U.S. Nuclear Regulatory Commission Operations Center Event Reports For 10/19/95 - 10/20/95 ** EVENT NUMBERS ** 29474 29475 29476 29477 29478 29479 29480 +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29474 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SOUTH TEXAS REGION: 4 |NOTIFICATION DATE: 10/19/95 | |UNIT: [1] [ ] [ ] STATE: TX |NOTIFICATION TIME: 01:25 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 10/18/95 | +------------------------------------------------+EVENT TIME: 21:55[CDT]| |NRC NOTIFIED BY: ROYCE BROWN |LAST UPDATE DATE: 10/19/95 | |HQ OPS OFFICER: RUDY KARSCH +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |PHIL HARRELL 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 +------------------------------------------------------------------------------+ | COMPONENT COOLING WATER PUMP "1A" AUTO-STARTED FOR REASONS STILL TO BE | | DETERMINED. THE LICENSEE SUSPECTS A DEFECTIVE PRESSURE SWITCH IS THE CAUSE | | OF THE UNEXPECTED START. TROUBLE SHOOTING IS PROGRESSING. THE PUMP IS | | STILL RUNNING AND IS CONSIDERED OPERABLE. THE LICENSEE WILL INFORM THE NRC | | RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29475 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BRAIDWOOD REGION: 3 |NOTIFICATION DATE: 10/19/95 | |UNIT: [1] [ ] [ ] STATE: IL |NOTIFICATION TIME: 13:50 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 10/19/95 | +------------------------------------------------+EVENT TIME: 09:06[CDT]| |NRC NOTIFIED BY: ZOLAN |LAST UPDATE DATE: 10/19/95 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BURDICK RDO | |ADAS 50.72(b)(2)(i) DEG/UNANALYZED COND | | |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 N 0 REFUELING | 0 REFUELING | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | EMERGENCY DIESEL GENERATOR OUTPUT BREAKER WOULD NOT CLOSE DURING TESTING. | | | | AT 0906, WHILE PERFORMING THE MONTHLY OPERABILITY TEST FOR THE "1B" | | EMERGENCY DIESEL GENERATOR, THE OUTPUT BREAKER FOR THE EDG WOULD NOT CLOSE | | ONTO THE ASSOCIATED EMERGENCY BUS. AN OPERATOR WAS DISPATCHED, AND | | DISCOVERED THAT THE OUTPUT BREAKER DID NOT APPEAR TO BE FULLY RACKED INTO | | ITS CUBICLE. THE BREAKER WAS RACKED OUT, CHECKED FOR OBSTRUCTIONS, AND | | RACKED BACK IN. AT 0940, THE BREAKER WAS CLOSED SUCCESSFULLY. | | | | THE LICENSEE'S PRELIMINARY REVIEW HAS DETERMINED THAT THE BREAKER HAD NOT | | BEEN FULLY RACKED IN SINCE 10/2/95, WHEN A TRAIN "B" MANUAL SAFETY | | INJECTION INITIATION SURVEILLANCE TEST HAD BEEN PERFORMED. THE "A" EDG HAS | | BEEN OUT OF SERVICE FOR MAINTENANCE SINCE 10/3/95. THE LICENSEE REPORTED | | THAT, FOR THE PERIOD OF 10/3/95 UNTIL 10/19/95, NO EMERGENCY DIESEL | | GENERATORS WERE OPERABLE FOR UNIT 1. THE UNIT IS IN A REFUELING OUTAGE, | | AND ALL FUEL HAS BEEN PLACED INTO THE SPENT FUEL POOL. THE NRC RESIDENT | | INSPECTOR HAS BEEN INFORMED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |OTHER NUCLEAR MATERIAL | |EVENT NUMBER: 29476 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: US ARMY (ROCK ISLAND ILLINOIS) |NOTIFICATION DATE: 10/19/95 | | CITY: ROCK ISLAND REGION: 3 |NOTIFICATION TIME: 14:50 [ET]| | COUNTY: STATE: IL |EVENT DATE: 10/18/95 | |LICENSE#: ML12-00722-06 AGREEMENT: Y |EVENT TIME: 00:00[CDT]| | DOCKET: |LAST UPDATE DATE: 10/19/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |BURDICK RDO | | |CAMPER EO | +------------------------------------------------+ | |NRC NOTIFIED BY: TIM MOHS | | |HQ OPS OFFICER: BOB STRANSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: UNUSUAL EVENT | | |10 CFR SECTION: | | |BAD2 20.2202(a)(2) EXCESSIVE RELEASE | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE US ARMY (ROCK ISLAND ILLINOIS) CALLED TO REPORT AN INCIDENT THAT | | OCCURRED AT FORT IRWIN, CA. | | | | AN EXPLOSION OF AN M109-A3 HOWITZER, SELF PROPELLED, AND AN M584 AMMUNITION | | CARRIER CAUSED A RELEASE OF AMERICIUM-241 AND TRITIUM FROM VARIOUS PIECES | | OF EQUIPMENT DESTROYED IN THE EXPLOSION. | | | | THE "A" COMPANY (4/5 FIELD ARTILLERY) OF THE 1ST INFANTRY DIVISION FROM | | FORT RILEY, KS WAS USING THE LIVE FIRE RANGE AT FORT IRWIN FOR TRAINING | | EXERCISES. AN EXPLOSION OCCURRED DUE TO THE COOK OFF OF ROUNDS WHICH WAS | | CAUSED BY THE IMPROPER PLACEMENT OF PROPELLANT BAGS. BOTH VEHICLES WERE | | DESTROYED. THE EXPLOSION CAUSED THE RELEASE OF RADIOACTIVE MATERIAL AS | | FOLLOWS: | | ONE M43A1 CHEMICAL AGENT ALARM Am-241 250ęCi | | ONE M1A1 COLUMNATOR TRITIUM 10Ci | | TWO M140 ALIGNMENT DEVICES TRITIUM 9Ci EACH | | ONE M1A2 GUNNERS QUADRANT TRITIUM 0.075 Ci | | | | FORT IRWIN AND US ARMY SAFETY PERSONNEL ARE LOOKING FOR ANY PIECES OF THE | | ABOVE MENTIONED SOURCES. NO PERSONNEL INJURIES, CONTAMINATIONS OR | | EXPOSURES HAVE BEEN REPORTED AS A RESULT OF THIS EVENT. ALL SOURCES | | INVOLVED IN THIS EVENT WERE ISSUED TO FORT RILEY, KS. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |TRANSPORTATION EVENT | |EVENT NUMBER: 29477 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: FEDERAL EXPRESS |NOTIFICATION DATE: 10/19/95 | | CITY: MEMPHIS REGION: 2 |NOTIFICATION TIME: 15:27 [ET]| | COUNTY: STATE: TN |EVENT DATE: 10/18/95 | |LICENSE#: AGREEMENT: Y |EVENT TIME: 07:55[EDT]| | DOCKET: |LAST UPDATE DATE: 10/19/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |POTTER RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: CHECKAN (NATL RESP CTR) | | |HQ OPS OFFICER: BOB STRANSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NTRA TRANSPORTATION EVENT | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE NATIONAL RESPONSE CENTER CALLED TO REPORT SEVERAL LOST RADIOACTIVE | | SOURCES. | | | | THREE LEAD PIGS, EACH CONTAINING 20 mCi OF Xe-133, HAVE BEEN MISPLACED AT | | THE FEDERAL EXPRESS HUB AT THE MEMPHIS AIRPORT IN MEMPHIS, TN. A THOROUGH | | SEARCH IS UNDERWAY BY THE CARRIER. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 29478 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: UNIVERSITY OF WISCONSIN |NOTIFICATION DATE: 10/19/95 | | CITY: MADISON REGION: 3 |NOTIFICATION TIME: 16:18 [ET]| | COUNTY: DANE STATE: WI |EVENT DATE: 10/19/95 | |LICENSE#: AGREEMENT: N |EVENT TIME: 11:30[CDT]| | DOCKET: |LAST UPDATE DATE: 10/19/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |BURDICK RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: BRESSELL | | |HQ OPS OFFICER: BOB STRANSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | A PATIENT RECEIVED AN UNNECESSARY 200 RAD DOSE TO THE UPPER LUNG DUE TO A | | MEDICAL MISADMINISTRATION. | | | | A MALE PATIENT WAS BEING TREATED WITH A HIGH DOSE AFTERLOADER USING TWO | | CATHETERS SIMULTANEOUSLY TO IRRADIATE TWO SEPARATE TUMORS. DURING | | PREPARATION FOR TREATMENT, SOME CONFUSION AROSE CONCERNING WHICH SOURCE | | SHOULD BE ROUTED TO EACH CATHETER, AND, AS A RESULT, THE SOURCE INTENDED | | FOR THE RIGHT CATHETER WAS ROUTED TO THE LEFT CATHETER, AND VICE VERSA. THE | | MISTAKE WAS IMMEDIATELY RECOGNIZED, AND THE DOSE WAS RECALCULATED SUCH THAT | | EACH TUMOR RECEIVED THE PROPER EXPOSURE. HOWEVER, AS A RESULT OF THE | | ERROR, THE UPPER LUNG AREA RECEIVED AN ADDITIONAL UNPLANNED 200 RAD | | EXPOSURE. | | | | THE LICENSEE HAS CONTACTED THE NRC REGION 3 OFFICE. AN NRC INSPECTOR WAS | | ONSITE TODAY, AND WILL RETURN TOMORROW TO COLLECT ADDITIONAL INFORMATION. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29479 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: INDIAN POINT REGION: 1 |NOTIFICATION DATE: 10/19/95 | |UNIT: [ ] [3] [ ] STATE: NY |NOTIFICATION TIME: 17:42 [ET]| |RX TYPE: [2] W-4-LP,[3] W-4-LP |EVENT DATE: 10/19/95 | +------------------------------------------------+EVENT TIME: 14:35[EDT]| |NRC NOTIFIED BY: MOHR |LAST UPDATE DATE: 10/19/95 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BORES RDO | |APRE 50.72(b)(2)(vi) OFFSITE NOTIFICATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 3 | N N 0 HOT SHUTDOWN | 0 HOT SHUTDOWN | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | LICENSEE NOTIFIED STATE OF NEW YORK REGARDING DIESEL FUEL SPILL ONSITE. | | | | AT 1435, THE LICENSEE NOTIFIED THE NEW YORK STATE DEPARTMENT OF | | ENVIRONMENTAL CONSERVATION (REPORT NO. 958897) REGARDING THE SPILL OF | | APPROXIMATELY 10 GALLONS OF DIESEL FUEL OIL OUTSIDE OF THE PROTECTED AREA. | | THE FUEL OIL WAS SPILLED IN A FIRE BRIGADE TRAINING AREA. CLEANUP | | ACTIVITIES ARE UNDERWAY, AND NO OIL REACHED THE HUDSON RIVER. | | | | THE LICENSEE REPORTED THAT THE OIL LEAKED FROM A STORAGE BARREL INTO A | | CATCH BASIN, BUT THAT A HOSE WAS LYING IN THE BASIN AND SET UP A SIPHON | | EFFECT, PERMITTING THE OIL TO LEAVE THE BASIN. THE OIL THEN SOAKED INTO | | THE GROUND NEAR THE CATCH BASIN. THE NRC RESIDENT INSPECTOR HAS BEEN | | INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29480 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: COOK REGION: 3 |NOTIFICATION DATE: 10/20/95 | |UNIT: [1] [ ] [ ] STATE: MI |NOTIFICATION TIME: 01:31 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 10/20/95 | +------------------------------------------------+EVENT TIME: 00:35[EDT]| |NRC NOTIFIED BY: BRYAN MUTZ |LAST UPDATE DATE: 10/20/95 | |HQ OPS OFFICER: RUDY KARSCH +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: | | |ADEV 50.72(b)(1)(i)(B) DEVIATION FROM T SPEC | | |NLCO TECH SPEC LCO A/S | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 HOT STANDBY | 0 HOT STANDBY | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | ENTRY INTO TECH SPEC 3.0.3 DUE TO NOT COMPLETING THE ACTION STATEMENT OF | | TECH SPEC 3.7.1.5 PRIOR TO THE EXPIRATION OF THE TIME LIMIT. | | | | UNIT 1 ENTERED MODE 3 AT 0117 EDT ON 10/18. TECH SPEC 3.7.1.5 REQUIRES | | THAT EACH STEAM GENERATOR STOP VALVE SHALL BE OPERABLE AT MODE CHANGE. WITH | | ONE OR MORE VALVE INOPERABLE, THE INOPERABLE VALVE MUST BE VERIFIED CLOSED | | WITHIN 8 HOURS OR RETURN TO MODE 4. CONTRARY TO THE TECH SPEC | | REQUIREMENTS, THE VALVES WERE NOT OPERABLE AT THE TIME OF THE MODE CHANGE | | ON 10/18, AND WERE NOT TESTED UNTIL 10/20, LONG AFTER THE EXPIRATION OF THE | | 8 HOUR TIME LIMIT. THE VALVES HAVE NOW PASSED APPLICABLE TESTS AND ARE | | OPEN. ALL TECH SPEC LCOs HAVE BEEN EXITED. THE LICENSEE WILL INFORM THE | | NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+