U.S. Nuclear Regulatory Commission Operations Center Event Reports For 12/06/94 - 12/07/94 ** EVENT NUMBERS ** 28011 28108 28112 28113 28114 28115 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 28011 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: WASHINGTON NUCLEAR REGION: 4 |NOTIFICATION DATE: 11/09/94 | |UNIT: [2] [ ] [ ] STATE: WA |NOTIFICATION TIME: 19:38 [ET]| |RX TYPE: [2] GE-5 |EVENT DATE: 11/09/94 | +------------------------------------------------+EVENT TIME: 15:55[PST]| |NRC NOTIFIED BY: PERINO |LAST UPDATE DATE: 12/06/94 | |HQ OPS OFFICER: GREG SCARFO +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |DALE POWERS RDO | |AINA 50.72(b)(2)(iii)(A) POT UNABLE TO SAFE SD | | |AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AN ENGINEERING ANALYSIS FOUND CABLE BRIDGING PROBLEMS BETWEEN DIVISION 1 | | AND DIVISION 2 CIRCUITRY. | | | | THE FOLLOWING IS THE TEXT OF A FACSIMILE SUBMITTED BY THE LICENSEE: | | "THIS IS A FOUR HOUR, NON-EMERGENCY NOTIFICATION. WHILE PERFORMING | | APPENDIX R ANALYSIS, WNP-2 DISCOVERED A DIRECT CABLE BRIDGING PROBLEM | | BETWEEN DIVISION 1 AND 2 CIRCUITS. THE PROBLEM APPEARS TO BE THREEFOLD. | | FIRST, A DIVISION 1 POWER PANEL CIRCUIT HAS DOWNSTREAM BRANCHES-IN-BOTH | | DIVISION 1 AND 2 CONTROL ROOM RACEWAYS. SECOND, A SEPARATE DIVISION 1 | | POWER PANEL CIRCUIT THAT FEEDS NON-SAFETY RELATED EQUIPMENT HAS NOT BEEN | | PROPERLY ISOLATED. THIRD, THE IMPROPERLY ISOLATED CIRCUIT IS ROUTED IN A | | NON-DIVISIONAL RACEWAY. | | | | THESE CIRCUITS RESIDE COMPLETELY IN THE MAIN CONTROL ROOM FLOOR DUCTS AND | | PANELS. CONTINUED OPERABILITY IS ALLOWED WITH IMPLEMENTATION OF | | COMPENSATIONAL ACTIONS INCLUDING A FIRE IMPAIRMENT AND CONTINUOUSLY MANNED | | AREA UNTIL MODIFICATIONS ARE IMPLEMENTED. | | | | AT THIS TIME THE PROBLEM APPEARS TO BE EASILY CORRECTABLE. THE IMPROPERLY | | ISOLATED CIRCUIT (THE CAUSE OF THE DIRECT BRIDGE) WILL BE DEACTIVATED AND | | ITS LOAD REPOWERED FROM AN ACCEPTABLE POWER SOURCE." END OF TEXT. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | | | | *** UPDATE 12/6/94 AT 2106 FROM JOHNSON TAKEN BY STRANSKY *** | | | | LICENSEE RETRACTED THIS EVENT NOTIFICATION. THE FOLLOWING IS TEXT OF A | | FACSIMILE SUBMITTED BY THE LICENSEE: | | | | "THIS IS A RETRACTION OF A FOUR-HOUR, NON-EMERGENCY NOTIFICATION MADE BY | | WNP-2 ON 11/9/94 AT 1938 EST. THREE PROBLEMS WERE REPORTED. | | | | FIRST, A DIVISION 1 POWER PANEL CIRCUIT WAS REPORTED AS BRIDGING BETWEEN | | BOTH DIVISION 1 AND DIVISION 2 RACEWAYS. ON EVALUATION, IT WAS DETERMINED | | THAT AN INTERMEDIARY POWER SUPPLY PROVIDES ADEQUATE ISOLATION IN THIS | | APPLICATION. | | | | THE SECOND AND THIRD CONCERNS INVOLVED A DIVISION 1 CIRCUIT THAT SUPPLIES | | POWER TO A NON-DIVISIONAL LOAD. A PORTION OF THE CIRCUIT IS ROUTED | | THROUGH A SECTION OF NON-DIVISIONAL RACEWAY. ISOLATION ADEQUACY WAS | | QUESTIONED. INVESTIGATION REVEALED THAT THE CIRCUIT MEETS ISOLATION | | REQUIREMENTS. THE IMPACT OF ROUTING TROUGH A SECTION OF NON-DIVISIONAL | | RACEWAY WAS EVALUATED AND DETERMINED TO BE NON-REPORTABLE SINCE THE | | NON-DIVISIONAL RACEWAY SECTION DID NOT CONTAIN CIRCUITS FROM THE REDUNDANT | | DIVISION." | | | | THE LICENSEE WILL INFORM THE RESIDENT INSPECTOR. NOTIFIED R4DO (BARNES). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 28108 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SUMMER REGION: 2 |NOTIFICATION DATE: 12/05/94 | |UNIT: [1] [ ] [ ] STATE: SC |NOTIFICATION TIME: 16:15 [ET]| |RX TYPE: [1] W-3-LP |EVENT DATE: 12/05/94 | +------------------------------------------------+EVENT TIME: 15:31[EST]| |NRC NOTIFIED BY: ALLEN |LAST UPDATE DATE: 12/06/94 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: UNUSUAL EVENT +-----------------------------+ |10 CFR SECTION: |POTTER RDO | |AAEC 50.72(a)(1)(i) EMERGENCY DECLARED |CHAFFEE EO | |NRCS RCS LEAKAGE |HERSKO FEMA | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | UNUSUAL EVENT DECLARED DUE TO UNISOLABLE REACTOR COOLANT SYSTEM (RCS) | | LEAKAGE. | | | | DURING AN INSPECTION OF THE REACTOR BUILDING, THE LICENSEE DISCOVERED A | | LEAK ON THE SEAL INJECTION LINE FOR THE "C" REACTOR COOLANT PUMP. THE LEAK | | IS LOCATED AT A SOCKET WELD WHERE THE LINE ATTACHES TO THE PUMP SEAL | | HOUSING. THE LICENSEE ESTIMATES THAT THE LEAKAGE IS APPROXIMATELY 0.18-0.26 | | GPM, BASED ON TOTAL REACTOR BUILDING SUMP INLEAKAGE. ALL SAFETY EQUIPMENT | | IS AVAILABLE IF NEEDED. | | | | THE LICENSEE IS PROCEEDING TO COLD SHUTDOWN IN ORDER TO DEPRESSURIZE THE | | RCS IN ORDER TO REPAIR THE WELD. THE LICENSEE HAS BEEN IN A REFUELING | | OUTAGE SINCE SEPTEMBER. THE LICENSEE HAS NOTIFIED THE NRC RESIDENT | | INSPECTOR, AS WELL AS STATE AND LOCAL AGENCIES. A PRESS RELEASE IS | | PLANNED. THE LICENSEE WILL REMAIN IN THE UNUSUAL EVENT UNTIL THE RCS HAS | | BEEN DEPRESSURIZED. | | | | ** UPDATE DATE/TIME:12/6/94 @ 0625 *FROM LICENSEE:O'QUINN BY:McGINTY ** | | THE LICENSEE TERMINATED THE UNUSUAL EVENT AT 0617 EST, UPON REACHING COLD | | SHUTDOWN CONDITIONS (MODE 5). THE LEAKAGE RATE HAS REMAINED RELATIVELY | | CONSTANT, AT LESS THAN 0.26 GPM. THE LICENSEE INTENDS TO PURSUE REPAIRS, | | AND WILL NOTIFY THE RESIDENT INSPECTOR. HOO NOTIFIED R2DO (HOSEY), EO | | (CHAFFEE) AND FEMA (SULLIVAN). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 28112 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PALO VERDE REGION: 4 |NOTIFICATION DATE: 12/06/94 | |UNIT: [ ] [2] [ ] STATE: AZ |NOTIFICATION TIME: 11:53 [ET]| |RX TYPE: [1] CE,[2] CE,[3] CE |EVENT DATE: 12/06/94 | +------------------------------------------------+EVENT TIME: 08:53[MST]| |NRC NOTIFIED BY: BANKS |LAST UPDATE DATE: 12/06/94 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BARNES 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | PLANT MOMENTARILY ENTERED TECHNICAL SPECIFICATION 3.0.3 WHEN BOTH TRAINS OF | | THE CONTROL ROOM ESSENTIAL VENTILATION SYSTEM BECAME INOPERABLE. | | | | WITH THE "A" TRAIN OF THE CONTROL ROOM ESSENTIAL VENTILATION SYSTEM | | INOPERABLE FOR MAINTENANCE, THE "B" TRAIN WAS MOMENTARILY DISABLED IN ORDER | | TO OBTAIN A CHEMISTRY SAMPLE. THE LICENSEE REPORTED THAT ELECTRICAL POWER | | TO THE "B" TRAIN CHILLER UNIT WAS REMOVED FOR APPROXIMATELY 5 SECONDS IN | | ORDER TO OBTAIN A SAMPLE FROM THE CHILLED WATER SYSTEM. DURING THE PERIOD | | THAT THE CHILLER UNIT WAS DEENERGIZED, THE "B" TRAIN WAS INOPERABLE. WITH | | BOTH TRAINS OF THE CONTROL ROOM ESSENTIAL VENTILATION SYSTEM INOPERABLE, | | THE PLANT MOMENTARILY ENTERED TECHNICAL SPECIFICATION 3.0.3, BUT DID NOT | | MAKE ANY POWER REDUCTION. | | | | THE LICENSEE REPORTED THAT THE SHIFT SUPERVISOR PERMITTED THE "B" TRAIN TO | | BE MOMENTARILY DEENERGIZED, AND SUBSEQUENTLY DETERMINED THAT THE PROCEDURE | | REQUIRED THAT CERTAIN COMPONENTS IN THE "A" TRAIN BE OPERABLE BEFORE MAKING | | THE "B" TRAIN INOPERABLE. AT THIS POINT, THE SHIFT SUPERVISOR RECOGNIZED | | THAT THE UNIT HAD MOMENTARILY ENTERED AND EXITED TS 3.0.3. THE LICENSEE | | WILL INFORM THE NRC RESIDENT INSPECTOR OF THIS EVENT. | | | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 28113 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: ZION REGION: 3 |NOTIFICATION DATE: 12/06/94 | |UNIT: [ ] [2] [ ] STATE: IL |NOTIFICATION TIME: 13:18 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 12/06/94 | +------------------------------------------------+EVENT TIME: 11:30[CST]| |NRC NOTIFIED BY: CARLSON |LAST UPDATE DATE: 12/06/94 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JORGENSEN 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 81 POWER OPERATION | 81 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | UNIT OUTSIDE DESIGN BASIS FOR 19 HOURS DURING PERIOD OF 10/31/94 - 11/1/94 | | DUE TO INOPERABILITY OF TWO EMERGENCY DIESEL GENERATORS. | | | | ON NOVEMBER 10, 1994, THE UNIT 0 (SHARED) EMERGENCY DIESEL GENERATOR (EDG) | | WAS DECLARED INOPERABLE FOR UNIT 2, DUE TO A MALFUNCTIONING CONTROL SWITCH, | | WHICH HAD BEEN DISCOVERED ON OCTOBER 29, 1994. (THE LICENSEE DID NOT | | DETERMINE THAT THE MALFUNCTION OF THE SWITCH RENDERED THE UNIT 0 EDG | | INOPERABLE UNTIL NOVEMBER 10, 1994.) THE SWITCH WAS REPAIRED, AND THE EDG | | DECLARED OPERABLE ON NOVEMBER 11, 1994. COINCIDENTALLY, THE 2A EDG WAS | | DECLARED INOPERABLE ON OCTOBER 31, 1994 DUE TO A MALFUNCTIONING LIGHTBULB | | ON THE CONTROL PANEL. THE 2A EDG WAS REPAIRED AND RETURNED TO SERVICE ON | | NOVEMBER 1, 1994. | | | | ON DECEMBER 6, THE LICENSEE DETERMINED THAT BOTH EDGs HAD BEEN INOPERABLE | | SIMULTANEOUSLY FOR 19 HOURS AND 43 MINUTES DURING THE PERIOD OF 10/31/94 TO | | 11/1/94, PLACING THE UNIT OUTSIDE OF ITS DESIGN BASIS. THE NRC RESIDENT | | INSPECTOR HAS BEEN INFORMED OF THIS EVENT BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |OTHER NUCLEAR MATERIAL | |EVENT NUMBER: 28114 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: SYNCOR PHARMACEUTICAL |NOTIFICATION DATE: 12/06/94 | | CITY: SWARTZ CREEK REGION: 3 |NOTIFICATION TIME: 18:03 [ET]| | COUNTY: STATE: MI |EVENT DATE: 12/06/94 | |LICENSE#: AGREEMENT: N |EVENT TIME: 05:42[EST]| | DOCKET: |LAST UPDATE DATE: 12/06/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |JORGENSEN RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: MUELLER | | |HQ OPS OFFICER: BOB STRANSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |BAB2 20.2201(a)(1)(ii) LOST/STOLEN LNM>10X | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | CALLER REPORTED THAT 545mCi OF TC-99m EVAPORATED INTO PHARMACY DURING | | PROCESSING | | | | MR. MUELLER OF THE SYNCOR HEADQUARTERS OFFICE CALLED TO REPORT THAT | | APPROXIMATELY 545 mCi OF TC-99m EVAPORATED DURING A HEATING PROCESS WHEN | | THE VIAL CONTAINING THE SOLUTION CRACKED. THE SOLUTION WAS BEING PROCESSED | | AT A COMPANY-OWNED PHARMACY IN SWARTZ CREEK, MICHIGAN. THE ISOTOPE, | | CONTAINED IN A SOLUTION CALLED "CARDIOLITE", WAS BEING HEATED IN A HEATING | | BLOCK WHEN THE EVENT OCCURRED. AT LEAST TWO PHARMACISTS WERE WORKING IN THE | | ROOM, WHICH WAS EQUIPPED WITH AN EXTERNAL EXHAUST HOOD. THE ISOTOPE | | CONTAMINATED THE SURROUNDING AREA, BUT WAS NOT DETECTED IN OTHER AREAS OF | | THE BUILDING. | | | | THE LICENSEE DECONTAMINATED EMPLOYEES WORKING IN THE AREA, BUT CHOSE NOT TO | | EXTENSIVELY DECONTAMINATE THE ROOM (TC-99m HAS A 6-HOUR HALF LIFE), | | ELECTING TO CLOSE OFF THE AREA INSTEAD UNTIL THE ISOTOPE DECAYS AWAY. | | BASED UPON PREVIOUS EXPERIENCE, THE CALLER ESTIMATED THAT WORKERS IN THE | | AREA RECEIVED A COMMITTED EFFECTIVE DOSE EQUIVALENT OF 50 - 100 mREM DUE TO | | THE RELEASE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 28115 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MILLSTONE REGION: 1 |NOTIFICATION DATE: 12/06/94 | |UNIT: [ ] [2] [ ] STATE: CT |NOTIFICATION TIME: 22:40 [ET]| |RX TYPE: [1] GE-3,[2] CE,[3] W-4-LP |EVENT DATE: 12/06/94 | +------------------------------------------------+EVENT TIME: 22:23[EST]| |NRC NOTIFIED BY: OLECHNOWICZ |LAST UPDATE DATE: 12/06/94 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |ESELGROTH RDO | |AINC 50.72(b)(2)(iii)(C) POT UNCNTRL RAD REL | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N N 0 REFUELING | 0 REFUELING | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | SUSPECTED DESIGN FLAW IN ENCLOSURE BUILDING FILTRATION SYSTEM (EBFS) | | FLOWPATH FOLLOWING A POSTULATED LOSS-OF-COOLANT-ACCIDENT (LOCA) | | | | THE LICENSEE HAS DISCOVERED A SUSPECTED DESIGN FLAW IN THE ENCLOSURE | | BUILDING FILTRATION SYSTEM FLOW PATH FOLLOWING A LOCA. DURING NORMAL | | OPERATION, THE ENCLOSURE BUILDING FILTRATION SYSTEM IS ALIGNED TO DISCHARGE | | INTO THE MILLSTONE UNIT 1 OFFGAS SYSTEM, WHICH CONTAINS A CHARCOAL FILTER | | BED TO REDUCE THE QUANTITIES OF RADIOACTIVE PARTICULATES RELEASED TO THE | | ATMOSPHERE. THE LICENSEE HAS DISCOVERED THAT THE UNIT EMERGENCY PROCEDURES | | DIRECT OPERATORS TO REALIGN DISCHARGE DAMPERS FOR THE EBFS TO ISOLATE THE | | FLOW PATH TO UNIT 1, AND TO DIRECT THE DISCHARGE TO THE UNIT 2 STACK, WHICH | | DOES NOT HAVE A CHARCOAL ADSORBER IN THE FLOWPATH. THE LICENSEE STATED | | THAT THIS IS UNACCEPTABLE DUE TO THE MAGNITUDE OF THE POTENTIAL OFFSITE | | RELEASE DURING ACCIDENT CONDITIONS. | | | | THE LICENSEE IS CURRENTLY EVALUATING THE SITUATION. THE UNIT IS CURRENTLY | | DEFUELED, WITH ALL FUEL LOCATED IN THE SPENT FUEL POOL. THE NRC RESIDENT | | INSPECTOR WILL BE INFORMED. | +------------------------------------------------------------------------------+