U.S. Nuclear Regulatory Commission Operations Center Event Reports For 11/13/95 - 11/14/95 ** EVENT NUMBERS ** 29463 29592 29593 29594 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29463 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BROWNS FERRY REGION: 2 |NOTIFICATION DATE: 10/16/95 | |UNIT: [ ] [2] [ ] STATE: AL |NOTIFICATION TIME: 10:30 [ET]| |RX TYPE: [1] GE-4,[2] GE-4,[3] GE-4 |EVENT DATE: 10/16/95 | +------------------------------------------------+EVENT TIME: 08:32[CDT]| |NRC NOTIFIED BY: MIKE MORROW |LAST UPDATE DATE: 11/13/95 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |THOMAS PEEBLES 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - HYPOTHETICAL APP R FIRE COULD CAUSE SPURIOUS RHR SYSTEM VALVES TO OPEN - | | | | LICENSEE DETERMINED THAT A HYPOTHETICAL APPENDIX R FIRE IN THE CONTROL | | BAY CABLE SPREADING ROOM COULD CAUSE SPURIOUS OPENINGS OF VALVES IN | | RHR SYSTEM I SUPPRESSION POOL TEST AND SPRAY PATHS. | | | | THIS CONDITION COULD RESULT IN A DRAIN DOWN OF RHR SYSTEM I, A SYSTEM | | REQUIRED BY THE SAFE SHUTDOWN PROGRAM FOR FIRES IN THE CABLE SPREADING | | ROOMS. | | | | A CONTINUOUS FIRE WATCH HAS PREVIOUSLY BEEN POSTED IN THIS AREA. | | | | LICENSEE IS DETERMINING CORRECTIVE ACTIONS. | | | | LICENSEE WILL DETERMINE IF A SIMILAR CONDITION EXISTS ON UNIT 3 AND | | WILL TAKE APPROPRIATE CORRECTIVE ACTIONS. | | | | LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | | | | NOTE: SEE EVENT #27838 FOR A RELATED EVENT. | | | | **** RETRACTION OF EVENT @ 1332EST 11/13/95 BY R NACOSTE TAKEN BY | | MACKINNON*** | | | | APPENDIX "R" REQUIRES EVALUATION OF A SINGLE SPURIOUS ACTUATION. EVALUATION | | OF MULTIPLE ACTUATIONS IS CONSERVATIVE AND IS NOT REQUIRED TO COMPLY WITH | | ANY FIRE PROTECTION REQUIREMENTS. SINCE ENGINEERING HAS DETERMINED THAT THE | | ABOVE MENTIONED EVENT REQUIRES MULTIPLE ACTUATIONS TO OCCUR BEFORE THE | | EVENT WOULD HAPPEN LICENSEE IS RETRACTING THIS EVENT. R2DO (SKINNER) | | NOTIFIED. | | | | RESIDENT INSPECTOR WILL BE INFORMED INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29592 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: ZION REGION: 3 |NOTIFICATION DATE: 11/13/95 | |UNIT: [1] [ ] [ ] STATE: IL |NOTIFICATION TIME: 00:59 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 11/12/95 | +------------------------------------------------+EVENT TIME: 22:53[CST]| |NRC NOTIFIED BY: KEITH KNUDTSON |LAST UPDATE DATE: 11/13/95 | |HQ OPS OFFICER: JOSEPH SEBROSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JOHN JACOBSON 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 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | A SAFETY INJECTION (SI) SIGNAL WAS GENERATED DURING TESTING RESULTING IN | | THE ACTUATION OF SEVERAL COMPONENTS. | | | | AN SI SIGNAL WAS GENERATED DURING THE PERFORMANCE OF A SPECIAL TEST | | PROCEDURE (TSSP-9195). THE SAFEGUARD DC POWER BREAKERS WERE ENERGIZED FOR | | THIS TEST TO TROUBLESHOOT VOLTAGE SPIKES INDUCED BY ENERGIZING/ | | DEENERGIZING RELAYS WITHIN THE SAFEGUARDS SYSTEM. UPON CLOSING THE DC | | BREAKERS A LOW PRESSURIZER PRESSURE SI SIGNAL FOR THE "B" TRAIN WAS | | GENERATED. THE "B" TRAIN SI SIGNAL CAUSED SEVERAL COMPONENTS TO START. SOME | | OF THE COMPONENTS THAT STARTED INCLUDE THE FOLLOWING; THE "B" RHR PUMP, | | THREE EMERGENCY DIESEL GENERATORS (EDG), AND COMPONENT COOLING WATER PUMPS | | AND SERVICE WATER PUMPS THAT WERE NOT ALREADY RUNNING. THE SIGNAL ALSO | | CAUSED THE "B" HIGH HEAD CHARGING PUMP TO REALIGN TO THE SAFETY INJECTION | | MODE. | | | | THE THREE EDGS STARTED BUT DID NOT LOAD ONTO THEIR RESPECTIVE BUSSES. THE | | "B" RHR PUMP THAT STARTED DID NOT INJECT ANY ADDITIONAL WATER INTO THE | | PRIMARY PLANT BECAUSE ONLY ONE OF THE TWO VALVES IN SERIES TO THE REFUELING | | WATER STORAGE TANK OPENED. THIS IS PER DESIGN AND IS THE EXPECTED PLANT | | RESPONSE. THE SUCTION SOURCE FOR THE "B" RHR PUMP WAS THE PRIMARY PLANT | | COOLANT LOOPS. THIS IS THE SAME SUCTION SOURCE FOR THE "A" RHR PUMP THAT | | WAS RUNNING PRIOR TO THE EVENT IN THE SHUTDOWN COOLING MODE OF OPERATION. | | | | THE "B" CHARGING PUMP THAT WAS RUNNING PRIOR TO THE EVENT REALIGNED TO THE | | SAFETY INJECTION MODE. THIS REALIGNMENT CAUSED AN INJECTION OF | | APPROXIMATELY 500 GALLONS INTO THE PRIMARY PLANT FROM THE REFUELING WATER | | STORAGE TANK. THIS HAD LITTLE EFFECT ON THE PLANT BECAUSE PRIOR TO THE | | EVENT THE PRIMARY PLANT WAS DRAINED DOWN TO THE 588 FOOT ELEVATION (NO | | LEVEL IN THE PRESSURIZER). | | | | OTHER COMPONENTS THAT WOULD HAVE NORMALLY STARTED WERE EITHER OUT OF | | SERVICE FOR MAINTENANCE (e.g. THE "B" SAFETY INJECTION PUMP), TAGGED OUT AS | | REQUIRED BY TECHNICAL SPECIFICATIONS, OR ALREADY RUNNING (e.g. SOME OF THE | | COMPONENT COOLING WATER AND SERVICE WATER PUMPS). THE PLANT WAS | | STABILIZED, THE SI SIGNAL WAS RESET, AND OPERATORS HAVE RETURNED THE | | EQUIPMENT THAT STARTED TO THEIR NORMAL LINEUPS. | | | | THE TEST PROCEDURE THAT INADVERTENTLY CAUSED THE SI SIGNAL WAS BEING | | PERFORMED FOR THE FIRST TIME. THE PROCEDURE WAS TITLED "EAGLE 21 | | PROTECTION SET II RACK 8 RELAY ACTUATION TEST". THIS SPECIAL TEST WAS | | BEING PERFORMED BECAUSE THE LICENSEE WAS TRYING TO DETERMINE WHY VOLTAGE | | SPIKES INDUCED BY ENERGIZING/DEENERGIZING RELAYS ON THE SAFEGUARDS SYSTEM | | WERE CAUSING SPURIOUS REACTOR PROTECTION SYSTEM (RPS) SIGNALS. AT THIS | | TIME, THE LICENSEE IS INVESTIGATING THE CAUSE OF THE LOW PRESSURIZER | | PRESSURE SI SIGNAL. | | | | THE LICENSEE HAS INFORMED THE RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 29593 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: FAIRFAX HOSPITAL |NOTIFICATION DATE: 11/13/95 | | CITY: FALLS CHURCH REGION: 2 |NOTIFICATION TIME: 11:15 [ET]| | COUNTY: STATE: VA |EVENT DATE: 09/28/95 | |LICENSE#: 45-17128-01 AGREEMENT: N |EVENT TIME: 00:00[EST]| | DOCKET: |LAST UPDATE DATE: 11/13/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |PIERCE SKINNER RDO | | |DONALD COOL EO | +------------------------------------------------+ | |NRC NOTIFIED BY: Dr. DEYE | | |HQ OPS OFFICER: JOSEPH SEBROSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |BAB1 20.2201(a)(1)(i) LOST/STOLEN LNM>1000X | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | FAIRFAX HOSPITAL OF FALLS CHURCH, VIRGINIA CALLED TO REPORT THE LOSS OF | | SOME I-125 SEEDS. | | | | THE SEEDS WERE IMPLANTED INTO A PATIENT BY JOHN HOPKINS HOSPITAL IN | | BALTIMORE, MD IN MARCH OF 1995. THE SEEDS WERE PERMANENTLY IMPLANTED AND | | CONSISTED OF TWENTY I-125 SEEDS OF 0.725 MILLICURIES EACH. THE PATIENT | | SUBSEQUENTLY DEVELOPED SOME PROBLEMS THAT REQUIRED AN OPERATION ON 9/28/95 | | AT FAIRFAX HOSPITAL. THE PLASTIC SURGEON DOING THE OPERATION WAS AWARE | | THAT THE SEEDS HAD BEEN IMPLANTED, AND HAD NOT ORIGINALLY INTENDED ON | | REMOVING THE TISSUE THAT CONTAINED THE SEEDS. DURING THE OPERATION THE | | SURGEON DECIDED TO REMOVE THE SEEDS. AT THE TIME THE SEEDS WERE REMOVED | | THE SURGEON INFORMED THE OPERATING STAFF THAT THE SEEDS WERE PROBABLY | | RADIOACTIVE AND NOT TO HANDLE THEM WITH THEIR FINGERS. THE CHARGE NURSE IN | | THE OPERATING ROOM HANDLED THE SEEDS WITH INSTRUMENTS AND PLACED THEM IN A | | CONTAINER WITH THE INTENTION OF LATER LABELING THE CONTAINER AS | | RADIOACTIVE. THIS CONTAINER WOULD THEN BE SENT TO THE PATHOLOGY DEPARTMENT | | FOR PROPER DISPOSAL. | | | | THE CHARGE NURSE LEFT THE AREA AND TASKED ANOTHER NURSE WITH THE PROBLEM. | | THIS NURSE EVIDENTIALLY DID NOT FOLLOW THROUGH ON THE INSTRUCTIONS BECAUSE | | A CONTAINER MARKED "RADIOACTIVE" WAS NEVER RECEIVED BY THE PATHOLOGY | | DEPARTMENT. THE LICENSEE NOW BELIEVES THAT THE MATERIAL WAS DISPOSED OF AS | | BIOLOGICAL WASTE. THE BIOLOGICAL WASTE IS PROCESSED THROUGH A DEVICE AT | | THE HOSPITAL WHICH SHREDS THE MATERIAL AND THEN MICROWAVES THE MATERIAL. | | THE MATERIAL IS THEN SENT TO THE LOCAL LANDFILL WITH NORMAL WASTE. | | | | THE RADIATION SAFETY OFFICER (RSO) WAS NOT INFORMED OF THE PROBLEM UNTIL | | RECENTLY. THE RSO HAS PERFORMED SURVEYS WITH A GM TUBE AND HAS DETECTED NO | | EVIDENCE OF CONTAMINATION IN THE BIOLOGICAL WASTE PROCESSING UNIT AT THE | | HOSPITAL. | | | | FAIRFAX HOSPITAL HAS BEEN IN CONTACT WITH REGION II (WRIGHT) ABOUT THIS | | PROBLEM. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29594 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PRAIRIE ISLAND REGION: 3 |NOTIFICATION DATE: 11/13/95 | |UNIT: [1] [ ] [ ] STATE: MN |NOTIFICATION TIME: 17:16 [ET]| |RX TYPE: [1] W-2-LP,[2] W-2-LP |EVENT DATE: 11/13/95 | +------------------------------------------------+EVENT TIME: 15:57[CST]| |NRC NOTIFIED BY: BOB CARLSON |LAST UPDATE DATE: 11/13/95 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BRUCE BURGESS RDO | |APRE 50.72(b)(2)(vi) OFFSITE NOTIFICATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | NOTIFIED THE STATE OF MINNESOTA DIVISION OF EMERGENCY MANAGEMENT (POLLUTION | | CONTROL) THAT THEY SPILLED 10 GALLONS OF 10% HYDRAZINE. | | | | AT 1506CST LICENSEE SPILLED 10 GALLONS OF 10% HYDRAZINE WHILE ADDING IT TO | | THEIR SECONDARY SYSTEM CHEMICAL ADDITION TANK. THE SPILL WAS CONTAINED AND | | THERE WAS NO RELEASE. THE SPILL IS BEING CLEANED UP. NOBODY WAS INJURED BY | | THE SPILL. LICENSEE NOTIFIED THE STATE OF MINNESOTA DIVISION OF EMERGENCY | | MANAGEMENT OF THE SPILL. | | | | RESIDENT INSPECTOR WAS INFORMED BY THE LICENSEE. | | | +------------------------------------------------------------------------------+