U.S. Nuclear Regulatory Commission Operations Center Event Reports For 01/11/95 - 01/12/95 ** EVENT NUMBERS ** 27709 27988 28229 28230 28231 +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27709 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MILLSTONE REGION: 1 |NOTIFICATION DATE: 08/25/94 | |UNIT: [ ] [2] [ ] STATE: CT |NOTIFICATION TIME: 16:50 [ET]| |RX TYPE: [1] GE-3,[2] CE,[3] W-4-LP |EVENT DATE: 08/25/94 | +------------------------------------------------+EVENT TIME: 16:30[EDT]| |NRC NOTIFIED BY: ROBERT BORCHERT |LAST UPDATE DATE: 01/11/95 | |HQ OPS OFFICER: THOMAS ANDREWS +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MOHAMED SHANBAKY 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AN ENGINEERING EVALUATION HAS IDENTIFIED A POSTULATED CONDITION WHERE A | | STEAM LINE BREAK OUTSIDE OF THE CONTAINMENT COULD CREATE AN ENVIRONMENT | | THAT MAY DEGRADE THE 120 VOLT VITAL AC ELECTRICAL SYSTEM. | | | | A POSTULATED STEAM LINE BREAK IN THE EAST ELECTRICAL PENETRATION ROOM WOULD | | CREATE A STEAM ENVIRONMENT THAT COULD CAUSE A SHORT CIRCUIT IN THE HYDROGEN | | MONITORS. THIS SHORT CIRCUIT IS POSTULATED TO DEGRADE THE 120 VOLT VITAL | | AC ELECTRICAL SYSTEM TO UNACCEPTABLY LOW LEVELS. LOADS SUCH AS THE | | ENGINEERED SAFETY FEATURES SYSTEM MAY NOT FUNCTION AS DESIGNED. | | | | THE LICENSEE IS EVALUATING CORRECTIVE ACTIONS. THE NRC RESIDENT INSPECTOR, | | STATE AND LOCAL OFFICIALS HAVE BEEN INFORMED. | | | | ***UPDATE FROM LICENSEE:SUDIGALI TO NRC:HUFFMAN AT 1933 EST ON 1/11/95*** | | THE LICENSEE TOOK ACTION TO INSTALL FUSING TO CORRECT THE CONDITION | | REPORTED ABOVE. HOWEVER, RECENT FURTHER ANALYSIS HAS REVEALED THAT THE | | DESIGN MODIFICATION IS STILL INADEQUATE TO PREVENT POTENTIAL DEGRADATION TO | | THE VITAL 120 VOLT AC SYSTEM. ADDITION MODIFICATIONS AND CIRCUIT INTERRUPT | | DEVICES ARE NOW BEING CONSIDERED. THE NRC RESIDENT INSPECTOR WILL BE | | NOTIFIED. RIDO(SHANBAKY) HAS BEEN INFORMED. | | | +------------------------------------------------------------------------------+ !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 27988 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SALEM REGION: 1 |NOTIFICATION DATE: 11/03/94 | |UNIT: [ ] [2] [ ] STATE: NJ |NOTIFICATION TIME: 21:56 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 11/03/94 | +------------------------------------------------+EVENT TIME: 20:48[EST]| |NRC NOTIFIED BY: KAFANTARIS |LAST UPDATE DATE: 01/11/95 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |CLIFFORD ANDERSON 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 N 0 REFUELING | 0 REFUELING | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | LETDOWN HEAT EXCHANGER (HX) ROOM DAMPER INSTALLED BACKWARDS | | | | THE #2 LETDOWN HX ROOM BACKDRAFT DAMPER WAS DISCOVERED TO BE INSTALLED | | BACKWARDS. THIS DAMPER IS DESIGNED TO PREVENT BREAK INDUCED STEAM FLOW | | FROM REACHING VITAL EQUIPMENT ON THE 84' ELEVATION OF THE AUXILIARY | | BUILDING. THE LICENSEE HAS NOT DETERMINED THE POTENTIAL EFFECT ON VITAL | | EQUIPMENT IN THE AREA. THIS REPORT IS BEING MADE IAW GENERIC LETTER 91-18 | | BECAUSE THE CONDITION IS "INDETERMINATE". | | | | DETAILED ENGINEERING EVALUATION IS UNDERWAY TO ASSESS THIS CONDITION & | | POTENTIAL EFFECT. THE EQUIVALENT DAMPER AT SALEM UNIT 1 HAS BEEN FOUND TO | | BE INSTALLED CORRECTLY. | | | | THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | | | | * * * UPDATE 1424 1/11/95 FROM GWIRTZ TO STRANSKY * * * | | | | LICENSEE WISHES TO RETRACT THIS EVENT BASED UPON A FOLLOWUP ENGINEERING | | ANALYSIS. ALTHOUGH THE DAMPER WAS INSTALLED BACKWARD, THE DAMPER IS | | SPRING-LOADED TO CLOSE. THE LICENSEE DETERMINED THAT THE PRESSURE REQUIRED | | TO OPEN DAMPER AGAINST SPRING PRESSURE WAS 0.177 PSID, WHILE THE MAXIMUM | | PRESSURE DEVELOPED IN THE ROOM ASSUMING THE WORST POSTULATED BREAK SIZE | | WOULD BE ONLY 0.09 PSIG. THEREFORE, THE LICENSEE BELIEVES THAT THE MAXIMUM | | POSTULATED PRESSURE IN THE ROOM WOULD NOT HAVE OPENED THIS DAMPER, AND THAT | | EQUIPMENT IN THE ADJACENT ROOM WOULD NOT BE SUBJECTED TO STEAM INPINGEMENT. | | THE RI WILL BE INFORMED. NOTIFIED R1(SHANBAKY). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 28229 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: SAINT MARYS HOSPITAL |NOTIFICATION DATE: 01/11/95 | | CITY: GREEN BAY REGION: 3 |NOTIFICATION TIME: 12:49 [ET]| | COUNTY: STATE: WI |EVENT DATE: 01/11/95 | |LICENSE#: 48-12786-01 AGREEMENT: N |EVENT TIME: 08:45[CST]| | DOCKET: |LAST UPDATE DATE: 01/11/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |ROY CANIANO RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: CINDY HAUPT | | |HQ OPS OFFICER: WILLIAM HUFFMAN | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | WRONG DIAGNOSTIC RADIOISOTOPE ADMINISTERED. | | | | 4.2 MILLICURIES OF THALLIUM-201 FOR HEART SCAN PRESCRIBED. | | | | 2.6 MILLICURIES OF TECHNETIUM-99m FOR LUNG SCAN ADMINISTERED. | | | | DISCOVERED IMMEDIATELY AFTER INJECTION. | | | | WRONG SYRINGE USED. | | | | NO ADVERSE HEALTH EFFECTS ANTICIPATED. | | | | PATIENT AND PHYSICIAN INFORMED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 28230 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: ARKANSAS NUCLEAR REGION: 4 |NOTIFICATION DATE: 01/11/95 | |UNIT: [1] [ ] [ ] STATE: AR |NOTIFICATION TIME: 15:10 [ET]| |RX TYPE: [1] B&W-L-LP,[2] CE |EVENT DATE: 01/11/95 | +------------------------------------------------+EVENT TIME: 13:52[CST]| |NRC NOTIFIED BY: SALISBURY |LAST UPDATE DATE: 01/11/95 | |HQ OPS OFFICER: GREG SCARFO +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |TOM STETKA 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 Y 72 POWER OPERATION | 72 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE ARKANSAS DEPARTMENT OF HEALTH WAS NOTIFIED OF AN INJURED WORKER | | TRANSPORTED TO A LOCAL HOSPITAL. NO CONTAMINATION WAS INVOLVED. | | | | AT 1305CST, A WORKER FELL DOWN A FLIGHT OF STAIRS WHILE IN TRANSIT FROM ONE | | JOB SITE TO ANOTHER AND SUSTAINED HEAD AND BACK INJURIES. AT 1338CST, AN | | AMBULANCE WAS REQUESTED TO THE PLANT TO TRANSPORT THE INJURED WORKER TO | | SAINT MARY'S HOSPITAL. THE WORKER WAS NOT CONTAMINATED. AT 1353CST, THE | | ARKANSAS DEPARTMENT OF HEALTH WAS NOTIFIED OF THE INJURY AND THE CURRENT | | STATUS OF THE WORKER AS A COURTESY. THE LICENSEE INFORMED THE NRC RESIDENT | | INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 28231 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: HADDAM NECK REGION: 1 |NOTIFICATION DATE: 01/11/95 | |UNIT: [1] [ ] [ ] STATE: CT |NOTIFICATION TIME: 16:06 [ET]| |RX TYPE: [1] W-4-LP |EVENT DATE: 01/11/95 | +------------------------------------------------+EVENT TIME: 15:45[EST]| |NRC NOTIFIED BY: NEVELLS |LAST UPDATE DATE: 01/11/95 | |HQ OPS OFFICER: GREG SCARFO +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MOHAMED SHANBAKY RDO | |HFIT 26.73 FITNESS FOR DUTY | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 CONTRACT SUPERVISOR TESTED POSITIVELY IN A PRE-ACCESS DRUG TEST. | | | | A CONTRACT SUPERVISOR TESTED POSITIVELY DURING A DRUG TEST CONDUCTED PRIOR | | TO GRANTING ACCESS TO THE PROTECTED AREA OF THE PLANT. THE CONTRACTOR | | NEVER HAD ACCESS TO THE PROTECTED AREA AND WILL NOT BE ALLOWED BACK ON | | SITE. THE STATE OF CONNECTICUT WAS NOTIFIED. THE LICENSEE INFORMED THE | | NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+