U.S. Nuclear Regulatory Commission Operations Center Event Reports For 11/03/95 - 11/06/95 ** EVENT NUMBERS ** 29549 29550 29551 29552 29553 29554 29555 29556 29557 29558 29559 29560 29561 29562 +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29549 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BRAIDWOOD REGION: 3 |NOTIFICATION DATE: 11/03/95 | |UNIT: [1] [2] [ ] STATE: IL |NOTIFICATION TIME: 10:47 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 11/02/95 | +------------------------------------------------+EVENT TIME: 16:41[CST]| |NRC NOTIFIED BY: TIM KIRMAN |LAST UPDATE DATE: 11/03/95 | |HQ OPS OFFICER: JOSEPH SEBROSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: | | |HFIT 26.73 FITNESS FOR DUTY | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 REFUELING | 0 REFUELING | | 2 | N Y 99 POWER OPERATION | 99 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | DURING A FOLLOWUP TEST ON A NON-LICENSED CONTRACT SUPERVISOR, THE | | SUPERVISOR TESTED POSITIVE FOR ALCOHOL. THE INDIVIDUAL'S ACCESS TO THE | | SITE HAS BEEN TERMINATED, AND THE LICENSEE IS PERFORMING A WORK PERFORMANCE | | REVIEW. | | | | THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 29550 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: VA MEDCIAL CENTER, RICHMONDS, VA. |NOTIFICATION DATE: 11/03/95 | | CITY: RICHMOND REGION: 2 |NOTIFICATION TIME: 11:59 [ET]| | COUNTY: STATE: VA |EVENT DATE: 10/05/95 | |LICENSE#: 45-09413-06 AGREEMENT: N |EVENT TIME: 11:00[EST]| | DOCKET: |LAST UPDATE DATE: 11/03/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |MILT SHYMLOCK RDO | | |FRED COMBS (NMSS) EO | +------------------------------------------------+ | |NRC NOTIFIED BY: PANOS FATOUROS | | |HQ OPS OFFICER: JOHN MacKINNON | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |BAB2 20.2201(a)(1)(ii) LOST/STOLEN LNM>10X | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | 500 æCi OF IODINE-125 WAS ACCIDENTALLY SENT TO A LANDFILL AND BURIED. | | | | THE RADIATION SAFETY OFFICER FOR THE VETERANS ADMINISTRATION MEDICAL CENTER | | LOCATED IN RICHMOND, VIRGINIA, REPORTED THAT 500 æCi OF I-125 (60-DAY HALF | | LIFE) WAS SHIPPED BY BFI WASTE COMPANY TO A LANDFILL ON OCTOBER 05, 1995. A | | CLEAR PLASTIC BAG WITH RADIATION MARKINGS ON THE OUTSIDE OF IT CONTAINED | | 500 æCi OF I-125 (SOLID WASTE). THE BAG WAS LOCATED IN A STORAGE ROOM | | INSIDE A RESEARCH LABORATORY WITH RADIATION SIGNS ON ITS DOOR, AND IT WAS | | ACCIDENTALLY PICKED UP BY THE VA MEDICAL CENTER TRASH PEOPLE. THE BAG WAS | | DROPPED DOWN A SHOOT TO A TRASH COMPACTOR AND WAS THEN COMPACTED. THE | | COMPACTED TRASH WAS THEN TAKEN BY BFI WASTE COMPANY TO A LOCAL LANDFILL. | | | | THE LICENSEE SUBMITTED A 30-DAY REPORT OF THIS INCIDENT TO REGION 2 (CHUCK | | HOSEY) ON NOVEMBER 2, 1995. THE LICENSEE NOW STORES ITS RADIOACTIVE TRASH | | IN YELLOW BAGS WITH RADIATION MARKINGS ON THE OUTSIDE OF THE BAGS. THE VA | | MEDICAL CENTER CLEANING PEOPLE HAVE ALSO BEEN INFORMED NOT TO THROW YELLOW | | PLASTIC BAGS IN THE TRASH. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29551 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PALISADES REGION: 3 |NOTIFICATION DATE: 11/03/95 | |UNIT: [1] [ ] [ ] STATE: MI |NOTIFICATION TIME: 12:44 [ET]| |RX TYPE: [1] CE |EVENT DATE: 11/03/95 | +------------------------------------------------+EVENT TIME: 11:45[EST]| |NRC NOTIFIED BY: M KANE |LAST UPDATE DATE: 11/03/95 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |LEWIS MILLER 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 100 POWER OPERATION | 100 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | DURING APPENDIX R PROGRAM RE-ANALYSIS, IT WAS FOUND THAT A FIRE IN THE | | CONTROL ROOM OR THE CABLE SPREADING ROOM COULD CAUSE THE LOSS OF VOLTAGE | | REGULATION TO ONE OF THE EMERGENCY DIESEL GENERATORS. | | | | DURING APPENDIX R PROGRAM RE-ANALYSIS, IT WAS FOUND THAT A FIRE IN THE | | CONTROL ROOM OR THE CABLE SPREADING ROOM COULD RESULT IN A LOSS OF VOLTAGE | | REGULATION TO ONE OF THE EMERGENCY DIESEL GENERATORS (EDG 1-1). A FIRE | | COULD CAUSE FUSES IN THE EMERGENCY DIESEL GENERATOR CIRCUIT TO | | ACTUATE/BLOW, AND THIS WOULD CAUSE THE LOSS OF VOLTAGE REGULATION TO THE | | AFFECTED EMERGENCY DIESEL GENERATOR. BOTH EMERGENCY DIESEL GENERATORS | | WOULD NOT BE MADE INOPERABLE BY THE SAME FIRE. THE LICENSEE STATED THAT | | ITS EMERGENCY DIESEL GENERATORS ARE CONSIDERED FULLY OPERABLE BECAUSE THE | | CONTROL ROOM IS ALWAYS MANNED AND BECAUSE A ROVING FIRE WATCH CHECKS THE | | CABLE SPREADING ROOM EVERY HOUR. | | | | THE NRC RESIDENT INSPECTOR WAS INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 29552 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: DANBURY HOSPITAL, DANBURY, CT |NOTIFICATION DATE: 11/03/95 | | CITY: DANBURY REGION: 1 |NOTIFICATION TIME: 14:04 [ET]| | COUNTY: STATE: CT |EVENT DATE: 10/20/95 | |LICENSE#: 06-08544-01 AGREEMENT: N |EVENT TIME: 00:00[EST]| | DOCKET: |LAST UPDATE DATE: 11/03/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |BILL LAZARUS RDO | | |DON COOL (NMSS) EO | +------------------------------------------------+ | |NRC NOTIFIED BY: TONY HO | | |HQ OPS OFFICER: JOHN MacKINNON | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | A 1.6-mCi IRIDIUM-192 SEED STAYED INSIDE A PATIENT 7 TO 8 HOURS AFTER IT | | SHOULD HAVE BEEN REMOVED. | | | | ON OCTOBER 16, 1995, A BRACHYTHERAPY PROCEDURE WAS PERFORMED ON A FEMALE | | PATIENT, AND 60 IRIDIUM-192 SEEDS (1.6 mCi each) WERE IN-PLANTED INTO THE | | PATIENT VIA CATHETERS WITH 6 SEEDS PER CATHETER. WHILE REMOVING THE SEEDS | | ON OCTOBER 20, 1995, ONE OF THE SEEDS BECAME STUCK. THE SEED WAS | | SURGICALLY REMOVED APPROXIMATELY 7 TO 8 HOURS AFTER IT SHOULD HAVE BEEN | | REMOVED. THE SEED STAYING IN THE PATIENT LONGER THAN IT SHOULD HAVE POSED | | NO HEALTH THREAT TO THE PATIENT. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |OTHER NUCLEAR MATERIAL | |EVENT NUMBER: 29553 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: NATIONAL RESPONSE CENTER |NOTIFICATION DATE: 11/03/95 | | CITY: PHILADELPIA REGION: 1 |NOTIFICATION TIME: 13:55 [ET]| | COUNTY: STATE: PA |EVENT DATE: 11/03/95 | |LICENSE#: AGREEMENT: N |EVENT TIME: 12:00[EST]| | DOCKET: |LAST UPDATE DATE: 11/03/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |BILL LAZARUS RDO | | |DON COOL (NMSS) EO | +------------------------------------------------+ | |NRC NOTIFIED BY: FINKBEINER | | |HQ OPS OFFICER: JOHN MacKINNON | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NINF INFORMATION ONLY | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | NATIONAL RESPONSE CENTER RECEIVED A CALL FROM M&N DISPLAYS LOCATED AT 7700 | | BREWSTER AVENUE IN PHILADELPHIA, PENNSYLVANIA, AND REPORTED THAT A CANISTER | | ABOUT 20" LONG AND 3" IN DIAMETER WAS FOUND WITH RADIOACTIVE MARKINGS ON | | THE OUTSIDE OF IT. THE CANISTER HAS A COAXIAL CABLE ATTACHED TO ONE END OF | | IT. | | | | * * * UPDATE 15:20 @ 11/03/95, FROM STEVE JORETT TAKEN BY MACKINNON * * * | | | | MR. STEVE JORETT OF THE PHILADELPHIA FIRE DEPARTMENT REPORTED THAT THEY | | FOUND A RADIOACTIVE CONTAMINATED CANISTER AT M&N DISPLAYS LOCATED AT 7700 | | BREWSTER AVENUE. THEY ARE GETTING ALPHA, BETA, AND GAMMA READINGS FROM THE | | CANISTER. THE CANISTER WAS MANUFACTURED BY INSTRUMENT CORPORATION. NOBODY | | HAS BEEN CONTAMINATED. | | | | THE R1DO (FRANK COSTELLO) AND NMSS EO (DON COOL) WERE NOTIFIED. FRANK | | COSTELLO OF REGION 1 SAID THAT REGION 1 HAD SENT PEOPLE TO THE SCENE. | | | | * * * UPDATE 15:56 @ 11/03/95, FROM COSTELLO TAKEN BY MACKINNON * * * | | | | REGION 1 (FRANK COSTELLO) INFORMED THE OPERATION'S CENTER THAT THE CANISTER | | WAS A SODIUM IODIDE DETECTOR WHICH IS USED FOR MEASURING GAMMA RAYS. IT | | HAS A TEST SOURCE OF AMERICIUM-241 WITHIN IT WITH AN ACTIVITY A LOT LESS | | THAN 1 æCi. FRANK COSTELLO SAID THAT THE CANISTER WAS BEING TAKEN BACK TO | | REGION 1. | | | | THE R1DO (BILL LAZARUS) AND NMSS EO (DON COOL) WERE NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 29554 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: WINCHESTER MEDICAL CENTER |NOTIFICATION DATE: 11/03/95 | | CITY: WINCHESTER REGION: 2 |NOTIFICATION TIME: 14:32 [ET]| | COUNTY: STATE: VA |EVENT DATE: 10/31/95 | |LICENSE#: 45-01589-01 AGREEMENT: N |EVENT TIME: 10:00[EST]| | DOCKET: |LAST UPDATE DATE: 11/03/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |WRIGHT RDO | | |DON COOL (NMSS) EO | +------------------------------------------------+ | |NRC NOTIFIED BY: D HARE | | |HQ OPS OFFICER: JOHN MacKINNON | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | PATIENT WAS TO RECEIVE A CONSULTATION BUT INSTEAD RECEIVED A 5-mCi, I-131, | | WHOLE BODY SCAN. | | | | ON OCTOBER 30, 1995, A DOCTOR IN MARTINSBURG, WEST VIRGINIA, ARRANGED FOR A | | CONSULTATION TO TAKE PLACE TUESDAY MORNING (OCTOBER 31, 1995) AT THE | | WINCHESTER MEDICAL CENTER FOR ONE OF HIS PATIENTS IN REGARDS TO GRAVES' | | DISEASE. WINCHESTER MEDICAL CENTER INSTEAD MISTAKENLY ENTERED INTO ITS | | COMPUTER THAT THE PATIENT WAS COMING IN FOR A I-131 WHOLE BODY SCAN (FIRST | | MISTAKE). THE SECOND MISTAKE WAS THAT A MEDICAL TECHNOLOGIST ORDERED A | | 5-mCi I-131 DOSE FOR THE PATIENT WITHOUT A DOCTOR APPROVING THE ORDER. THE | | THIRD MISTAKE WAS THAT A DOCTOR SIGNED OFF ON A QUALITY MANAGEMENT WORK | | SHEET FOR THE I-131 DOSE WITHOUT PROPERLY CHECKING THE WORK SHEET. | | | | ON THE MORNING OF OCTOBER 31, 1995, THE PATIENT WAS GIVEN THE 5-mCi, I-131, | | WHOLE BODY SCAN. (I-131 WHOLE BODY SCAN IS GIVEN ONLY TO PEOPLE AFTER THEY | | HAVE HAD CANCER THERAPY.) WHEN THE PATIENT RETURNED TO THE WINCHESTER | | MEDICAL CENTER ON NOVEMBER 3, 1995, IT WAS DISCOVERED THAT THE PATIENT | | SHOULD NOT HAVE BEEN GIVEN THE 5-mCi, I-131, WHOLE BODY SCAN AND SHOULD | | HAVE BEEN CONSULTED ABOUT HER GRAVES' DISEASE CONDITION. | | | | IT WAS SUBSEQUENTLY DETERMINED THAT THE PATIENT DOES NEED AN I-131 WHOLE | | BODY SCAN AND WILL BE GIVEN AN ADDITIONAL 10-mCi, I-131, WHOLE BODY SCAN | | NEXT WEEK. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29555 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BROWNS FERRY REGION: 2 |NOTIFICATION DATE: 11/03/95 | |UNIT: [1] [2] [3] STATE: AL |NOTIFICATION TIME: 16:17 [ET]| |RX TYPE: [1] GE-4,[2] GE-4,[3] GE-4 |EVENT DATE: 11/03/95 | +------------------------------------------------+EVENT TIME: 14:05[CST]| |NRC NOTIFIED BY: TIM GOLDEN |LAST UPDATE DATE: 11/03/95 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BRUNO URYC 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 | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | 3 | N N 0 REFUELING | 0 REFUELING | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | NOTIFIED THE STATE OF ALABAMA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OF A | | PROCESS STREAM WATER FLOW PATH THROUGH THE SITE STORM DRAIN SYSTEM | | | | LICENSEE ENVIRONMENTAL PERSONNEL MADE A REQUIRED, 24-HOUR, ORAL REPORT TO | | THE ALABAMA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT DUE TO A VIOLATION OF | | THE NPDES PERMIT. THE VIOLATION WAS DUE TO THE RESIN BED BACKWASH WATER | | FROM THE CONTRACTED DEMINERALIZED WATER PRODUCER BEING DISCHARGED TO THE | | WATERS OF THE U.S. VICE INTO THE EXISTING SETTLEMENT PONDS. THE BACKWASH | | WATER DISCHARGE PIPE WAS FOUND TO BE BROKEN RESULTING IN THE PROCESS | | BACKWASH STREAM BEING ROUTED TO THE SITE'S STORM DRAIN SYSTEM. NO | | RADIOLOGICAL MATERIAL OR PROCESSES WERE INVOLVED. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29556 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: WASHINGTON NUCLEAR REGION: 4 |NOTIFICATION DATE: 11/03/95 | |UNIT: [2] [ ] [ ] STATE: WA |NOTIFICATION TIME: 16:46 [ET]| |RX TYPE: [2] GE-5 |EVENT DATE: 11/03/95 | +------------------------------------------------+EVENT TIME: 13:02[PST]| |NRC NOTIFIED BY: R STEVENS |LAST UPDATE DATE: 11/03/95 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |DALE POWERS RDO | |DSAF 73.71(b)(1) SECURITY DEGRADATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | SAFEGUARDS INFORMATION WAS TRANSMITTED ON THE LOCAL AREA NETWORK. | | COMPENSATORY MEASURES WERE IMMEDIATELY TAKEN UPON DISCOVERY. | | | | THE NRC RESIDENT INSPECTOR WILL BE INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29557 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BRUNSWICK REGION: 2 |NOTIFICATION DATE: 11/03/95 | |UNIT: [1] [2] [ ] STATE: NC |NOTIFICATION TIME: 17:48 [ET]| |RX TYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 10/25/95 | +------------------------------------------------+EVENT TIME: 19:00[EST]| |NRC NOTIFIED BY: MARK SCHALL |LAST UPDATE DATE: 11/03/95 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BRUNO URYC 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 100 POWER OPERATION | 100 POWER OPERATION | | 2 | N Y 88 POWER OPERATION | 88 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | CONTROL ROOM ENVELOPE PRESSURE WAS FOUND TO BE SLIGHTLY NEGATIVE WHEN IT | | WAS SUPPOSED TO BE POSITIVE WHILE IN THE RADIATION PROTECTION MODE OF | | OPERATION. | | | | DURING CONTROL ROOM ENVELOPE PRESSURE TESTING ON OCTOBER 25, 1995, PRESSURE | | WAS MEASURED AS -0.04" OF WATER WHILE IN THE RADIATION PROTECTION MODE | | (POWER OPERATIONS). PRESSURE IS REQUIRED TO BE POSITIVE IN ACCORDANCE WITH | | TECHNICAL SPECIFICATION 4.7.2. SYSTEM CONFIGURATION CHANGES RESTORED | | POSITIVE PRESSURE APPROXIMATELY 2.5 HOURS LATER, AND COMPENSATORY ACTIONS | | WERE INITIATED AND COMPLETED TO ENSURE THAT PRESSURE REMAINS POSITIVE | | DURING ANY INITIATION IN THE RADIATION PROTECTION MODE. TROUBLESHOOTING | | AND ENGINEERING CALCULATIONS TO DATE HAVE BEEN UNABLE TO POSITIVELY | | CONCLUDE THAT THE DESIGN BASIS WAS MAINTAINED FOR THE SLIGHT NEGATIVE | | PRESSURE. THIS REPORT WAS SUBMITTED TO DOCUMENT THE EVENT PENDING | | COMPLETION OF ENGINEERING ANALYSIS. | | | | THE NRC RESIDENT INSPECTOR WAS INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29558 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: VERMONT YANKEE REGION: 1 |NOTIFICATION DATE: 11/04/95 | |UNIT: [1] [ ] [ ] STATE: VT |NOTIFICATION TIME: 10:30 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 11/04/95 | +------------------------------------------------+EVENT TIME: 10:23[EST]| |NRC NOTIFIED BY: SHIRL WOOKEY |LAST UPDATE DATE: 11/04/95 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |WILLIAM LAZARUS RDO | |ASHU 50.72(b)(1)(i)(A) PLANT S/D REQD BY TS | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | SHUTDOWN LIMITING CONDITION FOR OPERATION (LCO) AS A RESULT OF THE | | INOPERABILITY OF THE SERVICE WATER SUBSYSTEM LOOPS AND THE ALTERNATE | | COOLING TOWER FAN | | | | TECHNICAL SPECIFICATION 3.5.D.4 REQUIRES THAT BOTH STATION SERVICE WATER | | SUBSYSTEM LOOPS AND THE ALTERNATE COOLING TOWER TO BE OPERABLE OR THAT AN | | ORDERLY SHUTDOWN BE INITIATED AND THE REACTOR BE PLACED IN A COLD SHUTDOWN | | CONDITION WITHIN 24 HOURS. | | | | THE SERVICE WATER SUBSYSTEMS WERE DECLARED INOPERABLE (7-DAY LCO) AT 08:30 | | ON NOVEMBER 2, 1995, DUE TO A THROUGH-WALL LEAK ON A 1-1/2" SERVICE WATER | | LINE THAT PROVIDES KEEP FILL FOR THE FIRE WATER HEADERS DURING STANDBY | | OPERATION. THE LEAK HAS BEEN EVALUATED AS A PIN HOLE AT THE TOP OF THE | | 1-1/2" KEEP FILL LINE. THE LEAK IS SMALL, AND THE RATE OF LEAKAGE IS LESS | | THAN ONE DROPLET EVERY TWO MINUTES. THE LEAK IS BEING EVALUATED IN | | ACCORDANCE WITH THE GUIDELINES OF GENERIC LETTER 90-05, SERVICE WATER | | LEAKAGE EVALUATION. REPAIRS WERE ATTEMPTED ON NOVEMBER 3, 1995, AND | | ISOLATION OF THE AFFECTED LINE USING FREEZE SEALS AND VALVE BLOCKING POINTS | | WAS INEFFECTIVE IN GETTING AN ADEQUATE ISOLATION TO PERMIT MAINTENANCE | | REPAIRS GIVEN THE ORIGINAL MAINTENANCE PLAN. ENGINEERING DATA WAS OBTAINED | | BY TESTING TO CONCLUDE THAT SUFFICIENT METAL WAS AVAILABLE FOR MAINTAINING | | THE PRESSURE BOUNDARY. ALTHOUGH THE SERVICE WATER SUBSYSTEMS REMAIN | | INOPERABLE PENDING FINAL ENGINEERING RESOLUTION, THE SYSTEM IS CURRENTLY | | MAINTAINING SYSTEM PRESSURE. | | | | IN ADDITION, ON NOVEMBER 3, 1995, OIL IN THE ALTERNATE COOLING TOWER FAN | | (CTF 2-1) GEAR BOX WAS IDENTIFIED AS HAVING A POUR POINT OF 25øF, AND | | THEREFORE, QUESTIONS HAVE BEEN RAISED REGARDING THE FAN'S OPERABILITY | | STATUS IN COLD WEATHER. AS A CONSERVATIVE MEASURE PRIOR TO AMBIENT | | TEMPERATURE DROPPING TO 25øF, THE FAN WAS REMOVED FROM SERVICE AT 10:23 ON | | NOVEMBER 4, 1995, FOR A GEAR BOX OIL CHANGE BY MAINTENANCE. THE DURATION | | OF THE MAINTENANCE AND POST MAINTENANCE TESTING WAS ESTIMATED AT LESS THAN | | FOUR HOURS. A 24-HOUR SHUTDOWN LCO WAS ENTERED IN ACCORDANCE WITH | | TECHNICAL SPECIFICATION 3.5.D.4 WHEN THE ALTERNATE COOLING TOWER FAN WAS | | REMOVED FROM SERVICE FOR MAINTENANCE. | | | | THE LICENSEE PLANS TO NOTIFY THE NRC WHEN THE 24-HOUR SHUTDOWN LCO IS | | EXITED (FOLLOWING THE POST COOLING TOWER FAN MAINTENANCE AND POST | | MAINTENANCE TESTING OF THE ALTERNATE COOLING SYSTEM). THE LICENSEE | | NOTIFIED THE NRC RESIDENT INSPECTOR AND THE STATE. | | | | * * * 12:05 NOVEMBER 4, 1995, UPDATE FROM WOOKEY TAKEN BY MACKINNON * * * | | | | THE ALTERNATE COOLING TOWER FAN WAS RETURNED TO OPERABLE STATUS, AND THE | | 24-HOUR SHUTDOWN LCO WAS EXITED AT 11:58 ON NOVEMBER 4, 1995. THE 7-DAY | | SERVICE WATER LCO IS STILL IN EFFECT. | | | | THE LICENSEE HAS NOTIFIED THE NRC RESIDENT INSPECTOR AND PLANS TO NOTIFY | | THE STATE. THE NRC OPERATIONS OFFICER NOTIFIED THE R1DO (LAZARUS). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |OTHER NUCLEAR MATERIAL | |EVENT NUMBER: 29559 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: CIVIL ENVIRONMENTAL CONSULTANTS |NOTIFICATION DATE: 11/04/95 | | CITY: SULPHUR REGION: 2 |NOTIFICATION TIME: 16:56 [ET]| | COUNTY: STATE: KY |EVENT DATE: 11/04/95 | |LICENSE#: AGREEMENT: Y |EVENT TIME: 16:30[EST]| | DOCKET: |LAST UPDATE DATE: 11/04/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |B.J. HOLT/L. MILLER RDO | | |FRED COMBS EO | +------------------------------------------------+ | |NRC NOTIFIED BY: SCOTT NORDGREN |BRUNO URYC R2DO | |HQ OPS OFFICER: JOHN MacKINNON | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NDAM DAMAGE MEASURE GAUGE | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | A TROXLER MOISTURE DENSITY GAUGE (MODEL #3440) WAS RUN OVER BY AN EARTH | | MOVER. THE SOURCES WERE NOT DAMAGED. | | | | CIVIL AND ENVIRONMENTAL CONSULTANTS LOCATED AT 4665 CORNELL ROAD, SUITE | | 255, CINCINNATI, OHIO, REPORTED THAT ONE OF ITS TROXLER MOISTURE DENSITY | | GAUGES WAS RUN OVER BY AN EARTH MOVER AT THE LAIDLAW LANDFILL LOCATED IN | | SULPHUR, KENTUCKY (HIGHWAY 157). THE SOURCE ROD CAME OUT THE TOP OF THE | | TROXLER MOISTURE DENSITY GAUGE WHEN IT WAS RUN OVER. THE AREA WAS CLEARED. | | THEN THE SOURCE ROD WAS RE-INSERTED BACK INTO THE GAUGE, AND IT IS NOW IN | | ITS SAFE POSITION. THE LICENSEE PERFORMED RADIATION SURVEYS OF THE DAMAGED | | TROXLER MOISTURE DENSITY GAUGE, AND THE READINGS (TAKEN BY A GEIGER COUNTER | | PROVIDED BY TROXLER; LAST CHECKED MAY 1995) INDICATED THAT THE TROXLER | | MOISTURE DENSITY GAUGE WAS WITHIN ITS SAFE LIMITS. AS FAR AS THE LICENSEE | | KNOWS, THE 8-mCi Cs-137 AND 40-mCi Am-241/Be SOURCES WERE NOT DAMAGED. | | THERE WAS NO CONTAMINATION, AND THE SOURCES WERE NOT LEAKING. TROXLER | | INFORMED THE LICENSEE TO PERFORM A LEAK TEST OF THE GAUGE. IF THE GAUGE | | PASSES ITS LEAK TEST, THEN THE GAUGE IS TO BE STORED IN ITS CASE AND TAKEN | | BACK TO THE CIVIL AND ENVIRONMENTAL CONSULTANTS OFFICE FOR STORAGE. THE | | LICENSEE CALLER DID NOT HAVE NRC LICENSE NUMBER WITH HIM. | | | | THE R2DO (URYC) WILL HAVE A REGION 2 REPRESENTATIVE INFORM THE STATE OF | | KENTUCKY OF THIS EVENT. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29560 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MILLSTONE REGION: 1 |NOTIFICATION DATE: 11/04/95 | |UNIT: [1] [ ] [ ] STATE: CT |NOTIFICATION TIME: 17:57 [ET]| |RX TYPE: [1] GE-3,[2] CE,[3] W-4-LP |EVENT DATE: 11/04/95 | +------------------------------------------------+EVENT TIME: 17:40[EST]| |NRC NOTIFIED BY: WILLIAM SPAHN |LAST UPDATE DATE: 11/04/95 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BILL LAZARUS 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 HOT SHUTDOWN | 0 HOT SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | REMOVAL OF DRYWELL SHIELD PLUGS BEFORE ENTERING A COLD SHUTDOWN CONDITION | | IN THE LAST 14 REFUELING OUTAGES WAS NOT IN ACCORDANCE WITH NUREG-0612 | | RECOMMENDATIONS. | | | | AS A RESULT OF AN ENGINEERING REVIEW, IT WAS DETERMINED THAT PROCEDURE | | MP790, CONTROL OF HEAVY LOADS, DOES NOT EXPLICITLY STATE THAT REACTOR | | SAFETY CAVITY SHIELD BLOCK REMOVAL SHOULD NOT BE INITIATED UNTIL THE | | PRIMARY SYSTEM TEMPERATURE HAS REACHED 212øF OR LESS. AS A RESULT, THE | | POTENTIAL EXISTS THAT DURING PREVIOUS OUTAGES, THE SHIELD BLOCKS COULD HAVE | | BEEN MOVED PRIOR TO THIS TEMPERATURE. | | | | AN INITIAL REVIEW OF THE LICENSEE'S NUREG-0612 HEAVY LOADS EVALUATIONS HAS | | BEEN PERFORMED. THE REVIEW INDICATED THAT A POSTULATED DROP OF THE SHIELD | | BLOCKS ON THE REFUEL OPERATING FLOOR WAS EVALUATED AND WOULD NOT IMPACT | | SYSTEMS REQUIRED TO ACHIEVE SAFE SHUTDOWN. BASED ON THIS REVIEW, IT WAS | | NOT CLEAR WHETHER A POSTULATED DROP ON THE DRYWELL HEAD WAS EXPLICITLY | | EVALUATED. THUS, THE POTENTIAL EXISTED FOR DEGRADATION OF THE PRIMARY | | CONTAINMENT FUNCTION RESULTING FROM A SHIELD BLOCK DROP ON THE CONTAINMENT | | HEAD. THIS CONDITION IS BEING CONSERVATIVELY REPORTED. | | | | CORRECTIVE ACTION HAS BEEN TAKEN IN THAT SHIELD BLOCK REMOVAL WILL NOT BE | | INITIATED UNTIL THE PRIMARY SYSTEM TEMPERATURE IS BELOW 212øF. | | | | THE LICENSEE NOTIFIED STATE AND LOCAL OFFICIALS OF THIS EVENT. THE NRC | | RESIDENT INSPECTOR WAS ALSO INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29561 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: HARRIS REGION: 2 |NOTIFICATION DATE: 11/05/95 | |UNIT: [1] [ ] [ ] STATE: NC |NOTIFICATION TIME: 09:03 [ET]| |RX TYPE: [1] W-3-LP |EVENT DATE: 11/05/95 | +------------------------------------------------+EVENT TIME: 08:05[EST]| |NRC NOTIFIED BY: CHRIS GENTILE |LAST UPDATE DATE: 11/05/95 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: UNUSUAL EVENT +-----------------------------+ |10 CFR SECTION: |BRUNO URYC RDO | |AAEC 50.72(a)(1)(i) EMERGENCY DECLARED |LEE SPESSARD (NRR) EO | |ARPS 50.72(b)(2)(ii) RPS ACTUATION |STINEDURF FEMA | |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 +------------------------------------------------------------------------------+ | REACTOR TRIP AND UNUSUAL EVENT DUE TO UNPLANNED EMERGENCY CORE COOLING | | SYSTEM (ECCS) DISCHARGE TO THE VESSEL DURING ROUTINE SURVEILLANCE TESTING | | OF THE ENGINEERED SAFETY FEATURES (ESF) ACTIVATION SYSTEM | | | | A SPURIOUS REACTOR TRIP AND SAFETY INJECTION OCCURRED DURING ROUTINE ESF | | ACTIVATION SYSTEM SURVEILLANCE TESTING AT 07:38. SUBSEQUENTLY AT 8:05, THE | | LICENSEE DECLARED AN UNUSUAL EVENT DUE TO THE UNPLANNED ECCS DISCHARGE TO | | THE VESSEL. | | | | THE FIRST OUT ANNUNCIATOR WAS REACTOR TRIP, STEAM LINE ISOLATION, AND | | SAFETY INJECTION. ALL RODS FULLY INSERTED, AND ALL ESF EQUIPMENT OPERATED | | AS EXPECTED. THE CHARGING/HIGH HEAD SAFETY INJECTION PUMPS INJECTED | | APPROXIMATELY 4,000 TO 5,000 GALLONS OF WATER TO THE VESSEL FOR | | APPROXIMATELY 20 MINUTES. THE STEAM LINES ISOLATED DURING THE TRANSIENT. | | STEAM GENERATOR FEEDWATER ALSO ISOLATED DUE TO THE SAFETY INJECTION, AND | | AUXILIARY FEEDWATER AUTOMATICALLY ACTUATED. THE UNIT ALSO RECEIVED THE | | FOLLOWING ESF SIGNALS: CONTAINMENT ISOLATION, CONTAINMENT VENTILATION | | ISOLATION, AND CONTROL ROOM VENTILATION ISOLATION. PRESSURIZER LEVEL | | CONTINUALLY INCREASED DURING THE TRANSIENT UNTIL THE PRESSURE INCREASED | | ENOUGH TO LIFT THE POWER OPERATED RELIEF VALVES. THE PRESSURIZER RELIEF | | TANK RUPTURE DISC SUBSEQUENTLY RUPTURED BUT CAUSED NO CHANGE IN CONTAINMENT | | PRESSURE, TEMPERATURE, OR RADIATION PARAMETERS. | | | | THE PLANT IS CURRENTLY STABLE IN A HOT STANDBY CONDITION. ALL EMERGENCY | | DIESEL GENERATORS, SOURCES OF OFFSITE POWER, AND EMERGENCY SERVICE WATER | | SYSTEMS ARE OPERABLE AND AVAILABLE. PRIMARY INVENTORY, PRESSURE, | | TEMPERATURE, AND TRANSPORT CONTROL ARE BEING MAINTAINED BY THE USE OF | | NORMAL CHARGING AND MAKEUP, NORMAL PRESSURIZER HEATERS AND SPRAYS, AND THE | | REACTOR COOLANT PUMPS. STEAM GENERATOR LEVEL CONTROL IS BEING MAINTAINED | | BY THE USE OF AUXILIARY FEEDWATER, AND STEAM IS BEING DUMPED TO THE | | ATMOSPHERE VIA THE POWER OPERATED RELIEF VALVES. (THERE HAS BEEN NO | | HISTORY OR INDICATION OF ANY STEAM GENERATOR TUBE LEAKS.) | | | | THE REASON THE TESTING CAUSED THE PLANT TRANSIENT IS NOT FULLY UNDERSTOOD | | AT THIS TIME. THERE WAS A TEST CIRCUIT FAILURE, BUT THE EXTENT AND EXACT | | DETAILS ARE CURRENTLY UNDER INVESTIGATION. LICENSEE MANAGEMENT IS PRESENT | | AT THIS TIME AND IS CONSIDERING TERMINATION OF THE UNUSUAL EVENT BECAUSE | | SAFETY INJECTION HAS BEEN SECURED. | | | | THE LICENSEE NOTIFIED THE NRC RESIDENT INSPECTOR WHO WAS IN THE CONTROL | | ROOM AT THE TIME OF THIS NOTIFICATION. THE LICENSEE ALSO NOTIFIED THE | | STATE AND COUNTY WARNING POINTS. | | | | * * * 09:41 NOVEMBER 5, 1995, UPDATE FROM GENTILE TAKEN BY TROCINE * * * | | | | THE LICENSEE TERMINATED THE UNUSUAL EVENT AT 09:12 BASED ON THE ECCS | | DISCHARGE TO THE VESSEL BEING TERMINATED AND THE PLANT BEING STABLE IN MODE | | 3 (HOT STANDBY). THE CAUSE OF THE SPURIOUS SIGNAL DURING THE TESTING IS | | UNDER INVESTIGATION. | | | | THE LICENSEE NOTIFIED THE NRC RESIDENT INSPECTOR AND THE STATE AND COUNTY | | WARNING POINTS. THE NRC OPERATIONS OFFICE NOTIFIED THE R2DO (URYC), NRR EO | | (SPESSARD), AND FEMA (STINEDURF). | | | | * * UPDATE DURING MORNING STATUS ON NOVEMBER 6, 1995, TAKEN BY TROCINE * * | | | | A CONTACT ON A BLOCKING RELAY FAILED TO MAKE UP DURING THE ESF ACTIVATION | | SYSTEM SURVEILLANCE TESTING, AND THIS CAUSED A MAIN STEAM ISOLATION VALVE | | TO CLOSE. THE SUBSEQUENT STEAM GENERATOR PRESSURE TRANSIENT INITIATED THE | | SAFETY INJECTION AND REACTOR TRIP. THE NRC OPERATIONS CENTER NOTIFIED THE | | R2D0 (URYC). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29562 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: FARLEY REGION: 2 |NOTIFICATION DATE: 11/05/95 | |UNIT: [1] [ ] [ ] STATE: AL |NOTIFICATION TIME: 22:46 [ET]| |RX TYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 11/05/95 | +------------------------------------------------+EVENT TIME: 19:05[CST]| |NRC NOTIFIED BY: MURPHY |LAST UPDATE DATE: 11/05/95 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BRUNO URYC 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 27 POWER OPERATION | 1 STARTUP | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MAIN FEEDWATER PUMP 'B' TRIPPING ON LOW LUBE OIL PRESSURE CAUSED A MAIN | | FEEDWATER ISOLATION AND AUTOMATIC START OF THE MOTOR-DRIVEN AUXILIARY | | FEEDWATER PUMPS. | | | | INITIAL CONDITIONS OF THE REACTOR PLANT WERE AS FOLLOWS: 1) THE STEAM DUMP | | BYPASS CONTROL SYSTEM WAS INOPERABLE DUE TO REPLACEMENT OF A BAD CIRCUIT | | CARD, 2) CHANNEL 3 OF THE MAIN STEAM LINE ISOLATION PRESSURE TRANSMITTERS | | WAS IN TEST TO REPAIR THE #474 TRANSMITTER, 3) MAIN FEEDWATER PUMP 'B' WAS | | HAVING BEARING LUBE OIL PRESSURE PROBLEMS, 4) ROD CONTROL WAS IN AUTOMATIC, | | AND 5) ONE MAIN FEEDWATER PUMP WAS IN SERVICE. | | | | MAIN FEEDWATER PUMP 'B' LUBE OIL PUMP #2 WAS PLACED IN SERVICE BECAUSE THE | | LICENSEE THOUGHT THAT THE BEARING LUBE OIL PRESSURE PROBLEMS BEING | | EXPERIENCED WERE CAUSED BY LUBE OIL PUMP #1 WHICH WAS IN SERVICE. WHEN | | LUBE OIL PUMP #2 WAS PLACED IN SERVICE, LUBE OIL PUMP #1 WAS SECURED. WHEN | | LUBE OIL PUMP #1 WAS SECURED, MAIN FEEDWATER PUMP 'B' TRIPPED ON LOW LUBE | | OIL PRESSURE. TRIPPING OF THE ONLY OPERATING MAIN FEEDWATER PUMP CAUSED AN | | AUTOMATIC MAIN FEEDWATER ISOLATION AND THE AUTOMATIC START OF THE | | MOTOR-DRIVEN AUXILIARY FEEDWATER PUMPS. ON LOSS OF THE MAIN FEEDWATER | | PUMP, THE LICENSEE MANUALLY TRIPPED THE MAIN TURBINE. ROD CONTROL WHICH | | WAS IN AUTOMATIC REDUCED REACTOR POWER TO 15% AT WHICH POINT ROD CONTROL | | WAS PLACED IN MANUAL, AND RODS WERE INSERTED TO REDUCE REACTOR POWER DOWN | | TO 1%. (DURING THIS TIME, THE LICENSEE WAS ALSO BORATING THE REACTOR | | COOLANT SYSTEM.) WITH THE MOTOR-DRIVEN AUXILIARY FEEDWATER PUMPS FEEDING | | THE STEAM GENERATORS AND WITH REACTOR POWER BEING DECREASED BY INSERTING | | THE RODS AND BORATING, THE REACTOR COOLANT SYSTEM LOW-LOW Tave (545øF) WAS | | REACHED. WITH CHANNEL 3 OF THE MAIN STEAM LINE ISOLATION PRESSURE | | TRANSMITTERS IN TEST COINCIDENT WITH LOW-LOW Tave, THE LICENSEE RECEIVED A | | MAIN STEAM ISOLATION SIGNAL. ALL MAIN STEAM LINE ISOLATION VALVES CLOSED | | (THREE MAIN STEAM LINES). WITH MAIN STEAM LINE ISOLATION VALVES CLOSED, | | REACTOR COOLANT TEMPERATURE WAS MAINTAINED BY FEEDING THE STEAM GENERATORS | | VIA THE MOTOR-DRIVEN AUXILIARY FEEDWATER PUMPS AND DUMPING THE STEAM TO THE | | ATMOSPHERE VIA THE STEAM GENERATOR ATMOSPHERIC VALVES. (THERE WERE NO | | LEAKING STEAM GENERATOR TUBES.) THE STEAM DUMP BYPASS CONTROL SYSTEM WAS | | PLACED IN SERVICE AT 22:37 EST, AND THE MAIN STEAM ISOLATION VALVES WERE | | REOPENED AT 23:00 EST. | | | | THE LICENSEE WILL NOT INCREASE REACTOR POWER UNTIL THE MAIN FEEDWATER PUMP | | 'B' BEARING LUBE OIL PRESSURE PROBLEM HAS BEEN CORRECTED. THE NRC RESIDENT | | INSPECTOR IS IN THE CONTROL ROOM. | +------------------------------------------------------------------------------+