U.S. Nuclear Regulatory Commission Operations Center Event Reports For 07/03/96 - 07/05/96 ** EVENT NUMBERS ** 30602 30643 30705 30706 30707 30708 30709 30710 30711 30712 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30602 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MAINE YANKEE REGION: 1 |NOTIFICATION DATE: 06/07/96 | |UNIT: [1] [ ] [ ] STATE: ME |NOTIFICATION TIME: 20:52 [ET]| |RX TYPE: [1] CE |EVENT DATE: 06/07/96 | +------------------------------------------------+EVENT TIME: 20:00[EDT]| |NRC NOTIFIED BY: PETE EBERT |LAST UPDATE DATE: 07/03/96 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JENNY JOHANSEN RDO | |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 90 POWER OPERATION | 90 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - LOW BEARING COOLING WATER FLOW COULD DAMAGE SERVICE WATER PUMPS - | | | | MAINE YANKEE HAS FOUR SERVICE WATER PUMPS (#P-29A, B, C, & D). | | | | THE LOWER BEARINGS OF THE 'B' & 'C' PUMPS ARE NORMALLY COOLED WITH FRESH | | WATER AND HAVE A BACKUP SALT WATER SUPPLY. THE BEARING COOLING WATER | | SYSTEM IS DESIGNED SUCH THAT IF THE FRESH WATER SUPPLY PRESSURE DROPS | | FROM A NORMAL PRESSURE OF 25 PSIG TO 2 PSIG, THE BACKUP SALT COOLING WATER | | SUPPLY IS AUTOMATICALLY INITIATED. | | | | ENGINEERING DEPARTMENT PERSONNEL CALCULATED THAT IF THE FRESH WATER SUPPLY | | PRESSURE DROPPED BELOW 6.4 PSIG, THE FRESH WATER SUPPLY FLOW WOULD DROP | | BELOW THE 3 GPM MINIMUM COOLING FLOW SPECIFIED BY THE PUMP VENDOR. | | | | THE 'A' & 'D' SERVICE WATER PUMPS ARE NOT SUBJECT TO THIS CONDITION | | BECAUSE THEY ONLY HAVE THE SALT COOLING WATER SUPPLY. THERE ARE NO | | RESTRICTIONS ON REMOVING THE 'A' & 'D' PUMPS FROM SERVICE. THUS, WHEN | | THE 'A' & 'D' PUMPS ARE OUT OF SERVICE, THE 'B' & 'C' PUMPS ARE THE ONLY | | SERVICE WATER PUMPS AVAILABLE TO SATISFY THE DESIGN BASIS REQUIREMENTS. | | | | THE LICENSEE MANUALLY PLACED THE SALT COOLING WATER SUPPLY TO THE | | 'B' & 'C' SERVICE WATER PUMPS IN SERVICE. | | | | THERE IS NO EVIDENCE THAT THE POTENTIAL LOW FRESH COOLING WATER PRESSURE | | CONDITION EVER ACTUALLY OCCURRED NOR HAS THERE BEEN ANY BEARING DAMAGE | | WHICH HAS BEEN ATTRIBUTED TO A LOW FRESH COOLING WATER FLOW CONDITION. | | | | THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | | | | * * * UPDATE 1900 EDT 7/3/96 FROM PAUL WILLOUGHBY TO S.SANDIN * * * | | | | THE LICENSEE IS RETRACTING THIS EVENT BASED ON THE FOLLOWING: | | | | "SUBSEQUENT EVALUATION BY MAINE YANKEE ENGINEERING, THE PUMP OEM, AND THE | | BEARING MANUFACTURER SHOWS THAT THE MINIMUM FLOW RATE IS 1.2 GPM AND THAT | | THIS IS SUFFICIENT TO PROVIDE ADEQUATE COOLING AND LUBRICATION TO THE | | BEARINGS. THE REDUCED FLOW MAY HAVE AN IMPACT ON LONG TERM RELIABILITY | | RATHER THAN SHORT TERM RELIABILITY, AND THE PUMP IS CAPABLE OF PERFORMING | | ITS INTENDED SAFETY FUNCTION. | | | | IT IS ALSO SIGNIFICANT TO NOTE THAT DUE TO THE SHAFT DESIGN (WITH AN | | EXTERNAL SHAFT TUBE), THE BEARINGS WILL REMAIN SUBMERGED AT ALL TIMES, | | FURTHER ENHANCING THE COOLING AND LUBRICATION OF THE BEARINGS." | | | | THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. NOTIFIED | | R1DO(PASCIAK). | +------------------------------------------------------------------------------+ !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30643 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: INDIAN POINT REGION: 1 |NOTIFICATION DATE: 06/19/96 | |UNIT: [2] [ ] [ ] STATE: NY |NOTIFICATION TIME: 03:16 [ET]| |RX TYPE: [2] W-4-LP,[3] W-4-LP |EVENT DATE: 06/19/96 | +------------------------------------------------+EVENT TIME: 02:10[EDT]| |NRC NOTIFIED BY: CHRIS MASSARO |LAST UPDATE DATE: 07/03/96 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |CURTIS COWGILL 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 | 100 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | ESF ACTUATION | | | | WHILE PREPARING TO PERFORM AN ADJUSTMENT TO POWER RANGE NUCLEAR INSTRUMENT | | N-43, SEVERAL ALARMS WERE RECEIVED ASSOCIATED WITH THIS CHANNEL. HOWEVER, | | SINCE THE LOGIC IS 2 OUT OF 4, THERE WAS NO REACTOR TRIP AND NO ROD MOTION | | INTERLOCKS WERE INSTATED. | | | | THE ALARMS WERE RECEIVED WHEN OPERATORS UNLOCKED THE POTENTIOMETER USED TO | | ADJUST THE INSTRUMENT, BUT PRIOR TO ANY ACTUAL ADJUSTMENT OF THE | | POTENTIOMETER. | | | | THE OTHER 3 POWER RANGE NIs WERE ALL ADJUSTED WITHOUT INCIDENT AND THE | | LICENSEE CONSIDERS ALL FOUR OF THE POWER RANGE NIs OPERABLE. | | | | THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | | | | * * * UPDATE AT 0950 ON 7/3/96 BY LIJOI TAKEN BY WEAVER * * * | | UPON FURTHER REVIEW, THE LICENSEE DOES NOT BELIEVE THAT THIS EVENT | | CONSTITUTES AN ESF ACTUATION. THEREFORE IT HAS BEEN RETRACTED. THE HOO | | NOTIFIED THE R1DO (PASCIAK). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |TRANSPORTATION EVENT | |EVENT NUMBER: 30705 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: UNKNOWN |NOTIFICATION DATE: 07/03/96 | | CITY: DENVER REGION: 4 |NOTIFICATION TIME: 00:47 [ET]| | COUNTY: DENVER STATE: CO |EVENT DATE: 07/02/96 | |LICENSE#: AGREEMENT: Y |EVENT TIME: 22:30[MDT]| | DOCKET: |LAST UPDATE DATE: 07/03/96 | | +-----------------------------+ | |PERSON ORGANIZATION| | |CHARLES CAIN RDO | | |JOE HOLONICH EO | +------------------------------------------------+STU RUBIN AEOD | |NRC NOTIFIED BY: NATIONAL RESPONSE CENTER | | |HQ OPS OFFICER: DOUG WEAVER | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NTRA TRANSPORTATION EVENT | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE NATIONAL RESPONSE CENTER NOTIFIED THE NRC OPERATIONS CENTER AT 0047 ON | | 7/3/96, OF A SPILL OF 1 GALLON OF Ra-226 IN THE UPS STORAGE AREA AT THE | | DENVER INTERNATIONAL AIRPORT. TWO PEOPLE WERE TAKEN TO THE HOSPITAL AND AN | | UNKNOWN NUMBER WERE EVACUATED. THE LOCAL FIRE DEPARTMENT HAZMAT TEAM | | RESPONDED. | | | | THE NATIONAL RESPONSE CENTER ALSO NOTIFIED EPA AND DOE. | | | | * * UPDATE AT 0151 ON 7/3/96 BY BLANCHARD OF THE NAT'L RESPONSE CENTER * * | | THERE WAS NO ACTUAL RELEASE OF Ra-226, ONLY THE OUTSIDE OF THE PACKAGE WAS | | DAMAGED. THE PEOPLE WERE TAKEN TO THE HOSPITAL AS A PRECAUTIONARY MEASURE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |TRANSPORTATION EVENT | |EVENT NUMBER: 30706 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: UNKNOWN |NOTIFICATION DATE: 07/03/96 | | CITY: GALT REGION: 3 |NOTIFICATION TIME: 04:46 [ET]| | COUNTY: WHITESIDE STATE: IL |EVENT DATE: 07/03/96 | |LICENSE#: AGREEMENT: Y |EVENT TIME: 02:00[CDT]| | DOCKET: |LAST UPDATE DATE: 07/03/96 | | +-----------------------------+ | |PERSON ORGANIZATION| | |BRENT CLAYTON RDO | | |JOE HOLONICH EO | +------------------------------------------------+STUART RUBIN AEOD | |NRC NOTIFIED BY: NAT'L RESPONSE CENTER | | |HQ OPS OFFICER: DOUG WEAVER | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NTRA TRANSPORTATION EVENT | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE NATIONAL RESPONSE CENTER NOTIFIED THE NRC OPERATIONS CENTER OF A TRAIN | | DERAILMENT NEAR GALT, IL. THE DERAILMENT OCCURRED AT 0200 CDT NEAR | | MILEPOST 113. THE TRAIN IS OWNED BY UNION PACIFIC AND THE TRAIN NUMBER IS | | ELMT02. EIGHTEEN CARS DERAILED, FOUR OF WHICH CONTAINED LOW LEVEL | | RADIOACTIVE SOIL. NO OTHER DETAILS WERE IMMEDIATELY AVAILABLE. | | | | THE NATIONAL RESPONSE CENTER ALSO NOTIFIED EPA AND DOE. A CONTACT NAME AND | | NUMBER ARE AVAILABLE IN THE OPERATIONS CENTER. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30707 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BEAVER VALLEY REGION: 1 |NOTIFICATION DATE: 07/03/96 | |UNIT: [1] [2] [ ] STATE: PA |NOTIFICATION TIME: 11:07 [ET]| |RX TYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 07/03/96 | +------------------------------------------------+EVENT TIME: 11:00[EDT]| |NRC NOTIFIED BY: GRADA |LAST UPDATE DATE: 07/03/96 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |WALTER PASCIAK RDO | |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 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | EIGHT CONTAINMENT PENETRATIONS DO NOT HAVE RELIEF PROTECTION | | | | DURING TESTING OF MOTOR OPERATED VALVES IN THE RHR SYSTEM, ONE CONTAINMENT | | ISOLATION VALVE COULD NOT BE OPENED. INVESTIGATION REVEALED THAT THE VALVE | | DID NOT OPEN BECAUSE OF A BUILDUP OF PRESSURE BETWEEN THE INNER AND OUTER | | CONTAINMENT ISOLATION VALVES. THE LICENSEE DISCOVERED A TOTAL OF EIGHT | | CONTAINMENT PENETRATIONS WITH NO INSTALLED RELIEF PROTECTION BETWEEN THE | | INNER AND OUTER CONTAINMENT ISOLATION VALVES. THE SYSTEMS INVOLVED ARE | | RHR, COMPONENT COOLING WATER AND FUEL POOL PURIFICATION. | | | | THE LICENSEE WILL PARTIALLY DRAIN DOWN THE AFFECTED PIPING TO PREVENT A | | PRESSURE BUILDUP UNTIL A LONGER TERM SOLUTION IS ADOPTED. THE LICENSEE | | INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30708 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: HATCH REGION: 2 |NOTIFICATION DATE: 07/03/96 | |UNIT: [1] [ ] [ ] STATE: GA |NOTIFICATION TIME: 11:14 [ET]| |RX TYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 06/29/96 | +------------------------------------------------+EVENT TIME: 13:46[EDT]| |NRC NOTIFIED BY: BUTLER |LAST UPDATE DATE: 07/03/96 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |THOMAS DECKER 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 DETERMINED TODAY THAT WHEN HPCI BECAME INOPERABLE AFTER BEING | | TAGGED OUT, IT SHOULD HAVE BEEN REPORTED AS A 4 HOUR REPORTABLE EVENT. | | | | ON 6/29/96 HPCI WAS TAGGED OUT FOR AN OIL AND FILTER CHANGE, AND UPON | | RUNNING THE HPCI OPERABILITY TEST, THEY DISCOVERED THAT CONTROL | | VALVE("1E41F3082"), WHICH SUPPLIES OIL FOR THE MECHANICAL OVERSPEED TRIP, | | WAS LEAKING OIL. THIS WOULD HAVE CAUSED THE STOP VALVE TO SHUT, RESULTING | | IN ISOLATION OF THE STEAM SUPPLY TO THE HPCI TURBINE. THE PROBLEM WITH THE | | CONTROL VALVE WAS A FAILED DIAPHRAGM. THE VALVE WAS FIXED BY 23:55 ON | | 6/29/96. THE PLANT WAS IN A 14 DAY LCO ACTION STATEMENT AND, THE EVENT WAS | | NOT DETERMINED TO BE REPORTABLE UNTIL 7/3/96 @ 10:00 AFTER A FURTHER REVIEW | | HAD BEEN COMPLETED. THE RI WAS INFORMED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30709 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SAINT LUCIE REGION: 2 |NOTIFICATION DATE: 07/03/96 | |UNIT: [1] [ ] [ ] STATE: FL |NOTIFICATION TIME: 13:45 [ET]| |RX TYPE: [1] CE,[2] CE |EVENT DATE: 07/03/96 | +------------------------------------------------+EVENT TIME: 10:14[EDT]| |NRC NOTIFIED BY: STEVE MERRILL |LAST UPDATE DATE: 07/03/96 | |HQ OPS OFFICER: STEVE SANDIN +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |THOMAS DECKER 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 N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | UNEXPECTED CONTAINMENT SPRAY AND RECIRCULATION ACTUATION SIGNALS DURING | | TROUBLESHOOTING. | | | | "THE I&C DEPARTMENT WAS TROUBLESHOOTING POTENTIAL WIRING DISCREPANCIES IN | | THE "B" CHANNEL ESFAS ACTUATION CABINET PER FACILITY REVIEW GROUP (FRG) | | APPROVED PROCEDURE AP-0010142 "MANIPULATION OF SENSITIVE SYSTEMS". THESE | | POTENTIAL WIRING DISCREPANCIES WERE IDENTIFIED WHILE INVESTIGATING THE | | INADVERTENT RECEIPT OF A SAFETY INJECTION ACTUATION SIGNAL AND A | | CONTAINMENT ISOLATION ACTUATION SIGNAL REPORTED TO THE NRC ON 6/8/96 (EVENT | | #30604). | | | | THE OPERATING CREW RECOGNIZED THE POTENTIAL TO RECEIVE A SAFETY INJECTION | | ACTUATION SIGNAL, A CONTAINMENT ISOLATION ACTUATION SIGNAL, AND/OR A MAIN | | STEAM ISOLATION SIGNAL DUE TO THE TROUBLESHOOTING EFFORTS. HOWEVER, AT | | APPROXIMATELY 1014, A CONTAINMENT SPRAY ACTUATION SIGNAL, AND A | | RECIRCULATION ACTUATION SIGNAL WERE UNEXPECTEDLY RECEIVED. THE OPERATING | | CREW VERIFIED THAT ALL AFFECTED COMPONENTS ACTUATED PER DESIGN AND RESET | | THE COMPONENTS TO THEIR NORMAL CONFIGURATION." | | | | THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30710 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PRAIRIE ISLAND REGION: 3 |NOTIFICATION DATE: 07/03/96 | |UNIT: [1] [ ] [ ] STATE: MN |NOTIFICATION TIME: 15:42 [ET]| |RX TYPE: [1] W-2-LP,[2] W-2-LP |EVENT DATE: 07/03/96 | +------------------------------------------------+EVENT TIME: 11:40[CDT]| |NRC NOTIFIED BY: DOUG SMITH |LAST UPDATE DATE: 07/03/96 | |HQ OPS OFFICER: STEVE SANDIN +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BRENT CLAYTON 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 Y 92 POWER OPERATION | 92 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | LICENSEE NOTIFIED STATE OF MINNESOTA DUTY OFFICER AND NATIONAL RESPONSE | | CENTER OF SODIUM HYDROXIDE DISCHARGE TO THE MISSISSIPPI RIVER. | | | | "A SMALL QUANTITY (< 1 GALLON) OF 50% SODIUM HYDROXIDE LEAKED FROM A PUMP | | CASING TO THE UNIT 1 TURBINE BUILDING FLOOR. THE SOLUTION WAS PARTIALLY | | NEUTRALIZED, DILUTED AND FLUSHED TO THE TURBINE BUILDING SUMP. TURBINE | | SUMP WATER WAS SAMPLED AND ANALYZED FOR pH PRIOR TO DISCHARGE TO THE | | MISSISSIPPI RIVER. BECAUSE THE SOLUTION WAS ULTIMATELY DISCHARGED, CALLS | | WERE MADE TO THE STATE OF MN DUTY OFFICER AND THE NATIONAL RESPONSE CENTER. | | THE QUANTITY OF SODIUM HYDROXIDE DISCHARGED WAS NOT A REPORTABLE QUANTITY, | | DID NOT RESULT IN A PERMIT VIOLATION, WAS NOT MEDIA SENSITIVE AND DID NOT | | RESULT IN AN ENVIRONMENTAL ADVISORY." | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 30711 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: MAHONING VALLEY CANCER CENTER |NOTIFICATION DATE: 07/03/96 | | CITY: LEHIGHTON REGION: 1 |NOTIFICATION TIME: 16:24 [ET]| | COUNTY: CARBON STATE: PA |EVENT DATE: 12/31/95 | |LICENSE#: 37-30086-01 AGREEMENT: N |EVENT TIME: 17:30[EDT]| | DOCKET: |LAST UPDATE DATE: 07/03/96 | | +-----------------------------+ | |PERSON ORGANIZATION| | |WALTER PASCIAK RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: KAREN WAGNER | | |HQ OPS OFFICER: STEVE SANDIN | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NINF INFORMATION ONLY | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | TWO FEMALE PATIENTS RECEIVED LESS THAN THE PRESCRIBED DOSE FRACTION DUE TO | | PERSONNEL ERROR. | | | | ON JUNE 24/25, 1996, REGION I (NEELAM BHALLA) CONDUCTED A ROUTINE | | INSPECTION OF THE MAHONING VALLEY CANCER CENTER LOCATED AT 800 MAHONING | | STREET, SUITE E, LEHIGHTON PA 18235. THE INSPECTOR REVIEWED A LICENSEE | | QUALITY MANAGEMENT REVIEW CONDUCTED ON JANUARY 1, 1996, WHERE TWO FEMALE | | PATIENTS RECEIVING HIGH DOSE RATE (HDR) TREATMENT FOR VAGINAL CANCER DID | | NOT RECEIVE THE CORRECT DOSE IN ONE OF THE FIVE DOSE FRACTIONS PRESCRIBED. | | EACH PATIENT WAS PRESCRIBED 500 CENTIGRAY TO BE DELIVERED .5 CM. FROM THE | | SURFACE OF A 3 CM. DIAMETER VAGINAL CYLINDER WITH AN ACTIVE LENGTH OF 5 CM. | | THE ERROR OCCURRED WHEN THE STEPPING DISTANCE WAS INADVERTENTLY INPUT AS | | 10 CM. THIS RESULTED A DOSE OF 312 INSTEAD OF THE 500 CENTIGRAY TO TISSUE | | BEING TREATED AND AN ADDITIONAL DOSE OF 312 CENTIGRAY TO TISSUE NOT | | PRESCRIBED FOR TREATMENT. AN ADJUSTMENT TO THE TREATMENT PLAN WAS MADE | | SUCH THAT THE REGION UNDER TREATMENT RECEIVED THE PRESCRIBED DOSE. THIS | | OCCURRED IN THE SECOND FRACTION OF ONE PATIENT AND THE FOURTH FRACTION OF | | THE OTHER PATIENT ON THE SAME DAY. THE LICENSEE IDENTIFIED THE CAUSE AS | | PERSONNEL ERROR AND HAS INSTITUTED A DOUBLE CHECK POLICY FOR INPUTS TO THE | | BRACHYTHERAPY DEVICE. THE SOURCE AT THE TIME OF THE TREATMENT WAS | | IRIDIUM-192 APPROXIMATELY 1.6 CURIES STRENGTH. BOTH PATIENTS WERE INFORMED | | OF THE ERROR BY THE PHYSICIAN WHO ORDERED THE TREATMENT. | | | | THE LICENSEE HAS NOT CLASSIFIED THIS AS A MEDICAL MISADMINISTRATION AT THIS | | TIME. REGION I IS ISSUING A PNO DESCRIBING THIS EVENT. | | | | SEE HOO LOG FOR TELEPHONE NUMBER AND PHYSICIAN NAME. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30712 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: COOPER REGION: 4 |NOTIFICATION DATE: 07/03/96 | |UNIT: [1] [ ] [ ] STATE: NE |NOTIFICATION TIME: 17:20 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 07/03/96 | +------------------------------------------------+EVENT TIME: 13:30[CDT]| |NRC NOTIFIED BY: FRED SCHIZAS |LAST UPDATE DATE: 07/03/96 | |HQ OPS OFFICER: STEVE SANDIN +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |CHARLES CAIN 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 +------------------------------------------------------------------------------+ | HPCI DECLARED INOPERABLE DUE TO FAILURE TO MEET ACCEPTANCE CRITERIA DURING | | MONTHLY SURVEILLANCE TESTING. | | | | "TODAY AT 1330CDT HPCI WAS DECLARED INOPERABLE WHEN HPCI-MO-25, MINIMUM | | FLOW BYPASS VALVE, FAILED TO MEET THE ACCEPTANCE CRITERIA SPECIFIED IN | | STATION PROCEDURE 6.HPCI.101, HPCI MONTHLY TEST MODE SURVEILLANCE | | OPERATION. HPCI-MO-25 FAILED TO OPEN AND THEN CLOSE WHEN FLOW WAS GREATER | | THAN 800 GPM. | | | | HPCI-MO-25 IS DESIGNED TO OPEN WHEN PUMP FLOW IS < 400 GPM AND PUMP | | DISCHARGE PRESSURE > 125 PSIG. APPARENTLY FLOW HAD RISEN ABOVE 400 GPM | | BEFORE DISCHARGE PRESSURE HAD RISEN ABOVE 125 PSIG. | | | | PLANT PROCEDURE REQUIRES THAT A SYSTEM BE DECLARED INOPERABLE WHENEVER ANY | | ACCEPTANCE CRITERIA IS NOT MEET. | | | | RCIC, BOTH LPCI SUBSYSTEMS AND BOTH CS SUBSYSTEMS WERE VERIFIED TO BE | | OPERABLE. ADS WAS DEMONSTRATED TO BE OPERABLE. HPCI IS A SINGLE TRAIN | | SYSTEM." | | | | THIS PLACED THE UNIT IN A 7-DAY TS A/S 3.5.C.2. THE LICENSEE IS CONDUCTING | | AN ENGINEERING EVALUATION TO DETERMINE CORRECTIVE ACTIONS. ONE | | RECOMMENDATION IS TO CHANGE THE TEST PROCEDURE AND OPEN THE SUBJECT VALVE | | PRIOR TO STARTING THE PUMP. THIS WILL PREVENT THE "RELAY RACE" BETWEEN THE | | PRESSURE SWITCH WHICH IS PART OF AN INTERLOCK AND THE FLOW SWITCH. A | | SIMILAR OCCURRENCE WAS OBSERVED ON JANUARY 17, 1996, HOWEVER, AN EVALUATION | | AT THE TIME INAPPROPRIATELY CONCLUDED THAT IT WAS NOT AN OPERABILITY ISSUE. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+