U.S. Nuclear Regulatory Commission Operations Center Event Reports For 10/01/96 - 10/02/96 ** EVENT NUMBERS ** 31019 31076 31077 31078 31079 31080 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 31019 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: FERMI REGION: 3 |NOTIFICATION DATE: 09/18/96 | |UNIT: [2] [ ] [ ] STATE: MI |NOTIFICATION TIME: 13:09 [ET]| |RX TYPE: [2] GE-4 |EVENT DATE: 09/18/96 | +------------------------------------------------+EVENT TIME: 12:18[EDT]| |NRC NOTIFIED BY: SKLARCZYK |LAST UPDATE DATE: 10/01/96 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |WAYNE KROPP RDO | |DDDD 73.71 UNSPECIFIED PARAGRAPH | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 2 | N Y 89 POWER OPERATION | 89 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE LICENSEE REPORTED THAT AN INDIVIDUAL ATTEMPTED TO INTRODUCE CONTRABAND | | INTO THE ACCESS CONTROL AREA. COMPENSATORY MEASURES WERE TAKEN UPON | | DISCOVERY. | | | | THE NRC RESIDENT INSPECTOR WILL BE INFORMED. (REFER TO THE HOO LOG FOR | | FURTHER DETAILS.) | | | | * * * 1844 OCTOBER 1, 1996, UPDATE FROM GROFF RECEIVED BY TROCINE * * * | | | | THE LICENSEE IS RETRACTING THIS EVENT NOTIFICATION. THE EVENT INVOLVED THE | | DISCOVERY OF A REVOLVER IN A TRUCK BEING PROCESSED INTO THE PROTECTED AREA, | | AND THE LICENSEE'S INVESTIGATION DETERMINED THAT THERE WAS NO MALEVOLENT | | INTENT ON THE PART OF THE DRIVER. THE LICENSEE BELIEVES THAT THE DECISION | | TO RETRACT THIS EVENT NOTIFICATION IS CONSISTENT WITH THE GUIDANCE PROVIDED | | IN NUREG 1304. | | | | THE LICENSEE DISCUSSED THIS ISSUE WITH NRC REGION 3 PERSONNEL AND NOTIFIED | | THE NRC RESIDENT INSPECTOR. THE NRC OPERATIONS CENTER NOTIFIED THE R3DO | | (CREED). (REFER TO THE HOO LOG FOR A SITE CONTACT TELEPHONE NUMBER.) | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 31076 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: ROBINSON REGION: 2 |NOTIFICATION DATE: 09/30/96 | |UNIT: [2] [ ] [ ] STATE: SC |NOTIFICATION TIME: 18:25 [ET]| |RX TYPE: [2] W-3-LP |EVENT DATE: 09/30/96 | +------------------------------------------------+EVENT TIME: 16:00[EDT]| |NRC NOTIFIED BY: JAN KOZYRA |LAST UPDATE DATE: 10/01/96 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MILTON SHYMLOCK 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 2 | N N 0 REFUELING | 0 REFUELING | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | DETERMINATION THAT FLOATING DEBRIS RESULTING FROM A LOSS OF COOLANT | | ACCIDENT (LOCA) COULD BECOME WATER LOGGED AND SUBJECT THE EMERGENCY CORE | | COOLING SYSTEM (ECCS) SUMP SCREENS TO CLOGGING AND IDENTIFICATION OF GAPS | | IN THE ECCS SUMP SCREENS | | | | WITH UNIT 2 DEFUELED, THE LICENSEE PERFORMED AN ENGINEERING EVALUATION TO | | RESOLVE INCONSISTENCIES BETWEEN ENGINEERING INFORMATION AND THE UNIT 2 | | UPDATED FINAL SAFETY ANALYSIS REPORT (UFSAR) REGARDING THE ESTIMATED HIGH | | CONTAINMENT WATER LEVEL IN THE EVENT OF A LOCA. AT ROBINSON, THE ECCS IS | | COMPRISED OF THE RESIDUAL HEAT REMOVAL (RHR) SYSTEM, SAFETY INJECTION (SI) | | ACCUMULATORS, AND THE HIGH HEAD SI SYSTEM. THE EVALUATION DETERMINED THAT | | WHEN THE REFUELING WATER STORAGE TANK IS AT THE LOWEST LEVEL, THE RESULTING | | WATER LEVEL IN CONTAINMENT IS IN EXCESS OF THE BAFFLES IN THE SUMP AREA | | WHICH ARE DESIGNED TO EXCLUDE FLOATING DEBRIS FROM THE ECCS SUMP. | | CONSEQUENTLY, THE LICENSEE BELIEVES THAT FLOATING DEBRIS RESULTING FROM A | | LOCA CAN SUBSEQUENTLY BECOME WATER LOGGED AND THEN SUBJECT THE ECCS SUMP | | SCREENS TO CLOGGING. IF THE ECCS SUMP SCREENS ARE SUFFICIENTLY CLOGGED | | DURING THE RECIRCULATION PHASE OF A POSTULATED LOCA, INADEQUATE NET | | POSITIVE SUCTION HEAD FOR THE RHR PUMPS, AND SUBSEQUENT FAILURE OF THE RHR | | PUMPS COULD RESULT. (THE RHR PUMPS ARE UTILIZED FOR LONG-TERM LOW PRESSURE | | COOLING OF THE CORE AFTER A POSTULATED LOCA.) | | | | IN ADDITION, UFSAR SECTION 6.3.2.2.2 STATES THAT THE ECCS SUMP SCREENS ARE | | DESIGNED TO RESTRICT PARTICLES GREATER THAN 7/32" IN THE LARGEST DIMENSION | | TO PRECLUDE CLOGGING OF THE CONTAINMENT SPRAY SYSTEM SPRAY NOZZLES WHICH | | HAVE A CIRCULAR DIAMETER OF 3/8" AS STATED IN UFSAR SECTION 6.5.2.2. AN | | EARLIER INSPECTION OF THE ECCS SUMP SCREENS FOUND GAPS LARGER THAN THE | | UFSAR SPECIFIED 7/32" IN THE LARGEST DIMENSION. DISCREPANCIES HAVE ALSO | | BEEN FOUND BETWEEN THE UFSAR DESCRIPTION OF THE SCREENS AND THE INSTALLED | | SCREENS. BECAUSE THE INSTALLED SCREENS ARE NOT IN ACCORDANCE WITH THE | | UFSAR SPECIFICATIONS AS WRITTEN AND BECAUSE NO PRIOR EVALUATION OF | | ACCEPTABILITY OF THE SCREENS IN THEIR CURRENT CONDITION COULD BE FOUND, THE | | LICENSEE DETERMINED THAT THE PAST OPERABILITY OF THE CONTAINMENT SPRAY | | SYSTEM AS WELL AS OTHER ECCS SYSTEMS THAT TAKE SUCTION FROM THE ECCS SUMP | | IN THE RECIRCULATION MODE (I.E., RHR AND SI SYSTEMS) CANNOT BE ASSURED AT | | THIS TIME. | | | | ACCORDINGLY, DUE TO THE POTENTIAL FOR RENDERING THE VARIOUS PORTIONS OF THE | | ECCS AND CONTAINMENT SPRAY SYSTEMS INOPERABLE DURING THE POST-LOCA | | RECIRCULATION MODE, THE LICENSEE DETERMINED THIS EVENT TO BE REPORTABLE AS | | A CONDITION THAT ALONE COULD HAVE PREVENTED THE FULFILLMENT OF A SAFETY | | FUNCTION THAT IS NEEDED TO MITIGATE THE CONSEQUENCES OF AN ACCIDENT. THIS | | DETERMINATION WAS MADE AT 1600 ON SEPTEMBER, 30, 1996. | | | | THE LICENSEE NOTIFIED THE NRC RESIDENT INSPECTOR. | | | | HOO NOTE: DISCUSSION OF THIS ISSUE IS ADDRESSED IN THE FOLLOWING AEOD | | REPORTS: AEOD/T916, DEBRIS IN CONTAINMENT RECIRCULATION SUMPS; AEOD/T923, | | DELAMINATING FOIL INSULATION IN PRIMARY CONTAINMENT; AND AEOD/T94-04, | | POTENTIAL FOR BOILING WATER REACTOR EMERGENCY CORE COOLING SYSTEM BLOCKAGE | | DUE TO LOSS-OF-COOLANT ACCIDENT GENERATED DEBRIS. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 31077 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: NATIONAL NAVAL MEDICAL CENTER |NOTIFICATION DATE: 10/01/96 | | CITY: BETHESDA REGION: 1 |NOTIFICATION TIME: 13:42 [ET]| | COUNTY: MONTGOMERY STATE: MD |EVENT DATE: 09/12/96 | |LICENSE#: 45-23645-01NA AGREEMENT: Y |EVENT TIME: 00:00[EDT]| | DOCKET: |LAST UPDATE DATE: 10/01/96 | | +-----------------------------+ | |PERSON ORGANIZATION| | |JAMES JOYNER RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: LCDR JOHN POMERVILLE | | |HQ OPS OFFICER: LEIGH TROCINE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |BAB2 20.2201(a)(1)(ii) LOST/STOLEN LNM>10X | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | POSSIBLE LOST 1.35-MILLICURIE PALLADIUM-103 SOURCE AT THE NATIONAL NAVAL | | MEDICAL CENTER IN BETHESDA, MARYLAND | | | | THE LICENSEE RECEIVED A SHIPMENT OF 266 PALLADIUM SEEDS AT 1610 ON | | SEPTEMBER 10, 1996, AND A LICENSEE PHYSICIST PERFORMED A QUALITY ASSURANCE | | COUNT ON THE SHIPMENT. BECAUSE THESE SEEDS WERE VERY SMALL, THE PHYSICIST | | PICKED UP MORE THAN ONE WITH THE FORCEPS THAT WERE BEING USED FOR COUNTING. | | AS A RESULT, SECOND COUNT WAS PERFORMED BY ANOTHER INDIVIDUAL. AT | | APPROXIMATELY 1900 ON SEPTEMBER 10, 1996, THE SECOND COUNT YIELDED 265 | | SEEDS IN LIEU OF 266. ON SEPTEMBER 11, 1996, A PHYSICIAN LOADED THE SEEDS | | INTO NEEDLES. AFTER THIS PROCESS, THE PHYSICIST WAS INFORMED THAT THE SUM | | OF THE LOADED SEEDS PLUS THE REMAINING SEEDS EQUALED 266. SUBSEQUENTLY, A | | TOTAL OF 259 PALLADIUM SEEDS WERE USED FOR PROSTATE TREATMENT IMPLANTS FOR | | 2 PATIENTS, AND ONLY 6 SEEDS REMAINED INSTEAD OF 7. THEREFORE, ONE SEED | | REMAINED UNACCOUNTED FOR. | | | | THE POTENTIALLY MISSING SEED HAS AN ACTIVITY OF 1.35 MILLICURIES. THE | | LICENSEE BELIEVES THAT IT IS LARGE ENOUGH TO BE DETECTED WITH A SURVEY | | METER AT A DISTANCE OF 10 FEET, AND IT WOULD BE 0.3 MILLIREM AT A DISTANCE | | OF 1 METER IF IT WAS UNSHIELDED. AN INDIVIDUAL WOULD HAVE TO BE IN THE | | IMMEDIATE AREA OF THE SOURCE FOR 290 HOURS (12 DAYS) IN ORDER TO RECEIVED A | | DOSE GREATER THAN 100 MILLIREM. | | | | THE LICENSEE HAS IDENTIFIED THREE POSSIBILITIES FOR THE MISSING SEED. | | EITHER THE SEED WAS LOST DURING THE LOADING AND IMPLANT PROCESS, ONE OF THE | | NEEDLES WAS MISLOADED WITH AN EXTRA SEED, OR THE ACTUAL NUMBER OF SOURCES | | RECEIVED FROM THE VENDOR WAS ONE SHORT. THE LICENSEE PERFORMED EXTENSIVE | | SURVEYS IN THE AREAS WHERE THE SEEDS WERE TRANSPORTED, STORED, LOADED, | | IMPLANTED AND IN ALL AREAS INCLUDING THE OPERATING ROOM, RECOVERY ROOM, THE | | ROUTES FOLLOWED, THE PATIENTS' WARD, AND ALL LINENS AND BIOHAZARD WASTE | | CONTAINERS. THE LICENSEE ALSO X-RAYED THE PATIENTS. THIS WAS DIFFICULT | | BECAUSE SOME OF THE SEEDS OVERLAP EACH OTHER DUE TO THE GEOMETRY OF THE | | NEEDLES. THE LICENSEE DOES NOT BELIEVE THAT ONE SEED WILL MAKE A | | MEASURABLE DIFFERENCE IN THE AMOUNT OF DOSE THAT A PATIENT WOULD | | POTENTIALLY RECEIVE. THE LICENSEE ALSO CALLED THE VENDOR, AND THE VENDOR | | STATED THAT 266 SEEDS WERE SHIPPED. THE LICENSEE STATED THAT THE VENDOR | | DID NOT HAVE TWO INDIVIDUALS COUNT THE SOURCES WHEN THE SEEDS ARE LOADED | | INTO VIALS PRIOR TO SHIPMENT. | | | | THE LICENSEE NOTIFIED NRC REGION 2 (JAY HENSON) AND PLANS TO SUBMIT A | | WRITTEN REPORT. (REFER TO THE HOO LOG FOR A LICENSEE CONTACT TELEPHONE | | NUMBER, AND THE NAVY RADIOACTIVE MATERIALS PERMIT NUMBER.) | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 31078 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PEACH BOTTOM REGION: 1 |NOTIFICATION DATE: 10/01/96 | |UNIT: [2] [ ] [ ] STATE: PA |NOTIFICATION TIME: 13:47 [ET]| |RX TYPE: [2] GE-4,[3] GE-4 |EVENT DATE: 10/01/96 | +------------------------------------------------+EVENT TIME: 11:35[EDT]| |NRC NOTIFIED BY: JIM BRASSARD |LAST UPDATE DATE: 10/01/96 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JAMES JOYNER 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 2 | N N 0 STARTUP | 0 STARTUP | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | INOPERABILITY OF THE HIGH PRESSURE COOLANT INJECTION (HPCI) SYSTEM DUE TO | | EXCESSIVE HEAT ON A PUMP SEAL | | | | DURING SURVEILLANCE TESTING FOLLOWING A UNIT 2 OUTAGE, THE HPCI PUMP WAS | | PREMATURELY SHUT DOWN AFTER EXCESSIVE HEAT WAS FOUND ON A PUMP SEAL. AS A | | RESULT, THE HPCI SYSTEM WAS DECLARED INOPERABLE, AND A 14-DAY TECHNICAL | | SPECIFICATION LIMITING CONDITION FOR OPERATION WAS ENTERED. THE LICENSEE | | IS CURRENTLY INVESTIGATING THE CAUSE OF THE PUMP SEAL PROBLEM AND PLANS TO | | CORRECT THE PROBLEM PRIOR TO PLACING THE UNIT IN MODE 1. | | | | THE LICENSEE NOTIFIED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 31079 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: COOPER REGION: 4 |NOTIFICATION DATE: 10/01/96 | |UNIT: [1] [ ] [ ] STATE: NE |NOTIFICATION TIME: 14:50 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 10/01/96 | +------------------------------------------------+EVENT TIME: 10:25[CDT]| |NRC NOTIFIED BY: BERT CROW |LAST UPDATE DATE: 10/01/96 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |IAN BARNES 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 +------------------------------------------------------------------------------+ | INOPERABILITY OF THE CONTROL ROOM EMERGENCY FILTER SYSTEM (CREFS) | | | | AT 1025 CST, THE LICENSEE DECLARED THE CREFS TO BE INOPERABLE BECAUSE THE | | ACCEPTANCE CRITERIA OF SURVEILLANCE PROCEDURE 6.PRM.316, CONTROL ROOM | | VENTILATION SYSTEM KNOWN SOURCE CALIBRATION, WERE NOT MET. AT COOPER, | | CREFS IS A SINGLE TRAIN SYSTEM WHOSE FUNCTIONALITY IS CREDITED WITH | | MITIGATING THE CONSEQUENCES OF AN ACCIDENT. | | | | CREFS OPERABILITY REQUIRES THE FUNCTIONALITY OF RMV-RM-1, WHICH INITIATES | | THE CREFS ALIGNMENT TO ITS SAFETY MODE OF OPERATION UPON EXCEEDING THE | | RADIATION SETPOINT OF ANY OF ITS THREE PARAMETERS (GASEOUS, PARTICULATE, OR | | IODINE). TECHNICAL SPECIFICATION 4.2.D.4 REQUIRES RMV-RM-1 TO BE | | CALIBRATED ONCE EVERY THREE MONTHS. DURING PERFORMANCE OF THE CALIBRATION, | | THE AS-FOUND RESULTS OF THE PARTICULATE CHANNEL INDICATED THAT THE | | APPROPRIATE EXTENT OF THE ISOTOPIC SPECTRUM WAS NOT BEING SURVEYED. PENDING | | THE RESOLUTION OF THIS ISSUE, THE CREFS WAS DECLARED INOPERABLE IN | | ACCORDANCE WITH TECHNICAL SPECIFICATION 3.12.A.2, AND A 7-DAY LIMITING | | CONDITION FOR OPERATION WAS ENTERED. FURTHER INVESTIGATIONS ARE BEING | | PERFORMED TO DETERMINE IF THE CREFS COULD STILL BE CONSIDERED FUNCTIONAL | | DESPITE THE NON-CONSERVATISM OF THIS CONDITION. | | | | THE LICENSEE NOTIFIED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 31080 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MILLSTONE REGION: 1 |NOTIFICATION DATE: 10/02/96 | |UNIT: [1] [2] [3] STATE: CT |NOTIFICATION TIME: 03:47 [ET]| |RX TYPE: [1] GE-3,[2] CE,[3] W-4-LP |EVENT DATE: 10/02/96 | +------------------------------------------------+EVENT TIME: 02:41[EDT]| |NRC NOTIFIED BY: C. SPODA |LAST UPDATE DATE: 10/02/96 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JOYNER RDO | |DTHR 73.71(c) SECURITY DEGRADATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 REFUELING | 0 REFUELING | | 2 | N N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | 3 | N N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | SAFEGUARDS SYSTEM DEGRADATION RELATED TO COMPUTER FUNCTIONS. IMMEDIATE | | COMPENSATORY ACTIONS TAKEN UPON DISCOVERY. NRC RESIDENT INSPECTOR HAS BEEN | | INFORMED. SEE HOO LOG FOR DETAILS. | +------------------------------------------------------------------------------+