U.S. Nuclear Regulatory Commission Operations Center Event Reports For 09/08/95 - 09/11/95 ** EVENT NUMBERS ** 29275 29302 29305 29306 29307 29308 29309 29310 29311 29312 29313 +----------------------------------+ +-----------------------+ |FUEL CYCLE FACILITY | |EVENT NUMBER: 29275 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BABCOCK & WILCOX CO. |NOTIFICATION DATE: 09/01/95 | | RXTYPE: URANIUM FUEL FABRICATION |NOTIFICATION TIME: 15:44 [ET]| |COMMENTS: HEU FABRICATION & SCRAP RECOVERY |EVENT DATE: 08/29/95 | | NAVAL REACTOR FUEL |EVENT TIME: 22:00[EDT]| | |LAST UPDATE DATE: 09/08/95 | | CITY: LYNCHBURG REGION: 2 +-----------------------------+ | COUNTY: CAMPBELL STATE: VA |PERSON ORGANIZATION| |LICENSE#: SNM-42 AGREEMENT: N |GEORGE AL BELISLE RDO | | DOCKET: 07000027 |COMBS EO | +------------------------------------------------+ | |NRC NOTIFIED BY: OLSEN | | |HQ OPS OFFICER: GREG SCARFO | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NBNL RESPONSE-BULLETIN | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE AMOUNT OF URANIUM-235 STORED IN A UNIT OF A STORAGE RACK ASSOCIATED | | WITH THE SCRAP MATERIAL RECOVERY OPERATION AT THE B&W NAVAL NUCLEAR FUEL | | FABRICATION FACILITY IN LYNCHBURG, VIRGINIA, EXCEEDED THE ADMINISTRATIVE | | LIMIT OF 350 GRAMS AS STIPULATED IN GENERIC LETTER 91-01. | | | | THE FOLLOWING IS THE TEXT OF A FACSIMILE SUBMITTED BY THE LICENSEE: | | "AT ABOUT 10:00PM ON TUESDAY, AUGUST 29, 1995, AN OPERATOR DISCOVERED A | | POTENTIALLY UNSAFE CONDITION IN THAT A STORAGE UNIT WITH A POSTED LIMIT OF | | 350 GRAMS U-235 HAD AN ACTUAL AMOUNT OF 783.82 GRAMS OF U-235. THE | | OPERATOR IMMEDIATELY NOTIFIED THE FOREMAN OVER THE AREA. IMMEDIATE | | CORRECTIVE ACTION WAS TAKEN, AND EXCESS U-235 WAS REMOVED FROM THE UNIT | | SUCH THAT ALL UNITS HAD LESS THAN THE POSTED LIMIT OF 350 GRAMS U-235. | | | | THE UNIT WAS ONE OF 12 UNITS OF AN SNM STORAGE RACK LOCATED IN THE DRUM | | COUNT AREA. IN ADDITION TO THE IMMEDIATE CORRECTIVE ACTION TAKEN TO ASSURE | | THAT THE UNIT'S MASS LIMIT WAS BEING MET, ALL STORAGE UNITS AND LOCATIONS | | IN THE AREA HAVE BEEN CHECKED TO ENSURE THAT THERE ARE NO OTHER UNITS IN | | VIOLATION OF THEIR POSTED LIMIT. | | | | A SET OF CONSERVATIVE PHYSICS CALCULATIONS HAVE BEEN MADE AND Q.A. | | REVIEWED. THE 783.82 GRAMS WAS DRY, FULLY ENRICHED UO2. THE CALCULATIONS | | DEMONSTRATE THAT IF ALL 12 UNITS OF THE RACK, INSTEAD OF JUST ONE, HAD BEEN | | OVERLOADED TO 800 GRAMS OF THIS TYPE OF MATERIAL, THE KEFF WOULD STILL HAVE | | BEEN LESS THAN THE LICENSE LIMIT FOR NORMAL OPERATIONS, 0.85. THE ACTUAL | | EXISTING CONDITION, THEREFORE, DID NOT EXCEED ANY NNFD LICENSE LIMIT. | | | | A PRELIMINARY INVESTIGATION HAS BEEN MADE. IT IS BELIEVED THAT THE UNIT | | WAS IN A STATE OF OVERLOAD FOR ABOUT 8 TO 11 HOURS BEFORE BEING DISCOVERED. | | AT THIS TIME, THERE ARE NO EXPLANATIONS OF WHY THE RACK'S POSTED LIMITS | | WERE VIOLATED. AN INVESTIGATION TEAM IS BEING FORMED TO CONDUCT A DETAILED | | REVIEW OF THE INCIDENT TO DETERMINE ROOT CAUSES AND RECOMMEND CORRECTIVE | | ACTIONS TO PREVENT RECURRENCE. | | | | GIVEN THAT SPACING, REFLECTOR, AND MODERATION CONTROLS REMAINED INTACT, IT | | IS POSSIBLE THAT DOUBLE CONTINGENCY WAS NOT LOST. CALCULATIONS ARE BEING | | PERFORMED TO CONFIRM THIS. HOWEVER, THEY WILL NOT BE COMPLETE WITHIN 24 | | HOURS OF THE OCCURRENCE; THEREFORE, THIS REPORT IS BEING SUBMITTED. IF IT | | CAN BE CONFIRMED THAT DOUBLE CONTINGENCY WAS NOT LOST, THIS REPORT WILL BE | | WITHDRAWN. | | | | THE NRC RESIDENT HAS BEEN NOTIFIED. REGION II AND NRC STAFF HAVE ALSO BEEN | | ADVISED. THE GENERAL MANAGER HAVE BEEN BRIEFED." | | END OF TEXT. | | | | IN THE SCRAP MATERIAL RECOVERY PORTION OF THE FACILITY, A STORAGE RACK | | CONTAINS 12 STORAGE UNITS. EACH LOCATION CAN HOLD 8 2.5-LITER BOTTLES OF | | SCRAP U-235. THE ADMINISTRATIVE LIMIT ON U-235 FOR EACH STORAGE UNIT IS | | 350 GRAMS. EACH BOTTLE IS MARKED WITH THE AMOUNT OF U-235 IT CONTAINS | | PRIOR TO STORAGE BY AN OPERATOR. AN OPERATOR INCORRECTLY STORED 5 BOTTLES | | RANGING IN AMOUNTS FROM 90 GRAMS OF U-235 TO 250 GRAMS OF U-235 IN A | | PARTICULAR STORAGE UNIT. THIS EXCEEDED ITS 350 GRAM U-235 LIMIT. | | SUBSEQUENTLY, ANOTHER OPERATOR DISCOVERED THIS CONDITION AND IMMEDIATELY | | RE-CONFIGURED THE BOTTLES TO REDUCE THE U-235 INVENTORY IN THE STORAGE UNIT | | BELOW THE 350 GRAM LIMIT. | | | | AN INVESTIGATION IS ONGOING TO DETERMINED THE CAUSE OF THIS CONDITION. THE | | LICENSEE INFORMED THE NRC RESIDENT INSPECTOR, REGION II PERSONNEL, AND HQ | | PERSONNEL. | | | | * * * UPDATE @ 11:21 ON SEPTEMBER 8, 1995, FROM OLSEN TAKEN BY KARSCH * * * | | | | THREE MORE INSTANCES OF TOO MUCH MATERIAL IN TOO SMALL A SPACE WERE FOUND. | | THE LICENSEE HAS DISCUSSED THIS WITH REGION 2 REPRESENTATIVES (McALPINE, | | TROUP, ET AL). | | | | THE R2DO (BARR) WAS NOTIFIED BY THE NRC OPERATIONS CENTER. | | | | * * * UPDATE @ 12:12 ON SEPTEMBER 8, 1995, FROM OLSEN TAKEN BY WEAVER * * * | | | | DETAILS WERE PROVIDED REGARDING THE THREE ADDITIONAL INSTANCES. | | | | 1) DRUM COUNT AREA - AN ACCOUNTABILITY CART CONSISTING OF SEVERAL STORAGE | | UNITS EACH LIMITED TO 350 GRAMS U-235 WITH NO MODERATION (H/X) RESTRICTION | | OR 3.6 KILOGRAMS U-235 WITH A H/X OF < 20 WAS FOUND WITH 1 UNIT CONTAINING | | A 2.5 LITER CONTAINER OF 373.62 GRAMS U-235 OF DRY UO2 WITH A H/X OF 20.98. | | THE CONTAINER WAS IMMEDIATELY REMOVED TO AN AREA THAT IS LIMITED TO 3.1 kgs | | U-235 AND 1,850 GRAMS OF MODERATOR MATERIAL. | | | | 2) CENTRAL VAULT - A STORAGE UNIT LIMITED TO 350 GRAMS U-235 WITH NO H/X | | RESTRICTION OR 3.6 KILOGRAMS U-235 WITH H/X OF < 20 WAS FOUND WITH 2 | | CONTAINERS IN 1 UNIT TOTALING 375.5 GRAMS U-235 WITH H/X OF 50.86. ONE OF | | THE CONTAINERS WAS IMMEDIATELY MOVED TO ANOTHER STORAGE AREA. | | | | 3) RTRFE VAULT - THREE STORAGE UNITS, EACH LIMITED TO 350 GRAMS U-235 WITH | | NO H/X RESTRICTION OR 3.6 KILOGRAMS U-235 WITH H/X < 20, WHERE ONE WAS | | FOUND TO CONTAIN 474 GRAMS U-235 WITH H/X OF 138, ANOTHER CONTAINED 471 | | GRAMS U-235 WITH H/X OF 138, AND THE THIRD CONTAINED 934 GRAMS U-235 WITH | | H/X OF 127. THE CORRECTIVE ACTION CONSISTED OF IMMEDIATELY REMOVING THE | | CONTAINERS FROM THE VAULT TO A STORAGE LOCATION THAT COULD HOLD THESE | | QUANTITIES. | | | | UPON DISCOVERY OF ITEM 2, ABOVE, NNFD MANAGEMENT SUSPENDED ALL TRANSFERS TO | | OR FROM MASS/MODERATOR LIMITED AREAS PENDING COMPLETION OF INSPECTIONS OF | | THE ENTIRE PLANT. THIS INSPECTION HAS BEEN COMPLETED WITH NO ADDITIONAL | | EXAMPLES OF EXCEEDED MASS LIMITS BEING IDENTIFIED. TRANSFERS HAVE BEEN | | ALLOWED TO RESUME WITH THE IMPLEMENTATION OF A TWO-MAN RULE, WHEREBY, ONE | | INDIVIDUAL WILL ACTUALLY MAKE THE TRANSFER, AND THE OTHER WILL VERIFY THE | | CORRECTNESS OF THE TRANSFER. | | | | A ROOT CAUSE INVESTIGATION IS IN PROGRESS TO REVIEW THESE EVENTS AND ANY | | PRIOR SIMILAR EVENTS. ONE SIMILAR EVENT (WHICH WAS NOT REPORTABLE UNDER | | 91-01) OCCURRED ON AUGUST 8, 1995, AND IS BEING INCLUDED IN THE | | INVESTIGATION. THE TWO-MAN RULE WILL REMAIN IN EFFECT UNTIL THE | | INVESTIGATION IS COMPLETE AND APPROPRIATE MEASURES TAKEN. THE NRC RESIDENT | | INSPECTOR WILL BE INFORMED PRIOR TO DISCONTINUING THE TWO-MAN RULE. | | | | THIS INFORMATION WAS DISCUSSED WITH NRC REGION II AND NMSS ON SEPTEMBER 7, | | 1995, AND IS BEING PROVIDED TO ASSURE THE COMPLETENESS OF THE RECORD | | REGARDING EVENT NO. 29275. | | | | THE HOO NOTIFIED THE R2DO (BARR) AND NMSS EO (COMBS). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 29302 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: DEPT OF VETRAN'S AFFAIRS MED. CNTR. |NOTIFICATION DATE: 09/07/95 | | CITY: LEXINGTON REGION: 2 |NOTIFICATION TIME: 10:08 [ET]| | COUNTY: FAYETTE STATE: KY |EVENT DATE: 09/07/95 | |LICENSE#: 16-088-96-04 AGREEMENT: Y |EVENT TIME: 04:00[EDT]| | DOCKET: |LAST UPDATE DATE: 09/08/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |KENNETH BARR RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: MIKE HACKETT | | |HQ OPS OFFICER: RUDY KARSCH | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | LEXINGTON V.A. HOSPITAL, LEXINGTON, KENTUCKY. | | | | A PATIENT DISLODGED BRACHYTHERAPY SEEDS DURING TREATMENT RESULTING IN AN | | INSUFFICIENT DOSE. THE SEEDS CONSISTED OF 58.9 mCi OF Ir-192. THE PATIENT | | HAS BEEN ADVISED, AND THE COMPLETION OF TREATMENT IS SCHEDULED FOR LATER | | TODAY. | | | | THE LICENSEE DISCUSSED THIS EVENT WITH REGION 2 (ENNIS). | | | | * * * UPDATE @ 10:26 ON SEPTEMBER 8, 1995, FROM HACKETT BY KARSCH * * * | | | | THE PATIENT AGAIN REMOVED THE BRACHYTHERAPY SOURCE PRIOR TO THE COMPLETION | | OF TREATMENT. THE LICENSEE IS RE-EVALUATING ITS COURSE OF ACTION FOR | | TREATMENT OPTIONS. | | | | THE R2DO (BARR) WAS NOTIFIED BY THE NRC OPERATIONS CENTER. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29305 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: DRESDEN REGION: 3 |NOTIFICATION DATE: 09/08/95 | |UNIT: [ ] [ ] [3] STATE: IL |NOTIFICATION TIME: 02:28 [ET]| |RX TYPE: [1] GE-1,[2] GE-3,[3] GE-3 |EVENT DATE: 09/07/95 | +------------------------------------------------+EVENT TIME: 22:33[CDT]| |NRC NOTIFIED BY: BRYAN HANSON |LAST UPDATE DATE: 09/08/95 | |HQ OPS OFFICER: RUDY KARSCH +-----------------------------+ +------------------------------------------------+ 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | | | | | 3 | N Y 1 STARTUP | 1 STARTUP | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | VACUUM BREAKERS CYCLE UNEXPECTEDLY DURING ATTEMPTS TO RESTORE POSITIVE | | PRESSURE TO THE CONTAINMENT. | | | | ALL 12 DRYWELL TO TORUS VACUUM BREAKERS CYCLED DURING EFFORTS TO RESTORE | | POSITIVE PRESSURE IN CONTAINMENT DURING REACTOR STARTUP. INVESTIGATION BY | | THE LICENSEE DETERMINED THAT THE VACUUM BREAKER SETTINGS ARE CONSERVATIVE | | (NOMINAL 0.5 PSID, ACTUAL 0.16 PSID). INITIAL CONDITIONS WERE TORUS | | PRESSURE AT -0.21 AND DRYWELL PRESSURE AT -0.16. WHEN AIR WAS ADMITTED TO | | THE TORUS, A DIFFERENTIAL PRESSURE OF 0.16 PSID WAS EXPERIENCED, AND THE | | VACUUM BREAKERS OPENED. THE CONSERVATIVE SETTINGS WERE NOT EXPLICITLY | | KNOWN TO THE OPERATING CREW, AND CONSEQUENTLY, THE VALVES CYCLED | | UNEXPECTEDLY. | | | | THE LICENSEE WILL MAINTAIN THE PLANT AT 1% POWER UNTIL ITS ROOT CAUSE | | INVESTIGATION IS COMPLETED. THE LICENSEE INFORMED THE NRC RESIDENT | | INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29306 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: CALVERT CLIFFS REGION: 1 |NOTIFICATION DATE: 09/08/95 | |UNIT: [1] [2] [ ] STATE: MD |NOTIFICATION TIME: 09:32 [ET]| |RX TYPE: [1] CE,[2] CE |EVENT DATE: 09/08/95 | +------------------------------------------------+EVENT TIME: 07:20[EDT]| |NRC NOTIFIED BY: MARTENIS |LAST UPDATE DATE: 09/08/95 | |HQ OPS OFFICER: RUDY KARSCH +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |GLENN MEYER RDO | |HFIT 26.73 FITNESS FOR DUTY | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | SECURITY SHIFT SUPERVISOR - NUCLEAR TESTED POSITIVE FOR A CONTROLLED | | SUBSTANCE. HIS SITE ACCESS WAS TERMINATED, AND HE WAS ESCORTED OFF SITE. | | HE HAS BEEN OFFERED ACCESS TO A REHABILITATION PROGRAM. HIS LAST ENTRY | | INTO THE VITAL AREA WAS ON SEPTEMBER 7, 1995; HOWEVER, HE WAS ALWAYS UNDER | | OBSERVATION BY OTHER SECURITY PERSONNEL. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29307 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: WOLF CREEK REGION: 4 |NOTIFICATION DATE: 09/08/95 | |UNIT: [1] [ ] [ ] STATE: KS |NOTIFICATION TIME: 15:07 [ET]| |RX TYPE: [1] W-4-LP |EVENT DATE: 09/07/95 | +------------------------------------------------+EVENT TIME: 16:00[CDT]| |NRC NOTIFIED BY: TERRY DAMASHEK |LAST UPDATE DATE: 09/08/95 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |LAWRENCE YANDELL RDO | |NLTR LICENSEE 24 HR REPORT | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | EMERGENCY LIGHTING DOES NOT MEET ALL FIRE PROTECTION REQUIREMENTS | | | | THE LICENSEE DISCOVERED ON SEPTEMBER 7, 1995, THAT THE EXISTING PROGRAM FOR | | EMERGENCY LIGHTING DID NOT MEET ALL OF THE REQUIREMENTS OF THE FIRE | | PROTECTION PROGRAM (FPP) AS APPROVED IN THE SAFETY EVALUATION REPORT (SER) | | THROUGH SUPP. 5. | | | | LICENSE CONDITION 2.C.(5)(A) REQUIRES THE LICENSEE TO MAINTAIN IN EFFECT | | ALL PROVISIONS OF THE FPP AS DESCRIBED IN THE SER THROUGH SUPP. 5. | | SPECIFICALLY, THE SER REQUIRES THAT 8-HOUR EMERGENCY LIGHTING UNITS BE | | INSTALLED IN ALL AREAS OF THE PLANT NEEDED FOR OPERATION OF THE SAFE | | SHUTDOWN EQUIPMENT AND IN ACCESS AND EGRESS ROUTES. | | | | WALKDOWNS AND EVALUATIONS OF INSTALLED EMERGENCY LIGHTS HAVE IDENTIFIED | | QUESTIONABLE LIGHTING IN SOME AREAS AND HAVE IDENTIFIED THAT EXISTING | | PROCEDURES FOR MAINTENANCE AND TESTING DO NOT ADEQUATELY ADDRESS ALL OF | | THESE REQUIRED LIGHTS. | | | | THE LICENSEE IS CONTINUING TO EVALUATE THE RESULTS OF THE WALKDOWNS AND IS | | IMPLEMENTING CORRECTIVE ACTIONS TO RESOLVE THE PROBLEMS IDENTIFIED. UNTIL | | ALL CORRECTIVE ACTIONS ARE COMPLETED, OPERATION BUILDING WATCH PERSONNEL | | WILL BE REQUIRED TO CARRY OPERATING FLASHLIGHTS. THIS INTERIM ACTION HAS | | BEEN IN PLACE SINCE JULY 20, 1995, WHEN AN INITIAL CONCERN RELATED TO | | EMERGENCY LIGHTING WAS IDENTIFIED BY AN NRC INSPECTOR. | | | | THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |OTHER NUCLEAR MATERIAL | |EVENT NUMBER: 29308 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: AMERSHAM |NOTIFICATION DATE: 09/08/95 | | CITY: BURLINGTON REGION: 1 |NOTIFICATION TIME: 16:00 [ET]| | COUNTY: STATE: MA |EVENT DATE: 08/08/95 | |LICENSE#: AGREEMENT: N |EVENT TIME: 00:00[EDT]| | DOCKET: |LAST UPDATE DATE: 09/08/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | | | | | | +------------------------------------------------+KEVIN RAMSEY NMSS | |NRC NOTIFIED BY: CATHLEEN ROUGHAN | | |HQ OPS OFFICER: DOUG WEAVER | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |CCCC 21.21 UNSPECIFIED PARAGRAPH | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AMERSHAM CORPORATION | | | | THE PART 21 CONCERNS A MODEL-899 DRIVE CABLE CONNECTOR THAT PULLED OFF THE | | DRIVE CABLE DURING RADIOGRAPHIC OPERATIONS AT A DAYTON X-RAY FACILITY. THE | | LICENSEE IS CONDUCTING TESTING TO DETERMINE THE CAUSE OF THE FAILURE. | | | | THIS IS AN INTERIM REPORT WITH A FOLLOW-UP REPORT EXPECTED IN NOVEMBER. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29309 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: HOPE CREEK REGION: 1 |NOTIFICATION DATE: 09/08/95 | |UNIT: [1] [ ] [ ] STATE: NJ |NOTIFICATION TIME: 17:14 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 09/08/95 | +------------------------------------------------+EVENT TIME: 15:15[EDT]| |NRC NOTIFIED BY: JOHN DEDOMENICO |LAST UPDATE DATE: 09/08/95 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |GLENN MEYER 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 +------------------------------------------------------------------------------+ | HIGH PRESSURE COOLANT INJECTION (HPCI) SUCTION SWAPPED TO THE TORUS ON HIGH | | TORUS LEVEL | | | | AT 15:15, THE HPCI SYSTEM SUCTION FLOW PATH AUTOMATICALLY RE-ALIGNED FROM | | THE NORMAL CONDENSATE STORAGE TANK SOURCE TO THE TORUS. THE SUCTION FLOW | | PATH RE-ALIGNMENT WAS DUE TO A HIGH TORUS LEVEL SIGNAL. TORUS LEVEL | | CHANNELS ALL INDICATED LEVEL WAS WITHIN THE NORMAL BAND WITH THE HIGHEST | | CHANNEL APPROXIMATELY 1/2 INCH BELOW THE UPPER TORUS LEVEL LIMIT. TECHNICAL | | SPECIFICATIONS REQUIRE TORUS LEVEL TO BE MAINTAINED BETWEEN 74.5 AND 78.5 | | INCHES. TECHNICAL SPECIFICATIONS ALSO REQUIRE THE TORUS HIGH LEVEL SUCTION | | SWAP TRIP SETPOINT TO BE SET ó 78.5 INCHES. THE INSTRUMENTS THAT PROVIDE | | THE CONTROL ROOM INDICATION ARE INDEPENDENT OF THE INSTRUMENTS THAT CAUSE | | THE SUCTION TRANSFER. | | | | THE LICENSEE INTENDS TO LOWER TORUS LEVEL AND RESTORE THE HPCI SUCTION | | LINEUP. | | | | THE NRC RESIDENT INSPECTOR AND LOWER ALLOWAYS CREEK TOWNSHIP WERE NOTIFIED | | BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29310 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PEACH BOTTOM REGION: 1 |NOTIFICATION DATE: 09/08/95 | |UNIT: [2] [3] [ ] STATE: PA |NOTIFICATION TIME: 20:53 [ET]| |RX TYPE: [2] GE-4,[3] GE-4 |EVENT DATE: 09/08/95 | +------------------------------------------------+EVENT TIME: 16:20[EDT]| |NRC NOTIFIED BY: JIM KOVALCHICK |LAST UPDATE DATE: 09/08/95 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |GLENN MEYER 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 | | 3 | N Y 61 POWER OPERATION | 61 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | OFFSITE NOTIFICATION OF A FUEL OIL DISCHARGE | | | | APPROXIMATELY 10 GALLONS OF FUEL OIL WAS DISCHARGED TO THE SUSQUEHANNA | | RIVER FROM THE SITE'S STORM DRAIN SYSTEM. THE OIL HAS BEEN CONTAINED BY A | | BOOM ON THE RIVER. THE LICENSEE IS SEARCHING FOR THE SOURCE OF THE FUEL | | OIL. | | | | THE NATIONAL RESPONSE CENTER AND THE PENNSYLVANIA DEPARTMENT OF | | ENVIRONMENTAL RESOURCES WERE NOTIFIED BY THE LICENSEE. THE LICENSEE WILL | | ALSO INFORM THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29311 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: COOK REGION: 3 |NOTIFICATION DATE: 09/08/95 | |UNIT: [ ] [2] [ ] STATE: MI |NOTIFICATION TIME: 23:44 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 09/08/95 | +------------------------------------------------+EVENT TIME: 21:25[EDT]| |NRC NOTIFIED BY: RANDY PTACEK |LAST UPDATE DATE: 09/08/95 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |RON GARDNER RDO | |ARPS 50.72(b)(2)(ii) RPS ACTUATION | | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | M/R Y 100 POWER OPERATION | 0 HOT STANDBY | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | DURING SSPS TRAIN 'A' TESTING, A REACTOR OPERATOR INADVERTENTLY MANUALLY | | TRIPPED THE REACTOR. ALL SYSTEM OPERATED PROPERLY. | | | | DURING SSPS TRAIN 'A' SURVEILLANCE TESTING PER SURVEILLANCE TEST PROCEDURE | | 2-IHP-4030.STP.510, TRAIN 'A' RPS AND ESF REACTOR TRIP BREAKER AND SSPS | | AUTOMATIC TRIP ACTUATION LOGIC FUNCTIONAL TEST, A REACTOR OPERATOR | | MIS-OPERATED THE MANUAL REACTOR TRIP BREAKER SWITCH. THE PROCEDURE CALLED | | FOR THE BREAKER TO BE CLOSED, AND THE OPERATOR TOOK THE MANUAL BREAKER | | SWITCH TO THE OPEN POSITION. (THE 'A' BYPASS REACTOR TRIP BREAKER WAS | | CLOSED, AND THE 'B' REACTOR TRIP BREAKER WAS CLOSED WITH THE 'A' REACTOR | | TRIP BREAKER OPEN.) OPENING THE MANUAL REACTOR TRIP BREAKER OPENS ANY | | CLOSED REACTOR TRIP BREAKER. WHEN THE MANUAL REACTOR TRIP BREAKER OPENED, | | BOTH REACTOR TRIP BREAKER 'B' AND REACTOR BYPASS TRIP BREAKER 'A' OPENED. | | ALL CONTROL RODS FULLY INSERTED. THE TURBINE-DRIVEN AUXILIARY FEEDWATER | | PUMP AND BOTH MOTOR-DRIVEN AUXILIARY FEEDWATER PUMPS AUTOMATICALLY STARTED | | ON LOW-LOW STEAM GENERATOR WATER LEVEL. THE TURBINE-DRIVEN AUXILIARY | | FEEDWATER PUMP HAS BEEN SECURED, AND THE STEAM GENERATORS ARE BEING FED BY | | THE MOTOR-DRIVEN AUXILIARY FEEDWATER PUMPS. NO PRIMARY OR SECONDARY SIDE | | PORV VALVES OR CODE SAFETY VALVES OPENED. THE PLANT IS AT A Tave NO LOAD | | CONDITION OF 548øF AND 2,235 psig. ALL ECCS SYSTEMS AND EDGs ARE FULLY | | OPERABLE IF NEEDED. RESTART WILL PROBABLY BE WITHIN THE NEXT 24 HOURS. | | | | STEAM GENERATOR #1 FEEDWATER ISOLATION VALVE FMO-201 AND STEAM GENERATOR #4 | | FEEDWATER ISOLATION VALVE FMO-204 DID NOT AUTOMATICALLY CLOSE DUE TO THE | | TESTING CONDITIONS SET UP BY THE SURVEILLANCE TESTING OF SSPS TRAIN 'A'. | | THE REDUNDANT FEEDWATER ISOLATION VALVES, FMO-210 AND FMO-240, CLOSED. | | | | THE NRC RESIDENT INSPECTOR WAS INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29312 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: THREE MILE ISLAND REGION: 1 |NOTIFICATION DATE: 09/09/95 | |UNIT: [1] [ ] [ ] STATE: PA |NOTIFICATION TIME: 11:38 [ET]| |RX TYPE: [1] B&W-L-LP,[2] B&W-L-LP |EVENT DATE: 09/09/95 | +------------------------------------------------+EVENT TIME: 10:15[EDT]| |NRC NOTIFIED BY: MAX NELSON |LAST UPDATE DATE: 09/09/95 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |GLENN MEYER RDO | |ADAS 50.72(b)(2)(i) DEG/UNANALYZED COND |RICHARD WESSMAN EO | | |DIANE SCRENCI/REG. 1 PAO | | |JOE GILLILAND/HQ PAO | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | UN-ISOLABLE REACTOR COOLANT SYSTEM (RCS) LEAK FOUND ON AN RCS DRAIN LINE | | THAT COMES OFF OF THE COLD LEG (RCV-6B). THE LEAK RATE WAS MEASURED WITH | | THE RCS AT 2,000 psig, AND IT WAS 20 DROPS PER SECOND. | | | | AFTER SHUTTING DOWN THE PLANT TO ENTER THE ELEVENTH REFUELING OUTAGE, A | | HEALTH PHYSICIST NOTICED THAT CONTAINMENT RADIATION MONITOR (RMA2) SHOWED | | THAT IODINE LEVELS INSIDE CONTAINMENT WERE INCREASING. THE LICENSEE SENT | | PERSONNEL INSIDE CONTAINMENT TO FIND THE LEAK, AND A LEAK WAS DISCOVERED | | NEAR THE HEAT AFFECTED ZONE OF A WELD LOCATED ON THE RCS DRAIN LINE THAT | | COMES OFF THE COLD LEG (RCV-6B). THE LEAK WAS AN UN-ISOLABLE RCS LEAK | | LOCATED ON THE UPSTREAM SIDE OF THE ISOLATION LINE, AND THE LEAK RATE WAS | | DETERMINED TO BE 20 DROPS PER SECOND WHEN RCS PRESSURE WAS 2,000 psig. | | | | RCS PRESSURE IS CURRENTLY 1,080 psig, AND THE LEAK RATE HAS SIGNIFICANTLY | | DECREASED. THE LEAK SEEMS TO BE COMING FROM A PIN HOLE NEAR THE HEAT | | AFFECTED ZONE OF THE WELD. TO REDUCE IODINE LEVELS IN THE AREA NEAR THE | | LEAK, PLANT PERSONNEL PLACED A LARGE VENTILATION UNIT NEAR THE LEAK WHICH | | REDUCED THE IODINE LEVELS. THE LICENSEE DID NOT KNOW THE RADIATION MONITOR | | LEVEL FOR THE IODINE AND DID NOT KNOW WHAT THE RCS LEAK RATE WAS WHEN RCS | | PRESSURE WAS 1,080 psig. THE RCS SCHEDULE-160 PIPE IS A 2-INCH OUTSIDE | | DIAMETER PIPE. THE LICENSEE WILL CONTINUE ENTERING THE REFUELING OUTAGE | | AND WILL REPAIR THE LEAK. | | | | THE NRC RESIDENT INSPECTOR WAS INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |IRRETRIEVABLE WELL LOGGING SOURCE | |EVENT NUMBER: 29313 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: WESTERN ATLAS INTERNATIONAL |NOTIFICATION DATE: 09/09/95 | | CITY: HOUSTON REGION: 4 |NOTIFICATION TIME: 21:04 [ET]| | COUNTY: STATE: TX |EVENT DATE: 09/06/95 | |LICENSE#: 42-02964-01 AGREEMENT: Y |EVENT TIME: 00:00[CDT]| | DOCKET: |LAST UPDATE DATE: 09/09/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |LAWRENCE YANDELL RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: BILLY ROSE | | |HQ OPS OFFICER: LEIGH TROCINE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |EIRR 39.77(c) WELL LOGGING SOURCE | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | WESTERN ATLAS INTERNATIONAL - IRRETRIEVABLE WELL LOGGING SOURCES | | | | NAME OF WELL OWNER: VASTAR RESOURCES | | | | LOCATION OF THE WELL: SOUTH PASS BLOCK NUMBER 60; SLOT B; PLATFORM A; | | 5,825 FEET FROM THE NORTH LINE; AND 6,572 FEET FROM THE EAST LINE (API | | NUMBER 17-721-40015-00) | | | | WELL IDENTIFICATION: OUTER CONTINENTAL SHELF GULF 213783, SIDE TRACK 1 | | | | ISOTOPE: ONE AMERICIUM/BERYLLIUM NEUTRON SOURCE AND ONE CESIUM-137 SOURCE | | | | QUANTITY: 18 CURIES AND 2 CURIES, RESPECTIVELY | | | | REQUEST FOR IMMEDIATE NRC APPROVAL TO BEGIN ABANDONMENT: YES - THE | | ABANDONMENT PLAN INVOLVES PLACING 1,100 FEET OF DRILL PIPE (WHICH IS 4-1/2 | | INCHES IN DIAMETER) OVER THE TOP OF THE SOURCES AND SEALING THE DRILL PIPE | | WITH CEMENT. | | | | ADDITIONAL NOTIFICATIONS: THE LICENSEE HAS ALSO NOTIFIED THE MINERALS | | MANAGEMENT SERVICE. | | | | REFER TO THE HOO LOG FOR LICENSEE TELEPHONE NUMBER. | +------------------------------------------------------------------------------+