U.S. Nuclear Regulatory Commission Operations Center Event Reports For 01/19/95 - 01/20/95 ** EVENT NUMBERS ** 28254 28255 28256 28257 28258 28259 28260 28261 28262 +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 28254 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: INDIAN POINT REGION: 1 |NOTIFICATION DATE: 01/19/95 | |UNIT: [2] [ ] [ ] STATE: NY |NOTIFICATION TIME: 08:56 [ET]| |RX TYPE: [2] W-4-LP,[3] W-4-LP |EVENT DATE: 01/19/95 | +------------------------------------------------+EVENT TIME: 08:12[EST]| |NRC NOTIFIED BY: D. MURPHY |LAST UPDATE DATE: 01/19/95 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |WALTER PASCIAK RDO | |NINF INFORMATION ONLY | | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 2 | N Y 16 POWER OPERATION | 6 STARTUP | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | TURBINE TRIP ON HIGH STEAM GENERATOR WATER LEVEL. | | | | DURING A ROUTINE STARTUP POWER ASCENSION WITH MAIN FEED REG VALVES IN | | MANUAL, STEAM GENERATOR WATER LEVELS BECAME DIFFICULT TO CONTROL WITHIN THE | | NORMAL BAND. THIS LED TO A HIGH WATER LEVEL CONDITION IN THE "23" STEAM | | GENERATOR AND A CORRESPONDING PROTECTIVE TRIP OF THE MAIN TURBINE. A | | REACTOR TRIP DID NOT OCCUR BECAUSE POWER WAS BELOW THE 20% TRIP PERMISSIVE. | | | | ALL SYSTEMS FUNCTIONED AS REQUIRED. THE LICENSEE PLANS ON STABILIZING STEAM | | GENERATOR LEVELS AND THEN RETURN TO POWER ASCENSION AND PLACING THE TURBINE | | BACK ONLINE. | | | | THIS IS BEING REPORTED AS AN INFORMATION CALL. | | | | THE NRC RESIDENT INSPECTOR HAS BEEN NOTIFIED. | | | | *** UPDATE TO HUFFMAN FROM MURPHY AT 10:02 EST ON 1/19/95 *** | | UPON FURTHER REVIEW OF THE EVENT, THE LICENSEE NOTED THAT A FEEDWATER | | ISOLATION SIGNAL OCCURRED WITH A CORRESPONDING STARTUP OF THE AUXILIARY | | FEEDWATER PUMPS. THIS IS EXPECTED WITH A HIGH STEAM GENERATOR WATER LEVEL | | AND FUNCTIONED PROPERLY. THE LICENSEE IS NOW REPORTING THIS EVENT A FOUR | | HOUR 50.72 ESF ACTUATION. R1DO(PASCIAK) INFORMED. | | | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 28255 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: DRESDEN REGION: 3 |NOTIFICATION DATE: 01/19/95 | |UNIT: [ ] [2] [3] STATE: IL |NOTIFICATION TIME: 10:51 [ET]| |RX TYPE: [1] GE-1,[2] GE-3,[3] GE-3 |EVENT DATE: 01/19/95 | +------------------------------------------------+EVENT TIME: 08:55[CST]| |NRC NOTIFIED BY: SCOTT BRILEY |LAST UPDATE DATE: 01/19/95 | |HQ OPS OFFICER: WILLIAM HUFFMAN +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JAMES CREED RDO | |DDDD 73.71 UNSPECIFIED PARAGRAPH | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | 3 | N Y 100 POWER OPERATION | 100 POWER OPERATION | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | UNAUTHORIZED ACCESS INTO PLANT PROTECTED AREA. | | | | "AT 0855 ON 1/19/95, IT WAS DETERMINED THAT A RETIRED LICENSEE EMPLOYEE HAD | | GAINED UNESCORTED ACCESS TO THE PROTECTED AREA OF THE STATION. THIS | | UNAUTHORIZED ACCESS OCCURRED ON 1/16/95 BETWEEN THE HOURS OF 10:56 AND | | 15:50. | | | | INDICATION THAT THE INDIVIDUAL HAD RETIRED IN MIDYEAR 1994 WAS OBTAINED | | FROM A COMPUTER REPORT ON 1/18/95. THE SECURITY BADGE WAS PULLED. FURTHER | | INVESTIGATION ON 1/19/95 DETERMINED THAT THE INDIVIDUAL SHOULD NOT HAVE | | BEEN PERMITTED UNESCORTED ACCESS. | | | | THIS WAS LIMITED TO THE PROTECTED AREA ONLY; THERE WAS NO VITAL ACCESS." | | | | THE LICENSEE STATED THAT THE BADGE SHOULD HAVE BEEN DEACTIVATED AND PULLED | | WHEN THE EMPLOYEE RETIRED. INVESTIGATION INTO THE CAUSE OF THIS OVERSIGHT | | IS IN PROGRESS. | | | | THE REASON THE RETIRED EMPLOYEE RETURNED TO THE SITE WAS NOT KNOWN. THE | | LICENSEE BELIEVES THAT THIS EMPLOYEE MAY HAVE ALSO ENTERED THE QUAD CITIES | | SITE IN THE SAME MANOR. MALICIOUS INTENT IS NOT SUSPECTED. | | | | THE NRC RESIDENT INSPECTOR HAS BEEN INFORMED. | | | | ***UPDATE AT 14:51 BY BRILEY TO GOULD*** THE SAME INDIVIDUAL ALSO ENTERED | | LASALLE IN THE SAME MANOR. IT IS BELIEVED THAT HE ENTERED THESE FACILITIES | | IN SEARCH OF CONTRACTING WORK. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 28256 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PEACH BOTTOM REGION: 1 |NOTIFICATION DATE: 01/19/95 | |UNIT: [2] [3] [ ] STATE: PA |NOTIFICATION TIME: 11:53 [ET]| |RX TYPE: [2] GE-4,[3] GE-4 |EVENT DATE: 01/18/95 | +------------------------------------------------+EVENT TIME: 07:53[EST]| |NRC NOTIFIED BY: BIRMINGHAM |LAST UPDATE DATE: 01/19/95 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |WALTER PASCIAK RDO | |AESS 50.72(b)(1)(v) EMERGENCY SIREN INOP | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | 3 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE PLANT LOST CAPABILITY OF HAVING THE STATES OF PENNSYLVANIA AND MARYLAND | | TO ACTIVATE THE EMERGENCY SIRENS FROM THEIR LOCATIONS DUE TO A COMPUTER | | FAILURE. | | | | THE COMPUTER PROBLEM WAS NOT DISCOVERED UNTIL 01/19/95 @ 8:50 DURING A | | PLANT COMPUTER CHECK. THE PROBLEM WAS CORRECTED BY 8:58 BUT THEY ARE STILL | | INVESTIGATING THE CAUSE. THE COMPUTER MALFUNCTION MADE IT IMPOSSIBLE FOR | | THE STATES TO ACTUATE THE EMERGENCY SIRENS, BUT THE PLANT, HOWEVER, STILL | | HAD THE CAPABILITY TO ACTUATE THE SIRENS. THE LICENSEE DID NOT DETERMINE | | THAT THIS WAS A REPORTABLE EVENT UNTIL 11:30. THE RI WAS INFORMED AND THE | | STATES AND LOCAL AGENCIES WILL BE INFORMED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |OTHER NUCLEAR MATERIAL | |EVENT NUMBER: 28257 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: IDAHO DIV OF ENVIRONMENTAL QUALITY |NOTIFICATION DATE: 01/19/95 | | CITY: TWIN FALLS REGION: 4 |NOTIFICATION TIME: 13:45 [ET]| | COUNTY: STATE: ID |EVENT DATE: 01/19/95 | |LICENSE#: AGREEMENT: N |EVENT TIME: 00:00[MST]| | DOCKET: |LAST UPDATE DATE: 01/19/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |PELLET RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: ASKEW | | |HQ OPS OFFICER: CHAUNCEY GOULD | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NINF INFORMATION ONLY | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE IDAHO DIVISION OF ENVIRONMENTAL QUALITY WAS INFORMED OF AN ILLEGAL | | TRASH DUMP IN TWIN FALLS IDAHO. UPON INVESTIGATING THE SITE THEY DISCOVERED | | AT LEAST TWO VIALS WHICH HAD RAD MARKINGS AND PRESCRIPTION NUMBERS. THEY | | CONTACTED THE LAB THAT PREPARED THE MATERIALS AND IT WAS STATED THAT THE | | VIALS COULD HAVE CONTAINED IODINE 123, THALLIUM 201 OR TECHNETIUM. THE SITE | | WHERE THESE VIALS ARE HAS BEEN ISOLATED. THE STATE HAS CONTACTED INEL FOR | | ASSISTANCE. THEY BELIEVE THE VIALS MAY HAVE COME FROM ST BENEDICTS HOSPITAL | | IN JEROME ID. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 28258 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: ST AGNES HOSPITAL |NOTIFICATION DATE: 01/19/95 | | CITY: FONDDULAC REGION: 3 |NOTIFICATION TIME: 14:26 [ET]| | COUNTY: STATE: WI |EVENT DATE: 01/19/95 | |LICENSE#: 48-02419-03 AGREEMENT: N |EVENT TIME: 11:45[CST]| | DOCKET: |LAST UPDATE DATE: 01/19/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |JAMES CREED RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: SIMMONS | | |HQ OPS OFFICER: CHAUNCEY GOULD | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | ST AGNES HOSPITAL REPORTED A MEDICAL MISADMINISTRATION WHEN THEY INJECTED | | 3.0 MILLICURIES OF TECHNETIUM INTO A PATIENT INSTEAD OF THE PRESCRIBED 1 | | MILLICURIE OF THALLIUM 201. THE PATIENT WAS INFORMED AND RELEASE. THE | | LICENSEE STATED THAT THERE SHOULD BE NO ADVERSE AFFECTS. THE CAUSE WAS DUE | | TO CONFUSION ON THE IDENTIFICATION OF THE SYRINGES. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 28259 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: CALLAWAY REGION: 3 |NOTIFICATION DATE: 01/19/95 | |UNIT: [1] [ ] [ ] STATE: MO |NOTIFICATION TIME: 16:58 [ET]| |RX TYPE: [1] W-4-LP |EVENT DATE: 01/19/95 | +------------------------------------------------+EVENT TIME: 15:00[CST]| |NRC NOTIFIED BY: BLOSSER |LAST UPDATE DATE: 01/19/95 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JAMES CREED 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 WAS REPORTING ON THEIR WEATHER CONDITIONS AND THEIR ABILITY | | FOR EVACUATION DURING AN EMERGENCY. | | | | THE LICENSEE HAS TALKED WITH FEMA AND SEMA AND THEY HAVE PROVIDED ASSURANCE | | TO THE LICENSEE THAT IN THE EVENT THERE WAS AN ACCIDENT, SUFFICIENT | | RESOURCES COULD BE DIVERTED TO THE APPROPRIATE SECTORS TO PERFORM AN | | EMERGENCY EVACUATION IF NECESSARY. THE RI WAS INFORMED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |OTHER NUCLEAR MATERIAL | |EVENT NUMBER: 28260 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: SYNCOR INTERNATIONAL |NOTIFICATION DATE: 01/19/95 | | CITY: GRAND RAPIDS REGION: 3 |NOTIFICATION TIME: 17:05 [ET]| | COUNTY: STATE: MI |EVENT DATE: 01/19/95 | |LICENSE#: 21-19219-01MD AGREEMENT: N |EVENT TIME: 14:00[EST]| | DOCKET: |LAST UPDATE DATE: 01/19/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |JAMES CREED RDO | | |CHARLEY HAUGHNEY EO | +------------------------------------------------+ | |NRC NOTIFIED BY: PELLICCIARINI | | |HQ OPS OFFICER: CHAUNCEY GOULD | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NINF INFORMATION ONLY | | |IBBF 30.50(b)(2)(ii) EQUIP DISABLED/FAILS | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | SYNCOR INTERNATIONAL (RADIO-PHARMACY LICENSEE) LOCATED IN GRAND RAPIDS, MI. | | REPORTED THAT THE FUME HOOD WHICH THEY ARE REQUIRED TO STORE THEIR | | MATERIALS (XENON 133 AND IODINE 131) IN MALFUNCTIONED AND THEY HAD TO | | RELOCATE THE MATERIALS. | | | | THIS OCCURRED WHEN THE FUME HOOD ALARM WENT OFF. WHEN THE TECHNICIAN WENT | | TO RESET THE ALARM, HE FOUND THAT THE FUME HOOD WAS NOT RUNNING. THEY WERE | | UNABLE TO DETERMINE THE CAUSE OF THE FAILURE SO THEY HAVE A CALL FOR A | | REPAIR TECHNICIAN, BUT HE WILL NOT BE ABLE TO WORK ON IT UNTIL TOMORROW. | | THE MATERIALS HAVE BEEN TRANSFERRED TO A SMALLER VENT CABINET ADJACENT TO | | THE FUME HOOD UNTIL REPAIRS CAN BE COMPLETED. | | | | NOTE: SEE EVENT #28253 | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 28261 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: FITZPATRICK REGION: 1 |NOTIFICATION DATE: 01/19/95 | |UNIT: [1] [ ] [ ] STATE: NY |NOTIFICATION TIME: 17:30 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 01/19/95 | +------------------------------------------------+EVENT TIME: 16:30[EST]| |NRC NOTIFIED BY: HYME |LAST UPDATE DATE: 01/19/95 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |WALTER PASCIAK 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 +------------------------------------------------------------------------------+ | THE LICENSEE NOTIFIED THE NEW YORK DEPARTMENT OF ENVIRONMENTAL CONSERVATION | | THAT THEY HAD VIOLATED THEIR STATE POLLUTION DISCHARGE ELIMINATION SYSTEM | | PERMIT OF NON-COMPLIANCE. | | | | THIS OCCURRED WHEN THEY EXCEEDED THE LIMITS ON THE OUT FALL FROM THEIR | | SEWAGE TREATMENT PLANT EFFLUENT FOR TOTAL SUSPENDED SOLIDS, BIOLOGICAL | | OXYGEN DEMAND AND FECAL COLIFORM. THE RI WAS INFORMED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 28262 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SOUTH TEXAS REGION: 4 |NOTIFICATION DATE: 01/19/95 | |UNIT: [ ] [2] [ ] STATE: TX |NOTIFICATION TIME: 17:43 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 01/19/95 | +------------------------------------------------+EVENT TIME: 14:30[CST]| |NRC NOTIFIED BY: PINZON |LAST UPDATE DATE: 01/19/95 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JOHN PELLET RDO | |NLTR LICENSEE 24 HR REPORT | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | THE LICENSEE REPORTED THAT THEY HAD VIOLATED TS 3.4.1.4.1 WHILE IN MODE 5. | | | | THIS TS REQUIRES AT LEAST ONE TRAIN OF RHR TO BE OPERATIONAL WHILE IN MODE | | 5 WITH LOOPS FILLED. IT ALSO REQUIRES THAT AN ADDITIONAL RHR TRAIN OR TWO | | S/G'S WITH ADEQUATE INVENTORY BE AVAILABLE FOR DECAY HEAT REMOVAL. DURING | | CERTAIN PERIODS BETWEEN 4/22/94 AND 4/28/94 WITH THE UNIT IN MODE 5, THE | | S/G'S WERE USED AS A HEAT SINK WITH THE REACTOR COOLANT SYSTEM VENTED TO | | THE ATMOSPHERE THROUGH A TWO INCH VENT. AN ANALYSIS WAS COMPLETED AND | | REVIEWED(1/19/95) AND IT WAS DETERMINED THAT WITH THE REACTOR COOLANT | | SYSTEM VENTED TO ATMOSPHERE VIA A VENT LINE OR PRESSURIZER SAFETY, THE | | S/G'S WOULD NOT BE CAPABLE OF REMOVING DECAY HEAT VIA NATURAL CIRCULATION, | | THEREBY PUTTING THEM IN A CONDITION WHERE TS REQUIREMENTS WERE NOT MET. THE | | RI WAS INFORMED. | +------------------------------------------------------------------------------+