U.S. Nuclear Regulatory Commission Operations Center Event Reports For 12/21/95 - 12/22/95 ** EVENT NUMBERS ** 29680 29753 29754 29755 29756 29757 29758 29759 29760 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29680 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PALO VERDE REGION: 4 |NOTIFICATION DATE: 12/06/95 | |UNIT: [1] [2] [3] STATE: AZ |NOTIFICATION TIME: 19:01 [ET]| |RX TYPE: [1] CE,[2] CE,[3] CE |EVENT DATE: 12/06/95 | +------------------------------------------------+EVENT TIME: 16:00[MST]| |NRC NOTIFIED BY: DOUGLAS COXON |LAST UPDATE DATE: 12/21/95 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |TOM STETKA RDO | |DDDD 73.71 UNSPECIFIED PARAGRAPH | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 | | 3 | N Y 100 POWER OPERATION | 100 POWER OPERATION | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | DISCOVERY OF CRIMINAL ACT INVOLVING AN INDIVIDUAL GRANTED ACCESS TO THE | | SITE | | | | A CONTRACTOR EMPLOYEE WAS FOUND TO HAVE PROVIDED FALSE STATEMENTS ON HIS | | EMPLOYMENT APPLICATION. THE EMPLOYEE IS NOT CURRENTLY WORKING ON SITE. | | (REFER TO THE HOO LOG FOR ADDITIONAL INFORMATION.) | | | | THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | | | | *** UPDATE ON 12/21/95 AT 1216 EST, FROM GRABO & LEAVITT TAKEN BY KARSCH ** | | THE LICENSEE IS RETRACTING THIS EVENT BASED ON NRC ACCESS GUIDANCE THAT | | EMPLOYEE FALSIFICATION ON AN EMPLOYMENT APPLICATION IS NOT GROUNDS FOR | | REPORTABILITY. DECEPTION BY AN APPLICANT DOES NOT REPRESENT PROGRAMMATIC | | BREAKDOWN. THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. R4DO | | (PALLET) NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29753 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: ZION REGION: 3 |NOTIFICATION DATE: 12/21/95 | |UNIT: [1] [ ] [ ] STATE: IL |NOTIFICATION TIME: 00:53 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 12/20/95 | +------------------------------------------------+EVENT TIME: 23:10[CST]| |NRC NOTIFIED BY: LT HANSON |LAST UPDATE DATE: 12/21/95 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |ROY CANIANO RDO | |DDDD 73.71 UNSPECIFIED PARAGRAPH | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 73 POWER OPERATION | 73 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | SAFEGUARDS DEGRADATION RELATED TO AN AREA BOUNDARY | | | | IMMEDIATE COMPENSATORY MEASURES TAKEN UPON DISCOVERY. NO OUTSIDE AGENCIES | | WERE INVOLVED. THE NRC RESIDENT WAS NOT NOTIFIED. | | | | SEE HOO LOG FOR DETAILS. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29754 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SEQUOYAH REGION: 2 |NOTIFICATION DATE: 12/21/95 | |UNIT: [ ] [2] [ ] STATE: TN |NOTIFICATION TIME: 07:46 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 12/21/95 | +------------------------------------------------+EVENT TIME: 06:27[EST]| |NRC NOTIFIED BY: ROBBIN RUSSEL |LAST UPDATE DATE: 12/21/95 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |PIERCE SKINNER RDO | |ARPS 50.72(b)(2)(ii) RPS 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 +------------------------------------------------------------------------------+ | MANUAL REACTOR TRIP ON LOSS OF CONDENSER VACUUM | | | | UNIT TWO WAS MANUALLY TRIPPED WHEN OPERATORS NOTICED RISING MAIN CONDENSER | | BACK PRESSURE. THE RISE IN BACK PRESSURE WAS CAUSED BY A LOSS OF ALL THREE | | CONDENSER CIRCULATING WATER PUMPS. ALL CONTROL RODS FULLY INSERTED AND THE | | PLANT RESPONSE WAS AS EXPECTED. MAIN CONDENSER BACK PRESSURE PREVENTED THE | | STEAM DUMPS FROM OPENING. DECAY HEAT WAS INITIALLY REMOVED VIA THE STEAM | | GENERATOR ATMOSPHERIC DUMPS. A CIRCULATING WATER PUMP HAS SINCE BEEN | | RESTORED AND THE MAIN CONDENSER IS AVAILABLE FOR HEAT REMOVAL. | | | | THE CIRC WATER PUMPS WERE LOST AS THE RESULT OF A FAULT IN THE "A" PHASE OF | | A 161 KV SUPPLY LINE. | | | | THE PLANT IS STABLE IN MODE 3. THE LICENSEE INTENDS TO RESTART THE PLANT | | LATER TODAY. THE RESIDENT INSPECTOR WILL BE INFORMED. | | | | | | | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29755 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: DUANE ARNOLD REGION: 3 |NOTIFICATION DATE: 12/21/95 | |UNIT: [1] [ ] [ ] STATE: IA |NOTIFICATION TIME: 11:40 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 12/21/95 | +------------------------------------------------+EVENT TIME: 10:03[CST]| |NRC NOTIFIED BY: ALLEN |LAST UPDATE DATE: 12/21/95 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |ROY CANIANO RDO | |AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION | | |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 +------------------------------------------------------------------------------+ | THE LICENSEE DECLARED HPCI INOPERABLE DUE TO EXCESSIVE WATER IN THE TURBINE | | EXHAUST LINE AND ENTERED A 14 DAY LCO ACTION STATEMENT. | | | | THIS PROBLEM WAS DISCOVERED WHILE THEY WERE TROUBLESHOOTING A HIGH WATER | | LEVEL EXHAUST DRAIN POT ALARM. AS A RESULT OF THE TROUBLESHOOTING, THEY | | FOUND THAT THERE WAS EXCESSIVE WATER IN THE TURBINE EXHAUST LINE. THE CAUSE | | OF THIS EXCESS WATER ACCUMULATION IS UNKNOWN AND BEING INVESTIGATED. THE RI | | WAS NOTIFIED. | +------------------------------------------------------------------------------+ !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 29756 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: NORWOOD HOSPITAL |NOTIFICATION DATE: 12/21/95 | | CITY: NORWOOD REGION: 1 |NOTIFICATION TIME: 13:27 [ET]| | COUNTY: STATE: MA |EVENT DATE: 12/21/95 | |LICENSE#: 20-12560-01 AGREEMENT: N |EVENT TIME: 08:15[EST]| | DOCKET: |LAST UPDATE DATE: 12/21/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |MICHAEL MODES RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: RICHARD GOWE | | |HQ OPS OFFICER: RUDY KARSCH | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | NORWOOD HOSPITAL, NORWOOD, MASSACHUSETTS, REPORTED A MEDICAL | | MISADMINISTRATION. A BONE SCAN USING Tc 99 WAS ORDERED, BUT A LUNG SCAN | | USING Tc 99 WAS PERFORMED. THE PATIENT AND PHYSICIAN WILL BE NOTIFIED. THE | | LICENSEE WILL COLOR CODE THE DOSE CONTAINERS TO PREVENT THIS FROM HAPPENING | | IN THE FUTURE. | | | | * * * UPDATE AT 1617 ON 12/21/95 FROM GOWE TAKEN BY KARSCH * * * | | THIS EVENT IS BEING RETRACTED ON THE ADVICE OF REGION 1, BECAUSE THE | | EFFECTIVE DOSE WAS LOWER THAN THE 5 REM REPORTABILITY THRESHOLD. R1DO | | (MODES) NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29757 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PRAIRIE ISLAND REGION: 3 |NOTIFICATION DATE: 12/21/95 | |UNIT: [1] [2] [ ] STATE: MN |NOTIFICATION TIME: 15:00 [ET]| |RX TYPE: [1] W-2-LP,[2] W-2-LP |EVENT DATE: 12/21/95 | +------------------------------------------------+EVENT TIME: 10:05[CST]| |NRC NOTIFIED BY: CRAIG JOHNSON |LAST UPDATE DATE: 12/21/95 | |HQ OPS OFFICER: RUDY KARSCH +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |ROY CANIANO 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 89 POWER OPERATION | 89 POWER OPERATION | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AN INSTRUCTOR IN THE LICENSEE'S TRAINING FACILITY FAILED HIS SECOND DRUG | | TEST IN TWO MONTHS. | | | | THE LICENSEE HAS REVOKED PROTECTED AREA ACCESS AND IS CONSIDERING FURTHER | | ACTION AGAINST AN INSTRUCTOR IN THEIR TRAINING CENTER. HE TESTED POSITIVE | | FOR A CONTROLLED SUBSTANCE TWICE WITHIN A TWO MONTH PERIOD. THE INDIVIDUAL | | HOLDS AN INACTIVE OPERATORS LICENSE. THE LICENSEE DOES NOT THINK THE | | INDIVIDUAL WAS LIKELY TO HAVE COMMITTED ABERRANT ACTS DURING HIS VISITS TO | | THE SITE, BUT THEY ARE DOUBLE CHECKING HIS ACCESS HISTORY. THE LICENSEE | | INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29758 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: OCONEE REGION: 2 |NOTIFICATION DATE: 12/21/95 | |UNIT: [1] [ ] [ ] STATE: SC |NOTIFICATION TIME: 16:49 [ET]| |RX TYPE: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP |EVENT DATE: 11/04/95 | +------------------------------------------------+EVENT TIME: 16:00[EST]| |NRC NOTIFIED BY: DAVID NIX |LAST UPDATE DATE: 12/21/95 | |HQ OPS OFFICER: RUDY KARSCH +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |PIERCE SKINNER RDO | |ADAS 50.72(b)(2)(i) DEG/UNANALYZED COND | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 REFUELING | 100 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | RESTRAINTS FOR LOW TEMPERATURE OVERPRESSURE PROTECTION (LTOP) SYSTEM PIPING | | MAY HAVE BEEN REMOVED WHILE THE SYSTEM WAS STILL REQUIRED TO BE | | OPERATIONAL. | | | | THE LICENSEE DISCOVERED THAT CERTAIN PIPING RESTRAINTS HAD BEEN REMOVED TOO | | EARLY ON ONE TRAIN OF LTOP. THE UNIT WAS POTENTIALLY STILL UNDER LTOP | | CONDITIONS DURING THIS PERIOD. THE RESTRAINTS WERE REINSTALLED PRIOR TO | | ESTABLISHING LTOP CONDITIONS ON THE UNIT 1 RESTART. | | | | THE LICENSEE IS EVALUATING THE EFFECT OF THIS EVENT ON PAST OPERABILITY. | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29759 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PALO VERDE REGION: 4 |NOTIFICATION DATE: 12/21/95 | |UNIT: [1] [ ] [ ] STATE: AZ |NOTIFICATION TIME: 19:48 [ET]| |RX TYPE: [1] CE,[2] CE,[3] CE |EVENT DATE: 12/20/95 | +------------------------------------------------+EVENT TIME: 15:26[MST]| |NRC NOTIFIED BY: BERT GRABO |LAST UPDATE DATE: 12/21/95 | |HQ OPS OFFICER: RUDY KARSCH +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JOHN PELLET RDO | |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 Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE LICENSEE IS REINSTATING EVENT 29750 BECAUSE AN INOPERABLE MSIV BYPASS | | VALVE MAY PRECLUDE ISOLATION OF A FAULTED STEAM GENERATOR. | | | | MSIV BYPASS VALVE "SGUV169", AN AIR OPERATED VALVE, FAILED TO CLOSE DURING | | A SURVEILLANCE TEST. THE VALVE IS NORMALLY CLOSED WHEN THE PLANT IS AT | | POWER, HOWEVER, THIS VALVE IS OPEN AND BACK SEATED DUE TO A STEAM LEAK IN | | THE VALVE. BECAUSE OF THIS UNUSUAL VALVE LINE UP THE LICENSEE IS TESTING | | THE VALVE TWICE A MONTH TO ASSURE OPERABILITY. A REVIEW OF TEST RECORDS | | REVEALED THAT THE VALVE MAY HAVE BEEN INOPERABLE FOR SEVENTEEN DAYS. THE | | LICENSEE SUSPECTS THAT THE TEST TECHNICIAN MAY NOT HAVE RETURNED THE MANUAL | | HAND WHEEL TO THE NEUTRAL POSITION AFTER THE COMPLETION OF THE PREVIOUS | | SURVEILLANCE TEST. IF THE HAND WHEEL IS NOT IN THE NEUTRAL POSITION THE | | AIR OPERATOR CAN NOT FULLY CLOSE THE VALVE. WHEN THE HAND WHEEL WAS | | RETURNED TO THE NEUTRAL POSITION THE VALVE PASSED THE SURVEILLANCE TEST. | | THE OTHER BYPASS VALVES ON THE SITE WERE CHECKED AND ARE OPERABLE. THE | | LICENSEE WILL REPAIR THE STEAM LEAK IN THE VALVE AT THEIR NEXT REFUELING | | OUTAGE IN SEPTEMBER 1996. THE LICENSEE WILL INFORM THE NRC RESIDENT | | INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |GENERAL INFORMATION or OTHER | |EVENT NUMBER: 29760 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: AMERSHAM CORPORATION |NOTIFICATION DATE: 12/21/95 | | CITY: BURLINGTON REGION: 1 |NOTIFICATION TIME: 22:31 [ET]| | COUNTY: STATE: MA |EVENT DATE: 12/21/95 | |LICENSE#: AGREEMENT: N |EVENT TIME: 00:00[EST]| | DOCKET: |LAST UPDATE DATE: 12/21/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | | | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: CATHLEEN ROUGHAN |VERN HODGE NRR | |HQ OPS OFFICER: RUDY KARSCH |KEVIN RAMSEY NMSS | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |CCCC 21.21 UNSPECIFIED PARAGRAPH | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AMERSHAM CORPORATION, BURLINGTON, MA. IMPROPERLY TORQUED SCREWS ON A | | RADIOGRAPHY CAMERA (MODEL 660B) COULD CAUSE FAILURE OF THE SOURCE LOCKING | | DEVICE. | | | | TWO OF A PRODUCTION LOT OF SIXTEEN REAR PLATES HAVE HAD THE FOUR SCREWS | | HOLDING THE LOCKING ASSEMBLY ON TO THE REAR PLATE COME LOOSE. IF THE | | SCREWS HOLDING THE LOCKING ASSEMBLY LOOSEN FURTHER THE SOURCE COULD BE | | PULLED PAST THE FULLY SHIELDED POSITION. THE SCREWS MIGHT HAVE BEEN | | INSUFFICIENTLY TORQUED DURING MANUFACTURING. AMERSHAM WILL SEND AN | | INFORMATION NOTICE TO USERS ADVISING THEM OF THE PROBLEM | +------------------------------------------------------------------------------+