U.S. Nuclear Regulatory Commission Operations Center Event Reports For 06/12/95 - 06/13/95 ** EVENT NUMBERS ** 28931 28932 28933 28934 +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 28931 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: INDIAN POINT REGION: 1 |NOTIFICATION DATE: 06/12/95 | |UNIT: [2] [ ] [ ] STATE: NY |NOTIFICATION TIME: 09:54 [ET]| |RX TYPE: [2] W-4-LP,[3] W-4-LP |EVENT DATE: 06/12/95 | +------------------------------------------------+EVENT TIME: 08:48[EDT]| |NRC NOTIFIED BY: MASSARO |LAST UPDATE DATE: 06/12/95 | |HQ OPS OFFICER: TIM McGINTY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JENNY JOHANSEN 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 2 | A/R Y 90 POWER OPERATION | 0 HOT STANDBY | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AT 0848, THE UNIT 2 REACTOR TRIPPED DUE TO A GENERATOR TRIP. THE CAUSE IS | | UNKNOWN AND IS UNDER INVESTIGATION. | | | | ALL RODS FULLY INSERTED INTO THE CORE. ALL OFF-SITE POWER SUPPLIES | | REMAINED AVAILABLE AND THERE WERE NO PROBLEMS WITH ELECTRICAL BUSES. ALL | | EDG's AND ECCS's ARE OPERATIONAL AND AVAILABLE. AUXILIARY FEEDWATER | | AUTO-STARTED (ON LOW SG LEVELS), AS EXPECTED, AND IS BEING UTILIZED TO FEED | | THE STEAM GENERATORS. STEAM IS BEING REMOVED TO THE MAIN CONDENSER VIA THE | | DUMPS. THERE WERE NO UNUSUAL PRESSURE OR LEVEL TRANSIENTS ON EITHER THE | | PRIMARY OR SECONDARY SIDES. NO PRIMARY OR SECONDARY RELIEF VALVES LIFTED | | IN RESPONSE TO THE TRANSIENT. THE FIRST OUT FOR THE REACTOR TRIP IS THE | | MAIN GENERATOR TRIP, AND THE CAUSE OF THE GENERATOR TRIP IS UNKNOWN. | | | | ADDITIONALLY, THE "21, 22 & 24" MAIN FEEDWATER REGULATING VALVES FAILED TO | | CLOSE, AS EXPECTED, ON THE MAIN FEEDWATER ISOLATION RECEIVED (RX TRIP WITH | | LOW Tavg). OPERATORS MANUALLY CLOSED THE VALVES UPON RECEIPT OF THE | | ISOLATION. THE LICENSEE IS ALSO INVESTIGATING THIS PROBLEM. | | | | THE LICENSEE INFORMED THE RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 28932 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: ST. MARY'S HOSPITAL |NOTIFICATION DATE: 06/12/95 | | CITY: MEQUON REGION: 3 |NOTIFICATION TIME: 10:23 [ET]| | COUNTY: STATE: WI |EVENT DATE: 05/20/95 | |LICENSE#: 030-12682 AGREEMENT: N |EVENT TIME: 12:00[CDT]| | DOCKET: |LAST UPDATE DATE: 06/12/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |LEWIS MILLER RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: KLUG | | |HQ OPS OFFICER: TIM McGINTY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |FFFF 20.402 UNSPECIFIED PARAGRAPH | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | ST. MARY's HOSPITAL, LOCATED IN MEQOUN, WI, REPORTED THE LOSS OF A 10 | | MICRO-CURIE Cs-137 SOURCE TO BE USED FOR CALIBRATION OF A MULTI-CHANNEL | | ANALYZER THYROID PROBE. | | | | ON 3/23/95, A PACKAGE CONTAINING A 10 MICRO-CURIE Cs-137 BUTTON SOURCE | | SHIPPED FROM THE BIODEX CO. (LOCATED IN SHIRLEY, NY) VIA FEDERAL EXPRESS | | WAS RECEIVED AND SIGNED FOR BY THE SHIPPING DEPARTMENT AT ST. MARY's | | HOSPITAL. THE NUCLEAR MEDICINE DEPARTMENT AT THE HOSPITAL HAS NOT RECEIVED | | THE SOURCE. THE LICENSEE DETERMINED ON MAY 20th, 1995, THAT THE SOURCE HAD | | NOT BEEN RECEIVED, AND EFFORTS TO LOCATE IT IN THE INTERIM HAVE NOT BEEN | | SUCCESSFUL. THE LICENSEE HAS CONTACTED REGION 3 (GIBBONS), AND DOES NOT | | CONSIDER THE LOST SOURCE A POTENTIAL PERSONNEL HAZARD. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 28933 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: MADIGAN ARMY MEDICAL CENTER |NOTIFICATION DATE: 06/12/95 | | CITY: FORT LEWIS REGION: 4 |NOTIFICATION TIME: 14:02 [ET]| | COUNTY: STATE: WA |EVENT DATE: 02/03/95 | |LICENSE#: 46-02645-03 AGREEMENT: Y |EVENT TIME: 00:00[PDT]| | DOCKET: |LAST UPDATE DATE: 06/12/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |LAWRENCE YANDELL RDO | | |ROBERT PIERSON EO | +------------------------------------------------+ | |NRC NOTIFIED BY: HOULKOVICSH | | |HQ OPS OFFICER: JOSEPH SEBROSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MADIGAN ARMY MEDICAL CENTER OF FORT LEWIS, WASHINGTON CALLED TO REPORT A | | MEDICAL MISADMINISTRATION. | | | | THE LICENSEE HAS BEEN REVIEWING RECORDS DUE TO PROBLEMS WITH PAST MEDICAL | | MISADMINISTRATIONS (SEE EVENT #28884, AND 28915). DURING THIS REVIEW THE | | LICENSEE HAS DETERMINED THAT ANOTHER MEDICAL MISADMINISTRATION OCCURRED ON | | 2/3/95. THE INCIDENT OCCURRED WHEN 1500 RADS WAS PRESCRIBED USING IRIDIUM | | 192 SEEDS DURING A BRACHYTHERAPY TREATMENT. A WRONG CONVERSION CONSTANT | | WAS USED TO CALCULATE THE RADIUM EQUIVALENT RESULTING IN AN OVERDOSE OF | | 26.8% (2050 RADS). THE LICENSEE WILL INFORM THE PHYSICIAN AND THE PATIENT | | OF THE MALADMINISTRATION. NO ADVERSE HEALTH EFFECTS ARE EXPECTED TO THE | | PATIENT. | | | | THE LICENSEE HAS BEEN IN CONTACT WITH REGION 4 (SHAFFER) CONCERNING THIS | | EVENT. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 28934 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: OCONEE REGION: 2 |NOTIFICATION DATE: 06/12/95 | |UNIT: [ ] [ ] [3] STATE: SC |NOTIFICATION TIME: 16:08 [ET]| |RX TYPE: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP |EVENT DATE: 06/12/95 | +------------------------------------------------+EVENT TIME: 15:29[EDT]| |NRC NOTIFIED BY: OTTO KOHLER |LAST UPDATE DATE: 06/12/95 | |HQ OPS OFFICER: JOSEPH SEBROSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MILTON SHYMLOCK RDO | |AMED 50.72(b)(2)(v) OFFSITE MEDICAL | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | A POTENTIALLY CONTAMINATED INDIVIDUAL WAS TRANSPORTED BY AMBULANCE TO THE | | HOSPITAL. | | | | THE WORKER WAS WORKING IN THE REACTOR BUILDING FOR UNIT 3 WHEN HE SUFFERED | | AN APPARENT HEART ATTACK. CPR WAS PERFORMED ON THE INDIVIDUAL AT THE SITE | | AND THE INDIVIDUAL WAS TRANSPORTED TO THE OCONEE MEMORIAL HOSPITAL. | | | | THE LICENSEE HAS INFORMED THE RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+