U.S. Nuclear Regulatory Commission Operations Center Event Reports For 12/13/95 - 12/14/95 ** EVENT NUMBERS ** 29697 29705 29709 29710 29711 29712 29713 29714 29715 29716 29717 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 29697 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: VA MEDICAL CENTER, ALBANY, NY |NOTIFICATION DATE: 12/11/95 | | CITY: ALBANY REGION: 1 |NOTIFICATION TIME: 15:37 [ET]| | COUNTY: STATE: NY |EVENT DATE: 12/11/95 | |LICENSE#: 31-02755-05 AGREEMENT: Y |EVENT TIME: 15:15[EST]| | DOCKET: |LAST UPDATE DATE: 12/13/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |JAMES LINVILLE RDO | | |LARRY CAMPER, NMSS EO | +------------------------------------------------+ | |NRC NOTIFIED BY: DAVE RHOE, RAD SAFETY OFF | | |HQ OPS OFFICER: DICK JOLLIFFE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - PATIENT GIVEN WRONG RADIOPHARMACEUTICAL DURING A DIAGNOSTIC TREATMENT - | | | | A MALE PATIENT WAS GIVEN THE WRONG RADIOPHARMACEUTICAL BY AN IMAGING | | TECHNOLOGIST DURING A MEDICAL DIAGNOSTIC TREATMENT AT THE VETERANS AFFAIRS | | MEDICAL CENTER, ALBANY, NEW YORK. THE PATIENT WAS GIVEN 25 MILLICURIES OF | | TC-99m, MAG3 CHEMICAL FORM, WHICH IS USED FOR A RENAL STUDY INSTEAD OF 25 | | MILLICURIES OF TC-99m, ECD CHEMICAL FORM, WHICH IS USED FOR A BRAIN STUDY. | | THE ERROR SHOULD HAVE MINIMAL NEGATIVE MEDICAL EFFECTS ON THE PATIENT. | | | | HOSPITAL PERSONNEL ARE NOTIFYING THE PATIENT AND HIS REFERRING PHYSICIAN OF | | THE ERROR. | | | | LICENSEE PLANS TO REINSTRUCT THE TECHNOLOGIST ON PROPER MEDICAL PROCEDURES. | | | | LICENSEE INTENDS TO SUBMIT A WRITTEN REPORT TO THE NRC. | | | | SEE HOO LOG FOR RADIATION SAFETY OFFICER'S TELEPHONE NUMBER. | | | | * * * UPDATE AT 1452 ON 12/13/95 BY DAVE RHOE ENTERED BY HOO JOLLIFFE * * * | | | | LICENSEE DESIRES TO RETRACT THIS EVENT SINCE THE DOSE TO THE PATIENT | | DID NOT EXCEED 5 REMs EFFECTIVE DOSE EQUIVALENT (WHOLE BODY) OR | | 50 REMs EFFECTIVE DOSE EQUIVALENT TO ANY INDIVIDUAL ORGAN. | | REFERENCE: 10CFR35.2, DEFINITION OF MISADMINISTRATION, SECTION (6)(ii). | | | | HOO NOTIFIED R1DO JIM LINVILLE. | +------------------------------------------------------------------------------+ !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 29705 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: PROVIDENCE HOSPITAL, WASHINGTON, DC |NOTIFICATION DATE: 12/12/95 | | CITY: WASHINGTON REGION: 1 |NOTIFICATION TIME: 14:21 [ET]| | COUNTY: STATE: DC |EVENT DATE: 12/12/95 | |LICENSE#: 08-01728-01 AGREEMENT: N |EVENT TIME: 13:21[EST]| | DOCKET: |LAST UPDATE DATE: 12/13/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |JAMES LINVILLE RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: CHRISTIAN O. ALELE | | |HQ OPS OFFICER: LEIGH TROCINE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MEDICAL MISADMINISTRATION AT PROVIDENCE HOSPITAL, WASHINGTON, DC | | | | THE LICENSEE ADMINISTERED 8 MILLICURIES OF TECHNETIUM-99M SESTAMIBI TO A | | PATIENT IN LIEU OF 24 TO 25 MILLICURIES OF TECHNETIUM-99M MDP. BOTH OF | | THESE RADIOPHARMACEUTICALS ARE USED AS SCANNING AGENTS. TECHNETIUM-99M | | SESTAMIBI IS A CARDIOLYTE THAT OUTLINES THE HEART. TECHNETIUM-99M MDP | | OUTLINES THE BONES. THE LICENSEE HAS ATTRIBUTED THIS EVENT TO PERSONNEL | | ERROR. | | | | THE LICENSEE DOES NOT BELIEVE THAT THERE WILL BE ANY ADVERSE HEALTH AFFECTS | | AS A RESULT OF THIS MISADMINISTRATION AND PLANS TO ADMINISTER THE | | PRESCRIBED DOSAGE OF TECHNETIUM-99M MDP. THE LICENSEE ALSO PLANS TO NOTIFY | | THE REFERRING PHYSICIAN AND THE PATIENT. IN ADDITION, THE LICENSEE PLANS | | TO NOTIFY THE NRC REGION 1 OFFICE WITHIN 15 DAYS. | | | | (REFER TO THE HOO LOG FOR THE LICENSEE'S STREET ADDRESS AND TELEPHONE | | NUMBER.) | | | | * * * UPDATE AT 1448 ON 12/13/95 BY ALELA ENTERED BY HOO JOLLIFFE * * * | | | | LICENSEE DESIRES TO RETRACT THIS EVENT SINCE THE DOSE TO THE PATIENT | | DID NOT EXCEED 5 REMs EFFECTIVE DOSE EQUIVALENT (WHOLE BODY) OR | | 50 REMs EFFECTIVE DOSE EQUIVALENT TO ANY INDIVIDUAL ORGAN. | | REFERENCE: 10CFR35.2, DEFINITION OF MISADMINISTRATION, SECTION (6)(ii). | | | | HOO NOTIFIED R1DO JIM LINVILLE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29709 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: FERMI REGION: 3 |NOTIFICATION DATE: 12/13/95 | |UNIT: [2] [ ] [ ] STATE: MI |NOTIFICATION TIME: 14:06 [ET]| |RX TYPE: [2] GE-4 |EVENT DATE: 12/13/95 | +------------------------------------------------+EVENT TIME: 13:40[EST]| |NRC NOTIFIED BY: JOE SKLARCZYK |LAST UPDATE DATE: 12/13/95 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |THOMAS KOZAK RDO | |NLTR LICENSEE 24 HR REPORT | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 2 | N Y 22 POWER OPERATION | 22 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - 1 MWt NONCONSERVATIVE OMISSION FOUND IN CORE THERMAL POWER CALCULATION - | | | | LICENSEE DISCOVERED AN OMISSION IN THE HEAT BALANCE COMPUTER PROGRAM THAT | | CALCULATES CORE THERMAL POWER. CONTROL ROD DRIVE FLOW THAT IS DIRECTED | | TO THE REACTOR RECIRCULATION PUMPS FOR SEAL STAGING FLOW CONTRIBUTES | | APPROXIMATELY 4 GALLONS PER MINUTE OF COLD WATER TO THE PRIMARY COOLANT | | SYSTEM. THIS FLOW IS NOT ACCOUNTED FOR IN THE HEAT BALANCE CALCULATION. | | THE IMPACT TO THE HEAT BALANCE CALCULATION IS THAT CALCULATED CORE POWER | | IS APPROXIMATELY 1 MEGAWATT THERMAL (MWt) LOWER THAN ACTUAL POWER. | | | | THIS RESULTS IN A NONCONSERVATIVE ERROR IN THE HEAT BALANCE CALCULATION. | | DUE TO THIS ERROR, IT IS CONSIDERED LIKELY THAT FERMI 2 EXCEEDED ITS | | LICENSED POWER LIMIT OF 3292 MWt ON ONE OR MORE OCCASIONS DURING CYCLE #1 | | AND 3293 MWt ON ONE OR MORE OCCASIONS DURING CYCLES #2 AND #3 BY | | APPROXIMATELY 1 MWt. THE CURRENT LICENSED POWER LIMIT OF 3430 MWt HAS | | NOT BEEN EXCEEDED AS A RESULT OF THIS OMISSION. | | | | EXCEEDING THE LICENSED POWER LIMIT IS REPORTABLE TO THE NRC WITHIN 24 HOURS | | IN ACCORDANCE WITH LICENSE CONDITION 2.F. | | | | LICENSEE WILL SUBMIT A WRITTEN REPORT OF THIS EVENT TO THE NRC WITHIN | | 30 DAYS. | | | | LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | | | | NOTE: SEE THE FOLLOWING SIMILAR EVENTS; #29603, #29667, #29689, #29691, | | #29699, #29711 & #29716. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |OTHER NUCLEAR MATERIAL | |EVENT NUMBER: 29710 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: COMMUNITY HOSPITAL, TORRINGTON, WY |NOTIFICATION DATE: 12/13/95 | | CITY: TORRINGTON REGION: 4 |NOTIFICATION TIME: 16:33 [ET]| | COUNTY: STATE: WY |EVENT DATE: 11/07/94 | |LICENSE#: AGREEMENT: N |EVENT TIME: 12:00[MST]| | DOCKET: |LAST UPDATE DATE: 12/13/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |LINDA HOWELL RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: CHARLES MYERS | | |HQ OPS OFFICER: GREG SCARFO | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - 2 MEDICAL MISADMINISTRATIONS AT COMMUNITY HOSPITAL, TORRINGTON, WYOMING - | | | | CHARLES MYERS OF COMMUNITY HOSPITAL, TORRINGTON, WYOMING, REPORTED THAT | | TWO MEDICAL MISADMINISTRATIONS HAD OCCURRED DURING 1994. BOTH WERE | | INSTANCES OF IODINE-131 PRESCRIPTIONS FOR THYROID DIAGNOSTIC ANALYSIS. | | | | ON 09/06/94, A PHYSICIAN PRESCRIBED 6 MILLICURIES OF I-131 FOR A THYROID | | DIAGNOSTIC ANALYSIS ON AN UNSPECIFIED PATIENT BUT A TECHNICIAN ADMINISTERED | | 7.8 MILLICURIES OF I-131. | | | | ON 11/07/94, ANOTHER PHYSICIAN PRESCRIBED 4 MILLICURIES OF I-131 FOR A | | SIMILAR DIAGNOSTIC TEST ON ANOTHER UNSPECIFIED PATIENT BUT A TECHNICIAN | | ADMINISTERED 5.7 MILLICURIES OF I-131. | | | | NO ADVERSE HEALTH EFFECTS TO EITHER PATIENT ARE EXPECTED. | | | | IN BOTH CASES, THE CAUSE OF THE MISADMINISTRATION IS BELIEVED TO BE | | PERSONNEL ERROR. | | | | AS A CORRECTIVE ACTION, THE LICENSEE HAS TERMINATED THE AVAILABILITY OF | | I-131 THYROID DIAGNOSTIC TESTING. | | | | NOTE: SEE HOO LOG FOR CALLER'S TELEPHONE NUMBER. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29711 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: FITZPATRICK REGION: 1 |NOTIFICATION DATE: 12/13/95 | |UNIT: [1] [ ] [ ] STATE: NY |NOTIFICATION TIME: 14:38 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 12/13/95 | +------------------------------------------------+EVENT TIME: 13:00[EST]| |NRC NOTIFIED BY: ART ZAREMBA |LAST UPDATE DATE: 12/13/95 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JAMES LINVILLE RDO | |NINF INFORMATION ONLY | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | - 1 MWt NONCONSERVATIVE ERROR FOUND IN CORE THERMAL POWER CALCULATION - | | | | LICENSEE DETERMINED THAT APPROXIMATELY 6 GPM OF FLOW FROM THE CONTROL ROD | | DRIVE SYSTEM, WHICH IS USED TO PURGE THE REACTOR RECIRCULATION PUMP SEALS, | | IS NOT ACCOUNTED FOR IN THE CORE THERMAL HEAT BALANCE CALCULATION. | | | | THE NET EFFECT OF NOT ACCOUNTING FOR THIS FLOW IS THAT THE CORE THERMAL | | POWER CALCULATION MAY BE NONCONSERVATIVE. THIS ERROR MAY RESULT IN THERMAL | | POWER BEING UNDERESTIMATED BY APPROXIMATELY 1 MEGAWATT-THERMAL (MWt). | | | | POWER WILL BE LIMITED TO 2434 MWt (PREVIOUSLY 2436 MWt) UNTIL APPROPRIATE | | CHANGES ARE MADE TO THE CORE THERMAL HEAT BALANCE CALCULATION. | | | | LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | | | | NOTE - SEE THE FOLLOWING SIMILAR EVENTS: #29603, #29667, #29689, #29691, | | #29699, #29709 & #29716 | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |GENERAL INFORMATION or OTHER | |EVENT NUMBER: 29712 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: CHEESEBOROUGH PONDS COMPANY |NOTIFICATION DATE: 12/13/95 | | CITY: RAEFORD REGION: 2 |NOTIFICATION TIME: 15:22 [ET]| | COUNTY: STATE: NC |EVENT DATE: 12/13/95 | |LICENSE#: 0470587OG(NC) AGREEMENT: Y |EVENT TIME: 14:30[EST]| | DOCKET: |LAST UPDATE DATE: 12/13/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |CHARLES CASTO RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: SHARN JEFFRIES, NC DRP | | |HQ OPS OFFICER: DICK JOLLIFFE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |FLOM 20.402(a) THEFT/DIVERSION LNM | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - MISSING Po-210 STATIC ELIMINATOR RADIOACTIVE SOURCE - | | | | AT 1430 ON 12/13/95, SHARON JEFFRIES, NORTH CAROLINA DIVISION OF RADIATION | | PROTECTION, RECEIVED A REPORT FROM JAMES HOLLAND, MECHANICAL SYSTEMS | | MANAGER, CHEESEBOROUGH PONDS COMPANY (MANUFACTURER OF MAKEUP PRODUCTS), | | RAEFORD, NC. | | | | ON 12/05/95, CHEESEBOROUGH PONDS COMPANY (NORTH CAROLINA LICENSEE) WAS | | PREPARING A BATCH OF EXPIRED RADIOACTIVE SOURCES FROM STATIC ELIMINATORS | | FOR SHIPMENT TO THEIR SUPPLIER, NRT, INC, IN NEW YORK WHEN THEY DISCOVERED | | THAT ONE STATIC ELIMINATOR CONTAINING A RADIOACTIVE SOURCE WAS MISSING. THE | | SOURCE IS 22.5 MILLICURIES OF Po-210. THE MISSING STATIC ELIMINATOR WAS | | LAST ACCOUNTED FOR IN 08/95. CHEESEBOROUGH PONDS IS SEARCHING FOR THE | | MISSING STATIC ELIMINATOR. | | | | MR JEFFRIES NOTIFIED EPA AND NC EMERGENCY MANAGEMENT AGENCY. | | | | SEE HOO LOG FOR TELEPHONE NUMBERS. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |GENERAL INFORMATION or OTHER | |EVENT NUMBER: 29713 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: MERITUS HEALTH SYSTEMS COMPAANY |NOTIFICATION DATE: 12/13/95 | | CITY: ROANOKE REGION: 2 |NOTIFICATION TIME: 15:43 [ET]| | COUNTY: STATE: VA |EVENT DATE: 12/13/95 | |LICENSE#: AGREEMENT: N |EVENT TIME: 01:00[EST]| | DOCKET: |LAST UPDATE DATE: 12/13/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |CHARLES CASTO RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: DR FRANCIS GEORGE, RSO | | |HQ OPS OFFICER: DICK JOLLIFFE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NINF INFORMATION ONLY | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - TRUCK CARRYING CAMERAS WITH SEALED SOURCES OVERTURNED ON HIGHWAY - | | | | A LARGE ENCLOSED TRUCK BELONGING TO MERITUS HEALTH SYSTEMS COMPANY, | | A MEDICAL IMAGING COMPANY, ROANOKE, VA, OVERTURNED ON A HIGHWAY NEAR | | ABINGDON, VA. THE TRUCK CONTAINED GAMMA CAMERAS WITH SEALED SOURCES AND | | BIOMEDICAL WASTE MATERIALS (USED SYRINGES, USED MEDICAL NEEDLES, ETC). | | | | THE TRUCK WAS DAMAGED BUT NO SEALED SOURCES WERE EXPOSED OR DAMAGED. | | | | THERE WAS NO RELEASE OF RADIOACTIVE MATERIAL AND NO PERSONNEL WERE | | CONTAMINATED OR INJURED. | | | | DR GEORGE, RADIATION SAFETY OFFICER, HAS DISCUSSED THIS INCIDENT WITH | | R2 DOUG COLLINS. | | | | SEE HOO LOG FOR RSO TELEPHONE NUMBER. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |GENERAL INFORMATION or OTHER | |EVENT NUMBER: 29714 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: MQS INSPECTION COMPANY |NOTIFICATION DATE: 12/13/95 | | CITY: MILWAUKEE REGION: 3 |NOTIFICATION TIME: 15:48 [ET]| | COUNTY: STATE: WI |EVENT DATE: 12/13/95 | |LICENSE#: 12-00622-07 AGREEMENT: N |EVENT TIME: 12:30[CST]| | DOCKET: |LAST UPDATE DATE: 12/13/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |THOMAS KOZAK RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: STEVE VIGGIANO | | |HQ OPS OFFICER: DICK JOLLIFFE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |BAE1 20.2202(b)(1) PERS OVEREXPOSURE | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - X-RAY TECHNICIAN'S PROCESSED FILM BADGE INDICATED HIGH EXPOSURE - | | | | THE FILM BADGE OF A TECHNICIAN EMPLOYED BY MQS INSPECTION COMPANY, AN | | NDE/INDUSTRIAL RADIOGRAPHY TESTING COMPANY, WAS SENT TO LANDAUER COMPANY, | | A FILM BADGE PROCESSING COMPANY, TO BE PROCESSED. | | | | THE FILM IN THE BADGE WAS EXPOSED OVER A 2 WEEK PERIOD (11/15-30/95) BUT | | HAD BEEN WORN ON THE JOB BY THE TECHNICIAN FOR ONLY 4 DAYS (11/27-30/95). | | | | THE TECHNICIAN USED 2 X-RAY CAMERAS (1 MEV UNIT & 8 MEV UNIT) LICENSED BY | | WISCONSIN AND A COBALT-60 CAMERA LICENSED BY NRC WHILE HE WAS AT WORK. | | | | AFTER PROCESSING THE FILM, LANDAUER NOTIFIED MQS THAT THE FILM READ | | 116,120 MR. | | | | MQS HAS NOTIFIED THE TECHNICIAN AND RESTRICTED HIM FROM DOING ANY | | RADIOGRAPHY WORK. THE TECHNICIAN SHOWS NO SIGN OF FEELING ILL. | | | | MQS IS INVESTIGATING THIS EVENT AND WILL SUBMIT A WRITTEN REPORT TO THE NRC | | WITHIN 3O DAYS. | | | | LICENSEE HAS NOTIFIED THE STATE OF WISCONSIN AND HAS DISCUSSED THIS EVENT | | WITH R3 TOM YOUNG. | | | | SEE HOO LOG FOR MQS TELEPHONE NUMBER. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29715 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: DIABLO CANYON REGION: 4 |NOTIFICATION DATE: 12/13/95 | |UNIT: [1] [ ] [ ] STATE: CA |NOTIFICATION TIME: 15:49 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 12/13/95 | +------------------------------------------------+EVENT TIME: 10:33[PST]| |NRC NOTIFIED BY: MARK LEMKE |LAST UPDATE DATE: 12/13/95 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |LINDA HOWELL 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | M/R Y 50 POWER OPERATION | 0 HOT STANDBY | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - MANUAL TRIP FROM 50% POWER DUE TO KELP BUILDUP ON TRAVELING SCREENS - | | | | UNIT 1 IS OPERATING AT 50% POWER WITH 1 OF 2 CIRCULATING WATER PUMPS (#1-2) | | RUNNING. THE OTHER CIRCULATING WATER PUMP (#1-1) IS INOPERABLE FOR | | MAINTENANCE. | | | | HIGH WINDS AND HEAVY SEAS ARE CHURNING UP THE KELP AND THE LOOSE KELP IS | | BUILDING UP THE PLANT INTAKE TRAVELING SCREENS WHICH COULD CAUSE A LOSS | | OF THE CIRCULATING WATER PUMP AND THE LOSS OF MAIN CONDENSER VACUUM. | | | | LICENSEE ELECTED TO MANUALLY TRIP UNIT 1 FROM 50% POWER BECAUSE OF THIS | | CONDITION. ALL CONTROL RODS INSERTED COMPLETELY. THE AUXILIARY FEEDWATER | | SYSTEM STARTED, AS EXPECTED. STEAM IS BEING DUMPED TO THE ATMOSPHERE. | | | | UNIT 1 IS STABLE IN MODE 3 (HOT STANDBY). | | | | LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR AND WILL ISSUE A PRESS | | RELEASE. | | | | NOTE: LICENSEE IS ALSO SHUTTING UNIT 2 DOWN FOR SIMILAR REASONS. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29716 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BRUNSWICK REGION: 2 |NOTIFICATION DATE: 12/13/95 | |UNIT: [1] [2] [ ] STATE: NC |NOTIFICATION TIME: 18:11 [ET]| |RX TYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 12/13/95 | +------------------------------------------------+EVENT TIME: 15:00[EST]| |NRC NOTIFIED BY: BOB KITCHEN |LAST UPDATE DATE: 12/13/95 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |CHARLES CASTO RDO | |NINF INFORMATION ONLY | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 73 POWER OPERATION | 73 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | 1.5 MWt NONCONSERVATIVE ERROR FOUND IN CORE THERMAL PWR CALCULATION FOR | | BOTH UNITS | | | | LICENSEE HAS DETERMINED THAT APPROXIMATELY 8.5 GPM OF FLOW FROM THE CONTROL | | ROD DRIVE SYSTEM MAY NOT HAVE BEEN ACCOUNTED FOR IN THE CORE THERMAL HEAT | | BALANCE CALCULATION FOR EACH UNIT. LICENSEE HAS CALCULATED THAT NOT | | ACCOUNTING FOE THIS INPUT IN THE HEAT BALANCE CALCULATION MAY RESULT IN | | A NONCONSERVATIVE ERROR OF APPROXIMATELY 1.5 MEGAWATTS-THERMAL (MWt). | | | | LICENSEE HAS PROVIDED GUIDANCE TO THE OPERATING SHIFTS TO MAINTAIN THE | | SHIFT AVERAGE CORE THERMAL POWER 3 MWt LOWER THAN THE MAXIMUM POWER LEVEL | | STIPULATED IN THE PLANT OPERATING LICENSE. | | | | LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | | | | NOTE - SEE THE FOLLOWING SIMILAR EVENTS: #29603, #29667, #29689, #29691, | | #29699, #29709 & #29711. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29717 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: COOPER REGION: 4 |NOTIFICATION DATE: 12/13/95 | |UNIT: [1] [ ] [ ] STATE: NE |NOTIFICATION TIME: 21:50 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 12/13/95 | +------------------------------------------------+EVENT TIME: 16:58[CST]| |NRC NOTIFIED BY: JOHN MYERS |LAST UPDATE DATE: 12/13/95 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |LINDA HOWELL 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | A N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - Rx SCRAM SIGNAL & ESF ACTUATIONS DUE TO PERSONNEL ERROR WHILE SHUTDOWN - | | | | THE PLANT IS IN CONDITION 4 (COLD SHUTDOWN) IN A REFUELING OUTAGE THAT | | BEGAN ON 10/14/95. | | | | AT 1658 (CST), DURING MAINTENANCE ACTIVITIES, I & C TECHNICIANS INCORRECTLY | | ADDED WATER TO THE ACTIVE (VARIABLE) SIDE OF A REACTOR VESSEL WATER LEVEL | | INSTRUMENT TRANSMITTER INSTEAD OF THE REFERENCE SIDE. | | | | THIS CAUSED THE PLANT TO RECEIVE A FULL REACTOR SCRAM SIGNAL AND A | | TEMPORARY LOSS OF THE SHUTDOWN COOLING MODE OF THE RESIDUAL HEAT REMOVAL | | SYSTEM (PCIS GROUP 2) AND THE ISOLATION OF THE SECONDARY CONTAINMENT SYSTEM | | AND THE INITIATION OF THE STANDBY GAS TREATMENT SYSTEM (PCIS GROUP 6). | | THE REACTOR WATER CLEANUP SYSTEM (PCIS GROUP 3) WAS ALREADY IN AN ISOLATED | | STATE WHEN THE EVENT OCCURRED. | | | | AT 1706 (CST), LICENSEE RESET THE REACTOR SCRAM SIGNAL. | | | | AT 1707 (CST), LICENSEE RESET THE PCIS GROUPS 2, 3, & 6 ISOLATIONS. | | | | AT 1724 (CST), LICENSEE RESTORED SHUTDOWN COOLING. REACTOR COOLANT SYSTEM | | TEMPERATURE HAD INCREASED 2 DEGREES F. | | | | LICENSEE IS INVESTIGATING THE ROOT CAUSE OF THIS EVENT. | | | | LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+