U.S. Nuclear Regulatory Commission Operations Center Event Reports For 10/20/95 - 10/23/95 ** EVENT NUMBERS ** 29480 29481 29482 29483 29484 29485 29486 29487 29488 29489 29490 29491 29492 29493 29494 +----------------------------------+ +-----------------------+ |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: |THOMAS BURDICK RDO | |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 VALVES 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. | +------------------------------------------------------------------------------+ !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29481 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MONTICELLO REGION: 3 |NOTIFICATION DATE: 10/20/95 | |UNIT: [1] [ ] [ ] STATE: MN |NOTIFICATION TIME: 10:14 [ET]| |RX TYPE: [1] GE-3 |EVENT DATE: 10/20/95 | +------------------------------------------------+EVENT TIME: 07:10[CDT]| |NRC NOTIFIED BY: STEVE GORTON |LAST UPDATE DATE: 10/23/95 | |HQ OPS OFFICER: RUDY KARSCH +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |THOMAS BURDICK RDO | |AINC 50.72(b)(2)(iii)(C) POT UNCNTRL RAD REL | | |NLCO TECH SPEC LCO A/S | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | LICENSEE IS IN A 12 HOUR TECH SPEC LCO DUE TO LOSS OF CONTAINMENT | | INTEGRITY. | | | | WHILE PERFORMING TEST 255-18-1A; "TIP (TRAVELING IN-CORE PROBE) BALL VALVE | | QUARTERLY EXERCISE" STEP FIVE, TIP 2-1 OPENED, BUT THE CLOSING FUNCTION ON | | THE CONTROL UNIT MODULE WAS LOST. THIS MEANS THAT THE VALVE CAN NOT BE | | CLOSED FROM THE MODULE AND MAY ALSO PRECLUDE AUTOMATIC OPERATION ON A GROUP | | 2 ISOLATION. THE LICENSEE IS TROUBLESHOOTING TO ATTEMPT TO DETERMINE IF | | THE AUTOMATIC CLOSING FEATURE HAS ALSO BEEN LOST. SINCE THE ONLY BACK-UP | | TO THIS VALVE IS THE CRUSH VALVE, WHICH THE LICENSEE WILL ONLY CLOSE IN AN | | ACTUAL EMERGENCY, THE LICENSEE IS IN TECH SPEC 3.7.A.2 (CONTAINMENT | | INTEGRITY REQUIREMENTS). THIS TECH SPEC HAS A 12 HOUR ACTION STATEMENT. | | THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | | | | * * * UPDATE 10/20/95 @ 1443 BY GORTON TAKEN BY STRANSKY * * * | | | | THE LICENSEE IS RETRACTING THIS EVENT NOTIFICATION. THE LICENSEE HAS | | DETERMINED THAT THE VALVE WOULD HAVE CLOSED IF A GROUP 2 ISOLATION SIGNAL | | OCCURRED. THE NRC RESIDENT INSPECTOR WILL BE INFORMED. NOTIFIED R3DO | | (BURDICK). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |GENERAL INFORMATION or OTHER | |EVENT NUMBER: 29482 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: METOREX |NOTIFICATION DATE: 10/20/95 | | CITY: REGION: 1 |NOTIFICATION TIME: 10:43 [ET]| | COUNTY: STATE: PA |EVENT DATE: 10/20/95 | |LICENSE#: 37-28461-01 AGREEMENT: N |EVENT TIME: 00:00[EDT]| | DOCKET: |LAST UPDATE DATE: 10/20/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |ROBERT BORES RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: STAN PIOREK | | |HQ OPS OFFICER: RUDY KARSCH | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NINF INFORMATION ONLY | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | METOREX | | | | ONE OF SEVERAL IRON 55 SOURCES READY TO BE RETURNED TO THE MANUFACTURER, | | AMERSHAM, WAS FOUND TO BE LEAKING. THE SOURCE IS IN ITS PIG. THERE WAS NO | | SPREAD OF CONTAMINATION TO TOOLS OR THE PIG. THE UNIT WILL BE RETURNED IN | | ITS PRESENT CONDITION. THIS SOURCE EMITS A LOW ENERGY X-RAY (5.9 KEV). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 29483 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: WALTER REED ARMY MEDICAL CENTER |NOTIFICATION DATE: 10/20/95 | | CITY: KENSINGTON REGION: 1 |NOTIFICATION TIME: 12:00 [ET]| | COUNTY: MONTGOMERY STATE: MD |EVENT DATE: 10/20/95 | |LICENSE#: AGREEMENT: Y |EVENT TIME: 00:00[EDT]| | DOCKET: |LAST UPDATE DATE: 10/20/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |BORES RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: WILLIAM JOHNSON | | |HQ OPS OFFICER: BOB STRANSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | LICENSEE CALLED TO REPORT A MEDICAL MISADMINISTRATION. | | | | A PATIENT AT WALTER REED ARMY MEDICAL CENTER WAS SCHEDULED TO RECEIVE A | | DOSE OF 29.9 mCi I-131 THROUGH AN NG TUBE. THE DOCTOR WHO WAS | | ADMINISTERING THE DOSE INADVERTENTLY INJECTED THE DOSE INTO A DRAINAGE TUBE | | FROM AN ABDOMINAL WOUND. THE PHYSICIAN NOTICED THAT THE WOUND DRESSING HAD | | BECOME WET, AND IMMEDIATELY DISCOVERED HIS ERROR. THE DRESSING WAS | | REMOVED, AND THE WOUND WAS CLEANED THOROUGHLY. | | | | THE RADIOPHARMACIST ESTIMATED THE PATIENT'S UPTAKE AT 6 mCi. A SECOND DOSE | | OF APPROXIMATELY 22 mCi IS BEING PREPARED, AND WILL BE ADMINISTERED TO THE | | PATIENT. THE LICENSEE HAS ALREADY CONTACTED REGION 1 (DR. SHANBACKY) | | CONCERNING THIS EVENT. | | | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29484 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: COOK REGION: 3 |NOTIFICATION DATE: 10/20/95 | |UNIT: [1] [ ] [ ] STATE: MI |NOTIFICATION TIME: 14:36 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 10/20/95 | +------------------------------------------------+EVENT TIME: 13:21[EDT]| |NRC NOTIFIED BY: PTACEK |LAST UPDATE DATE: 10/20/95 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BURDICK 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 N 0 HOT STANDBY | 0 HOT STANDBY | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | UNIT RECEIVED REACTOR TRIP SIGNAL WHEN FUSES WERE PULLED FOR MAINTENANCE. | | | | DURING REPAIRS TO INTERMEDIATE RANGE NEUTRON INSTRUMENTATION CHANNEL 1N36, | | I&C TECHNICIANS DETERMINED THAT THE LOG AMPLIFIER WAS DRIFTING, AND NEEDED | | TO BE REPLACED. THE NI DRAWER WAS DEENERGIZED BY REMOVING BOTH CONTROL AND | | INSTRUMENT POWER FUSES. WHEN THE FUSES WERE REMOVED, A REACTOR TRIP SIGNAL | | WAS GENERATED. THE TRIP SIGNAL WAS EXPECTED BY THE I&C TECHNICIANS, BUT | | NOT BY THE CONTROL ROOM OPERATORS. | | | | WHEN THE TRIP SIGNAL OCCURRED, THE REACTOR TRIP BREAKERS OPENED, BUT ALL | | CONTROL RODS WERE ALREADY FULLY INSERTED INTO THE CORE. NO OTHER ESF | | ACTUATIONS WERE EXPECTED AS A RESULT OF THE TRIP SIGNAL. THE NRC RESIDENT | | INSPECTOR HAS BEEN INFORMED OF THIS EVENT BY THE LICENSEE. | | | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29485 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: DRESDEN REGION: 3 |NOTIFICATION DATE: 10/20/95 | |UNIT: [ ] [2] [ ] STATE: IL |NOTIFICATION TIME: 15:03 [ET]| |RX TYPE: [1] GE-1,[2] GE-3,[3] GE-3 |EVENT DATE: 10/20/95 | +------------------------------------------------+EVENT TIME: 11:00[CDT]| |NRC NOTIFIED BY: MATTSON |LAST UPDATE DATE: 10/20/95 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BURDICK RDO | |AINA 50.72(b)(2)(iii)(A) POT UNABLE TO SAFE SD | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N N 0 REFUELING | 0 REFUELING | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | DESIGN PROBLEM IN SCRAM DISCHARGE VOLUME HIGH LEVEL REACTOR SCRAM LOGIC. | | | | THE FOLLOWING IS TEXT OF A FACSIMILE SUBMITTED BY THE LICENSEE: | | | | "DURING THE PERFORMANCE OF DIS 400-05, U2 SDV LEVEL SENSOR CALIBRATION AND | | FUNCTIONAL TEST, THE INSTRUMENT MAINTENANCE DEPARTMENT DISCOVERED A PROBLEM | | WITH THE ARRANGEMENT OF THE SCRAM INSTRUMENT VOLUME SCRAM LEVEL SWITCHES IN | | THE RPS SYSTEM. | | | | THE 1 OUT OF 2 TAKEN TWICE LOGIC IS MET FOR THE ASSIGNMENT OF THE LEVEL | | SWITCHES TO THE RPS SUBCHANNELS, HOWEVER, SINGLE FAILURE CRITERIA IS NOT | | MET IN THAT THE FAILURE OF A SINGLE SUBCHANNEL RELAY CONCURRENT WITH A | | HI-HI LEVEL IN ONE SCRAM INSTRUMENT VOLUME WOULD FAIL TO GENERATE A FULL | | REACTOR SCRAM. | | | | A SPECIFIC EXAMPLE IS THAT THE RPS A1 LOGIC RELAY (590-100A) IS ACTUATED BY | | TWO SDV LEVEL SWITCHES, IN SERIES, WHICH ARE BOTH LOCATED ON THE WEST SDV. | | IF RELAY 590-100A FAILED TO ACTUATE (SINGLE FAILURE) WITH A HIGH LEVEL IN | | THE WEST SDV, A RPS CHANNEL 'A' SCRAM WOULD NOT OCCUR." | | | | THE LICENSEE STATED THAT THIS PROBLEM DOES NOT AFFECT UNIT 3. A DESIGN | | MODIFICATION TO THE UNIT 2 SDV LEVEL LOGIC WAS PERFORMED IN THE LATE 1980s. | | THE ENGINEERING DEPARTMENT HAS CONTACTED QUAD CITIES STATION TO ALERT THEM | | TO THIS PROBLEM. THE NRC RESIDENT INSPECTOR HAS BEEN INFORMED BY THE | | LICENSEE. | | | | SEE EVENT # 29492 ON 10/21/95 FOR SIMILAR EVENT. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29486 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SUSQUEHANNA REGION: 1 |NOTIFICATION DATE: 10/20/95 | |UNIT: [ ] [2] [ ] STATE: PA |NOTIFICATION TIME: 15:35 [ET]| |RX TYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 10/20/95 | +------------------------------------------------+EVENT TIME: 16:00[EDT]| |NRC NOTIFIED BY: WALSH |LAST UPDATE DATE: 10/20/95 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BORES RDO | |ASHU 50.72(b)(1)(i)(A) PLANT S/D REQD BY TS | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N Y 8 STARTUP | 8 STARTUP | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | UNIT IS COMMENCING A TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO | | INOPERABLE SAFETY/RELIEF VALVE ACOUSTIC MONITOR. | | | | THE FOLLOWING IS TEXT OF A FACSIMILE SUBMITTED BY THE LICENSEE: | | | | "UNIT 2 WILL BE MANUALLY SCRAMMED FROM 8% POWER TO ALLOW DRYWELL ENTRY FOR | | REPAIR OF AN INOPERABLE MAIN STEAM SAFETY/RELIEF VALVE ACOUSTIC MONITOR. | | THIS IS A TECH SPEC REQUIRED SHUTDOWN PER TECH SPEC SECTION 3.4.2 AND | | 3.3.7.5." | | | | THE NRC RESIDENT INSPECTOR WILL BE INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 29487 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: WISE APPALACHIAN HOSPITAL |NOTIFICATION DATE: 10/20/95 | | CITY: WISE REGION: 2 |NOTIFICATION TIME: 16:29 [ET]| | COUNTY: STATE: VA |EVENT DATE: 10/20/95 | |LICENSE#: AGREEMENT: N |EVENT TIME: 00:00[EDT]| | DOCKET: |LAST UPDATE DATE: 10/20/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |POTTER RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: GREG DALTON | | |HQ OPS OFFICER: BOB STRANSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |BAD1 20.2202(a)(1) PERS OVEREXPOSURE | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | WISE APPALACHIAN HOSPITAL EMPLOYEE DOSIMETER READING FOUND HIGH. | | | | THE LICENSEE CALLED TO REPORT A HIGH DOSIMETER READING FROM A TECHNICIAN'S | | FILM BADGE DOSIMETER. THE READING FOR THIS TECHNICIAN'S FILM BADGE WAS | | 51.58 REM, WITH AN AVERAGE ENERGY SPECTRUM OF >250keV. THE LICENSEE | | REPORTED THAT THIS READING APPEARS TO BE ANOMALOUS IN THAT THE HOSPITAL | | DOES NOT USE ANY MATERIALS WITH ENERGIES OF >125keV. ADDITIONALLY, THE | | TECHNICIAN'S FINGER DOSIMETER DID NOT READ ABNORMALLY, AND NO BLOOD CHANGES | | WERE DETECTED IN A RECENT ANNUAL EMPLOYEE PHYSICAL EXAMINATION. | | | | THE LICENSEE HAS ALREADY CONTACTED THE COMMONWEALTH OF VIRGINIA BUREAU OF | | RADIOLOGICAL HEALTH AND NRC REGION 2 REGARDING THIS ISSUE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29488 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: HATCH REGION: 2 |NOTIFICATION DATE: 10/20/95 | |UNIT: [ ] [2] [ ] STATE: GA |NOTIFICATION TIME: 17:19 [ET]| |RX TYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 10/20/95 | +------------------------------------------------+EVENT TIME: 15:58[EDT]| |NRC NOTIFIED BY: URQUHART |LAST UPDATE DATE: 10/20/95 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |POTTER RDO | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N N 0 REFUELING | 0 REFUELING | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | EMERGENCY DIESEL GENERATORS STARTED DURING PERFORMANCE OF CORE SPRAY SYSTEM | | SURVEILLANCE TEST. | | | | DURING PERFORMANCE OF AN 18-MONTH LOGIC SYSTEM FUNCTIONAL TEST ON THE 2A | | CORE SPRAY SYSTEM, THE EMERGENCY DIESEL GENERATORS AUTOMATICALLY STARTED | | WHEN A LOCA INITIATION SIGNAL WAS APPLIED TO THE 2A CORE SPRAY PUMP. THIS | | WAS NOT EXPECTED TO OCCUR. ADDITIONALLY, THE TURBINE BUILDING PLANT | | SERVICE WATER SYSTEM ISOLATION VALVES CLOSED AND THE CONTROL ROOM | | VENTILATION SYSTEM WENT INTO PRESSURIZATION MODE. | | | | THE LICENSEE HAS TERMINATED THE TEST AND RESTORED ALL SYSTEMS TO NORMAL. | | THE LICENSEE IS INVESTIGATING A POSSIBLE PROBLEM WITH THE TEST PROCEDURE. | | THE NRC RESIDENT INSPECTOR HAS BEEN INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29489 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: COOPER REGION: 4 |NOTIFICATION DATE: 10/20/95 | |UNIT: [1] [ ] [ ] STATE: NE |NOTIFICATION TIME: 20:33 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 10/20/95 | +------------------------------------------------+EVENT TIME: 18:55[CDT]| |NRC NOTIFIED BY: GAUCHAT |LAST UPDATE DATE: 10/20/95 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |HARRELL RDO | |DSAF 73.71(b)(1) SECURITY DEGRADATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | SECURITY EVENT RELATED TO LOST/UNACCOUNTED FOR SECURITY WEAPON. IMMEDIATE | | COMPENSATORY ACTIONS TAKEN UPON DISCOVERY. NRC RESIDENT INSPECTOR WILL BE | | INFORMED. SEE HOO LOG FOR DETAILS. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29490 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: INDIAN POINT REGION: 1 |NOTIFICATION DATE: 10/21/95 | |UNIT: [ ] [3] [ ] STATE: NY |NOTIFICATION TIME: 12:50 [ET]| |RX TYPE: [2] W-4-LP,[3] W-4-LP |EVENT DATE: 10/21/95 | +------------------------------------------------+EVENT TIME: 12:41[EDT]| |NRC NOTIFIED BY: DAVID MOHR |LAST UPDATE DATE: 10/21/95 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BORES RDO | |ASHU 50.72(b)(1)(i)(A) PLANT S/D REQD BY TS | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | TECHNICAL SPECIFICATION COOLDOWN DUE TO POTENTIAL PROBLEM WITH CONTAINMENT | | ISOLATION VALVE. | | | | THE UNIT IS BEING TAKEN TO COLD SHUTDOWN IN ACCORDANCE WITH TECHNICAL | | SPECIFICATION 3.6.A.3 DUE TO A LOSS OF CONTAINMENT INTEGRITY. CONTAINMENT | | ISOLATION VALVE 43-5 (SERVICE WATER SUPPLY SIDE DRAIN TO FAN COOLER UNIT) | | WAS DECLARED INOPERABLE AT 1205 DUE TO QUESTIONABLE VALVE STRUCTURAL | | INTEGRITY. THE VALVE BODY HAS A SMALL HOLE DOWNSTREAM OF THE VALVE DISC, | | AND ULTRASONIC TESTING SHOWS POSSIBLE VALVE BODY WALL THINNING. THE | | LICENSEE PLANS TO INSPECT THE VALVE ONCE THE UNIT HAS REACHED COLD | | SHUTDOWN. | | | | THE NRC RESIDENT INSPECTOR WILL BE INFORMED OF THIS EVENT BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29491 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: DIABLO CANYON REGION: 4 |NOTIFICATION DATE: 10/21/95 | |UNIT: [1] [ ] [ ] STATE: CA |NOTIFICATION TIME: 13:05 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 10/21/95 | +------------------------------------------------+EVENT TIME: 09:51[PDT]| |NRC NOTIFIED BY: ANDERSON |LAST UPDATE DATE: 10/21/95 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: UNUSUAL EVENT +-----------------------------+ |10 CFR SECTION: |HARRELL RDO | |AAEC 50.72(a)(1)(i) EMERGENCY DECLARED |MARSH EO | |AFIR 50.72(b)(1)(vi) FIRE (ONSITE) |WITSBURG FEMA | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 REFUELING | 0 REFUELING | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | UNUSUAL EVENT DECLARED DUE TO FIRE IN AUXILIARY TRANSFORMER AND LOSS OF | | OFFSITE POWER. | | | | THE LICENSEE DECLARED AN UNUSUAL EVENT WHEN A FIRE OCCURRED IN AUXILIARY | | TRANSFORMER BANK 1-1, AND OFFSITE POWER TO THE UNIT WAS LOST. THE | | CALIFORNIA DEPARTMENT OF FORESTRY HAS BEEN CONTACTED TO ASSIST IN FIGHTING | | THE FIRE. RESIDUAL HEAT REMOVAL WAS INTERRUPTED FOR APPROXIMATELY TWO | | MINUTES WHEN OFFSITE POWER WAS LOST TO THE UNIT. THE LICENSEE DID NOT | | OBSERVE A HEATUP OF THE FUEL IN THE REACTOR VESSEL BEFORE RHR WAS RESTORED. | | THE THREE EMERGENCY DIESEL GENERATORS HAVE STARTED AND ARE SUPPLYING POWER | | TO VITAL EQUIPMENT LOADS. | | | | UNIT 2 IS NOT AFFECTED BY THIS EVENT. THE NRC RESIDENT INSPECTOR WILL BE | | INFORMED BY THE LICENSEE. THE LICENSEE PLANS TO MAKE A PRESS RELEASE. | | | | * * * UPDATE 1350 FROM ANDERSON TAKEN BY STRANSKY * * * | | | | THE UNIT REMAINS IN THE UNUSUAL EVENT. OFFSITE POWER HAS NOT YET BEEN | | RESTORED. THE FIRE HAS BEEN EXTINGUISHED, AND CLEANUP IS CURRENTLY | | UNDERWAY. THE LICENSEE REPORTED THAT THE FIRE WAS APPARENTLY CAUSED WHEN | | WORKERS ATTEMPTED TO PLACE A 25kV TO 12kV STEPDOWN TRANSFORMER INTO | | SERVICE. THE TRANSFORMER HAD A "GROUND BUGGY" (A MODIFIED BREAKER WHICH | | SHUNTS THE ELECTRICAL PHASES TO GROUND) INSTALLED ON THE HIGH VOLTAGE SIDE, | | AND WHEN THE FEEDER WAS ENERGIZED, A PHASE-TO-GROUND FAULT WAS INTRODUCED. | | THE LICENSEE ESTIMATES THAT OFFSITE POWER WILL NOT BE RESTORED FOR SEVERAL | | MORE HOURS. NOTIFIED R4DO(HARRELL). | | | | * * * UPDATE @ 0441EDT 10/22/95 BY GOELZER TAKEN BY MACKINNON * * * | | | | UNUSUAL EVENT TERMINATED AT 0429EDT WHEN OFFSITE POWER WAS RESTORED AND | | THEIR EMERGENCY DIESEL GENERATORS WERE SECURED. LICENSEE IS SUPPLYING | | OFFSITE ELECTRICAL POWER TO THEIR 4.16KV VITAL BUSES FROM THEIR 230KV | | STARTUP BUS THROUGH NO. 12 STANDBY STARTUP TRANSFORMER. MAIN TRANSFORMER | | FIRE WAS EXTINGUISHED WITHIN 10 TO 15 MINUTES AFTER IT HAD STARTED. NOBODY | | WAS INJURED. LICENSEE NOTIFIED THE STATE OF CALIFORNIA, LOCAL COUNTY, AND | | THE RESIDENT INSPECTOR THAT THE UNUSUAL EVENT HAD BEEN TERMINATED. R4DO | | (PHIL HARRELL), EO (TAD MARSH) & FEMA (MIKE MOSTELLER) NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29492 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: QUAD CITIES REGION: 3 |NOTIFICATION DATE: 10/21/95 | |UNIT: [1] [2] [ ] STATE: IL |NOTIFICATION TIME: 23:33 [ET]| |RX TYPE: [1] GE-3,[2] GE-3 |EVENT DATE: 10/21/95 | +------------------------------------------------+EVENT TIME: 21:45[CDT]| |NRC NOTIFIED BY: KEN PIOTEREK |LAST UPDATE DATE: 10/21/95 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |TOM BURDICK RDO | |ASHU 50.72(b)(1)(i)(A) PLANT S/D REQD BY TS | | |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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | 2 | M/R Y 25 POWER OPERATION | 0 HOT SHUTDOWN | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | TECHNICAL SPECIFICATION SHUTDOWN FOR BOTH UNITS DUE TO DESIGN PROBLEM IN | | SCRAM DISCHARGE VOLUME HIGH LEVEL REACTOR SCRAM LOGIC. | | | | THE FOLLOWING TEXT IS FROM A FACSIMILE SENT BY THE LICENSEE | | | | "AT 2145 (CDT) QUAD CITIES ENTERED TECH SPEC 3.1 TABLE 3.1. BASED ON THE | | DETERMINATION THAT THE SCRAM DISCHARGE VOLUME LEVEL INPUT TO THE REACTOR | | PROTECTION SYSTEM DOES NOT MEET THE SINGLE FAILURE CRITERIA SPECIFIED BY | | OUR DESIGN. BOTH QUAD CITY UNITS WILL HAVE ALL CONTROL RODS INSERTED WITHIN | | 4 HOURS OF DISCOVERY AS REQUIRED BY OUR TECH SPECS. | | UNIT 2 HAD ALL RODS INSERTED AT 2158 (CDT). | | UNIT 1 BEGAN ITS POWER REDUCTION AT 2232 (CDT)". | | | | THE 1 OUT OF 2 TAKEN TWICE LOGIC IS MET FOR THE ASSIGNMENT OF THE LEVEL | | SWITCHES TO THE REACTOR PROTECTION SYSTEM SUBCHANNELS, HOWEVER, SINGLE | | FAILURE CRITERION IS NOT MET IN THAT THE FAILURE OF A SINGLE SUBCHANNEL | | RELAY CONCURRENT WITH A HI-HI LEVEL IN ONE SCRAM INSTRUMENT VOLUME WOULD | | FAIL TO GENERATE A FULL REACTOR SCRAM. SEE DRESDEN UNIT 2 EVENT # 29485 | | REPORTED ON 10/20/95 FOR FURTHER DETAILS. | | | | ALL CONTROL RODS FOR UNIT TWO FULLY INSERTED INTO THE CORE AFTER THE MANUAL | | REACTOR SCRAM WAS PERFORMED AT 2158 CDT. STEAM IS BEING DUMPED TO THE MAIN | | CONDENSER VIA THE TURBINE BYPASS VALVES. | | UNIT ONE SHOULD BE PERFORMING A MANUAL REACTOR SCRAM FROM APPROXIMATELY 20% | | REACTOR POWER AROUND 0020 CDT 10/22/95. | | ALL EMERGENCY CORE COOLING SYSTEMS AND EMERGENCY DIESEL GENERATORS FOR BOTH | | UNITS ARE FULLY OPERABLE IF NEEDED. THE ELECTRICAL GRID IS STABLE. | | | | LICENSEE SAID THAT THEY MAY BE SHUTDOWN FOR A WEEK OR MORE TO REPAIR THE | | ABOVE MENTIONED PROBLEM. SARGENT & LUNDY DESIGNED THE SCRAM DISCHARGE | | VOLUME HIGH LEVEL REACTOR SCRAM LOGIC. | | | | RESIDENT INSPECTOR WAS INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29493 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PEACH BOTTOM REGION: 1 |NOTIFICATION DATE: 10/22/95 | |UNIT: [2] [3] [ ] STATE: PA |NOTIFICATION TIME: 17:29 [ET]| |RX TYPE: [2] GE-4,[3] GE-4 |EVENT DATE: 10/22/95 | +------------------------------------------------+EVENT TIME: 10:23[EDT]| |NRC NOTIFIED BY: KOVALCHICK |LAST UPDATE DATE: 10/22/95 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BORES RDO | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 2 | N Y 100 POWER OPERATION | 90 POWER OPERATION | | 3 | N Y 97 POWER OPERATION | 83 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | CONTAINMENT ISOLATIONS OCCURRED DUE TO LOSS OF 13kV STARTUP POWER SUPPLY TO | | SITE. | | | | AT 1023, ONE OF THE TWO IN-SERVICE 13kV STARTUP POWER SOURCES WAS LOST DUE | | TO A LINE FAULT OFFSITE. 4160V EMERGENCY BUSES FAST-TRANSFERRED TO THEIR | | ALTERNATE SOURCES. DURING THE TRANSFER, POWER WAS MOMENTARILY LOST TO | | CERTAIN EMERGENCY ELECTRICAL CIRCUITS, RESULTING IN SEVERAL CONTAINMENT | | ISOLATIONS. PCIS GROUP 2 (DRYWELL SUMP AND INSTRUMENT NITROGEN SUPPLY) | | ISOLATIONS WERE EXPERIENCED IN UNIT 2 (OUTBOARD) AND UNIT 3 (INBOARD). | | REACTOR WATER CLEANUP SYSTEM ISOLATIONS ALSO OCCURRED ON EACH UNIT. | | | | IN ADDITION, ONE FEEDWATER HEATER STRING WAS LOST ON EACH UNIT, RESULTING | | IN AN INCREASE IN CORE INLET SUBCOOLING AND INCREASED REACTIVITY. OPERATORS | | MANUALLY REDUCED POWER (UNIT 1 WAS REDUCED TO 90%; UNIT 2 TO 84%) TO | | MAINTAIN SCRAM REACTIVITY MARGINS. ALL SYSTEMS FUNCTIONED AS EXPECTED | | DURING THIS EVENT. THE LICENSEE DID NOT RECOGNIZE THE REPORTABILITY OF | | THIS EVENT UNTIL THIS AFTERNOON. THE NRC RESIDENT INSPECTOR HAS BEEN | | INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29494 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: DIABLO CANYON REGION: 4 |NOTIFICATION DATE: 10/22/95 | |UNIT: [1] [ ] [ ] STATE: CA |NOTIFICATION TIME: 23:54 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 10/22/95 | +------------------------------------------------+EVENT TIME: 18:45[PDT]| |NRC NOTIFIED BY: GOELZER |LAST UPDATE DATE: 10/22/95 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: | | |AINC 50.72(b)(2)(iii)(C) POT UNCNTRL RAD REL | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 REFUELING | 0 REFUELING | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | EDDY CURRENT TESTING ON STEAM GENERATOR 1-2 SHOWS THAT AT LEAST 45 TUBES | | HAVE INDICATIONS THAT THEY NEED TO BE PLUGGED. | | | | THE FOLLOWING TEXT IS FROM A FACSIMILE SENT BY THE LICENSEE | | | | "ON OCTOBER 22, 1995, AT APPROXIMATELY 1845 PDT, ANALYSIS OF EDDY CURRENT | | TESTING ON SG 1-2 SHOWS AT LEAST 45 PLUGGABLE INDICATIONS (APPROXIMATELY | | 333 TUBES WERE EDDY CURRENT TESTED), WHICH EXCEEDS 1% OF THE TOTAL TUBES | | INSPECTED. THUS, SG 1-2 IS CLASSIFIED AS TECHNICAL SPECIFICATION (TS) | | CATEGORY C-3. TS TABLE 4.4-2 REQUIRES NRC NOTIFICATION IN ACCORDANCE WITH | | 10 CFR 50.72 (b) (2). THE MAJORITY OF THE INDICATIONS ARE DUE TO PRIMARY | | WATER STRESS CORROSION CRACKING (PWSCC). THE OTHER THREE STEAM GENERATORS | | HAD PLUGGABLE INDICATIONS LESS THAN 1%. THIS EVENT IS BEING REPORTED AS A | | FOUR HOUR NON-EMERGENCY NOTIFICATION IN ACCORDANCE WITH 10 CFR 50.72 | | (b)(2)(iii)(C)." | | | | RESIDENT INSPECTOR WAS INFORMED BY THE LICENSEE. | | | +------------------------------------------------------------------------------+