U.S. Nuclear Regulatory Commission Operations Center Event Reports For 07/18/95 - 07/19/95 ** EVENT NUMBERS ** 29079 29080 29081 29082 29083 +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29079 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PALO VERDE REGION: 4 |NOTIFICATION DATE: 07/18/95 | |UNIT: [ ] [2] [ ] STATE: AZ |NOTIFICATION TIME: 06:24 [ET]| |RX TYPE: [1] CE,[2] CE,[3] CE |EVENT DATE: 07/17/95 | +------------------------------------------------+EVENT TIME: 23:31[MST]| |NRC NOTIFIED BY: ROBERSON |LAST UPDATE DATE: 07/18/95 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |TOM STETKA RDO | |ARPS 50.72(b)(2)(ii) RPS ACTUATION | | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | |NLCO TECH SPEC LCO A/S | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | A/R Y 100 POWER OPERATION | 0 HOT STANDBY | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE PLANT HAD A REACTOR TRIP FROM 100% POWER DUE TO LOW STEAM GENERATOR | | LEVEL ON STEAM GENERATOR 2. | | | | PRIOR TO THE REACTOR TRIP, CONTROL ROOM PERSONNEL WERE SWITCHING THE | | NON-CLASS "1E" 13.8KV SWITCHGEAR (NAN-SO5) FROM THE NORMAL POWER SUPPLY | | (STARTUP TRANSFORMER X01) TO THE ALTERNATE POWER SUPPLY (STARTUP | | TRANSFORMER X02) IN ORDER TO TAKE THE STARTUP TRANSFORMER X01 OUT OF | | SERVICE FOR MAINTENANCE. WHEN THE REACTOR OPERATOR CLOSED THE ALTERNATE | | BREAKER, THERE WAS NO INDICATION THAT EITHER BREAKER POSITION HAD CHANGED | | (NORMAL OR ALTERNATE) AT THE CONTROL BOARD. BELIEVING THAT THE ALTERNATE | | BREAKER HAD NOT CLOSED AND CONCERNED ABOUT AN INADVERTENT BREAKER CLOSURE, | | THE REACTOR OPERATOR RESET THE ALTERNATE BREAKER, WHICH RESULTED IN | | DE-ENERGIZING THE NAN-S05, NAN-S03, AND THE CLASS "1E" 4.16KV BUS (PBA-S03) | | AND A SUBSEQUENT LOSS OF POWER. EMERGENCY DIESEL GENERATOR "A" STARTED AS | | DESIGNED, AND POWER WAS RESTORED TO PBA-S03. | | | | WHEN NAN-S03 DE-ENERGIZED, THE CONTROL POWER (NNN-D11) TO THE STEAM BYPASS | | CONTROL SYSTEM (SBCS) AND FEEDWATER CONTROL SYSTEM (FWCS) DID NOT TRANSFER | | TO THE ALTERNATE SOURCE FED FROM THE UNIT AUXILIARY TRANSFORMER (NAN-S01). | | THE LOSS OF THE FWCS CAUSED A LOSS OF MAIN FEEDWATER TO BOTH STEAM | | GENERATORS. BOTH STEAM GENERATOR LEVELS DROPPED. THE REACTOR TRIP | | OCCURRED ON LOW STEAM GENERATOR LEVEL FOR STEAM GENERATOR 2. BOTH | | AUXILIARY FEEDWATER ACTUATION SYSTEMS 1 AND 2 ACTUATED, AND STEAM GENERATOR | | LEVEL WAS RESTORED USING AUXILIARY FEEDWATER PUMP B. | | | | NO OTHER ESF ACTUATIONS OCCURRED, AND NONE WERE REQUIRED. IT WAS | | DETERMINED THAT THE REACTOR TRIP WAS UNCOMPLICATED. ALL RODS FULLY | | INSERTED, AND THE STEAM BYPASS WAS UNAVAILABLE DUE TO LOSS OF CONTROL POWER | | RESULTING IN STEAM RELEASE THROUGH THE STEAM GENERATOR 1 AND STEAM | | GENERATOR 2 MAIN STEAM SAFETY RELIEF VALVES (ONE ON EACH STEAM GENERATOR). | | THE VALVES FULLY RESEATED WITHIN 30 SECONDS, AND SUBSEQUENT HEAT REMOVAL | | WAS RESTORED USING THE DUMP VALVES AND LATER USING SBCS. | | | | THE ELECTRICAL BUS TRANSFER PROBLEMS INCLUDED FAULTY INDICATION AT THE | | CONTROL BOARD AND FAILURE OF CONTROL POWER TO TRANSFER. THE LOSS OF | | INDICATION FOR BREAKER POSITION HAS BEEN ATTRIBUTED TO A MULTIPLEXER | | PROBLEM. THE NORMAL AND ALTERNATE BREAKERS PHYSICALLY SWITCHED AS | | REQUIRED. THE FAILURE OF CONTROL SYSTEM TO SWAP POWER SOURCES IS STILL | | UNDER INVESTIGATION. | | | | THE PLANT ALSO ENTERED (00:42MST) AND EXITED (02:25MST) AN LCO ACTION | | STATEMENT WHEN THE PRESSURIZER LEVEL EXCEEDED 56% (APPROXIMATELY 82.25%) | | UNTIL IT WAS MANUALLY RESTORED TO THE CORRECT LEVEL. | | | | THE RESIDENT INSPECTOR WAS INFORMED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29080 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: OCONEE REGION: 2 |NOTIFICATION DATE: 07/18/95 | |UNIT: [ ] [ ] [3] STATE: SC |NOTIFICATION TIME: 07:21 [ET]| |RX TYPE: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP |EVENT DATE: 07/18/95 | +------------------------------------------------+EVENT TIME: 06:52[EDT]| |NRC NOTIFIED BY: MARTY STASNY |LAST UPDATE DATE: 07/18/95 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: UNUSUAL EVENT +-----------------------------+ |10 CFR SECTION: |WILLIAM RANKIN RDO | |AAEC 50.72(a)(1)(i) EMERGENCY DECLARED |ED GOODWIN EO | | |GARY BELCHER FEMA | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | | | | | 3 | N N 0 HOT SHUTDOWN | 0 HOT SHUTDOWN | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | UNUSUAL EVENT DECLARED DUE TO UNIDENTIFIED REACTOR COOLANT SYSTEM LEAKAGE | | INCREASING TO APPROXIMATELY SEVEN GALLON PER MINUTE (GPM) WITH THE UNIT IN | | HOT SHUTDOWN. | | | | WHILE PREPARING THE UNIT FOR STARTUP FOLLOWING A REFUELING OUTAGE, THE | | UNIDENTIFIED REACTOR COOLANT SYSTEM LEAKAGE INCREASED TO APPROXIMATELY 7 | | GPM OVER A SHORT PERIOD OF TIME, AND AN UNUSUAL EVENT WAS DECLARED AT | | 06:52. THE TECHNICAL SPECIFICATIONS REQUIRE THE UNIT TO SHUT DOWN WITHIN | | 24 HOURS IF THE UNIDENTIFIED LEAKAGE BECOMES GREATER THAN 1 GPM, AND THE | | UNIT WAS IN HOT SHUTDOWN AT THE TIME OF THE EVENT. THE LICENSEE IS IN THE | | PROCESS OF COOLING DOWN THE UNIT AND PLANS TO ENTER COLD SHUTDOWN IN ORDER | | TO CONFIRM THE LOCATION OF THE LEAK AND FACILITATE THE LEAK REPAIR. THE | | LICENSEE CURRENTLY BELIEVES THAT THERE MAY BE A PACKING LEAK ON PRESSURIZER | | SPRAY BLOCK VALVE #3RC3. | | | | THERE HAVE BEEN NO PROTECTIVE ACTIONS RECOMMENDED BY THE LICENSEE, AND | | THERE ARE NO SAFETY-RELATED SYSTEMS OUT OF SERVICE AT THIS TIME. CHARGING | | AND MAKEUP IS BEING USED FOR PRIMARY SYSTEM INVENTORY CONTROL, AND MAIN | | FEEDWATER IS BEING USED FOR STEAM GENERATOR INVENTORY CONTROL. THE UNIT IS | | ALSO STEAMING TO THE CONDENSER. THE LICENSEE NOTIFIED THE NRC RESIDENT | | INSPECTOR AND THE STATE AND LOCAL GOVERNMENTS. | | | | * * * UPDATE AT 2255 EDT FROM KOHLER TAKEN BY KARSCH * * * | | THE LICENSEE TERMINATED THE UNUSUAL EVENT AT 2243 WHEN THE REACTOR REACHED | | COLD SHUTDOWN MODE. THE MAXIMUM LEAK RATE FROM THE PRESSURIZER SPRAY BLOCK | | VALVE PACKING WAS 35 GPM WHILE THE PRESSURIZER SPRAY THROTTLE VALVE WAS | | OPEN. THE LICENSEE WILL NOTIFY THE NRC RESIDENT INSPECTOR AND STATE AND | | COUNTY AUTHORITIES. HOO NOTIFIED NRR EO BUTCHER, R2DO VIAS, FEMA AUSTIN. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29081 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SALEM REGION: 1 |NOTIFICATION DATE: 07/18/95 | |UNIT: [1] [2] [ ] STATE: NJ |NOTIFICATION TIME: 13:43 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 07/18/95 | +------------------------------------------------+EVENT TIME: 13:30[EDT]| |NRC NOTIFIED BY: MARIOS KAFANTARIS |LAST UPDATE DATE: 07/18/95 | |HQ OPS OFFICER: RUDY KARSCH +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |FRANK COSTELLO RDO | |AOUT 50.72(b)(1)(ii)(B) OUTSIDE DESIGN BASIS | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 | N N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | CALCULATIONS DEMONSTRATING COMPLIANCE WITH GDC 19 FOR CONTROL ROOM HVAC DO | | NOT EXIST. PRELIMINARY CALCULATIONS SHOW THAT THE SYSTEM OPERATING MODE | | ASSUMED IN THE UFSAR ACCIDENT ANALYSIS LEADS TO AN UNACCEPTABLE THYROID | | DOSE; HOWEVER, OTHER MODES OF OPERATION MIGHT BE SATISFACTORY. IN THE NEAR | | TERM, THE LICENSEE MUST IDENTIFY AN ACCEPTABLE OPERATING SCHEME PRIOR TO | | THE RESTART OF HOPE CREEK (WHICH IS SCHEDULED FOR 07/20/95). IN THE LONG | | TERM, THE LICENSEE WILL PERFORM AN ANALYSIS TO IDENTIFY THE CORRECT RATIO | | OF RECIRCULATION TO MIXED AIR MODE AND WILL SUBMIT THE CALCULATIONS. THE | | LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 29082 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: ARLINGTON HOSPITAL |NOTIFICATION DATE: 07/18/95 | | CITY: ARLINGTON REGION: 2 |NOTIFICATION TIME: 15:59 [ET]| | COUNTY: ARLINGTON STATE: VA |EVENT DATE: 07/17/95 | |LICENSE#: 45-01099-01 AGREEMENT: N |EVENT TIME: 09:00[EDT]| | DOCKET: |LAST UPDATE DATE: 07/18/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |STEVEN VIAS RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: DR LANDIS | | |HQ OPS OFFICER: RUDY KARSCH | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | ARLINGTON HOSPITAL, ARLINGTON, VIRGINIA. A PATIENT WAS ADMINISTERED A | | HIGHER DOSE THAN REQUESTED DURING A DIAGNOSTIC PROCEDURE. | | | | THE HOSPITAL DETERMINED AT 1400 EDT ON 7/18/95 THAT A PATIENT RECEIVED | | 160 MICROCURIES OF I-131 VERSUS 100 MICROCURIES OF I-131. THIS RESULTED IN | | A HIGHER THAN EXPECTED DOSE TO THE PATIENT'S THYROID GLAND. THE PATIENT'S | | PHYSICIAN HAS BEEN INFORMED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29083 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: COMANCHE PEAK REGION: 4 |NOTIFICATION DATE: 07/18/95 | |UNIT: [1] [2] [ ] STATE: TX |NOTIFICATION TIME: 19:33 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 07/18/95 | +------------------------------------------------+EVENT TIME: 15:30[CDT]| |NRC NOTIFIED BY: EUGENE SKELTON |LAST UPDATE DATE: 07/18/95 | |HQ OPS OFFICER: RUDY KARSCH +-----------------------------+ +------------------------------------------------+ 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 100 POWER OPERATION | 100 POWER OPERATION | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE LICENSEE NOTIFIED THE TEXAS NATURAL RESOURCE CONSERVATION COUNCIL AND | | INTENDS TO NOTIFY THE TEXAS PARK AND WILDLIFE COMMISSION REGARDING A FISH | | KILL IN SQUAW CREEK RESERVOIR. ABOUT 50 DEAD FISH WERE OBSERVED. THE | | CAUSE OF THE FISH KILL IS NOT KNOWN. THE LICENSEE INFORMED THE NRC | | RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+