U.S. Nuclear Regulatory Commission Operations Center Event Reports For 02/01/96 - 02/02/96 ** EVENT NUMBERS ** 29574 29780 29916 29921 29922 29923 +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29574 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: FT CALHOUN REGION: 4 |NOTIFICATION DATE: 11/08/95 | |UNIT: [1] [ ] [ ] STATE: NE |NOTIFICATION TIME: 16:02 [ET]| |RX TYPE: [1] CE |EVENT DATE: 11/08/95 | +------------------------------------------------+EVENT TIME: 14:08[CST]| |NRC NOTIFIED BY: O'CONNER |LAST UPDATE DATE: 02/01/96 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |CHARLES CAIN RDO | |AOUT 50.72(b)(1)(ii)(B) OUTSIDE DESIGN BASIS | | |ACNC 50.72(b)(1)(ii)(C) COND OUTSIDE EOPS | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | GENERAL ELECTRIC RMS-9 TRIP UNITS ARE SUBJECT TO SPURIOUS TRIPPING. | | | | ABOUT 3 YEARS AGO GENERAL ELECTRIC RMS-9 TRIP UNITS WERE INSTALLED ON THE | | 480V CIRCUIT BREAKERS WHICH REPLACED ALL THE OIL DASH POT TRIP UNITS. IT | | HAS BEEN DETERMINED THAT THE RMS-9 TRIP UNITS ARE SUBJECT TO SPURIOUS | | TRIPPING. THE SPURIOUS BREAKER TRIPS ARE BELIEVED TO BE CAUSED BY GROUNDS | | ON THE 480V 3-PHASE FLOATING DELTA SYSTEMS INDUCING NOISE ON THE 480V | | SYSTEM. | | | | THE BREAKER TRIPPING IS A RESULT OF THE RMS-9's APPARENT OVER SENSITIVITY | | TO SHORT DURATION CURRENT SPIKES (ON THE ORDER OF 100 MICROSECONDS) ON THE | | INPUTS TO THE RMS-9s. THE NOISE SPIKES ARE BEING INTERPRETED BY THE RMS-9s | | AS OVERCURRENT CONDITIONS THAT REQUIRE A BREAKER TRIP. | | | | GROUNDS ON THE 480V SYSTEM ARE POSSIBLE FROM EQUIPMENT LOCATED IN | | CONTAINMENT OR ROOM 81 THAT IS 1) NOT ELECTRICAL EQUIPMENT QUALIFICATION | | PROGRAM QUALIFIED AND THAT IS 2) NOT NORMALLY OFF OR THAT IS NOT LOAD | | SHEDDED IN DESIGN BASIS ACCIDENTS (DBA). THESE LOADS COULD ACT AS THE | | SOURCE OR PROPAGATOR OF A 480V SYSTEM GROUND. THIS CONDITION HAS BEEN | | DETERMINED TO BE OUTSIDE THE DESIGN BASIS OF THE PLANT. ACTIONS BEING | | TAKEN TO REDUCE THE POTENTIAL FOR GROUND INDUCED TRIPS INCLUDE: | | | | 1. TAGGING OPEN LOADS WHICH HAVE BEEN IDENTIFIED THAT WOULD CONTRIBUTE TO | | THIS PROBLEM (i.e., WELDING RECEPTACLES), | | | | 2. PROVIDING OPERATOR GUIDANCE TO DISCONNECT CERTAIN LOADS DURING A DBA, | | | | 3. INCREASING OPERATOR AWARENESS OF THIS SITUATION, AND | | | | 4. INITIATION OF A MODIFICATION TO REVIEW THIS CONDITION WITH THE RMS-9 | | TRIP UNITS. | | | | THE NRC RESIDENT INSPECTOR WAS INFORMED BY THE LICENSEE. | | | | * * * UPDATE 1220 02/01/96, FROM MUELLER TAKEN BY STRANSKY * * * | | | | THE LICENSEE HAS CONSERVATIVELY EXPANDED THE SCOPE OF SUSCEPTIBLE BREAKERS | | TO INCLUDE THOSE FEEDING CERTAIN SAFEGUARDS MOTORS. | | | | THE NRC RESIDENT INSPECTOR HAS BEEN INFORMED BY THE LICENSEE. THE NRC | | OPERATIONS CENTER NOTIFIED THE R4DO (SANBORN). | +------------------------------------------------------------------------------+ !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 29780 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: CULPEPPER MEMORIAL HOSPITAL |NOTIFICATION DATE: 12/29/95 | | CITY: CULPEPPER REGION: 2 |NOTIFICATION TIME: 16:33 [ET]| | COUNTY: STATE: VA |EVENT DATE: 12/29/95 | |LICENSE#: 45-23040-01 AGREEMENT: N |EVENT TIME: 09:50[EST]| | DOCKET: |LAST UPDATE DATE: 02/01/96 | | +-----------------------------+ | |PERSON ORGANIZATION| | |THOMAS DECKER RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: DEBBIE CLINGAMPEEL | | |HQ OPS OFFICER: LEIGH TROCINE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MEDICAL MISADMINISTRATION OF 7 MILLICURIES OF TECHNETIUM-99m AT CULPEPPER | | MEMORIAL HOSPITAL LOCATED IN CULPEPPER, VIRGINIA, DUE A LABELLING ERROR BY | | THE LICENSEE'S PHARMACEUTICAL COMPANY (NORTHERN VIRGINIA ISOTOPES OF | | STERLING, VIRGINIA) | | | | AT 0950, A PATIENT WAS INJECTED WITH WHAT WAS BELIEVED TO BE 7 MILLICURIES | | OF TECHNETIUM-99m MAA WHICH MARKS THE LUNGS FOR SCANNING PURPOSES. THE | | LICENSEE SUSPECTED THAT THE WRONG ISOTOPE HAD BEEN USED BECAUSE THE LUNGS | | DID NOT SHOW UP DURING THE SCANNING PROCEDURE. AS A RESULT, THE LICENSEE | | CONTACTED ITS PHARMACEUTICAL COMPANY (NORTHERN VIRGINIA ISOTOPES OF | | STERLING, VIRGINIA) WHO LATER CONFIRMED THAT THE ISOTOPE WAS ACTUALLY | | TECHNETIUM-99m MAG3 IN A TECHNETIUM-99m MAA LABELLED SYRINGE. AS A RESULT, | | THE PATIENT HAD RECEIVED 7 MILLICURIES OF TECHNETIUM-99m MAG3, WHICH MARKS | | THE KIDNEYS FOR SCANNING PURPOSES, IN LIEU OF THE PRESCRIBED DOSAGE OF 7 | | MILLICURIES OF TECHNETIUM-99m MAA. THIS WAS CONFIRMED AT 1530. | | | | THE PATIENT IS AWARE OF THIS MISADMINISTRATION, AND THE LICENSEE DOES NOT | | BELIEVE THAT THERE WILL BE ANY RESULTING ADVERSE AFFECTS TO THE PATIENT. | | THE LICENSEE CURRENTLY PLANS TO REPEAT THIS PROCEDURE NEXT WEEK. THE | | LICENSEE ALSO PLANS TO FACSIMILE ITS DIAGNOSTIC MISADMINISTRATION FORM TO | | NORTHERN VIRGINIA ISOTOPES FOR COMPLETION AND PLANS TO CONTACT THE REGION 2 | | OFFICE NEXT WEEK. | | | | (REFER TO THE NRC HOO LOG FOR CONTACT NAMES, ADDRESSES, AND TELEPHONE | | NUMBERS.) | | | | * * * UPDATE 1206 02/01/96, FROM CLINGAMPEEL TAKEN BY STRANSKY * * * | | | | AFTER DISCUSSIONS WITH NRC REGION 2, THE LICENSEE IS RETRACTING THIS | | NOTIFICATION. THE DOSE RECEIVED DUE TO THIS ERROR IS BELOW THE LEVEL FOR | | REPORTABILITY. | | | | THE NRC OPERATIONS CENTER NOTIFIED THE R2DO (HOSEY). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |GENERAL INFORMATION or OTHER | |EVENT NUMBER: 29916 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: CANADIAN WORCESTER CONTROLS LTD. |NOTIFICATION DATE: 01/31/96 | | CITY: SCARBOROUGH REGION: 0 |NOTIFICATION TIME: 14:36 [ET]| | COUNTY: STATE: |EVENT DATE: 01/31/96 | |LICENSE#: AGREEMENT: |EVENT TIME: 00:00[ ]| | DOCKET: |LAST UPDATE DATE: 02/01/96 | | +-----------------------------+ | |PERSON ORGANIZATION| | | | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: GLENN KOTACK |VERN HODGE NRR | |HQ OPS OFFICER: RUDY KARSCH | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |CDEG 21.21(c)(3)(i) DEFECTS/NONCOMPLIANCE | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | CANADIAN WORCESTER CONTROLS LTD. (CWCL) REPORTED THAT BALL VALVES SUPPLIED | | BY CARDINAL INDUSTRIAL PRODUCTS CONTAINED "SUSPECT" PRESSURE BOUNDARY | | BOLTING. (REFER TO EVENT NUMBER 29328.) | | | | PRESSURE BOUNDARY BOLTING WAS FOUND TO BE "SUSPECT" ON 3/4-INCH BALL VALVES | | USED AT COMANCHE PEAK AND BRUNSWICK. A CWCL SUPPLIER (CARDINAL INDUSTRIAL | | PRODUCTS) IDENTIFIED THE SUSPECT BOLTS AS ORIGINATING FROM A HEAT LOT | | CHARGE THAT CONTAINED DEFECTIVE PRODUCT. ALL OF THE BOLTING IDENTIFIED BY | | CARDINAL INDUSTRIAL PRODUCTS AS BEING DEFECTIVE HAS BEEN ACCOUNTED FOR, AND | | NOTIFICATIONS WERE ISSUED TO ALL CUSTOMERS WHO HAD RECEIVED ANY PRODUCT | | CONTAINING THE SUSPECT BOLTING. CWCL'S CORRECTIVE ACTION TO HAVE THE | | BOLTING REPLACED HAS BEEN COMPLETED. THE SUSPECT BOLTING IN CWCL'S | | POSSESSION HAS BEEN RETURNED TO THE SUPPLIER. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29921 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PRAIRIE ISLAND REGION: 3 |NOTIFICATION DATE: 02/01/96 | |UNIT: [1] [2] [ ] STATE: MN |NOTIFICATION TIME: 04:14 [ET]| |RX TYPE: [1] W-2-LP,[2] W-2-LP |EVENT DATE: 02/01/96 | +------------------------------------------------+EVENT TIME: 02:15[CST]| |NRC NOTIFIED BY: DUANE JOHNSON |LAST UPDATE DATE: 02/01/96 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |RONALD GARDNER 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 N 0 REFUELING | 0 REFUELING | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | STATE NOTIFICATION OF A DIESEL FUEL OIL LEAK INSIDE THE PROTECTED AREA | | | | A TEMPORARY PORTABLE DIESEL GENERATOR INSIDE THE PROTECTED AREA DEVELOPED A | | LEAK IN A FUEL LINE. THIS CAUSED APPROXIMATELY 50 GALLONS OF DIESEL FUEL | | OIL TO SPILL ONTO THE GROUND UNDER THE GENERATOR. THE SPILL HAS BEEN | | CONTAINED, AND NO OIL WAS RELEASED FROM THE SITE. CLEANUP OPERATIONS ARE | | UNDERWAY. | | | | THE LICENSEE NOTIFIED THE MINNESOTA STATE AGENCIES AND PLANS TO NOTIFY THE | | NRC RESIDENT INSPECTOR. THE LICENSEE HAS NOT YET DECIDED ON WHETHER OR NOT | | A PRESS RELEASE WILL BE ISSUED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29922 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: OCONEE REGION: 2 |NOTIFICATION DATE: 02/01/96 | |UNIT: [1] [2] [3] STATE: SC |NOTIFICATION TIME: 16:36 [ET]| |RX TYPE: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP |EVENT DATE: 02/01/96 | +------------------------------------------------+EVENT TIME: 13:30[EST]| |NRC NOTIFIED BY: CLARKSON |LAST UPDATE DATE: 02/01/96 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |HOSEY 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 | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | 3 | N Y 100 POWER OPERATION | 100 POWER OPERATION | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | POTENTIAL FOR WATER ACCUMULATION IN SUCTION PIPING TO HYDROGEN RECOMBINER | | AND PURGE UNITS | | | | THE FOLLOWING IS TEXT OF A FACSIMILE SUBMITTED BY THE LICENSEE: | | | | "AT 1330 HOURS TODAY, AN LCO WAS ENTERED DUE TO PRELIMINARY ENGINEERING | | ANALYSIS INDICATION THAT THE POTENTIAL EXISTS FOR WATER TO ACCUMULATE IN | | THE SUCTION PIPING TO THE HYDROGEN RECOMBINER AND HYDROGEN PURGE UNIT. THIS | | WATER ACCUMULATION MAY PREVENT THE REACTOR BUILDING HYDROGEN CONTROL | | FUNCTION FROM BEING FULFILLED. TECHNICAL SPECIFICATIONS STATE THAT | | CONTAINMENT HYDROGEN CONTROL SYSTEMS ARE REQUIRED TO LIMIT HYDROGEN | | CONCENTRATION TO 4.1% BY VOLUME. WITH WATER ACCUMULATION IN THE SUCTION | | PIPING, PRELIMINARY ANALYSIS INDICATES THAT IT MAY NOT BE POSSIBLE TO LIMIT | | REACTOR BUILDING HYDROGEN CONCENTRATION TO 4.1% BY VOLUME. THIS CONDITION | | IS BEING CONSERVATIVELY REPORTED PENDING FINAL ENGINEERING EVALUATION." | | | | THE NRC RESIDENT INSPECTOR HAS BEEN INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29923 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: DIABLO CANYON REGION: 4 |NOTIFICATION DATE: 02/01/96 | |UNIT: [1] [2] [ ] STATE: CA |NOTIFICATION TIME: 20:34 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 02/01/96 | +------------------------------------------------+EVENT TIME: 17:10[PST]| |NRC NOTIFIED BY: MAGRUDER |LAST UPDATE DATE: 02/01/96 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |SANBORN RDO | |AUNA 50.72(b)(1)(ii)(A) UNANALYZED COND OP | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | CLOSING OF CENTRIFUGAL CHARGING PUMP MINIMUM FLOW RECIRCULATION LINE DURING | | TESTING PLACES UNITS IN UNANALYZED CONDITION. | | | | THE LICENSEE REPORTED THAT THE CLOSURE OF THE CENTRIFUGAL CHARGING PUMP | | COMMON RECIRCULATION FLOW PATH VALVE DURING QUARTERLY PUMP SURVEILLANCE | | TESTING (IN ACCORDANCE WITH ASME SECTION XI REQUIREMENTS) PLACES THE UNIT | | IN AN UNANALYZED CONDITION. SPECIFICALLY, WITH THE VALVE CLOSED, SAFETY | | INJECTION FLOW DURING A STEAM GENERATOR TUBE RUPTURE EVENT WOULD BE | | APPROXIMATELY 100 GPM ABOVE THAT ANALYZED IN THE PLANT ACCIDENT ANALYSIS. | | THE VALVE IS CLOSED BY PROCEDURE TO PROVIDE FOR ACCURATE PUMP FLOW | | MEASUREMENT. | | | | THE LICENSEE HAS REVISED THE SURVEILLANCE TEST PROCEDURE TO PREVENT CLOSURE | | OF THE VALVE DURING TESTING. | | | | THE NRC RESIDENT INSPECT HAS BEEN INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+