U.S. Nuclear Regulatory Commission Operations Center Event Reports For 11/21/94 - 11/22/94 ** EVENT NUMBERS ** 28048 28052 28053 28054 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 28048 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: COLLETON REGIONAL HOSPITAL |NOTIFICATION DATE: 11/18/94 | | CITY: WALTERBOROUGH REGION: 2 |NOTIFICATION TIME: 18:49 [ET]| | COUNTY: COLLETON STATE: SC |EVENT DATE: 11/18/94 | |LICENSE#: 226 AGREEMENT: Y |EVENT TIME: 16:15[EST]| | DOCKET: |LAST UPDATE DATE: 11/21/94 | | +-----------------------------+ | |PERSON ORGANIZATION| | |EDWARD MCALPINE RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: MANLEY | | |HQ OPS OFFICER: TIM McGINTY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | COLLETON REGIONAL HOSPITAL, LOCATED IN WALTERBOROUGH, SC, REPORTED A | | MEDICAL MISADMINISTRATION. | | | | A LUNG SCAN WAS BEING PERFORMED ON A PATIENT, AND INSTEAD OF INJECTING 4 | | MILLI-CURIES OF TC-99M MAA, 4 MILLI-CURIES OF TC-99M DPTA (A KIDNEY SEEKER) | | WAS INJECTED. THE VIAL THAT CONTAINED THE RADIO-PHARMACEUTICAL WAS | | MIS-LABELED, DUE TO AN ADMINISTRATIVE ERROR. THE PATIENT WAS NOTIFIED OF | | THE MIS-ADMINISTRATION, AND THERE ARE NO ADVERSE CONSEQUENCES EXPECTED. | | | | ****RETRACTION 11/21/94 @ 1106ET BY MANLEY TAKEN BY MACKINNON**** | | | | COLLETON REGIONAL HOSPITAL IS RETRACTING THIS EVENT AFTER DISCUSSING THIS | | EVENT WITH REGION 2 (JERRY ENNIS). REASON FOR THE RETRACTION OF THIS EVENT | | IS BECAUSE COLLETON REGIONAL HOSPITAL IS LOCATED IN AN AGREEMENT STATE. | | R2DO (ED McALPINE) NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 28052 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: OCONEE REGION: 2 |NOTIFICATION DATE: 11/21/94 | |UNIT: [ ] [2] [ ] STATE: SC |NOTIFICATION TIME: 04:44 [ET]| |RX TYPE: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP |EVENT DATE: 11/21/94 | +------------------------------------------------+EVENT TIME: 01:40[EST]| |NRC NOTIFIED BY: TOM STEVENS |LAST UPDATE DATE: 11/21/94 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |ED McALPINE 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N Y 72 POWER OPERATION | 72 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | NUCLEAR INSTRUMENT (NI) # 8 DELTA FLUX (TOP TO BOTTOM OF CORE) WAS FOUND TO | | BE RESPONDING OPPOSITE OF OTHER NUCLEAR INSTRUMENT CHANNELS (# 5, 6, & 7). | | | | DURING POWER ESCALATION FOR PHYSICS TESTING IT WAS NOTED THAT NI # 8 DELTA | | FLUX WAS RESPONDING OPPOSITE OF NI's 5, 6, & 7 WHEN REACTOR POWER | | DISTRIBUTION WAS BEING CHANGED. AT 0140ET RPS CHANNEL "D" (NI # 8) WAS | | DECLARED INOPERABLE AND PLACED IN MANUAL BYPASS AT 0201ET. INVESTIGATION BY | | I&E TECHNICIANS SHOWED THAT WHEN THE OUTPUT LEADS FOR NI # 8 DELTA FLUX | | WERE REVERSED IN THE RPS CHANNEL "D" PROPER NI RESPONSE WAS ACHIEVED. | | PREVIOUS TO THIS THERE WAS NI CALIBRATIONS PERFORMED ON NI's 5, 6, & 7 | | WITHOUT NI # 8 (RPS CHANNEL "D") BEING IN THE TRIPPED POSITION. THIS | | RESULTED IN THE RPS BEING IN A 2 OUT OF 2 LOGIC INSTEAD OF BEING IN 2 OUT | | OF 3 WHICH IS THE NORMAL CASE WHEN CALIBRATIONS ARE BEING PERFORMED. | | LICENSEE WILL REMAIN AT 72% POWER UNTIL INVESTIGATION IS COMPLETED AND THE | | LEADS ARE PROPERLY CONNECTED BEFORE INCREASING REACTOR POWER. LICENSEE | | THINKS THAT THE LEADS FOR NI # 8 (RPS CHANNEL "D") WERE IMPROPERLY HOOKED | | UP DURING THEIR REFUELING OUTAGE. DELTA FLUX IS USED IN THE RPS FOR THE | | FLUX TO FLOW IMBALANCE TRIP. | | IF EITHER NI's 5, 6, OR 7 HAVE TO BE CALIBRATED BEFORE NI # 8 IS CORRECTED | | LICENSEE WILL PLACE RPS CHANNEL "D" (NI # 8) IN ITS TRIPPED POSITION BEFORE | | CALIBRATING THE OTHER CHANNEL. | | | | RESIDENT INSPECTOR WILL BE INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 28053 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MCGUIRE REGION: 2 |NOTIFICATION DATE: 11/21/94 | |UNIT: [1] [ ] [ ] STATE: NC |NOTIFICATION TIME: 11:54 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 11/18/94 | +------------------------------------------------+EVENT TIME: 11:55[EST]| |NRC NOTIFIED BY: IDDINGS |LAST UPDATE DATE: 11/21/94 | |HQ OPS OFFICER: GREG SCARFO +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |EDWARD MCALPINE 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 +------------------------------------------------------------------------------+ | AN IMPROPERLY INSTALLED JUMPER RESULTED IN A STEAM GENERATOR (SG) BLOWDOWN | | (B/D) ISOLATION DURING ENGINEERED SAFETY FEATURES (ESF) ACTUATION LOGIC | | TESTING. | | | | WHILE PERFORMING TRAIN "B" SLAVE RELAY TESTING ON THE SG "C" B/D ISOLATION | | VALVE, A JUMPER INSTALLED TO PREVENT THE VALVE FROM CLOSING WHEN THE SLAVE | | RELAY IS ACTUATED BECAME UNATTACHED RESULTING IN THE ISOLATION OF THE | | VALVE. SG B/D FOR THE "C" SG WAS ISOLATED AND REMAINED ISOLATED FOR LESS | | THAN ONE HOUR BEFORE BEING RESTORED. | | | | ON 11/18/94, AN INITIAL INVESTIGATION INTO THE REPORTABILITY OF THIS EVENT | | DETERMINED THAT IT WAS NOT REPORTABLE. FURTHER INVESTIGATION RESULTED IN A | | REVERSAL OF THAT DETERMINATION ON 11/21/94. AN INVESTIGATION INTO THE | | CAUSE OF THE FAULTY JUMPER INSTALLATION IS ONGOING. THE LICENSEE INFORMED | | THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 28054 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: INDIAN POINT REGION: 1 |NOTIFICATION DATE: 11/21/94 | |UNIT: [ ] [3] [ ] STATE: NY |NOTIFICATION TIME: 19:05 [ET]| |RX TYPE: [2] W-4-LP,[3] W-4-LP |EVENT DATE: 11/21/94 | +------------------------------------------------+EVENT TIME: 15:45[EST]| |NRC NOTIFIED BY: SMYERS |LAST UPDATE DATE: 11/21/94 | |HQ OPS OFFICER: GREG SCARFO +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |WILLIAM RULAND RDO | |APRE 50.72(b)(2)(vi) OFFSITE NOTIFICATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | THE NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION WAS NOTIFIED OF | | A FREON LEAK FROM A BUILDING COOLING SYSTEM. | | | | THE NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION WAS NOTIFIED OF | | A FREON LEAK FROM A CHILLER UNIT IN THE TRAINING BUILDING. THE SOURCE OF | | THE LEAK WAS A RELIEF VALVE WHICH LIFTED FOR UNKNOWN REASONS. LESS THAN | | ONE POUND OF FREON-22 WAS RELEASED TO THE ATMOSPHERE. AN INVESTIGATION | | INTO THE EVENT IS ONGOING. THE LICENSEE WILL INFORM THE NRC RESIDENT | | INSPECTOR. | +------------------------------------------------------------------------------+