYSTEM WHICH MONITORS FOR | | THE PRESENCE OF IODINE-131 IN THE AIR WITHIN THE FACILITY AND IN THE AIR | | RELEASED TO THE ENVIRONMENT THROUGH CHARCOAL FILTERS IN THE FUME HOOD | | VENTILATION CABINET AND THE EXHAUST STACK. AIR SAMPLES TAKEN TO DATE | | INDICATE THAT AIR CONCENTRATIONS OF IODINE-131 ARE WELL WITHIN REGULATORY | | LIMITS. ANY INCREASES IN THE LEVELS OF AIRBORNE IODINE-131 WILL BE | | DETECTED BY THE FACILITY'S AIR SAMPLING SYSTEM. | | | | NO IODINE-131 PRODUCTS WERE COMPOUNDED (i.e., MIXED WITH OTHER INGREDIENTS | | TO BE ADMINISTERED TO PATIENTS) FOLLOWING THE FAILURE OF THE FUME HOOD | | EXHAUST SYSTEM AND NONE WILL BE COMPOUNDED UNTIL THE FUME HOOD EXHAUST | | SYSTEM IS RESTORED TO SERVICE. | | | | XENON-133 GAS IS STORED AND HANDLED ONLY IN THE MANUFACTURER'S UNOPENED | | SEALED VIALS INSIDE THE FUME HOOD; ALTHOUGH THE SEALED VIALS DO LEAK | | SLIGHTLY. BASED ON THE ACTIVITY OF THE XENON-133 GAS INSIDE THE FUME HOOD, | | THE LEAKAGE FACTOR FOR THE XENON-133 GAS, AND THE VOLUME FLOW RATE OF AIR | | INTO THE ROOM THAT CONTAINS THE FUME HOOD, THE CONCENTRATION OF XENON-133 | | IN THE ROOM HAS BEEN CALCULATED TO BE NEGLIGIBLE. | | | | NO MANIPULATION OF THE GAS ITSELF HAS TAKEN PLACE SINCE THE FUME HOOD | | EXHAUST SYSTEM FAILURE NOR WILL TAKE PLACE UNTIL THE EXHAUST SYSTEM IS | | RESTORED TO SERVICE. | | | | AN ELECTRICIAN IS SCHEDULED TO REPLACE THE FAILED FUME HOOD EXHAUST FAN | | MOTOR LOCATED ON THE ROOF OF THE BUILDING BY 1600 (CST) TODAY. | | | | SYNCOR WILL SUBMIT A WRITTEN REPORT OF THIS EVENT TO THE NRC WITHIN | | 30 DAYS. | | | | SEE HOO LOG FOR SYNCOR ADDRESS AND TELEPHONE NUMBERS. | | | | NOTE: SEE EVENT #27358 FOR A SIMILAR EVENT. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 28193 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PILGRIM REGION: 1 |NOTIFICATION DATE: 12/28/94 | |UNIT: [1] [ ] [ ] STATE: MA |NOTIFICATION TIME: 17:56 [ET]| |RX TYPE: [1] GE-3 |EVENT DATE: 12/28/94 | +------------------------------------------------+EVENT TIME: 17:50[EST]| |NRC NOTIFIED BY: TREPANIER |LAST UPDATE DATE: 12/28/94 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JOHN KINNEMAN RDO | |AINC 50.72(b)(2)(iii)(C) POT UNCNTRL RAD REL | | |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 | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | -PRIMARY CONTAINMENT INTEGRITY LOST DUE TO MISSING D/P TRANSMITTER VENT CAP | | | | AT 1135, WHILE PERFORMING A TECH SPEC SURVEILLANCE TEST OF THE DRYWELL | | AND TORUS PRESSURE INSTRUMENTATION, INSTRUMENTATION & CONTROL TECHNICIANS | | DISCOVERED THAT A VENT CAP WAS MISSING ON DIFFERENTIAL PRESSURE TRANSMITTER | | #DPT-5021 THAT DETECTS THE DIFFERENCE IN PRESSURE BETWEEN THE TORUS | | (PRIMARY CONTAINMENT) AND THE REACTOR BUILDING (SECONDARY CONTAINMENT). | | THE CAP WAS MISSING FROM THE 3/8 INCH TUBING SWEDGE LOCK VENT FITTING ON | | THE TORUS SIDE. WITH THE VENT CAP NOT INSTALLED DURING ACCIDENT CONDITIONS | | WHEN THE TORUS IS PRESSURIZED, GAS (AIR, STEAM, HALOGEN, ETC) WOULD HAVE | | LEAKED THROUGH THIS 0.19 INCH DIAMETER HOLE IN THE PRIMARY CONTAINMENT | | BOUNDARY. DURING NON-ACCIDENT CONDITIONS WHEN THE TORUS IS NOT | | PRESSURIZED, THERE IS VIRTUALLY NO PRESSURE DIFFERENCE ACROSS THIS | | TRANSMITTER. | | LICENSEE ENTERED TECH SPEC LCO A/S #A94-236 WHICH REQUIRES THE LICENSEE | | TO PLACE THE PLANT IN COLD SHUTDOWN CONDITION WITHIN 24 HOURS WITH PRIMARY | | CONTAINMENT INTEGRITY NOT INTACT. | | | | AT 1646, LICENSEE INSTALLED A SAFETY RELATED VENT CAP, TESTED IT | | SATISFACTORILY, AND EXITED THE LCO A/S. THE PLANT REMAINED AT 100% POWER | | THROUGHOUT THIS EVENT. | | | | LICENSEE IS INVESTIGATING THE CAUSE OF THE MISSING VENT CAP. THE LAST TECH | | SPEC SURVEILLANCE TEST OF THIS INSTRUMENTATION WAS PERFORMED ON 11/22/94. | | | | AT 1750, LICENSEE DETERMINED THIS EVENT TO BE REPORTABLE TO THE NRC BASED | | ON ACCIDENT CONDITIONS CALCULATIONS. | | | | LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 28194 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: HATCH REGION: 2 |NOTIFICATION DATE: 12/29/94 | |UNIT: [1] [ ] [ ] STATE: GA |NOTIFICATION TIME: 02:33 [ET]| |RX TYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 12/28/94 | +------------------------------------------------+EVENT TIME: 20:53[CST]| |NRC NOTIFIED BY: URQUHART |LAST UPDATE DATE: 12/29/94 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |STEVEN VIAS RDO | |NINF INFORMATION ONLY | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 LICENSEE REPORTED DAMAGE TO THE STAINLESS STEEL SPENT FUEL POOL FLOOR. | | | | THIS INCIDENT OCCURRED WHILE THEY WERE CONDUCTING A SPENT FUEL POOL CLEANUP | | CAMPAIGN AND WHILE REMOVING A 350LB 15' BY 3" DIA. USED SHROUD HEAD BOLT, | | IT FELL TO THE BOTTOM OF THE POOL. THIS BOLT PENETRATED THE SS FUEL POOL | | FLOOR AND LEFT A 3" HOLE ALLOWING APPROXIMATELY 2000 GAL OF WATER TO DRAIN | | TO THE SPENT FUEL POOL CONCRETE LINER. THIS LOWERED THE WATER LEVEL OF THE | | SPENT FUEL POOL BY 2" FROM ITS NORMAL LEVEL. THE LINER CONTAINED THE WATER | | AND DRAINED IT OFF TO THE RAD WASTE AS DESIGNED. WHEN THE LEAK WAS NOTICED, | | THEY CLOSED THE NORMALLY OPEN LINER DRAIN VALVE AS PER PROCEDURE AND THAT | | TERMINATED THE LEAK FROM THE SPENT FUEL POOL. THEY OPENED THEIR MAKEUP | | WATER VALVE TO THE FUEL POOL UNTIL LEVEL WAS RESTORED TO THE POOL AT 21:10. | | THE POOL LEVEL HAS REMAINED NORMAL SINCE THEN AND THEY HAVE STATIONED A | | CONSTANT POOL WATCH ON THE REFUEL FLOOR. THEY HAVE ACTIVATED AN EVENT | | REVIEW TEAM AND REPAIR TEAM. THERE WERE NO RELEASES, RAD LEVEL INCREASES OR | | CONTAMINATION. THEY DO CURRENTLY HAVE FUEL IN THE POOL. THE RI WAS | | INFORMED. | +------------------------------------------------------------------------------+