U.S. Nuclear Regulatory Commission Operations Center Event Reports For 04/04/96 - 04/05/96 ** EVENT NUMBERS ** 30232 30233 30234 30235 30236 30237 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 30232 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: MARSHFIELD CLINIC |NOTIFICATION DATE: 04/04/96 | | CITY: MARSHFIELD REGION: 3 |NOTIFICATION TIME: 09:53 [ET]| | COUNTY: STATE: WI |EVENT DATE: 04/03/96 | |LICENSE#: AGREEMENT: N |EVENT TIME: 10:00[CST]| | DOCKET: |LAST UPDATE DATE: 04/04/96 | | +-----------------------------+ | |PERSON ORGANIZATION| | |SHEAR RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: WALRAVEN | | |HQ OPS OFFICER: BOB STRANSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | PATIENT RECEIVED NONPRESCRIBED 25 mCi DOSE OF Tc-99m. | | | | THE LICENSEE REPORTED THAT A PATIENT HAD RECEIVED 25 mCi OF Tc-99m | | CARDIOLYTE FOR A DIAGNOSTIC HEART STUDY WHEN ONLY AN EKG STRESS TEST WAS | | PRESCRIBED. THE PATIENT'S PHYSICIAN HAS BEEN NOTIFIED OF THE ERROR, AND | | THE LICENSEE WILL INFORM THE PATIENT TODAY OR TOMORROW. | | | | * * * UPDATE AT 1127 EST FROM WALRAVEN TAKEN BY KARSCH * * * | | AFTER CONSULTATION WITH REGION 3 (WIEDEMAN) THE LICENSEE DETERMINED THAT | | THIS EVENT DOES NOT MEET THE CRITERIA FOR REPORTABILITY. THE PATIENT'S | | EXPOSURE DID NOT EXCEED THE ANNUAL DOSE LIMITS OF 5 REM WHOLE BODY OR 50 | | REM TO AN ORGAN. THE LICENSEE IS RETRACTING THIS NOTIFICATION. R3DO | | (SHEAR) NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30233 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: FITZPATRICK REGION: 1 |NOTIFICATION DATE: 04/04/96 | |UNIT: [1] [ ] [ ] STATE: NY |NOTIFICATION TIME: 11:20 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 04/04/96 | +------------------------------------------------+EVENT TIME: 10:30[EST]| |NRC NOTIFIED BY: HORNING |LAST UPDATE DATE: 04/04/96 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |GRAY 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | ADS SOLENOIDS FOUND WITH OUT-OF-TOLERANCE COIL RESISTANCE READINGS | | | | DURING PERFORMANCE OF ST-22C, "ADS LOGIC SYSTEM FUNCTIONAL TEST," THREE ADS | | SAFETY/RELIEF VALVE SOLENOID COIL RESISTANCE READINGS WERE FOUND | | OUT-OF-RANGE HIGH. THE LICENSEE ENTERED A 24-HOUR TECHNICAL SPECIFICATION | | SHUTDOWN ACTION STATEMENT. | | | | THE LICENSEE STATED THAT THESE SOLENOIDS WERE REPLACED IN MARCH OF 1996, | | AND ARE OF A DIFFERENT TYPE THAN THE OTHER ADS SOLENOIDS. THE LICENSEE'S | | PRELIMINARY ENGINEERING EVALUATION INDICATES THAT THE EFFECT ON SOLENOID | | COIL RESISTANCE DUE TO LOCAL VALVE TEMPERATURE MAY NOT HAVE BEEN ADEQUATELY | | CONSIDERED IN DETERMINING THE ACCEPTANCE CRITERIA. THE LICENSEE EXPECTS TO | | COMPLETE ITS ENGINEERING EVALUATION WITHIN THE NEXT SEVERAL HOURS. THE NRC | | RESIDENT INSPECTOR HAS BEEN INFORMED BY THE LICENSEE. | | | | * * * UPDATE AT 1331 ON 4/4/96 BY ZAREMBA TAKEN BY WEAVER * * * | | THE LICENSEE HAS EXITED THE SHUTDOWN ACTION STATEMENT. A REVISED APPROVED | | ENGINEERING CALCULATION HAS SHOWN THAT THE ORIGINAL RESISTANCE BAND IN THE | | SURVEILLANCE PROCEDURE DID NOT TAKE INTO ACCOUNT THE TEMPERATURE OF THE | | DRYWELL. THE ORIGINAL RESISTANCE BAND WAS BASED ON EXPECTED RESISTANCES | | SUPPLIED BY THE MANUFACTURER, BUT THESE EXPECTED READINGS WERE NOT FOR THE | | SAME TEMPERATURE AS THAT FOUND IN THE DRYWELL. | | THE HOO NOTIFIED THE RDO (GRAY). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30234 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MONTICELLO REGION: 3 |NOTIFICATION DATE: 04/04/96 | |UNIT: [1] [ ] [ ] STATE: MN |NOTIFICATION TIME: 12:05 [ET]| |RX TYPE: [1] GE-3 |EVENT DATE: 04/04/96 | +------------------------------------------------+EVENT TIME: 10:40[CST]| |NRC NOTIFIED BY: ALLEN WOJCHOUSKI |LAST UPDATE DATE: 04/04/96 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |GARY SHEAR RDO | |AOUT 50.72(b)(1)(ii)(B) OUTSIDE DESIGN BASIS | | |AINB 50.72(b)(2)(iii)(B) POT RHR INOP | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 80 POWER OPERATION | 80 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | SOME SAFETY RELATED SWITCHGEAR COMPONENTS DO NOT MEET THE ENVIRONMENTAL | | QUALIFICATIONS REQUIRED FOR POST ACCIDENT CONDITIONS. | | | | AN ENGINEERING REVIEW IDENTIFIED NON-CONSERVATIVE ERRORS IN THE | | THERMO-HYDRAULIC MODEL FOR THE ENVIRONMENTAL EFFECTS DUE TO A PIPE RUPTURE. | | A HIGH ENERGY LINE BREAK (HELB) IN THE FEEDWATER SYSTEM COULD POTENTIALLY | | CREATE A HARSH ENVIRONMENT IN WHICH SOME SAFETY RELATED COMPONENTS ARE NOT | | DESIGNED TO OPERATE. SPECIFICALLY, THE MOTOR CONTROL CENTER FOR THE RHR | | SYSTEM IN THE TURBINE BUILDING IS VULNERABLE TO THE HIGH ENERGY LINE BREAK | | MENTIONED ABOVE. | | | | THE LICENSEE INTENDS TO STATION A HELB "WATCH". THE PURPOSE OF THIS WATCH | | WOULD BE TO IDENTIFY ANY LEAKS AT AN EARLY STAGE AND SHUT DOWN THE PLANT | | BEFORE THE LEAK THREATENED ANY SAFETY RELATED EQUIPMENT. THE PLANT IS | | ABOUT ONE WEEK AWAY FROM STARTING A REFUELING OUTAGE. | | | | THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 30235 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: ST. FRANCIS HOSPITAL |NOTIFICATION DATE: 04/04/96 | | CITY: HARTFORD REGION: 1 |NOTIFICATION TIME: 13:13 [ET]| | COUNTY: STATE: CT |EVENT DATE: 03/12/96 | |LICENSE#: 06-00854-03 AGREEMENT: N |EVENT TIME: 00:00[EST]| | DOCKET: |LAST UPDATE DATE: 04/04/96 | | +-----------------------------+ | |PERSON ORGANIZATION| | |HAROLD GRAY RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: STEWART KORCHIN | | |HQ OPS OFFICER: DOUG WEAVER | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MEDICAL MISADMINISTRATION | | | | A PATIENT BEING TREATED WITH A BRACHYTHERAPY UNIT RECEIVED A DOSE OF 440 | | cGy TO THE INNER THIGH AND THE VULVA. THE PATIENT COUGHED ABOUT THREE | | QUARTERS OF THE WAY THROUGH THE TREATMENT CAUSING THE Ir-192 CYLINDER TO | | DISLODGE, THUS EXPOSING THE UNINTENDED AREAS TO RADIATION. SOME ERYTHEMA | | WAS OBSERVED ON THE THIGH. NO OTHER ADVERSE HEALTH AFFECTS ARE EXPECTED. | | THE PATIENTS PHYSICIAN WILL INFORM THE PATIENT. | | | | THE EVENT OCCURRED ON 3/12/96 AND WAS NOT IMMEDIATELY RECOGNIZED AS A | | MISADMINISTRATION. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30236 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PALO VERDE REGION: 4 |NOTIFICATION DATE: 04/04/96 | |UNIT: [ ] [2] [ ] STATE: AZ |NOTIFICATION TIME: 20:08 [ET]| |RX TYPE: [1] CE,[2] CE,[3] CE |EVENT DATE: 04/04/96 | +------------------------------------------------+EVENT TIME: 17:14[MST]| |NRC NOTIFIED BY: BRAD EKLUND |LAST UPDATE DATE: 04/04/96 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: ALERT +-----------------------------+ |10 CFR SECTION: |TOM STETKA RDO | |AAEC 50.72(a)(1)(i) EMERGENCY DECLARED |EDWARD BUTCHER EO | | |JIM MUSE FEMA | | |MOORE DOE | | |BICKERTON USDA | | |GRAY HHS | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N N 0 REFUELING | 0 REFUELING | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | FIRE IN A LIGHTING PANEL IN THE CONTROL ROOM | | | | "AT APPROXIMATELY 1700 HOURS A SMOKE CONDITION WAS DISCOVERED ON THE 140' | | ELEVATION OF THE CONTROL ROOM BEHIND THE MAIN CONTROL PANEL. THIS FIRE WAS | | AT A LIGHTING PANEL WHICH WAS DOWN POWERED. LIGHT SMOKE WAS PRESENT IN THE | | LOCAL AREA. MAIN CONTROL ROOM ACCESS WAS NOT LOST AND EVACUATION OF | | CONTROL ROOM STAFF WAS NOT REQUIRED. HVAC EQUIPMENT WAS SWITCHED TO SMOKE | | REMOVAL MODE AND THE SMOKE WAS QUICKLY REMOVED FROM THE AREA. | | | | "ADDITIONALLY, FIRE WAS NOTED NEAR THE CLASS DC "B" SWITCHGEAR ROOM IN A | | LIGHTING VOLTAGE REGULATOR, FIRE TEAMS RESPONDED TO BOTH AREAS. THIS | | EQUIPMENT WAS DEENERGIZED AND THE FIRE PUT OUT AT 1735. THE ALERT WAS | | TERMINATED AT 1805." | | | | THIS EVENT IS RECEIVING A LARGE AMOUNT OF MEDIA INTEREST. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR AS WELL AS STATE AND LOCAL | | GOVERNMENTS. THE HOO ALSO NOTIFIED THE EPA (MOOREHOUSE). | | | | * * * COMMISSIONERS' ASSISTANTS BRIEFING AT 2200 ON 4/4/96 * * * | | EDO (DEAN); SECY (HART); CONGRESSIONAL AFFAIRS (CALLAHAN); COMM ROGERS' | | ASST (SORENSEN); COMM DICUS' ASST (MARKLEY); AEOD (JORDAN); ERB (BARRET); | | IP (HAUBER); CHAIRMAN JACKSON'S ASST (BOYLE); RIV (CALLAN) PLUS OTHER | | REGIONAL PERSONNEL. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30237 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: POINT BEACH REGION: 3 |NOTIFICATION DATE: 04/05/96 | |UNIT: [1] [ ] [ ] STATE: WI |NOTIFICATION TIME: 03:22 [ET]| |RX TYPE: [1] W-2-LP,[2] W-2-LP |EVENT DATE: 04/05/96 | +------------------------------------------------+EVENT TIME: 01:28[CST]| |NRC NOTIFIED BY: GROTE |LAST UPDATE DATE: 04/05/96 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |SHEAR 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 REFUELING | 0 REFUELING | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | SPURIOUS SAFETY INJECTION SIGNAL DURING TROUBLESHOOTING | | | | THE FOLLOWING IS TEXT OF A FACSIMILE SUBMITTED BY THE LICENSEE: | | | | "AT 0128 CST ON 4/5/96, INDICATION OF A 'B' TRAIN SAFETY INJECTION AND | | CONTAINMENT ISOLATION SIGNAL OCCURRED ON UNIT 1. UNIT 1 IS CURRENTLY IN A | | REFUELING SHUTDOWN CONDITION. THE ACTUATION RESULTED IN AUTO STARTS OF THE | | 'B' RHR PUMP, 'B' AFW PUMP, 'B' TRAIN SERVICE WATER PUMPS AND THE TWO 'B' | | TRAIN EMERGENCY DIESEL GENERATORS. | | | | A SERVICE WATER ISOLATION OCCURRED WHEN THE 'A' TRAIN SERVICE WATER PUMPS | | WERE SECURED TO LOWER SERVICE WATER HEADER PRESSURE. THESE SERVICE WATER | | LOADS WERE ALL RESTORED. AT THIS POINT, THE EXACT CAUSE IS UNKNOWN, | | ALTHOUGH IT IS SUSPECTED TO BE DUE TO INVESTIGATION OF THE CAUSE OF A | | GROUND ON THE 'B' TRAIN DC SYSTEM. DECAY HEAT REMOVAL WAS NEVER LOST AS A | | RESULT OF THE ACTUATION, AND THERE WAS NO INTERRUPTION OF NORMAL OFFSITE | | POWER. NORMAL REFUELING SHUTDOWN ALIGNMENT IS BEING RESTORED. THERE WAS | | NO ECCS DISCHARGE TO THE RCS." | | | | THE LICENSEE WILL NOTIFY THE NRC RESIDENT INSPECTOR OF THIS EVENT. | +------------------------------------------------------------------------------+ U.S. Nuclear Regulatory Commission Operations Center Event Reports For 04/04/96 - 04/05/96 ** EVENT NUMBERS ** 30232 30233 30234 30235 30236 30237 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 30232 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: MARSHFIELD CLINIC |NOTIFICATION DATE: 04/04/96 | | CITY: MARSHFIELD REGION: 3 |NOTIFICATION TIME: 09:53 [ET]| | COUNTY: STATE: WI |EVENT DATE: 04/03/96 | |LICENSE#: AGREEMENT: N |EVENT TIME: 10:00[CST]| | DOCKET: |LAST UPDATE DATE: 04/04/96 | | +-----------------------------+ | |PERSON ORGANIZATION| | |SHEAR RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: WALRAVEN | | |HQ OPS OFFICER: BOB STRANSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | PATIENT RECEIVED NONPRESCRIBED 25 mCi DOSE OF Tc-99m. | | | | THE LICENSEE REPORTED THAT A PATIENT HAD RECEIVED 25 mCi OF Tc-99m | | CARDIOLYTE FOR A DIAGNOSTIC HEART STUDY WHEN ONLY AN EKG STRESS TEST WAS | | PRESCRIBED. THE PATIENT'S PHYSICIAN HAS BEEN NOTIFIED OF THE ERROR, AND | | THE LICENSEE WILL INFORM THE PATIENT TODAY OR TOMORROW. | | | | * * * UPDATE AT 1127 EST FROM WALRAVEN TAKEN BY KARSCH * * * | | AFTER CONSULTATION WITH REGION 3 (WIEDEMAN) THE LICENSEE DETERMINED THAT | | THIS EVENT DOES NOT MEET THE CRITERIA FOR REPORTABILITY. THE PATIENT'S | | EXPOSURE DID NOT EXCEED THE ANNUAL DOSE LIMITS OF 5 REM WHOLE BODY OR 50 | | REM TO AN ORGAN. THE LICENSEE IS RETRACTING THIS NOTIFICATION. R3DO | | (SHEAR) NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30233 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: FITZPATRICK REGION: 1 |NOTIFICATION DATE: 04/04/96 | |UNIT: [1] [ ] [ ] STATE: NY |NOTIFICATION TIME: 11:20 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 04/04/96 | +------------------------------------------------+EVENT TIME: 10:30[EST]| |NRC NOTIFIED BY: HORNING |LAST UPDATE DATE: 04/04/96 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |GRAY 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | ADS SOLENOIDS FOUND WITH OUT-OF-TOLERANCE COIL RESISTANCE READINGS | | | | DURING PERFORMANCE OF ST-22C, "ADS LOGIC SYSTEM FUNCTIONAL TEST," THREE ADS | | SAFETY/RELIEF VALVE SOLENOID COIL RESISTANCE READINGS WERE FOUND | | OUT-OF-RANGE HIGH. THE LICENSEE ENTERED A 24-HOUR TECHNICAL SPECIFICATION | | SHUTDOWN ACTION STATEMENT. | | | | THE LICENSEE STATED THAT THESE SOLENOIDS WERE REPLACED IN MARCH OF 1996, | | AND ARE OF A DIFFERENT TYPE THAN THE OTHER ADS SOLENOIDS. THE LICENSEE'S | | PRELIMINARY ENGINEERING EVALUATION INDICATES THAT THE EFFECT ON SOLENOID | | COIL RESISTANCE DUE TO LOCAL VALVE TEMPERATURE MAY NOT HAVE BEEN ADEQUATELY | | CONSIDERED IN DETERMINING THE ACCEPTANCE CRITERIA. THE LICENSEE EXPECTS TO | | COMPLETE ITS ENGINEERING EVALUATION WITHIN THE NEXT SEVERAL HOURS. THE NRC | | RESIDENT INSPECTOR HAS BEEN INFORMED BY THE LICENSEE. | | | | * * * UPDATE AT 1331 ON 4/4/96 BY ZAREMBA TAKEN BY WEAVER * * * | | THE LICENSEE HAS EXITED THE SHUTDOWN ACTION STATEMENT. A REVISED APPROVED | | ENGINEERING CALCULATION HAS SHOWN THAT THE ORIGINAL RESISTANCE BAND IN THE | | SURVEILLANCE PROCEDURE DID NOT TAKE INTO ACCOUNT THE TEMPERATURE OF THE | | DRYWELL. THE ORIGINAL RESISTANCE BAND WAS BASED ON EXPECTED RESISTANCES | | SUPPLIED BY THE MANUFACTURER, BUT THESE EXPECTED READINGS WERE NOT FOR THE | | SAME TEMPERATURE AS THAT FOUND IN THE DRYWELL. | | THE HOO NOTIFIED THE RDO (GRAY). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30234 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MONTICELLO REGION: 3 |NOTIFICATION DATE: 04/04/96 | |UNIT: [1] [ ] [ ] STATE: MN |NOTIFICATION TIME: 12:05 [ET]| |RX TYPE: [1] GE-3 |EVENT DATE: 04/04/96 | +------------------------------------------------+EVENT TIME: 10:40[CST]| |NRC NOTIFIED BY: ALLEN WOJCHOUSKI |LAST UPDATE DATE: 04/04/96 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |GARY SHEAR RDO | |AOUT 50.72(b)(1)(ii)(B) OUTSIDE DESIGN BASIS | | |AINB 50.72(b)(2)(iii)(B) POT RHR INOP | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 80 POWER OPERATION | 80 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | SOME SAFETY RELATED SWITCHGEAR COMPONENTS DO NOT MEET THE ENVIRONMENTAL | | QUALIFICATIONS REQUIRED FOR POST ACCIDENT CONDITIONS. | | | | AN ENGINEERING REVIEW IDENTIFIED NON-CONSERVATIVE ERRORS IN THE | | THERMO-HYDRAULIC MODEL FOR THE ENVIRONMENTAL EFFECTS DUE TO A PIPE RUPTURE. | | A HIGH ENERGY LINE BREAK (HELB) IN THE FEEDWATER SYSTEM COULD POTENTIALLY | | CREATE A HARSH ENVIRONMENT IN WHICH SOME SAFETY RELATED COMPONENTS ARE NOT | | DESIGNED TO OPERATE. SPECIFICALLY, THE MOTOR CONTROL CENTER FOR THE RHR | | SYSTEM IN THE TURBINE BUILDING IS VULNERABLE TO THE HIGH ENERGY LINE BREAK | | MENTIONED ABOVE. | | | | THE LICENSEE INTENDS TO STATION A HELB "WATCH". THE PURPOSE OF THIS WATCH | | WOULD BE TO IDENTIFY ANY LEAKS AT AN EARLY STAGE AND SHUT DOWN THE PLANT | | BEFORE THE LEAK THREATENED ANY SAFETY RELATED EQUIPMENT. THE PLANT IS | | ABOUT ONE WEEK AWAY FROM STARTING A REFUELING OUTAGE. | | | | THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 30235 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: ST. FRANCIS HOSPITAL |NOTIFICATION DATE: 04/04/96 | | CITY: HARTFORD REGION: 1 |NOTIFICATION TIME: 13:13 [ET]| | COUNTY: STATE: CT |EVENT DATE: 03/12/96 | |LICENSE#: 06-00854-03 AGREEMENT: N |EVENT TIME: 00:00[EST]| | DOCKET: |LAST UPDATE DATE: 04/04/96 | | +-----------------------------+ | |PERSON ORGANIZATION| | |HAROLD GRAY RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: STEWART KORCHIN | | |HQ OPS OFFICER: DOUG WEAVER | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MEDICAL MISADMINISTRATION | | | | A PATIENT BEING TREATED WITH A BRACHYTHERAPY UNIT RECEIVED A DOSE OF 440 | | cGy TO THE INNER THIGH AND THE VULVA. THE PATIENT COUGHED ABOUT THREE | | QUARTERS OF THE WAY THROUGH THE TREATMENT CAUSING THE Ir-192 CYLINDER TO | | DISLODGE, THUS EXPOSING THE UNINTENDED AREAS TO RADIATION. SOME ERYTHEMA | | WAS OBSERVED ON THE THIGH. NO OTHER ADVERSE HEALTH AFFECTS ARE EXPECTED. | | THE PATIENTS PHYSICIAN WILL INFORM THE PATIENT. | | | | THE EVENT OCCURRED ON 3/12/96 AND WAS NOT IMMEDIATELY RECOGNIZED AS A | | MISADMINISTRATION. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30236 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PALO VERDE REGION: 4 |NOTIFICATION DATE: 04/04/96 | |UNIT: [ ] [2] [ ] STATE: AZ |NOTIFICATION TIME: 20:08 [ET]| |RX TYPE: [1] CE,[2] CE,[3] CE |EVENT DATE: 04/04/96 | +------------------------------------------------+EVENT TIME: 17:14[MST]| |NRC NOTIFIED BY: BRAD EKLUND |LAST UPDATE DATE: 04/04/96 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: ALERT +-----------------------------+ |10 CFR SECTION: |TOM STETKA RDO | |AAEC 50.72(a)(1)(i) EMERGENCY DECLARED |EDWARD BUTCHER EO | | |JIM MUSE FEMA | | |MOORE DOE | | |BICKERTON USDA | | |GRAY HHS | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N N 0 REFUELING | 0 REFUELING | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | FIRE IN A LIGHTING PANEL IN THE CONTROL ROOM | | | | "AT APPROXIMATELY 1700 HOURS A SMOKE CONDITION WAS DISCOVERED ON THE 140' | | ELEVATION OF THE CONTROL ROOM BEHIND THE MAIN CONTROL PANEL. THIS FIRE WAS | | AT A LIGHTING PANEL WHICH WAS DOWN POWERED. LIGHT SMOKE WAS PRESENT IN THE | | LOCAL AREA. MAIN CONTROL ROOM ACCESS WAS NOT LOST AND EVACUATION OF | | CONTROL ROOM STAFF WAS NOT REQUIRED. HVAC EQUIPMENT WAS SWITCHED TO SMOKE | | REMOVAL MODE AND THE SMOKE WAS QUICKLY REMOVED FROM THE AREA. | | | | "ADDITIONALLY, FIRE WAS NOTED NEAR THE CLASS DC "B" SWITCHGEAR ROOM IN A | | LIGHTING VOLTAGE REGULATOR, FIRE TEAMS RESPONDED TO BOTH AREAS. THIS | | EQUIPMENT WAS DEENERGIZED AND THE FIRE PUT OUT AT 1735. THE ALERT WAS | | TERMINATED AT 1805." | | | | THIS EVENT IS RECEIVING A LARGE AMOUNT OF MEDIA INTEREST. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR AS WELL AS STATE AND LOCAL | | GOVERNMENTS. THE HOO ALSO NOTIFIED THE EPA (MOOREHOUSE). | | | | * * * COMMISSIONERS' ASSISTANTS BRIEFING AT 2200 ON 4/4/96 * * * | | EDO (DEAN); SECY (HART); CONGRESSIONAL AFFAIRS (CALLAHAN); COMM ROGERS' | | ASST (SORENSEN); COMM DICUS' ASST (MARKLEY); AEOD (JORDAN); ERB (BARRET); | | IP (HAUBER); CHAIRMAN JACKSON'S ASST (BOYLE); RIV (CALLAN) PLUS OTHER | | REGIONAL PERSONNEL. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30237 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: POINT BEACH REGION: 3 |NOTIFICATION DATE: 04/05/96 | |UNIT: [1] [ ] [ ] STATE: WI |NOTIFICATION TIME: 03:22 [ET]| |RX TYPE: [1] W-2-LP,[2] W-2-LP |EVENT DATE: 04/05/96 | +------------------------------------------------+EVENT TIME: 01:28[CST]| |NRC NOTIFIED BY: GROTE |LAST UPDATE DATE: 04/05/96 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |SHEAR 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 REFUELING | 0 REFUELING | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | SPURIOUS SAFETY INJECTION SIGNAL DURING TROUBLESHOOTING | | | | THE FOLLOWING IS TEXT OF A FACSIMILE SUBMITTED BY THE LICENSEE: | | | | "AT 0128 CST ON 4/5/96, INDICATION OF A 'B' TRAIN SAFETY INJECTION AND | | CONTAINMENT ISOLATION SIGNAL OCCURRED ON UNIT 1. UNIT 1 IS CURRENTLY IN A | | REFUELING SHUTDOWN CONDITION. THE ACTUATION RESULTED IN AUTO STARTS OF THE | | 'B' RHR PUMP, 'B' AFW PUMP, 'B' TRAIN SERVICE WATER PUMPS AND THE TWO 'B' | | TRAIN EMERGENCY DIESEL GENERATORS. | | | | A SERVICE WATER ISOLATION OCCURRED WHEN THE 'A' TRAIN SERVICE WATER PUMPS | | WERE SECURED TO LOWER SERVICE WATER HEADER PRESSURE. THESE SERVICE WATER | | LOADS WERE ALL RESTORED. AT THIS POINT, THE EXACT CAUSE IS UNKNOWN, | | ALTHOUGH IT IS SUSPECTED TO BE DUE TO INVESTIGATION OF THE CAUSE OF A | | GROUND ON THE 'B' TRAIN DC SYSTEM. DECAY HEAT REMOVAL WAS NEVER LOST AS A | | RESULT OF THE ACTUATION, AND THERE WAS NO INTERRUPTION OF NORMAL OFFSITE | | POWER. NORMAL REFUELING SHUTDOWN ALIGNMENT IS BEING RESTORED. THERE WAS | | NO ECCS DISCHARGE TO THE RCS." | | | | THE LICENSEE WILL NOTIFY THE NRC RESIDENT INSPECTOR OF THIS EVENT. | +------------------------------------------------------------------------------+