U.S. Nuclear Regulatory Commission Operations Center Event Reports For 11/13/96 - 11/14/96 ** EVENT NUMBERS ** 31294 31298 31303 31328 31329 31330 31331 31332 31333 31334 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 31294 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: DRESDEN REGION: 3 |NOTIFICATION DATE: 11/07/96 | |UNIT: [ ] [2] [3] STATE: IL |NOTIFICATION TIME: 18:45 [ET]| |RX TYPE: [1] GE-1,[2] GE-3,[3] GE-3 |EVENT DATE: 11/07/96 | +------------------------------------------------+EVENT TIME: 16:45[CST]| |NRC NOTIFIED BY: BILL CARTER |LAST UPDATE DATE: 11/13/96 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MICHAEL J. JORDAN RDO | |AOUT 50.72(b)(1)(ii)(B) OUTSIDE DESIGN BASIS | | |NLCO TECH SPEC LCO A/S | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | 3 | N N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | UNIT 2 NITROGEN CONTAINMENT AIR DILUTION (NCAD) SYSTEM AND UNIT 3 | | ATMOSPHERE CONTAINMENT AND DILUTION (ACAD) SYSTEM OPERABILITY QUESTIONS | | | | THE ACCEPTANCE CRITERIA OF 29 SCFM INJECTION FLOW RATE INTO PRIMARY | | CONTAINMENT FOR HYDROGEN DILUTION FOLLOWING A LOSS OF COOLANT ACCIDENT | | ASSUMED 7X7 AND 8X8 FUEL. THE LICENSEE IS CURRENTLY USING 9X9 FUEL WHICH | | RAISES A QUESTION AS TO THE VALIDITY OF THE CALCULATIONS TO ARRIVE AT THE | | 29 SCFM VALUE. AS A RESULT, THE LICENSEE HAS DECLARED THE NCAD SYSTEM | | INOPERABLE, AND THE UNIT ENTERED A 7-DAY LIMITING CONDITION FOR OPERATION | | PER TECHNICAL SPECIFICATION 3.7.6 AT 1645 CST. THE LICENSEE BELIEVES THAT | | NO OTHER SYSTEMS HAVE BEEN AFFECTED BY THIS ISSUE. | | | | THE LICENSEE PLANS TO NOTIFY THE NRC RESIDENT INSPECTOR. | | | | *** 2027 EST NOVEMBER 7, 1996, UPDATE FROM CARTER RECEIVED BY TROCINE *** | | | | THE LICENSEE IDENTIFIED THAT THIS OPERABILITY ISSUE ALSO APPLIES TO THE | | UNIT 3 ACAD SYSTEM. UNIT 3 IS NOT CURRENTLY IN ANY TECHNICAL SPECIFICATION | | LIMITING CONDITIONS FOR OPERATION AS A RESULT OF THIS ISSUE BECAUSE IT IS | | IN A COLD SHUTDOWN CONDITION. (ON UNIT 2, THE NCAD SYSTEM REPLACED THE | | ACAD SYSTEM.) | | | | THE LICENSEE PLANS TO NOTIFY THE NRC RESIDENT INSPECTOR. THE NRC | | OPERATIONS CENTER NOTIFIED THE R3DO (JORDAN). | | | | *** 2046 EST NOVEMBER 13, 1996, UPDATE FROM CARTER RECEIVED BY TROCINE *** | | | | THE LICENSEE IS RETRACTING THIS EVENT. ON NOVEMBER 11, 1996, THE LICENSEE | | PERFORMED A NEW CALCULATION TO EVALUATE THE IMPACT OF THE 9X9 FUEL ON THE | | ORIGINAL ANALYSIS. THE USE OF 9X9 FUEL RESULTS IN A NET CHANGE IN THE | | AMOUNT OF HYDROGEN IN CONTAINMENT OF LESS THAN 0.1% WHICH IS WITHIN THE | | ESTIMATED ACCURACY OF THE ORIGINAL CALCULATIONS OF 0.5%. IN ADDITION, THE | | LICENSEE CONCLUDED THAT THE TIME TO REACH 50% OF CONTAINMENT DESIGN | | PRESSURE WAS ALSO UNAFFECTED. THEREFORE, THE LICENSEE BELIEVES THAT THE | | UNIT DID NOT OPERATE OUTSIDE THE DESIGN BASIS AS A RESULT OF USING THE 9X9 | | FUEL. | | | | THE LICENSEE PLANS TO NOTIFY THE NRC RESIDENT INSPECTOR. THE NRC | | OPERATIONS CENTER NOTIFIED THE R3DO (GARDNER.) | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |OTHER NUCLEAR MATERIAL | |EVENT NUMBER: 31298 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: PROFESSIONAL SERVICE INDUSTRIES INC |NOTIFICATION DATE: 11/08/96 | | CITY: BRISTOL REGION: 2 |NOTIFICATION TIME: 11:16 [ET]| | COUNTY: STATE: VA |EVENT DATE: 05/01/96 | |LICENSE#: 45-25088-01 AGREEMENT: N |EVENT TIME: 00:00[EST]| | DOCKET: |LAST UPDATE DATE: 11/13/96 | | +-----------------------------+ | |PERSON ORGANIZATION| | |EDWARD MCALPINE RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: ACKERMANN | | |HQ OPS OFFICER: CHAUNCEY GOULD | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |BAE1 20.2202(b)(1) PERS OVEREXPOSURE | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | POSSIBLE EXPOSURE TO A PROFESSIONAL SERVICE INDUSTRIES, INC. TECHNICIAN'S | | EXTREMITY (POSSIBLY IN EXCESS OF 50 REM) DURING DIRECT HANDLING OF A | | PORTABLE MOISTURE DENSITY GAUGE SOURCE ROD OVER A 6-MONTH TIME PERIOD | | | | WHILE WORKING OUT OF THE LICENSEE'S BRISTOL, VIRGINIA, OFFICE AT LOCATIONS | | IN BOTH VIRGINIA AND TENNESSEE, A TECHNICIAN WAS DIRECTLY HANDLING THE | | SOURCE ROD OF A PORTABLE MOISTURE DENSITY GAUGE OVER A TIME PERIOD FROM MAY | | 1996 TO THE END OF OCTOBER 1996. DIRECT HANDLING OF THE SOURCE ROD | | OCCURRED WHEN THE INDIVIDUAL OPENED THE SHUTTER ON THE BOTTOM OF THE DEVICE | | AND POSITIONED OF THE ROD INTO THE HOLE FOR TESTING. THE MOISTURE DENSITY | | GAUGE WAS A CAMPBELL PACIFIC NUCLEAR DEVICE (MODEL NUMBER MC-1), AND IT | | CONTAINED A 10-MILLICURIE CESIUM-137 SEALED SOURCE. | | | | AT THIS TIME, THE INDIVIDUAL DOES NOT EXHIBIT ANY SIGNIFICANT PHYSICAL | | EFFECTS FROM THE DIRECT HANDLING OF THE SOURCE ROD, AND THE LICENSEE DOES | | NOT HAVE AN ACCURATE ESTIMATE OF THE EXPOSURE RECEIVED BY THE INDIVIDUAL. | | THE INDIVIDUAL WAS WEARING A WHOLE BODY DOSIMETER BUT BELIEVES THAT IT | | WOULD HAVE BEEN SHIELDED BY THE DEVICE. THE INDIVIDUAL WAS NOT WEARING AN | | EXTREMITY MONITORING DEVICE BECAUSE CONTACT WITH THE SOURCE ROD WAS NOT | | EXPECTED. THE LICENSEE BELIEVES THAT THE INDIVIDUAL PRIMARILY USED ONE | | HAND BUT MAY HAVE SWITCHED HANDS OCCASIONALLY. THE LICENSEE ALSO BELIEVES | | THAT THE INDIVIDUAL'S BODY WAS SHIELDED BY THE DEVICE AND ITS INTERNAL | | SHIELDING BASED UPON THE INDIVIDUAL'S DESCRIPTION. AN EXAMINATION AT A | | MEDICAL FACILITY NOTED A COUPLE OF EXTREMELY SUPERFICIAL BLISTERS ON THE | | INDIVIDUAL'S LEFT HAND. | | | | AN NRC REGION 2 INSPECTOR WAS ON SITE YESTERDAY AND WAS AWARE OF THIS | | EVENT. (REFER TO THE HOO LOG FOR LICENSEE CONTACT TELEPHONE NUMBERS.) | | | | * * * 1600 NOVEMBER 13, 1996, UPDATE BY TROCINE * * * | | | | A COMMISSIONERS' ASSISTANTS BRIEFING WAS CONDUCTED AT 1600 ON NOVEMBER 13, | | 1996, IN ORDER TO DISCUSS THE STATUS OF AN AUGMENTED INSPECTION TEAM THAT | | IS CURRENTLY ONSITE. THE BRIEFING NOTIFICATIONS WERE MADE (*INDICATES | | OFFICE DID NOT PARTICIPATE): AEOD (*), IRD (*), JACKSON (BOYLE AND MOORE), | | ROGERS (*), DICUS (LUBANAU), DIAZ (RADDATZ), McGAFFIGAN (SCHLUETER), EDO | | (SHAFFER), NMSS EO (COOL), R2DO (*), PAO (BEECHER), CAO (KEELING), SECY | | (BATES), STATE (BANGART), BRIEFER (HOSEY), AND OTHERS (COLLINS, COMBS, | | DECKER, MALLETT, AND PAPERIELLO). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 31303 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: HOPE CREEK REGION: 1 |NOTIFICATION DATE: 11/08/96 | |UNIT: [1] [ ] [ ] STATE: NJ |NOTIFICATION TIME: 19:38 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 11/08/96 | +------------------------------------------------+EVENT TIME: 17:15[EST]| |NRC NOTIFIED BY: KURT KRUDGER |LAST UPDATE DATE: 11/13/96 | |HQ OPS OFFICER: RUDY KARSCH +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |RICHARD CONTE 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 Y 87 POWER OPERATION | 87 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | A SINGLE CONTROL ROD SCRAM OCCURRED. | | | | THE LICENSEE WAS ENGAGED IN TURBINE VALVE TESTING. DURING THIS TESTING, A | | HALF SCRAM OCCURRED ON THE 'A' REACTOR PROTECTION SYSTEM (RPS) CHANNEL. A | | FUSE FOR ROD #42-07 ON THE 'B' RPS CHANNEL WAS BLOWN COMPLETING THE LOGIC | | FOR A FULL SCRAM. THE ROD INSERTED FULLY AND WAS SUBSEQUENTLY RETURNED TO | | ITS FULL OUT POSITION. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR AND THE LOWER ALLOWAYS | | CREEK TOWNSHIP. | | | | * * * 1331 NOVEMBER 13, 1996, UPDATE FROM PRICE RECEIVED BY TROCINE * * * | | | | THE CAUSE OF THE SINGLE CONTROL ROD SCRAM WAS ORIGINALLY SUSPECTED TO BE A | | BLOWN FUSE FOR CONTROL ROD #42-07 ON THE 'B' CHANNEL OF RPS. FURTHER | | INVESTIGATION HAS REVEALED THAT THE 'B' SCRAM SOLENOID OPERATED VALVE (SOV) | | FOR CONTROL ROD #42-07 STUCK IN THE DE-ENERGIZED OR SCRAMMED POSITION. THE | | SINGLE CONTROL ROD SCRAM OCCURRED DURING THE PERFORMANCE OF HALF SCRAM | | SURVEILLANCES FOR TURBINE VALVE TESTING ON THE 'A' CHANNEL. THE LICENSEE | | WAS GENERATING 'A' CHANNEL HALF SCRAMS FOR SURVEILLANCE TESTING, AND THE | | 'B' PILOT SCRAM (SOV) FOR CONTROL ROD #42-07 WAS ALREADY STUCK IN THE | | DE-ENERGIZED POSITION. THIS CAUSED A FULL SCRAM ON THAT ROD. THE FAULTY | | SCRAM (SOV) WAS REPLACED ON NOVEMBER 9, 1996, AND THE CONTROL ROD WAS | | SUCCESSFULLY SCRAM TIME TESTED ON NOVEMBER 10, 1996. THE UNIT HAS SINCE | | BEEN RETURNED TO 100% REACTOR POWER. | | | | THE LICENSEE NOTIFIED THE NRC RESIDENT INSPECTOR AND THE LOWER ALLOWAYS | | CREEK TOWNSHIP. THE NRC OPERATIONS CENTER NOTIFIED THE R1DO (BARKLEY). | +------------------------------------------------------------------------------+ !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 31328 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SAINT LUCIE REGION: 2 |NOTIFICATION DATE: 11/13/96 | |UNIT: [1] [2] [ ] STATE: FL |NOTIFICATION TIME: 08:21 [ET]| |RX TYPE: [1] CE,[2] CE |EVENT DATE: 11/13/96 | +------------------------------------------------+EVENT TIME: 07:35[EST]| |NRC NOTIFIED BY: CZARNECKI |LAST UPDATE DATE: 11/13/96 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |KENNETH BARR RDO | |DDDD 73.71 UNSPECIFIED PARAGRAPH |AL CHAFFEE, NRR EO | | |RICH BARRETT, IRD AEOD | | |LOREN BUSH, NRR IAT | | |ROBERTA WARREN, NMSS IAT | | |DOUG COLLINS, REG 2 IAT | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | SECURITY EVENT REGARDING POTENTIAL TAMPERING WITH SECURITY EQUIPMENT. | | | | THERE WERE NO ADVERSE CONSEQUENCES TO PLANT. COMPENSATORY MEASURES TAKEN | | WERE UPON DISCOVERY. (REFER TO THE HOO LOG FOR ADDITIONAL INFORMATION.) | | | | NRC RESIDENT INSPECTOR WILL BE INFORMED BY THE LICENSEE. | | | | *** 1356 NOVEMBER 13, 1996, UPDATE FROM CZARNECKI RECEIVED BY TROCINE *** | | | | THE LICENSEE IS RETRACTING THIS NOTIFICATION. FURTHER INVESTIGATION BY THE | | LICENSEE DID NOT CONFIRM ANY DELIBERATE TAMPERING WITH SECURITY SYSTEMS. | | THE LICENSEE DETERMINED THAT THE MOST PROBABLE CAUSE WAS UNINTENTIONAL AND | | NOT DUE TO ANY DELIBERATE ATTEMPT TO DEFEAT OR TAMPER WITH THE SYSTEM. | | (REFER TO THE HOO LOG FOR ADDITIONAL INFORMATION.) | | | | THE LICENSEE NOTIFIED THE NRC RESIDENT INSPECTOR. THE NRC OPERATIONS | | CENTER NOTIFIED THE R2DO (BARR), AEOD IRD (BARRETT), NRR EO (CHAFFEE), NRR | | IAT (McPEEK), NMSS IAT (WARREN), AND REGION 2 IAT (COLLINS). (REFER TO THE | | HOO LOG FOR A SITE CONTACT TELEPHONE NUMBER.) | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |OTHER NUCLEAR MATERIAL | |EVENT NUMBER: 31329 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: FRAMATOM/COGEMA |NOTIFICATION DATE: 11/13/96 | | CITY: LYNCHBURG REGION: 2 |NOTIFICATION TIME: 09:54 [ET]| | COUNTY: CAMPBELL STATE: VA |EVENT DATE: 11/13/96 | |LICENSE#: AGREEMENT: N |EVENT TIME: 00:00[EST]| | DOCKET: |LAST UPDATE DATE: 11/13/96 | | +-----------------------------+ | |PERSON ORGANIZATION| | |KENNETH BARR RDO | | |DON COOL, NMSS EO | +------------------------------------------------+RICH BARRETT, IRD AEOD | |NRC NOTIFIED BY: JOHN ANDERSON |JOE YARDUMIAN, NMSS IAT | |HQ OPS OFFICER: BOB STRANSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |KFIS 70.52(b) LOSS OF SNM/FISSILE | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | LOSS OF AN UN-IRRADIATED FUEL ASSEMBLY | | | | THE LICENSEE REPORTED THE LOSS OF ONE FUEL ASSEMBLY (CONTAINING 1.9 kg OF | | U-235) AT AN ENRICHMENT OF 1.9% BY WEIGHT. THE ASSEMBLY WAS ONE OF 108 | | ASSEMBLIES RECEIVED IN LATE SEPTEMBER FROM GERMANY FOR DISASSEMBLY. THE | | LICENSEE VERIFIED THE SHIPPING MANIFEST AT THE TIME OF RECEIPT BUT BELIEVES | | THAT THE SUBJECT ASSEMBLY WAS NOT REMOVED FROM THE SHIPPING CASK AND THAT | | THE CASK WAS SUBSEQUENTLY RETURNED TO GERMANY FOR THE NEXT SHIPMENT. | | | | THE LICENSEE STATED THAT THE FUEL ASSEMBLIES ARE PACKED INTO INDIVIDUAL | | TUBES WITHIN THE SHIPPING CASK, WHICH HOLDS UP TO SIX ASSEMBLIES. THE | | ASSEMBLIES ARE SURROUNDED BY A PLASTIC SLEEVE WHEN WITHIN THE CASK, AND THE | | LICENSEE STATED THAT THE SLEEVE MAY HAVE OBSCURED THE PRESENCE OF THE FUEL | | ASSEMBLY DURING UNLOADING. THE LICENSEE BECAME AWARE OF THE MISSING | | ASSEMBLY WHEN IT WAS DISCOVERED THAT THERE WAS ONE MORE INVENTORY SHEET | | THAN FUEL ASSEMBLIES. THE LICENSEE IS PERFORMING AN INVENTORY OF ALL BOXES | | OF STORED FUEL PELLETS TO DETERMINE WHETHER THE ASSEMBLY HAD BEEN | | DISASSEMBLED AND THE PELLETS PLACED INTO THE WRONG BOX. THE LICENSEE IS | | ALSO CONTACTING THE SHIPPER IN ORDER TO TRACK DOWN THE SHIPPING CONTAINER | | AND DETERMINE WHETHER THE FUEL ASSEMBLY IS STILL INSIDE. | | | | *** 1556 NOVEMBER 13, 1996, UPDATE FROM ANDERSON RECEIVED BY TROCINE *** | | | | THE LICENSEE HAS NOT HEARD ANYTHING FROM GERMANY YET AND DOES NOT EXPECT TO | | HEAR ANYTHING UNTIL TOMORROW MORNING BECAUSE OF THE TIME DIFFERENCE. THE | | LICENSEE BELIEVES THAT THE CURRENT TIME IN GERMANY IS APPROXIMATELY 2200. | | THE NRC OPERATIONS CENTER NOTIFIED THE R2DO (BARR), AEOD IRD (BARRETT), | | NMSS EO (BELL), AND NMSS IAT (YARDUMIAN). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 31330 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: BAYONNE HOSPITAL |NOTIFICATION DATE: 11/13/96 | | CITY: BAYONNE REGION: 1 |NOTIFICATION TIME: 13:58 [ET]| | COUNTY: HUDSON STATE: NJ |EVENT DATE: 11/12/96 | |LICENSE#: 29-12253-01 AGREEMENT: N |EVENT TIME: 16:00[EST]| | DOCKET: |LAST UPDATE DATE: 11/13/96 | | +-----------------------------+ | |PERSON ORGANIZATION| | |RICHARD BARKLEY RDO | | |MIKE BELL, NMSS EO | +------------------------------------------------+RICH BARRETT, IRD AEOD | |NRC NOTIFIED BY: STEVEN MAHOOD | | |HQ OPS OFFICER: LEIGH TROCINE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AN INCORRECT DWELL TIME DURING THE PERFORMANCE OF A BRACHYTHERAPY TREATMENT | | RESULTED IN A 32% OVERDOSE AT BAYONNE HOSPITAL IN BAYONNE, NEW JERSEY. | | | | AN OVERDOSE OCCURRED DURING THE TREATMENT OF A PATIENT WITH A REMOTE, | | HIGH-DOSE-RATE, REMOTE-AFTER-LOADING, BRACHYTHERAPY DEVICE WITH A 5-CURIE | | IRIDIUM-192 SOURCE. (THE SOURCE HAS A DOSE RATE OF FIVE CENTIGRAYS PER | | HOUR AT A DISTANCE OF ONE CENTIMETER PER MILLICURIE.) APPARENTLY, THE | | INCORRECT DWELL TIME WAS ENTERED INTO THE TREATMENT UNIT. DURING THE | | TREATMENT, THE LICENSEE UTILIZED TWO CAMERAS: ONE TO MONITOR THE PATIENT | | AND ONE TO MONITOR THE TREATMENT UNIT'S STEPPING MOTOR DEVICE. THE | | INDIVIDUAL WHO WAS MONITORING THE CAMERAS NOTICED THAT THE STEPPING MOTOR | | DEVICE WAS STAYING IN POSITION FOR A LONG TIME AND MENTIONED THIS TO | | ANOTHER INDIVIDUAL. THE SECOND INDIVIDUAL CHECKED THE LIQUID CRYSTAL | | DISPLAY OF THE TREATMENT UNIT AND NOTICED THAT THE WRONG DWELL TIME HAD | | BEEN ENTERED INTO THE UNIT. THE TREATMENT WAS IMMEDIATELY ABORTED (PRIOR | | TO EXPIRATION OF THE INCORRECT DWELL TIME). THE PRESCRIBED DWELL TIME WAS | | 12.8 SECONDS, THE DWELL TIME ENTERED INTO THE BRACHYTHERAPY UNIT WAS 208 | | SECONDS, AND THE TREATMENT WAS TERMINATED WITHIN 69.1 SECONDS. | | | | THE LICENSEE DETERMINED THAT THE PATIENT RECEIVED A 32% OVERDOSE BASED UPON | | THE ISODOSE DISTRIBUTION AND A SERIES OF DOSE POINTS AROUND THE APPLICATOR. | | THE LICENSEE WAS ORIGINALLY PLANNING TO TREAT TWO ADDITIONAL POSITIONS | | AFTER THIS TREATMENT. THE LICENSEE DOES NOT BELIEVE THAT THERE WILL BE ANY | | ADVERSE AFFECTS TO THE PATIENT AS A RESULT OF THIS EVENT. THE PATIENT HAS | | BEEN INFORMED. IN ORDER TO PREVENT RECURRENCE, THE LICENSEE IS CURRENTLY | | PLANNING TO ADD AN INDEPENDENT VERIFICATION FOR THE DATA. THE LICENSEE | | NOTIFIED NRC REGION 1 (DWYER). (REFER TO THE HOO LOG FOR THE LICENSEE'S | | STREET ADDRESS AND TELEPHONE NUMBER.) | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 31331 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MILLSTONE REGION: 1 |NOTIFICATION DATE: 11/13/96 | |UNIT: [1] [ ] [ ] STATE: CT |NOTIFICATION TIME: 14:58 [ET]| |RX TYPE: [1] GE-3,[2] CE,[3] W-4-LP |EVENT DATE: 11/13/96 | +------------------------------------------------+EVENT TIME: 14:00[EST]| |NRC NOTIFIED BY: LOUIS DILUNA |LAST UPDATE DATE: 11/13/96 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |RICHARD BARKLEY 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 | 0 REFUELING | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | DISCOVERY THAT TWO ISOLATION CONDENSER LINES ARE NOT SEISMICALLY QUALIFIED | | | | DURING AN ENGINEERING REVIEW OF THE PIPING CONNECTED TO THE ISOLATION | | CONDENSER, THE LICENSEE DISCOVERED THAT TWO LINES WERE INADEQUATELY | | SUPPORTED AND WERE, THEREFORE, NOT SEISMICALLY QUALIFIED. THE LINES IN | | QUESTION INCLUDED A THREE-INCH DIAMETER ISOLATION CONDENSER FILL LINE AND A | | ONE-INCH DIAMETER ISOLATION CONDENSER SHELL SIDE LEVEL CONTROL LINE. THE | | LICENSEE BELIEVES THAT INVENTORY WOULD BE LOST FROM THE SHELL SIDE OF THE | | ISOLATION CONDENSER IF THESE LINES WERE TO RUPTURE DURING A SEISMIC EVENT. | | THE LICENSEE BELIEVES THAT THESE LINES DO NOT MEET THE OPERABILITY CRITERIA | | IN GENERIC LETTER 91-18. THE UNIT IS NOT CURRENTLY IN ANY TECHNICAL | | SPECIFICATION LIMITING CONDITIONS FOR OPERATION BECAUSE THE SYSTEM IS OUT | | OF SERVICE WHILE THE UNIT'S CURRENT MODE OF OPERATION. (THE UNIT IS | | DEFUELED AT THIS TIME.) | | | | THE LICENSEE NOTIFIED THE NRC RESIDENT INSPECTOR AND THE APPLICABLE STATE | | AND LOCAL AGENCIES. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 31332 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: COMANCHE PEAK REGION: 4 |NOTIFICATION DATE: 11/13/96 | |UNIT: [1] [2] [ ] STATE: TX |NOTIFICATION TIME: 15:20 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 11/13/96 | +------------------------------------------------+EVENT TIME: 12:20[CST]| |NRC NOTIFIED BY: TOM BEAUDIN |LAST UPDATE DATE: 11/13/96 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |LAWRENCE YANDELL 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 HOT STANDBY | 0 HOT STANDBY | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | OFFSITE NOTIFICATION OF A CHEMICAL SPILL AT THE SERVICE WATER INTAKE | | STRUCTURE | | | | THE LICENSEE NOTIFIED THE TEXAS NATIONAL RESOURCE CONSERVATION COMMISSION, | | THE ENVIRONMENTAL PROTECTION AGENCY NATIONAL RESPONSE CENTER, AND THE LOCAL | | EMERGENCY RESPONSE CENTER (THE LOCAL SHERIFF'S DEPARTMENT) ABOUT A CHEMICAL | | SPILL AT THE SERVICE WATER INTAKE STRUCTURE. THE LICENSEE REPORTED THAT | | THE SPILL INVOLVED APPROXIMATELY 100 GALLONS HEDP DILUTED WITH WATER. (HEDP | | IS AN ORGANIC PHOSPHATE ACID WITH A POLYMER WHICH IS USED AS A SERVICE | | WATER CORROSION INHIBITOR.) THE LICENSEE SUSPECTS THAT THE FAILURE OF A | | RELIEF VALVE ON THE SERVICE WATER INJECTION INHIBIT EQUIPMENT ALLOWED THE | | DILUTED CHEMICAL IN THE SERVICE WATER TO FLOOD A BERMED AREA. THE FLUID | | THEN OVERFLOWED ONTO THE CONCRETE FLOOR, WENT DOWN THE BUILDING STORM | | DRAINS, AND FLOWED OUTSIDE THE BUILDING ONTO THE GROUND. THE SPILL HAS | | BEEN SECURED. | | | | THE LICENSEE PLANS TO NOTIFY THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |OTHER NUCLEAR MATERIAL | |EVENT NUMBER: 31333 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: BAXTER HEALTH CARE |NOTIFICATION DATE: 11/13/96 | | CITY: AIBONITA REGION: 2 |NOTIFICATION TIME: 16:43 [ET]| | COUNTY: STATE: PR |EVENT DATE: 11/13/96 | |LICENSE#: 52-21175-01 AGREEMENT: N |EVENT TIME: 17:00[AT ]| | DOCKET: |LAST UPDATE DATE: 11/13/96 | | +-----------------------------+ | |PERSON ORGANIZATION| | |KENNETH BARR RDO | | |MIKE BELL, NMSS EO | +------------------------------------------------+RICH BARRETT, IRD AEOD | |NRC NOTIFIED BY: JUAN RIVERA | | |HQ OPS OFFICER: LEIGH TROCINE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |MAAE 36.83(a)(5) INOP ACCESS CTRL SYS | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | INOPERABLE SAFETY DEVICE (FLOOR MAT) AT AN IRRADIATOR FACILITY (BAXTER | | HEALTH CARE) IN AIBONITA, PUERTO RICO. | | | | THE STERILIZATION FACILITY UTILIZES 3.9 MILLION CURIES OF COBALT-60 IN AN | | UNDERWATER (CATEGORY III) RACK-TYPE IRRADIATOR. IN ORDER TO PREVENT ANY | | UNAUTHORIZED ENTRANCE TO THE IRRADIATION FACILITY, THE LICENSEE UTILIZES | | FLOOR MATS COMPOSED OF A COUPLE OF CELLS. THE FUNCTION OF THIS FLOOR MAT | | IS TO DETECT ATTEMPTED ENTRY AND TO PROTECT THE INDIVIDUAL ATTEMPTING | | ENTRY. WHEN AN INDIVIDUAL STEPS ON THE MAT, ALARMS ARE ANNUNCIATED, AND | | THE SOURCE IS LOWERED TO PROTECT THE INDIVIDUAL. THERE IS ALSO A BACKUP | | ACCESS CONTROL SYSTEM. | | | | IN THIS CASE, ONE OF THE FLOOR MAT CELLS WAS DAMAGED WHEN ONE OF THE | | CARRIERS HIT IT. THE CELL HAS BEEN FIXED, AND BOTH ACCESS CONTROL SYSTEMS | | ARE CURRENTLY IN OPERATION. THERE WAS NO PROBLEM WITH THE SOURCE, SOURCE | | RACKS, CARRIER, OR POOL. | | | | THE LICENSEE NOTIFIED NORDION INTERNATIONAL IN CANADA OF THIS PROBLEM WITH | | A SAFETY DEVICE AND PLANS TO CALL THE NRC REGION 2 OFFICE TOMORROW. (REFER | | TO THE HOO LOG FOR A SITE CONTACT NAME AND TELEPHONE NUMBER.) | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 31334 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: OYSTER CREEK REGION: 1 |NOTIFICATION DATE: 11/13/96 | |UNIT: [1] [ ] [ ] STATE: NJ |NOTIFICATION TIME: 21:30 [ET]| |RX TYPE: [1] GE-2 |EVENT DATE: 11/13/96 | +------------------------------------------------+EVENT TIME: 14:45[EST]| |NRC NOTIFIED BY: FRANK SIGANIK |LAST UPDATE DATE: 11/13/96 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |RICHARD BARKLEY RDO | |NLTR LICENSEE 24 HR REPORT | | |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 +------------------------------------------------------------------------------+ | DISCOVERY THAT FOUR SUPPORT BOLTS WERE MISSING FROM THE SEISMIC RESTRAINT | | OF A MOTOR CONTROL CENTER (MCC) | | | | THE LICENSEE DISCOVERED THAT FOUR SUPPORT BOLTS WERE MISSING FROM THE | | SEISMIC RESTRAINT OF MCC-DC2, AND ENGINEERING PERSONNEL DETERMINED THAT | | SUPPORT WAS INADEQUATE. AS A RESULT, THE LICENSEE DECLARED MCC-DC2 TO BE | | INOPERABLE AT 1445. FURTHER INVESTIGATION REVEALED THAT THE BOLTS HAD BEEN | | REMOVED DURING THE LAST REFUELING OUTAGE (16R). THIS REQUIRED THE UNIT TO | | BE PLACED IN A COLD SHUTDOWN CONDITION WITHIN 30 HOURS PER TECHNICAL | | SPECIFICATION 3.7, AUXILIARY ELECTRICAL POWER. THE LICENSEE ALSO DECLARED | | THE 'B' ISOLATION CONDENSER TO BE INOPERABLE BECAUSE IT UTILIZES TWO DC | | VALVES WHICH ARE POWERED FROM MCC-DC2. | | | | THE LICENSEE REPLACED THE FOUR MISSING BOLTS AND RETURNED BOTH MCC-DC2 AND | | 'B' TO SERVICE AT 1825. THE LICENSEE PLANS TO ISSUE A LICENSEE EVENT | | REPORT WITHIN 30 DAYS. | | | | THE LICENSEE PLANS TO NOTIFY THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+