U.S. Nuclear Regulatory Commission Operations Center Event Reports For 07/25/95 - 07/26/95 ** EVENT NUMBERS ** 29043 29104 29105 29106 29107 29108 29109 29110 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29043 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SALEM REGION: 1 |NOTIFICATION DATE: 07/09/95 | |UNIT: [1] [2] [ ] STATE: NJ |NOTIFICATION TIME: 20:05 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 07/09/95 | +------------------------------------------------+EVENT TIME: 16:43[EDT]| |NRC NOTIFIED BY: HAMILTON |LAST UPDATE DATE: 07/25/95 | |HQ OPS OFFICER: RUDY KARSCH +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |WILLIAM LAZARUS 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 | | 2 | N N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE LICENSEE FOUND A SERVICE WATER BAY SUMP PUMP MOTOR HORSEPOWER RATING | | DISCREPANCY WHICH COULD RESULT IN EXCEEDING THE EMERGENCY DIESEL GENERATOR | | (EDG) LOAD LIMITS. | | | | DIFFERENCES BETWEEN DESIGN DOCUMENTATION AND INSTALLATION DATA HAVE CAUSED | | QUESTIONS TO ARISE REGARDING THE EDG LOADING DURING AN SI/LOOP. THE | | LICENSEE IS ATTEMPTING TO ASCERTAIN THE ACTUAL MOTOR RATINGS AT THIS TIME. | | PENDING RESOLUTION OF THIS ISSUE ELECTRICAL POWER TO THE PUMPS HAS BEEN | | SHUT OFF. AN OPERATOR HAS BEEN STATIONED AT THE SERVICE WATER BAY TO | | MANUALLY OPERATE THE PUMPS TO CONTROL SUMP LEVEL. THE LICENSEE WILL INFORM | | THE NRC RESIDENT INSPECTOR AND LOWER ALLOWAYS CREEK TOWNSHIP. | | | | * * * UPDATE 1227 7/25/95 FROM KAFANGARIS TAKEN BY STRANSKY * * * | | | | LICENSEE IS RETRACTING THIS NOTIFICATION. THE FOLLOWING IS TEXT OF A | | FACSIMILE SUBMITTED BY THE LICENSEE: | | | | "THIS IS A RETRACTION OF A 4-HOUR REPORT MADE ON 7/9/95 AT 2006. THE | | REPORT WAS ON THE SW BAY SUMP PUMPS BEING AT A HIGHER RATED MOTOR CAPACITY | | THAN USED IN THE D/G LOAD ANALYSIS. SUBSEQUENT INVESTIGATION AS TO ACTUAL | | PUMP MOTOR RATINGS, AND USING THIS RATING IN THE LOAD ANALYSIS SHOWS THAT | | ALL LOAD CALCULATIONS ARE WITHIN ACCEPTABLE LIMITS. THE UNIT 2 SUMP PUMP | | MOTORS WERE AT THE SAME VALUE USED IN THE LOAD STUDY, THEREFORE NO CHANGES | | IN THE ANALYSIS WERE SEEN. THE UNIT 1 SUMP PUMPS WERE FOUND TO BE AT 28 | | VICE 24.8 AMPS USED IN THE ANALYSIS. A REANALYSIS SHOWED ALL U1 LOADS TO | | BE ACCEPTABLE." | | | | THE NRC RESIDENT INSPECTOR HAS BEEN INFORMED BY THE LICENSEE. NOTIFIED | | R1DO (KEIMIG). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29104 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: OYSTER CREEK REGION: 1 |NOTIFICATION DATE: 07/25/95 | |UNIT: [1] [ ] [ ] STATE: NJ |NOTIFICATION TIME: 01:52 [ET]| |RX TYPE: [1] GE-2 |EVENT DATE: 07/24/95 | +------------------------------------------------+EVENT TIME: 23:45[EDT]| |NRC NOTIFIED BY: FRANK CIGANIK |LAST UPDATE DATE: 07/25/95 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |RICHARD KEIMIG 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 90 POWER OPERATION | 90 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE LICENSEE PLANS TO NOTIFY THE STATE OF HIGH DISCHARGE CANAL TEMPERATURE | | | | THE LICENSEE PLANS TO MAKE AN ENVIRONMENTAL NOTIFICATION TO THE NEW JERSEY | | DEPARTMENT OF ENVIRONMENTAL PROTECTION AND ENERGY BECAUSE THE DISCHARGE | | CANAL TEMPERATURE REACHED THE PERMIT REPORTABILITY LEVEL OF 97.7øF AT THE | | BRIDGE MONITORING POINT. THIS TEMPERATURE LEVEL IS NOT A LIMIT. THE | | LICENSEE IS NOT REQUIRED TO MAINTAIN DISCHARGE CANAL TEMPERATURE BELOW THIS | | LEVEL BUT IS REQUIRED TO MAKE AN ENVIRONMENTAL REPORT WITHIN 24 HOURS IF | | THE LEVEL IS EXCEEDED. | | | | THERE ARE TWO DISCHARGE CANAL TEMPERATURE SENSORS. ONE READ 95.5øF, AND | | THE OTHER READ 97.7øF. THE WATER FROM THIS CANAL DISCHARGES INTO THE BAY. | | | | THE LICENSEE WILL ALSO NOTIFY THE RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 29105 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: HEALTH EAST ST. JOHNS HOSPITAL |NOTIFICATION DATE: 07/25/95 | | CITY: MAPLEWOOD REGION: 3 |NOTIFICATION TIME: 10:08 [ET]| | COUNTY: STATE: MN |EVENT DATE: 07/17/95 | |LICENSE#: 22-24441-01 AGREEMENT: N |EVENT TIME: 09:00[CDT]| | DOCKET: |LAST UPDATE DATE: 07/25/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |THOMAS BURDICK RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: RICH HANSON | | |HQ OPS OFFICER: LEIGH TROCINE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MEDICAL MISADMINISTRATION OF A DIAGNOSTIC I-131 CAPSULE AT HEALTH EAST ST. | | JOHNS HOSPITAL IN MAPLEWOOD, MN. | | | | WHILE REVIEWING THE PROGRAM AT APPROXIMATELY 1700 ON JULY 24, 1995, THE | | LICENSEE DISCOVERED THAT A MEDICAL MISADMINISTRATION HAD OCCURRED AT 0900 | | ON MAY 17, 1995. THE WRITTEN DIRECTIVE CALLED FOR A DOSE OF 3.0 | | MILLICURIES OF I-131 TO DIAGNOSE ANY METASTATIC THYROID CANCER, AND A DOSE | | OF 3.67 MILLICURIES OF I-131 WAS ADMINISTERED. THE WAS ABOVE THE 20% | | LIMIT. | | | | THE PRIMARY PHYSICIAN (ENDOCRINOLOGIST) WAS INFORMED AND DID NOT WISH THAT | | THE PATIENT BE INFORMED OF THE MISADMINISTRATION. THE LICENSEE DID NOT | | BELIEVE THAT THERE WERE ANY ADVERSE EFFECTS TO THE PATIENT BECAUSE THE | | PATIENT'S THYROID (THE TARGET ORGAN) WAS PREVIOUSLY REMOVED AND BECAUSE | | THERE WAS MINIMAL INCREASED DOSAGE TO THE PATIENT. | | | | FOR THE 3.67 MILLICURIE ADMINISTRATION, THE ESTIMATED TOTAL BODY DOSE WAS | | 1.7249 RADS. THE DOSE TO THE BLADDER WALL WAS 9.909 RADS, AND THE DOSE TO | | THE STOMACH WALL WAS 5.1872 RADS. THE DOSES TO THE LIVER, RED MARROW, | | SKELETON, AND OVARIES WERE 1.2845 RADS, 0.734 RADS, 0.6606 RADS, AND 0.5138 | | RADS, RESPECTIVELY. THE ESTIMATED DOSE FOR A 3.0 MILLICURIE ADMINISTRATION | | OF I-131 WOULD HAVE BEEN 1.41 RADS. THE DOSE TO THE BLADDER WALL WOULD | | HAVE BEEN 8.10 RADS, AND THE DOSE TO THE STOMACH WALL WOULD HAVE BEEN 4.80 | | RADS. THE DOSES TO THE LIVER, RED MARROW, SKELETON, AND OVARIES WOULD HAVE | | BEEN 1.05 RADS, 0.60 RADS, 0.540 RADS, AND 0.420 RADS, RESPECTIVELY. | | | | THE LICENSEE PLANS TO NOTIFY THE NRC REGIONAL OFFICE AND IS INVESTIGATING | | THE REQUIREMENTS FOR NOTIFYING THE STATE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29106 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: VERMONT YANKEE REGION: 1 |NOTIFICATION DATE: 07/25/95 | |UNIT: [1] [ ] [ ] STATE: VT |NOTIFICATION TIME: 14:17 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 07/25/95 | +------------------------------------------------+EVENT TIME: 14:10[EDT]| |NRC NOTIFIED BY: WOOKEY |LAST UPDATE DATE: 07/25/95 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |KEIMIG 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 Y 94 POWER OPERATION | 94 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | REMOTE SHUTDOWN PANEL OPERATION OF RCIC AND RHR SYSTEMS COULD BE AFFECTED | | BY 10 CFR PART 50, APPENDIX R, HOT SHORT CONDITIONS. | | | | A LICENSEE REEVALUATION OF ITS RESPONSE TO NRC INFORMATION NOTICE 92-18 | | DETERMINED THAT EVALUATIONS FOR 24 MOTOR OPERATED VALVES (MOVs) HAD NOT | | BEEN COMPLETED. OF THESE VALVES, 3 MAY NOT BE ACCESSIBLE FOR MANUAL | | OPERATION, AND THEIR OPERATION FROM THE ALTERNATE SHUTDOWN PANEL HAS BEEN | | QUESTIONED. THE THREE AFFECTED VALVES ARE LOCATED IN THE RCIC AND RHR | | SYSTEMS. DUE TO THIS CONDITION, THE LICENSEE HAS DETERMINED THAT THE PLANT | | IS OUTSIDE OF ITS DESIGN BASIS. | | | | AS A COMPENSATORY ACTION, THE LICENSEE HAS INITATED A ROVING FIRE WATCH. | | THE NRC RESIDENT INSPECTOR HAS BEEN INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29107 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: ROBINSON REGION: 2 |NOTIFICATION DATE: 07/25/95 | |UNIT: [2] [ ] [ ] STATE: SC |NOTIFICATION TIME: 15:02 [ET]| |RX TYPE: [2] W-3-LP |EVENT DATE: 07/25/95 | +------------------------------------------------+EVENT TIME: 11:10[EDT]| |NRC NOTIFIED BY: CROOK |LAST UPDATE DATE: 07/25/95 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |CRLENJAK RDO | |APRE 50.72(b)(2)(vi) OFFSITE NOTIFICATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | LICENSEE NOTIFIED STATE OF SOUTH CAROLINA REGARDING SMALL OIL SHEEN SPOTTED | | ON LAKE NEAR PLANT INTAKE STRUCTURE. | | | | THE LICENSEE NOTIFIED THE SOUTH CAROLINA DEPARTMENT OF HEALTH AND | | ENVIRONMENTAL CONTROL AND THE NATIONAL RESPONSE CENTER REGARDING AN OIL | | SHEEN SPOTTED ON LAKE ROBINSON. A LEAKING SERVICE WATER STRAINER GEAR BOX | | LOWER OIL SEAL AT THE INTAKE STRUCTURE WAS FOUND. THE OIL DRIPPED INTO A | | SUMP WHICH IS AUTOMATICALLY PUMPED DOWN. THE OIL SHEEN IS APPROXIMATELY 20 | | FEET BY 25 FEET. | | | | THE LICENSEE HAS DISABLED THE AUTOMATIC SUMP LEVEL CONTROL SYSTEM, AND IS | | CURRENTLY CLEANING UP THE SPILL. THE NRC RESIDENT INSPECTOR HAS BEEN | | INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29108 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: DUANE ARNOLD REGION: 3 |NOTIFICATION DATE: 07/25/95 | |UNIT: [1] [ ] [ ] STATE: IA |NOTIFICATION TIME: 15:28 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 07/25/95 | +------------------------------------------------+EVENT TIME: 12:29[CDT]| |NRC NOTIFIED BY: FOWLER |LAST UPDATE DATE: 07/25/95 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BURDICK RDO | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | INADVERTENT RCIC SYSTEM ISOLATION DURING TESTING. | | | | AN AUTOMATIC CLOSURE OF THE RCIC INBOARD ISOLATION VALVE OCCURRED DURING A | | SURVEILLANCE TEST WHEN A RELAY WHICH WAS BEING BLOCKED AS PART OF THE | | SURVEILLANCE TEST WAS BUMPED, CAUSING AN INBOARD GROUP 6 ISOLATION SIGNAL. | | | | THE LICENSEE ABORTED THE TEST, RESET THE ISOLATION, AND RESTORED RCIC TO | | OPERABLE STATUS WITHIN APPROXIMATELY THREE MINUTES. THE NRC RESIDENT | | INSPECTOR HAS BEEN INFORMED BY THE LICENSEE. | | | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29109 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: VOGTLE REGION: 2 |NOTIFICATION DATE: 07/25/95 | |UNIT: [1] [ ] [ ] STATE: GA |NOTIFICATION TIME: 15:24 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 07/25/95 | +------------------------------------------------+EVENT TIME: 11:45[EDT]| |NRC NOTIFIED BY: MEYER |LAST UPDATE DATE: 07/25/95 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |CRLENJAK RDO | |AINC 50.72(b)(2)(iii)(C) POT UNCNTRL RAD REL | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 HOT STANDBY | 0 HOT STANDBY | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | CONTAINMENT VENTILATION ISOLATION LOGIC INADVERTENTLY LEFT BLOCKED. | | | | THE AUTOMATIC HIGH RADIATION CLOSURE PORTION OF THE CONTAINMENT VENTILATION | | ISOLATION (CVI) SYSTEM LOGIC WAS INADVERTENTLY LEFT BLOCKED FOR A PERIOD OF | | 3 HOURS AND 42 MINUTES FOLLOWING AN EVOLUTION INSIDE THE CONTAINMENT | | CONDUCTED ON 7/24/95. THIS CONDITION WAS DISCOVERED DURING A REVIEW OF | | SHIFT LOGS. THE CONTAINMENT REMAINED ISOLATED DURING THIS PERIOD. | | | | THE LICENSEE STATED THAT THE CVI HIGH RADIATION LOGIC HAD BEEN BLOCKED AS | | PART OF THE MOVEMENT OF A SOURCE RANGE MONITOR DETECTOR WITHIN THE | | CONTAINMENT. ALTHOUGH THE HIGH RADIATION LOGIC OF THE CVI SYSTEM WAS | | BLOCKED, IN THE EVENT OF AN ACCIDENT, THE CVI LOGIC WOULD HAVE ACTUATED DUE | | TO REDUNDANT SIGNALS GENERATED BY THE SAFETY INJECTION, CONTAINMENT | | ISOLATION ACTUATION, AND CONTAINMENT SPRAY SYSTEMS. THE NRC RESIDENT | | INSPECTOR HAS BEEN INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29110 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: OYSTER CREEK REGION: 1 |NOTIFICATION DATE: 07/25/95 | |UNIT: [1] [ ] [ ] STATE: NJ |NOTIFICATION TIME: 18:23 [ET]| |RX TYPE: [1] GE-2 |EVENT DATE: 07/25/95 | +------------------------------------------------+EVENT TIME: 14:33[EDT]| |NRC NOTIFIED BY: CIGANIK |LAST UPDATE DATE: 07/25/95 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |KEIMIG 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 | 91 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | LICENSEE NOTIFIED STATE REGARDING EXCESSIVE DISCHARGE CANAL WATER | | TEMPERATURES. | | | | THE LICENSEE NOTIFIED THE NEW JERSEY BUREAU OF STANDARD PERMITTING, | | DIVISION OF WATER QUALITY, REGARDING A PLANT DISCHARGE CANAL TEMPERATURE IN | | EXCESS OF THE REPORTING LIMIT. (ALSO SEE RELATED EVENT #29104.) THE | | LICENSEE STATED THAT THE TEMPERATURE IN THE PLANT DISCHARGE CANAL EXCEEDED | | 97øF AT 1433, AND HAS REMAINED NEAR THAT TEMPERATURE THROUGHOUT THE | | AFTERNOON. THE LICENSEE IS CURRENTLY REDUCING REACTOR POWER IN ORDER TO | | COMPENSATE FOR INCREASING INTAKE TEMPERATURES. THE NRC RESIDENT INSPECTOR | | HAS BEEN NOTIFIED BY THE LICENSEE. | +------------------------------------------------------------------------------+