U.S. Nuclear Regulatory Commission Operations Center Event Reports For 06/08/95 - 06/09/95 ** EVENT NUMBERS ** 28907 28908 28909 28910 28911 28912 28913 28914 28915 28916 +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 28907 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SALEM REGION: 1 |NOTIFICATION DATE: 06/08/95 | |UNIT: [1] [2] [ ] STATE: NJ |NOTIFICATION TIME: 01:52 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 06/07/95 | +------------------------------------------------+EVENT TIME: 23:01[EDT]| |NRC NOTIFIED BY: KAFANTARIS |LAST UPDATE DATE: 06/08/95 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |WALTER PASCIAK RDO | |ARPS 50.72(b)(2)(ii) RPS ACTUATION | | |AESF 50.72(b)(2)(ii) ESF ACTUATION |JOHN WHITE R1 | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | 2 | A/R Y 10 STARTUP | 0 HOT STANDBY | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - REACTOR TRIP FROM 10% POWER DUE TO LOSS OF Rx COOLANT SYSTEM FLOW - | | | | WITH UNIT 2 AT APPROXIMATELY 10% POWER & SHUTTING DOWN (SEE EVENT #28904), | | THE REACTOR AUTO TRIPPED DUE TO THE LOSS OF REACTOR COOLANT SYSTEM (RCS) | | FLOW ON #23 & #24 RCPs AT GREATER THAN 10% POWER (P-7). THE LOSS OF RCS | | FLOW WAS DUE TO DEENERGIZATION OF #2F & #2G GROUP BUSES DUE TO A BREAKER | | FAILURE ACTUATION SIGNAL ON THE 500 KV #1-9 BREAKER. THE BREAKER FAILURE | | ACTUATED AND CAUSED A LOSS OF 500 KV BUS SECTION #1, AND 13 KV BUS SECTION | | SECTION #4. THE #2B VITAL BUS TRANSFERRED TO THE #24 STATION POWER | | TRANSFORMER AND RESTORED POWER TO THE INDIVIDUAL ROD POSITION INDICATION | | TO SHOW THAT ALL CONTROL RODS HAD INSERTED COMPLETELY. | | | | ONE OF 3 STATION AIR COMPRESSORS (#2) WAS INOPERABLE FOR MAINTENANCE. | | #3 STATION AIR COMPRESSOR TRIPPED DUE TO THE LOSS OF #1G GROUP BUS. | | #1 STATION AIR COMPRESSOR FAILED TO START DUE TO THE AUX OIL PUMP BEING | | FED FROM #1F GROUP BUS WHICH LOST POWER. | | | | THE TWO EMERGENCY AIR COMPRESSORS AUTO STARTED AND RESTORED CONTROL AIR | | HEADER PRESSURE. | | | | CONTROL ROOM OPERATORS MANUALLY STARTED 3 TEMPORARY AIR COMPRESSORS IN | | ACCORDANCE WITH STATION ABNORMAL OPERATING PROCEDURES TO MAINTAIN STATION | | AIR PRESSURE. | | | | THE NON-SAFETY RELATED STATION BLACKOUT AIR COMPRESSOR IS INOPERABLE DUE TO | | MAINTENANCE. | | | | CONTROL ROOM OPERATORS MANUALLY STARTED THE AUXILIARY FEEDWATER PUMPS. | | THE AFW PUMPS DID NOT AUTO START DUE TO THE REACTOR TRIP AT LOW POWER. | | | | CONTROL ROOM OPERATORS SHUT THE MSIVs TO CONTROL RCS COOLDOWN. | | | | THE PRESSURIZER SPRAYS WERE INEFFECTIVE IN REDUCING RCS PRESSURE. | | CONTROL ROOM OPERATORS INITIATED AUXILIARY SPRAY IN ACCORDANCE WITH | | EMERGENCY OPERATING PROCEDURES TO CONTROL RCS PRESSURE. NO PORVs LIFTED. | | THE HIGHEST RCS PRESSURE REACHED WAS 2315 PSIG (NORMAL OPERATING PRESSURE | | IS 2235 PSIG). | | | | AT THE PRESENT TIME, ALL VITAL BUSES ARE BEING POWERED FROM #24 STATION | | POWER TRANSFORMER. | | | | ALL 3 EDGs ARE OPERABLE AND IN STANDBY MODE. | | | | STEAM IS BEING DUMPED TO THE ATMOSPHERE. | | | | #24 RCP SEAL LEAKOFF DRIFTED LOW BUT HAS RECOVERED. | | | | UNIT 2 IS STABLE IN MODE 3 (HOT STANDBY) COOLING DOWN TO MODE 5 (COLD | | SHUTDOWN). | | | | LICENSEE IS INVESTIGATING THE CAUSE OF THE BREAKER FAILURE AND THE | | PRESSURIZER SPRAY SITUATION. | | | | OFFSITE POWER IS ESTABLISHED FOR UNITS 1 & 2. | | | | THIS EVENT HAD THE FOLLOWING EFFECTS ON UNIT 1 WHICH IS IN MODE 5 | | (COLD SHUTDOWN) IN A MAINTENANCE OUTAGE: | | POWER TO #1F & 1G GROUP BUSES WAS LOST. THE MAIN GENERATOR EXPERIENCED | | A LOSS OF HYDROGEN PRESSURE APPARENTLY DUE TO THE DC OIL PUMP BEING IN | | MANUAL MODE FOR UNKNOWN REASONS. LICENSEE IS INVESTIGATING THE CAUSE. | | | | SHUTDOWN COOLING WAS NOT AFFECTED. | | | | ONE OF 3 UNIT 1 EDGs (#1A) IS INOPERABLE FOR MAINTENANCE. #1B & #1C EDGs | | ARE FUNCTIONAL BUT INOPERABLE DUE TO CONCERNS ABOUT JACKET WATER PIPING. | | (SEE EVENT #28908). TECH SPEC LCO A/S 3.8.2.2 REQUIRES LICENSEE TO | | ESTABLISH CONTAINMENT INTEGRITY WITHIN 8 HOURS WITH TWO UNIT 1 EDGs | | INOPERABLE (LICENSEE HAS DONE SO). | | | | LICENSEE NOTIFIED THE NRC RESIDENT INSPECTOR, WILL NOTIFY LOCAL OFFICIALS, | | AND WILL ISSUE A PRESS RELEASE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 28908 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SALEM REGION: 1 |NOTIFICATION DATE: 06/08/95 | |UNIT: [1] [ ] [ ] STATE: NJ |NOTIFICATION TIME: 03:58 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 06/08/95 | +------------------------------------------------+EVENT TIME: 01:30[EDT]| |NRC NOTIFIED BY: KAFANTARIS |LAST UPDATE DATE: 06/08/95 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |WALTER PASCIAK RDO | |ADAS 50.72(b)(2)(i) DEG/UNANALYZED COND | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - THREE OF THREE EMERGENCY DIESEL GENERATORS DECLARED INOPERABLE - | | | | THIS REPORT IS BEING INITIATED DUE TO CONCERNS RAISED WITH THE JACKET | | WATER PIPING ON THE UNIT 1 EDGs. THE ORIGINAL ISSUE WAS THAT THE | | #1C EDG HAD SCHEDULE 40 PIPE INSTALLED INSTEAD OF SCHEDULE 80 PIPING. | | AS A RESULT, THE #1C EDG WAS DECLARED INOPERABLE. | | | | IN ADDITION TO THE PIPING CONCERN, FOLLOW UP RESONANCE FREQUENCY TESTS | | WERE CONDUCTED. THIS WAS PROMPTED BY THE 06/01/95 FAILURE OF A JACKET | | WATER PIPE NIPPLE ON THE #1A EDG. EDG #1A IS INOPERABLE FOR MAINTENANCE. | | TEST RESULTS INDICATED THAT THE 3/8 INCH DIAMETER LINES CONTAINING VALVES | | #1DA4GB & #1DA4GC ON THE #1B & #1C EDGs ARE SUSCEPTIBLE TO FAILURE DUE | | TO MATCHING RESONANT FREQUENCIES. BASED UPON THIS, OPERABILITY OF THE | | #1B & #1C EDGs COULD NOT BE ASSURED. THUS, IN ADDITION TO EDG #1C ALREADY | | BEING DECLARED INOPERABLE, EDG #1B WAS ALSO DECLARED INOPERABLE. | | | | SIMILAR TESTS WERE CONDUCTED ON THE UNIT 2 EDGs AND THERE WERE NO | | INDICATION OF PROBLEMS ASSOCIATED WITH THE MATCHING RESONANT FREQUENCIES. | | | | THE LICENSEE WILL INFORM THE RESIDENT INSPECTOR AND HAS INFORMED LOCAL | | OFFICIALS OF THIS EVENT. | | | | NOTE: SEE EVENT #28904 AND #28907 FOR RELATED EVENTS. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 28909 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: WASHINGTON NUCLEAR REGION: 4 |NOTIFICATION DATE: 06/08/95 | |UNIT: [2] [ ] [ ] STATE: WA |NOTIFICATION TIME: 03:08 [ET]| |RX TYPE: [2] GE-5 |EVENT DATE: 06/07/95 | +------------------------------------------------+EVENT TIME: 20:17[PDT]| |NRC NOTIFIED BY: R.J. PECHE |LAST UPDATE DATE: 06/08/95 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |PHIL HARRELL RDO | |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 N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - AUTO CLOSURE OF MSIVs DURING TEST DUE TO INADEQUATE TEST PROCEDURE - | | | | AT 2017 ON 06/07/95, AN AUTOMATIC ESF ISOLATION SIGNAL TO THE MAIN STEAM | | ISOLATION VALVES (MSIVs) WAS RECEIVED DURING PERFORMANCE OF A SURVEILLANCE | | TEST. THE CLOSURE OF THE VALVES WAS CAUSED BY AN INVALID INITIATION SIGNAL | | AND WAS UNANTICIPATED. | | | | FOLLOWUP INVESTIGATION INDICATED THAT THE MSIV ISOLATION FUNCTIONED AS | | DESIGNED, AND THAT THE ISOLATION RESULTED FROM AN INADEQUACY IN THE TEST | | PROCEDURE. | | | | AS A RESULT OF THE ISOLATION SIGNAL, 8 OF 8 MSIVs STROKED CLOSED. THE | | PLANT IS IN OPERATIONAL CONDITION 4 (COLD SHUTDOWN) AND THEREFORE THE | | MSIVs ARE NOT REQUIRED TO BE OPEN FOR HEAT REMOVAL OR PRESSURE CONTROL. | | THE TEST PROCEDURE HAS BEEN CORRECTED AND MSIV TESTING COMPLETED WITHOUT | | FURTHER COMPLICATION. | | | | LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 28910 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: CALLAWAY REGION: 3 |NOTIFICATION DATE: 06/08/95 | |UNIT: [1] [ ] [ ] STATE: MO |NOTIFICATION TIME: 10:24 [ET]| |RX TYPE: [1] W-4-LP |EVENT DATE: 06/08/95 | +------------------------------------------------+EVENT TIME: 05:53[CDT]| |NRC NOTIFIED BY: SCHOENBACH |LAST UPDATE DATE: 06/08/95 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |GARY SHEAR RDO | |ARPS 50.72(b)(2)(ii) RPS ACTUATION | | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | A/R Y 100 POWER OPERATION | 0 HOT STANDBY | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - AUTO Rx TRIP FROM 100% POWER DUE TO LOW Rx COOLANT SYSTEM FLOW - | | | | DURING A LOCAL THUNDERSTORM, A TREE FELL ONTO NON-SAFETY 13.8 KV POWER | | LINES TO THE INTAKE STRUCTURE CAUSING THE INTAKE FEEDER CIRCUIT BREAKER | | #PA-0210 TO OPEN. THIS CAUSED THE UNDER VOLTAGE / UNDER FREQUENCY RELAYS | | FOR THE REACTOR COOLANT PUMPS TO ACTIVATE WHICH CAUSED THE 'C' & 'D' | | REACTOR COOLANT PUMPS TO TRIP. THIS CAUSED THE REACTOR TO AUTO TRIP FROM | | 100% POWER DUE TO LOW REACTOR COOLANT SYSTEM FLOW. ALL CONTROL RODS | | INSERTED COMPLETELY. | | | | THE MAIN FEEDWATER SYSTEM ISOLATED AND THE AUXILIARY FEEDWATER SYSTEM | | ACTUATED, AS DESIGNED. STEAM IS BEING DUMPED TO THE MAIN CONDENSER. | | | | THE PLANT IS STABLE IN MODE 3 (HOT STANDBY). | | | | LICENSEE PLANS TO RESTART THE PLANT LATER TODAY. | | | | LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 28911 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: HOPE CREEK REGION: 1 |NOTIFICATION DATE: 06/08/95 | |UNIT: [1] [ ] [ ] STATE: NJ |NOTIFICATION TIME: 13:09 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 06/08/95 | +------------------------------------------------+EVENT TIME: 11:32[EDT]| |NRC NOTIFIED BY: ARCHIE FAULKNER |LAST UPDATE DATE: 06/08/95 | |HQ OPS OFFICER: RUDY KARSCH +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |WALTER PASCIAK 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | HPCI WAS INADVERTENCY RENDERED INOPERABLE FOR APPROXIMATELY TEN HOURS | | DURING THE PERFORMANCE OF A SURVEILLANCE TEST. | | | | DURING REVIEW OF DATA FOLLOWING A CHANGE AND SURVEILLANCE TO THE HPCI | | SYSTEM, THE REVIEWERS DISCOVERED THAT THE CHANGE CLOSED VALVE "1BJV048", | | WHICH CLOSED THE COOLING WATER FLOW PATH TO THE HPCI LUBE OIL COOLER. THIS | | RENDERED HPCI INOPERABLE. DURING THE SURVEILLANCE TEST ON 5/29 & 30/95 IT | | WAS NOT RECOGNIZED THAT HPCI WAS INOPERABLE. THE DURATION OF INOPERABILITY | | WAS TEN HOURS OR LESS. THE LICENSEE IS DETERMINING A MORE ACCURATE | | DURATION OF INOPERABILITY. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR AND LOWER ALLOWAYS CREEK | | TOWNSHIP. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |OTHER NUCLEAR MATERIAL | |EVENT NUMBER: 28912 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: COGEMA MINING, INC |NOTIFICATION DATE: 06/08/95 | | CITY: CASPER REGION: 4 |NOTIFICATION TIME: 14:02 [ET]| | COUNTY: JOHNSON STATE: WY |EVENT DATE: 06/08/95 | |LICENSE#: SUA 1341 AGREEMENT: N |EVENT TIME: 11:30[MDT]| | DOCKET: 00408502 |LAST UPDATE DATE: 06/08/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |LINDA HOWELL RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: JOHN VASELIN | | |HQ OPS OFFICER: RUDY KARSCH | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NLTR LICENSEE 24 HR REPORT | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | COGEMA MINING, INC OF CASPER, WYO. | | | | A TEST/MONITOR WELL PICKED UP A HORIZONTAL MIGRATION OF CHLORIDES AND | | ALKALINITY THAT EXCEEDED THE LICENSEE'S LIMITS. THIS REPORT IS MADE AS | | NOTIFICATION THAT A LICENSE CONDITION HAS BEEN EXCEEDED. R4 (CAIN) IS ON | | SITE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |OTHER NUCLEAR MATERIAL | |EVENT NUMBER: 28913 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: FROEHLING & ROBERTSON |NOTIFICATION DATE: 06/08/95 | | CITY: LEESBURG REGION: 2 |NOTIFICATION TIME: 15:45 [ET]| | COUNTY: LOUDEN STATE: VA |EVENT DATE: 06/08/95 | |LICENSE#: 45-088-90-02 AGREEMENT: N |EVENT TIME: 15:00[EDT]| | DOCKET: 00306580 |LAST UPDATE DATE: 06/08/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |MILTON SHYMLOCK RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: CHARLES MITCHELL |PAT SANTIAGO NMSS | |HQ OPS OFFICER: RUDY KARSCH | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NDAM DAMAGE MEASURE GAUGE | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | FROEHLING & ROBERTSON OF RICHMOND, VA | | | | MOISTURE DENSITY GAGE DAMAGED BY A FRONT END LOADER'S BUCKET AT | | CONSTRUCTION SITE IN LEESBURG, VA. SURVEY METER SHOWED NORMAL RADIATION | | LEVELS. THE LICENSEE WILL PACK THE GAGE INTO ITS CARRYING CASE AND RETURN | | IT TO THE MANUFACTURER. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 28914 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: OCONEE REGION: 2 |NOTIFICATION DATE: 06/08/95 | |UNIT: [1] [2] [3] STATE: SC |NOTIFICATION TIME: 16:14 [ET]| |RX TYPE: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP |EVENT DATE: 06/08/95 | +------------------------------------------------+EVENT TIME: 15:48[EDT]| |NRC NOTIFIED BY: SCOTT HOLLINGWORTH |LAST UPDATE DATE: 06/08/95 | |HQ OPS OFFICER: RUDY KARSCH +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MILTON SHYMLOCK 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 100 POWER OPERATION | 100 POWER OPERATION | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | 3 | N N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE LICENSEE NOTIFIED THE FOLLOWING AGENCIES ABOUT THE RELEASE OF TWO | | GALLONS OF HYDRAULIC FLUID TO LAKE KEOWEE: THE OCONEE COUNTY EMERGENCY | | PLANNING DIVISION, THE STATE HEALTH AND ENVIRONMENTAL CONTROL DIVISION, AND | | THE NATIONAL RESPONSE CENTER. THE LICENSEE HAS DEPLOYED OIL BOOMS TO | | CONTAIN THE SPILL. THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 28915 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: MADIGAN ARMY MEDICAL CENTER |NOTIFICATION DATE: 06/08/95 | | CITY: FORT LEWIS REGION: 4 |NOTIFICATION TIME: 20:09 [ET]| | COUNTY: PIERCE STATE: WA |EVENT DATE: 02/09/94 | |LICENSE#: 46-02645-03 AGREEMENT: Y |EVENT TIME: 00:00[PDT]| | DOCKET: |LAST UPDATE DATE: 06/08/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |LINDA HOWELL RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: RANDY HOULKOVICSH | | |HQ OPS OFFICER: RUDY KARSCH | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MADIGAN ARMY MEDICAL CENTER, FORT LEWIS, WASHINGTON. | | | | THREE OVEREXPOSURES TO TWO PATIENTS OCCURRED ON 2/9/94, 8/23/94 AND 1/11/95 | | DUE TO IMPROPER CALCULATION OF RADIUM EQUIVALENT. Ir-192 IMPLANTS WERE | | USED FOR TREATMENT. THE INCORRECT CONSTANT WAS USED TO CALCULATE THE | | RADIUM EQUIVALENT RESULTING IN OVERDOSES OF 24.5%, 45%, AND 36% | | RESPECTIVELY. ONE PATIENT (ONE DOSE) SUBSEQUENTLY DIED OF HIS DISEASE AND | | THE OTHER PATIENT (TWO DOSES) IS DOING BETTER THAN EXPECTED. | | | | THESE MISADMINISTRATIONS WERE DISCOVERED AFTER A REVIEW OF RECORDS PROMPTED | | BY AN INSPECTION BY REGION 4 PERSONNEL (SHAFFER AND CRUZ) AND EVENT #28884 | | ON 6/2/95. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 28916 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BRUNSWICK REGION: 2 |NOTIFICATION DATE: 06/09/95 | |UNIT: [1] [ ] [ ] STATE: NC |NOTIFICATION TIME: 03:23 [ET]| |RX TYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 06/09/95 | +------------------------------------------------+EVENT TIME: 00:07[EDT]| |NRC NOTIFIED BY: LONG |LAST UPDATE DATE: 06/09/95 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MILTON SHYMLOCK 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - HPCI SYSTEM INOP DUE TO LARGE ELECTRICAL GROUND DURING OPERABILITY TEST - | | | | DURING THE PERFORMANCE OF A HPCI SYSTEM OPERABILITY TEST, A SIGNIFICANT | | ELECTRICAL GROUND INDICATION ON THE 'A' BATTERY BUS WAS RECEIVED DUE TO | | A LARGE GROUND IN THE HPCI BAROMETRIC CONDENSER VACUUM PUMP. THIS CAUSED | | AN INCREASE IN INDICATED HPCI TURBINE SPEED AND A DECREASE IN INDICATED | | SYSTEM FLOWRATE. HOWEVER, ACTUAL HPCI TURBINE SPEED REMAINED CONSTANT. | | | | WITH THE HPCI SYSTEM INOPERABLE FOR THE TEST, TECH SPEC LCO A/S 3.5.1 | | REQUIRES LICENSEE TO RESTORE THE HPCI SYSTEM TO OPERABLE STATUS WITHIN | | 14 DAYS OR TO PLACE UNIT 1 IN AT LEAST HOT SHUTDOWN CONDITION WITHIN | | THE NEXT 12 HOURS PROVIDED THE AUTO DEPRESSURIZATION, CORE SPRAY, AND | | LPCI SYSTEMS ARE IN OPERABLE STATUS (WHICH THEY ARE). | | | | LICENSEE IS TAKING CORRECTIVE ACTIONS. | | | | LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+