U.S. Nuclear Regulatory Commission Operations Center Event Reports For 09/05/95 - 09/06/95 ** EVENT NUMBERS ** 29154 29163 29290 29291 29292 29293 29294 29295 29296 29297 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29154 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: COOPER REGION: 4 |NOTIFICATION DATE: 08/03/95 | |UNIT: [1] [ ] [ ] STATE: NE |NOTIFICATION TIME: 06:40 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 08/03/95 | +------------------------------------------------+EVENT TIME: 04:45[CDT]| |NRC NOTIFIED BY: HITZEL |LAST UPDATE DATE: 09/05/95 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |PELLET 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 +------------------------------------------------------------------------------+ | HIGH PRESSURE COOLANT INJECTION (HPCI) SYSTEM DECLARED INOPERABLE. | | | | THE LICENSEE DECLARED THE HPCI SYSTEM INOPERABLE AND PLACED THE HPCI | | AUXILIARY OIL PUMP CONTROL SWITCH IN PULL-TO-LOCK DUE TO CONCERNS REGARDING | | WATER ACCUMULATION IN THE TURBINE EXHAUST LINE. FOLLOWING OPERATION OF THE | | HPCI SYSTEM, A SMALL QUANTITY OF WATER ACCUMULATES IN THE HPCI TURBINE | | EXHAUST LINE. THE LICENSEE HAS DETERMINED THAT THE PRESENCE OF THIS WATER | | IN THE EXHAUST LINE COULD CAUSE EXCESSIVE HYDRODYNAMIC LOADS TO BE | | GENERATED DURING THE STARTING OF THE HPCI TURBINE. THESE FORCES COULD | | CAUSE DAMAGE TO EXHAUST LINE PIPING SUPPORTS. | | | | THE LICENSEE IS PLANNING TO MODIFY THE HPCI TURBINE GOVERNOR CONTROL | | CIRCUITRY TO CAUSE THE GOVERNOR VALVE TO RAMP OPEN DURING TURBINE STARTUP | | TO REDUCE THE LOADS THAT WOULD BE GENERATED BY WATER IN THE EXHAUST LINE. | | THE RCIC SYSTEM IS CURRENTLY OPERABLE. THE NRC RESIDENT INSPECTOR HAS BEEN | | NOTIFIED BY THE LICENSEE. | | | | * * * RETRACTION 9/5/95 @ 15:39 FROM KAUL TAKEN BY SEBROSKY * * * | | | | THE FOLLOWING IS A TEXT OF A FACSIMILE FROM THE LICENSEE: | | | | "AS INDICATED ON THE INITIAL FOUR HOUR NOTIFICATION AN ONGOING | | INVESTIGATION WAS BEING CONDUCTED REGARDING THE ACCUMULATION OF WATER IN | | THE HPCI TURBINE EXHAUST LINE. THE BASIS FOR REPORTABILITY WAS THAT THE | | HYDRODYNAMIC LOAD THAT COULD RESULT AFTER A HPCI TURBINE RESTART DURING | | CERTAIN ACCIDENT SCENARIOS COULD EXCEED THE ALLOWABLE STRESS FOR THE HPCI | | TURBINE EXHAUST PIPING SUPPORTS AND THAT DAMAGE AND OR FAILURE TO THE PIPE | | SUPPORTS MAY RESULT. FURTHER INVESTIGATION REVEALED THAT THE ACTUAL WATER | | ACCUMULATION HAD OCCURRED ON 7/5/95 AND 7/6/95 THAT WOULD HAVE BEEN | | SUFFICIENT TO OVER STRESS THE HPCI PIPE, PIPE SUPPORT, AND CONTAINMENT | | PENETRATION BY A SUBSTANTIAL MARGIN. THIS RESULTS IN A ONE HOUR | | NOTIFICATION ON 8/5/95. [SEE EVENT # 29163] | | | | RECENT HYDRODYNAMIC ANALYSIS HAVE BEEN PERFORMED USING MORE REALISTIC | | ASSUMPTIONS REGARDING A PROCESS FLUID'S ACCELERATION OF A SUBCOOLED WATER | | SLUG IN THE PIPING. THIS REEVALUATION CONCLUDED THAT GIVEN THE WORST CASE | | HPCI TURBINE EXHAUST LINE WATER SLUG THE RESULTING FORCES ARE WITHIN THE | | OPERABILITY STRESS ALLOWABLE LIMITS OF THE HPCI PIPING AND PIPE SUPPORTS. | | ACCORDINGLY, THE OPERABILITY OF HPCI AND PRIMARY CONTAINMENT WERE, IN FACT, | | UNAFFECTED BY THIS CONDITION, AND THEREFORE, THESE TWO NOTIFICATIONS ARE | | BEING RETRACTED." END OF TEXT. | | | | THE OTHER EVENT THE LICENSEE IS RETRACTING IS EVENT #29163. THE LICENSEE | | HAS INFORMED THE RESIDENT INSPECTOR OF THIS RETRACTION. HOO NOTIFIED | | R4DO(BATES). | | | +------------------------------------------------------------------------------+ !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29163 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: COOPER REGION: 4 |NOTIFICATION DATE: 08/05/95 | |UNIT: [1] [ ] [ ] STATE: NE |NOTIFICATION TIME: 03:56 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 08/05/95 | +------------------------------------------------+EVENT TIME: 02:18[CDT]| |NRC NOTIFIED BY: STEVE SMALLFOOT |LAST UPDATE DATE: 09/05/95 | |HQ OPS OFFICER: RUDY KARSCH +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JOHN PELLET RDO | |AUNA 50.72(b)(1)(ii)(A) UNANALYZED COND OP | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 DECLARED INOPERABLE DUE TO WATER HAMMER STRESSES WHICH MAY RESULT FROM | | THE ACCUMULATION OF WATER IN THE EXHAUST LINE. | | | | THE FOLLOWING IS THE TEXT OF A FAX RECEIVED FROM THE LICENSEE: "ON 8-3-95 | | HPCI WAS DECLARED INOPERABLE DUE TO ANALYSIS OF WATER ACCUMULATION IN THE | | EXHAUST LINE. THIS WAS REPORTED AS A 4 HOUR NOTIFICATION AT 0540 ON | | 8-3-95." (REFER TO EVENT NUMBER 29154.) "AS PART OF THE CONTINUING | | ANALYSIS OF THIS CONDITION GENERAL ELECTRIC AND VECTRA HAVE PERFORMED A | | CONSERVATIVE HYDRODYNAMIC AND PIPE STRESS EVALUATION OF THE POTENTIAL WATER | | HAMMER EFFECTS TO THE HPCI EXHAUST LINE. THIS EVALUATION INCLUDED A | | CONDITION WHICH OCCURRED ON JULY 5, 1995 AND JULY 6, 1995 DURING WHICH A | | SIGNIFICANT AMOUNT OF WATER ACCUMULATED IN THE EXHAUST LINE WHICH WAS | | UNDETECTED DUE TO A FAILED EXHAUST LINE LEVEL SWITCH (MINOR WATER | | ACCUMULATION AFTER TURBINE OPERATION IS NORMAL AND SHOULD BE REMOVED BY THE | | DRAIN SYSTEM). THIS ANALYSIS DETERMINED THAT, ON THESE DATES, A TURBINE | | START COULD HAVE RESULTED IN THE PIPE, SUPPORT, AND CONTAINMENT PENETRATION | | STRESSES EXCEEDING DESIGN CRITERIA BY A SUBSTANTIAL MARGIN." | | | | "THE INTERIM ACTION PERFORMED WAS THE OPERATIONS STAFF PERFORMED MANUAL | | DRAINING OF THE HPCI EXHAUST LINE TO PREVENT SIGNIFICANT WATER | | ACCUMULATION." | | | | "CURRENTLY COOPER IS IN THE PROCESS OF PERFORMING TWO MODIFICATIONS WHICH | | WILL ALLEVIATE THIS CONCERN." | | | | THE LICENSEE WILL MODIFY THE GOVERNOR TO RAMP UP TURBINE SPEED AND WILL | | INSTALL A BIGGER SNUBBER ON THE EXHAUST LINE. THE LICENSEE WILL ALSO | | INFORM THE NRC RESIDENT INSPECTOR. | | | | * * * RETRACTION 9/5/95 @ 15:39 FROM KAUL TAKEN BY SEBROSKY * * * | | | | THE BASIS FOR THE RETRACTION CAN BE FOUND IN EVENT #29154. THE LICENSEE | | HAS INFORMED THE RESIDENT INSPECTOR. HOO NOTIFIED R4DO(BATES). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29290 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SURRY REGION: 2 |NOTIFICATION DATE: 09/05/95 | |UNIT: [ ] [2] [ ] STATE: VA |NOTIFICATION TIME: 02:53 [ET]| |RX TYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 09/05/95 | +------------------------------------------------+EVENT TIME: 02:02[EDT]| |NRC NOTIFIED BY: HARTKA |LAST UPDATE DATE: 09/05/95 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BELISLE RDO | |AARC 50.72(b)(1)(v) OTHER ASMT/COMM INOP | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | UNIT 2 SAFETY PARAMETER DISPLAY SYSTEM (SPDS) INOPERABLE. | | | | AT 0102, THE UNIT 2 SPDS BECAME INOPERABLE WHEN ONE OF EIGHT DATA LINKS TO | | THE MASTER RECEIVER FAILED. THE BACKUP MASTER RECEIVER HAD A PREVIOUSLY | | EXISTING HARDWARE FAILURE IN ONE OF ITS EIGHT DATA LINKS. THE SPDS WAS NOT | | RESTORED TO OPERABLE STATUS WITHIN ONE HOUR, CONSTITUTING A MAJOR LOSS OF | | EMERGENCY ASSESSMENT CAPABILITY. NO CONTROL ROOM ANNUNCIATORS OR | | INDICATION ARE AFFECTED BY THE FAILURE OF THE SPDS. | | | | THE LICENSEE STATED THAT THE CAUSE OF THE HARDWARE FAILURE IS CURRENTLY | | UNKNOWN, AND THEREFORE NO ESTIMATE OF REPAIR TIME IS AVAILABLE. THE UNIT 2 | | SPDS COULD BE PLACED INTO SERVICE USING ANOTHER BACKUP MASTER RECEIVER, BUT | | THIS WOULD RENDER THE UNIT 1 SPDS INOPERABLE. THE LICENSEE IS | | INVESTIGATING THE CAUSE OF THE FAILURE. THE NRC RESIDENT INSPECTOR WILL BE | | INFORMED BY THE LICENSEE. | | | | * * * UPDATE @ 12:02 9/5/95 FROM HELMS TAKEN BY SEBROSKY * * * | | THE SPDS SYSTEM HAS BEEN RETURNED TO SERVICE AND HAS BEEN OPERATING | | PROPERLY FOR THE LAST SIX HOURS, THEREFORE THE LICENSEE NOW CONSIDERS THE | | SYSTEM OPERABLE. THE LICENSEE WILL INFORM THE RESIDENT INSPECTOR. HOO | | NOTIFIED R2DO(BARR). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29291 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: RIVER BEND REGION: 4 |NOTIFICATION DATE: 09/05/95 | |UNIT: [1] [ ] [ ] STATE: LA |NOTIFICATION TIME: 03:54 [ET]| |RX TYPE: [1] GE-6 |EVENT DATE: 09/05/95 | +------------------------------------------------+EVENT TIME: 00:30[CDT]| |NRC NOTIFIED BY: CARLSON |LAST UPDATE DATE: 09/05/95 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |HARRELL RDO | |AINB 50.72(b)(2)(iii)(B) POT RHR INOP | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | HIGH PRESSURE CORE SPRAY SYSTEM DECLARED INOPERABLE. | | | | THE HIGH PRESSURE CORE SPRAY (HPCS) SYSTEM WAS DECLARED INOPERABLE WHEN | | AUXILIARY BUILDING UNICOOLER NO. 5, WHICH SUPPLIES VENTILATION TO THE HPCS | | PUMP ROOM, FAILED CATASTROPHICALLY. THE LICENSEE REPORTED THAT THE FAN | | RIPPED LOOSE FROM ITS HOUSING AND FELL TO THE BOTTOM OF THE UNICOOLER. ALL | | OTHER ECCS EQUIPMENT IS CURRENTLY AVAILABLE. | | | | THE LICENSEE IS CURRENTLY ASSESSING THE EXTENT OF DAMAGE TO THE FAN AND | | UNICOOLER, AND NOTED THAT NEITHER A SPARE FAN NOR MOTOR IS AVAILABLE | | ONSITE. THE INOPERABILITY OF THE HPCS SYSTEM PLACES THE UNIT IN A 14-DAY | | LIMITING CONDITION FOR OPERATION. THE NRC RESIDENT INSPECTOR HAS BEEN | | INFORMED OF THIS EVENT BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29292 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: DRESDEN REGION: 3 |NOTIFICATION DATE: 09/05/95 | |UNIT: [ ] [ ] [3] STATE: IL |NOTIFICATION TIME: 07:18 [ET]| |RX TYPE: [1] GE-1,[2] GE-3,[3] GE-3 |EVENT DATE: 09/05/95 | +------------------------------------------------+EVENT TIME: 04:24[CDT]| |NRC NOTIFIED BY: K POLSON |LAST UPDATE DATE: 09/06/95 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |PAT HILAND RDO | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | | | | | 3 | N N 0 REFUELING | 0 REFUELING | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | RECEIVED GROUP 5 ISOLATION (ISOLATION CONDENSER) WHILE PERFORMING STARTUP | | CHECKLIST. | | | | WHILE PERFORMING THE STARTUP CHECKLIST IN PREPARATION FOR STARTUP ON SECOND | | SHIFT, A GROUP 5 ISOLATION WAS RECEIVED[ISOLATION CONDENSER ISOLATION | | VALVES 1301-4(AC) & 1301-1 (AC) CLOSED]. THIS OCCURRED WHILE ATTEMPTING TO | | PLACE THE ISOLATION CONDENSER IN STANDBY. 3-1301-4(AC) VALVE HAD BEEN FULLY | | OPENED. WHILE OPENING 3-1301-1 (AC) VALVE, THE ISOLATION OCCURRED. LICENSEE | | SAYS THAT THIS PROBLEM HAS HAPPENED BEFORE. AT THE PRESENT TIME THE | | LICENSEE CANNOT RESET THE ISOLATION SIGNAL. | | | | RESIDENT INSPECTOR WILL BE INFORMED BY THE LICENSEE. | | | | * * * UPDATE AT 0005 EDT ON 9/6/95 FROM BRYAN HANSON TAKEN BY KARSCH * * * | | TROUBLESHOOTING REVEALED SEVERAL SENSING LINES THAT WERE DRAINED. THEY | | WERE REFILLED. AT 2045 CDT ON 9/5/95, WHEN THE LICENSEE ATTEMPTED TO PLACE | | THE ISOLATION CONDENSER INTO STANDBY IT ISOLATED AGAIN. A MORE EXTENSIVE | | ROOT CAUSE INVESTIGATION WILL BE CONDUCTED. THE LICENSEE INFORMED THE NRC | | RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29293 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: KEWAUNEE REGION: 3 |NOTIFICATION DATE: 09/05/95 | |UNIT: [1] [ ] [ ] STATE: WI |NOTIFICATION TIME: 12:32 [ET]| |RX TYPE: [1] W-2-LP |EVENT DATE: 09/05/95 | +------------------------------------------------+EVENT TIME: 08:38[CDT]| |NRC NOTIFIED BY: GEORGE RUITER |LAST UPDATE DATE: 09/05/95 | |HQ OPS OFFICER: JOSEPH SEBROSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |RONALD GARDNER RDO | |ARPS 50.72(b)(2)(ii) RPS ACTUATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | A/R Y 96 POWER OPERATION | 0 HOT SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | REACTOR TRIP DURING THE PERFORMANCE OF A SURVEILLANCE TEST. | | | | DURING PERFORMANCE OF SURVEILLANCE PROCEDURE 47-010A (CHANNEL 1 REACTOR | | COOLANT TEMPERATURE AND PRESSURIZER PRESSURE INSTRUMENT CHANNEL TEST) THE | | REACTOR TRIPPED UNEXPECTEDLY. THIS OCCURRED WHEN AN INSTRUMENTATION AND | | CONTROL TECHNICIAN PLACED THE LOW PRESSURE TRIP SIGNAL IN THE TRIPPED | | POSITION. | | | | THE POST TRIP RESPONSE WAS NORMAL WITH THE EXCEPTION THAT SOURCE RANGE | | CHANNEL N31 DID NOT RESPOND AS EXPECTED. ALL RODS INSERTED AND NO PRIMARY | | RELIEF, OR PRIMARY PORV VALVES LIFTED. AUXILIARY FEEDWATER (AFW) STARTED | | AS EXPECTED AND RESTORED, AND IS STILL MAINTAINING, STEAM GENERATOR WATER | | LEVELS. THE MAIN CONDENSER IS AVAILABLE AS A HEAT SINK AND ALL ECCS AND | | EDGs ARE OPERABLE. | | | | THE LICENSEE IS STILL INVESTIGATING THE CAUSE OF THE TRIP. THE TECHNICIAN | | APPEARS TO HAVE PERFORMED THE TEST CORRECTLY. (THE TRIPPING OF THE LOW | | PRESSURE TRIP SIGNAL SHOULD NOT HAVE GENERATED A REACTOR TRIP SIGNAL). | | | | THE LICENSEE HAS INFORMED THE RESIDENT INSPECTOR AND WILL INFORM LOCAL | | GOVERNMENT OFFICIALS. THE LICENSEE ALSO MAY ISSUE A PRESS RELEASE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29294 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: FITZPATRICK REGION: 1 |NOTIFICATION DATE: 09/05/95 | |UNIT: [1] [ ] [ ] STATE: NY |NOTIFICATION TIME: 13:30 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 09/05/95 | +------------------------------------------------+EVENT TIME: 13:03[EDT]| |NRC NOTIFIED BY: PHILIP RUSSELL |LAST UPDATE DATE: 09/05/95 | |HQ OPS OFFICER: JOSEPH SEBROSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |GLENN MEYER RDO | |ARPS 50.72(b)(2)(ii) RPS 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 SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | REACTOR SCRAM DUE TO LOW REACTOR VESSEL WATER LEVEL. | | | | THE LOW WATER LEVEL WAS CAUSED BY A PROBLEM WITH THE MAIN FEEDWATER SYSTEM. | | HIGH PRESSURE COOLANT INJECTION (HPCI) AND REACTOR CORE ISOLATION COOLING | | (RCIC) AUTOMATICALLY STARTED AND RESTORED REACTOR VESSEL WATER LEVEL. HPCI | | AND RCIC SUBSEQUENTLY TRIPPED ON HIGH WATER LEVEL. CURRENTLY THE REACTOR | | VESSEL WATER LEVEL IS BEING MAINTAINED BY THE MAIN FEEDWATER AND CONDENSATE | | SYSTEM. | | | | ALL RODS INSERTED AND NO SAFETY RELIEF VALVES LIFTED. THE MAIN CONDENSER | | IS AVAILABLE AS THE HEAT SINK. ALL ELECTRICAL BUSSES TRANSFERRED AS | | EXPECTED AND ALL ECCS AND EDGs ARE OPERABLE. | | | | THE LICENSEE IS INVESTIGATING THE CAUSE OF THE SCRAM. AT THIS TIME IT | | APPEARS THAT THE MAIN FEEDWATER SYSTEM PROBLEM WAS CAUSED BY A TECHNICIAN | | REMOVING THE WRONG FUSE DURING MAINTENANCE WORK. THE TECHNICIAN WAS | | WORKING ON THE PRIMARY CONTAINMENT ISOLATION SYSTEM (PCIS) RESET SWITCH AND | | WAS SUPPOSED TO REMOVE A FUSE IN THAT SYSTEM TO PERFORM MAINTENANCE ON A | | RESET SWITCH. IT APPEARS THAT THE TECHNICIAN MAY HAVE REMOVED A FUSE IN THE | | MAIN FEEDWATER SYSTEM INSTEAD, CAUSING A PROBLEM WITH THE MAIN FEEDWATER | | PUMPS. | | | | THE LICENSEE HAS INFORMED THE RESIDENT INSPECTOR AND WILL PROBABLY ISSUE A | | PRESS RELEASE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 29295 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: SAN DIEGO NAVAL MEDICAL CENTER |NOTIFICATION DATE: 09/05/95 | | CITY: SAN DIEGO REGION: 4 |NOTIFICATION TIME: 16:48 [ET]| | COUNTY: STATE: CA |EVENT DATE: 08/29/95 | |LICENSE#: 45-32645-01NA AGREEMENT: Y |EVENT TIME: 00:00[PDT]| | DOCKET: |LAST UPDATE DATE: 09/05/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |KENNETH BARR RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: COMMANDER HIGGINS | | |HQ OPS OFFICER: JOSEPH SEBROSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | A MEDICAL MISADMINISTRATION OCCURRED AT THE NAVAL MEDICAL CENTER IN SAN | | DIEGO CALIFORNIA. THE MASTER MATERIAL'S LICENSE FOR THE NAVY IS | | 45-23645-01NA AND IS THE RESPONSIBILITY OF NRC REGION II. | | | | A PATIENT WAS PRESCRIBED TO RECEIVE 4 SOURCES OF CESIUM 137 OF 15 | | MILLICURIES EACH. THE SOURCES WERE IMPLANTED IN A DELCOSE APPLICATOR TO | | TREAT CERVICAL CANCER. ON 8/29/95 THE SOURCES WERE REMOVED AND IT WAS | | DISCOVERED THAT 4 SOURCES OF CESIUM 137 OF 10 MILLICURIES EACH HAD BEEN | | IMPLANTED. THIS RESULTED IN AN UNDER DOSE TO THE PATIENT OF APPROXIMATELY | | 30 PERCENT. THE PATIENT HAS BEEN INFORMED AND THERE ARE NO ADVERSE EFFECTS | | EXPECTED TO THE PATIENT. THE ATTENDING PHYSICIAN HAS DETERMINED THAT AN | | ADDITIONAL DOSE TO THE PATIENT WILL NOT BE PRESCRIBED TO MAKE UP FOR THE | | UNDER DOSE. | | | | THE LICENSEE IS INVESTIGATING THE CAUSE OF THE MISADMINISTRATION AND IS | | ALSO INVESTIGATING THE DELAY IN REPORTING THE MISADMINISTRATION. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29296 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: COOK REGION: 3 |NOTIFICATION DATE: 09/05/95 | |UNIT: [1] [ ] [ ] STATE: MI |NOTIFICATION TIME: 20:48 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 09/05/95 | +------------------------------------------------+EVENT TIME: 17:20[EDT]| |NRC NOTIFIED BY: RANDY PTACEK |LAST UPDATE DATE: 09/05/95 | |HQ OPS OFFICER: JOSEPH SEBROSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |RONALD GARDNER 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 N 0 REFUELING | 0 REFUELING | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | DEENERGIZATION OF A UNIT 1 BUS CAUSED AN AUTO START OF A UNIT 2 ESSENTIAL | | SERVICE WATER (ESW) PUMP. | | | | THE ESW SYSTEM AT THE SITE IS DESIGNED SUCH THAT A SAFETY INJECTION (SI) | | SIGNAL ON EITHER UNIT WILL AUTO START THE ESW PUMP FOR THAT UNIT AS WELL AS | | THE ESW PUMP FOR THE OPPOSITE UNIT. THIS IS DONE IN ANTICIPATION OF | | INCREASED ESW DEMAND DURING AN ACCIDENT. | | | | AT 17:20 ON UNIT 1 CONTROL ROOM INDICATION DISTRIBUTION (CRID) BUS 1 WAS | | REMOVED FROM SERVICE FOR INVERTER PREVENTIVE MAINTENANCE. THIS CAUSED THE | | DEENERGIZATION OF A RELAY WHICH AUTO STARTED THE UNIT 2 WEST ESW PUMP PER | | DESIGN. THE ESW PUMP FOR UNIT 1 DID NOT START AS EXPECTED BECAUSE THERE | | WAS NOT AN SI SIGNAL. THE START OF THE PUMP FOR UNIT 2 WAS NOT ANTICIPATED | | BY THE OPERATORS AT THE TIME OF THE DEENERGIZATION OF CRID BUS 1. THE WEST | | ESW PUMP FOR UNIT 2 WAS PLACED IN THE RUN CONDITION AND WILL STAY IN THIS | | CONDITION UNTIL POWER IS RESTORED TO UNIT 1'S CRID BUS 1. | | | | UNIT 2 IS CURRENTLY IN MODE 3. PRIOR TO THE EVENT THE EAST ESW PUMP FOR | | UNIT 2 WAS RUNNING. AFTER THE EVENT BOTH ESW PUMPS FOR UNIT 2 WERE RUNNING | | AND WILL REMAIN RUNNING UNTIL THE UNIT 1 BUS IS RESTORED. | | | | THE LICENSEE HAS INFORMED THE RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29297 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SOUTH TEXAS REGION: 4 |NOTIFICATION DATE: 09/06/95 | |UNIT: [ ] [2] [ ] STATE: TX |NOTIFICATION TIME: 00:37 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 09/05/95 | +------------------------------------------------+EVENT TIME: 01:00[CDT]| |NRC NOTIFIED BY: WALT SMITH |LAST UPDATE DATE: 09/06/95 | |HQ OPS OFFICER: RUDY KARSCH +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: | | |NLCO TECH SPEC LCO A/S | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | VIOLATION OF TECHNICAL SPECIFICATIONS REPORTABLE UNDER SECTION G OF THE | | OPERATING LICENSE. | | | | A CONTROL ROOM RADIATION MONITOR, RT-8034, FAILED A CHANNEL CHECK AT 0100 | | EDT ON 9/5/95. THIS WAS NOT NOTED BY THE CONTROL ROOM OPERATORS UNTIL | | ALMOST 13 HOURS HAD ELAPSED. THE ACTIONS OF TECH SPEC TABLE 3.3.3.10.D | | ACTION 28 WERE NOT PERFORMED WITHIN THE REQUIRED TIME LIMIT. THE LICENSEE | | INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+