U.S. Nuclear Regulatory Commission Operations Center Event Reports For 03/14/96 - 03/15/96 ** EVENT NUMBERS ** 30109 30110 30111 30112 30113 +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30109 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: FT CALHOUN REGION: 4 |NOTIFICATION DATE: 03/14/96 | |UNIT: [1] [ ] [ ] STATE: NE |NOTIFICATION TIME: 10:57 [ET]| |RX TYPE: [1] CE |EVENT DATE: 03/14/96 | +------------------------------------------------+EVENT TIME: 08:58[CST]| |NRC NOTIFIED BY: JAMES COOK |LAST UPDATE DATE: 03/14/96 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |WILLIAM JOHNSON RDO | |ASHU 50.72(b)(1)(i)(A) PLANT S/D REQD BY TS |AL CHAFFEE EO | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | TECH SPEC REQUIRED SHUTDOWN | | | | "AT 0843 CST, 480 VAC MOTOR CONTROL CENTER MCC-4A2 WAS REMOVED FROM SERVICE | | FOR MAINTENANCE ACTIVITIES, AND AN EIGHT HOUR LCO WAS ENTERED IN IAW TECH | | SPEC 2.7(2)g. | | | | "AT 0858 CST, I&C WAS INVESTIGATING NOISE ON INSTRUMENT LOOP 340, | | CONTAINMENT SPRAY TEMPERATURE, WHEN A TECHNICIAN ACCIDENTALLY SHORTED AN AC | | LEAD. THIS CAUSED INSTRUMENT BUS AI-40B TO REVERSE TRANSFER TO THE BYPASS | | TRANSFORMER. THIS SUPPLIES THE INSTRUMENT BUS FROM 480 VAC MCC-4B1 INSTEAD | | OF STATIC INVERTER EE-8J AND RENDERS THE INSTRUMENT BUS INOPERABLE SINCE IT | | IS NOT SUPPLIED FROM ITS NORMAL POWER SOURCE. | | | | "THE LOSS OF THE INSTRUMENT BUS WOULD HAVE BEEN AN EIGHT HOUR LCO IAW TECH | | SPEC 2.7(2)H, HOWEVER THE MODIFICATION OF MINIMUM REQUIREMENTS FOR TECH | | SPEC 2.7 ONLY ALLOWS ONE CONDITION TO EXIST AT A TIME. IF MORE THAN ONE | | EXISTS, THE REACTOR MUST BE PLACED IN HOT SHUTDOWN WITHIN THE FOLLOWING 12 | | HOURS. | | | | "IAW EPIP-OSC-1, A TECH SPEC REQUIRED SHUTDOWN MEETS THE CONDITIONS FOR | | DECLARING AN UNUSUAL EVENT, BUT INSTRUMENT BUS AI-40B WAS RETURNED TO ITS | | NORMAL POWER SUPPLY (EE-8J) AT 0905 CST. THIS NOTIFICATION IS BEING MADE | | AS INFORMATION THAT CONDITIONS EXISTED FOR DECLARATION OF AN UNUSUAL EVENT, | | BUT ONE WAS NOT DECLARED SINCE THE CONDITION WAS CORRECTED IN AN EXPEDIENT | | TIME FRAME." | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR AS WELL AS THE STATES OF | | NEBRASKA AND IOWA. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30110 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: WATTS BAR REGION: 2 |NOTIFICATION DATE: 03/14/96 | |UNIT: [1] [2] [ ] STATE: TN |NOTIFICATION TIME: 14:57 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 03/14/96 | +------------------------------------------------+EVENT TIME: 06:30[EST]| |NRC NOTIFIED BY: HAMILTON |LAST UPDATE DATE: 03/14/96 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |PEEBLES RDO | |HFIT 26.73 FITNESS FOR DUTY | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 N 0 UNDER CONSTRUCT | 0 UNDER CONSTRUCT | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | A LICENSEE SUPERVISOR WAS DETERMINED TO BE UNDER THE INFLUENCE OF ALCOHOL | | DURING A FOR-CAUSE TEST. THE EMPLOYEE'S ACCESS TO THE PLANT HAS BEEN | | TERMINATED. SEE HOO LOG FOR DETAILS. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 30111 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: STATE OF NORTH CAROLINA |NOTIFICATION DATE: 03/14/96 | | CITY: REGION: 2 |NOTIFICATION TIME: 18:22 [ET]| | COUNTY: STATE: NC |EVENT DATE: 03/12/96 | |LICENSE#: AGREEMENT: Y |EVENT TIME: 18:30[EST]| | DOCKET: |LAST UPDATE DATE: 03/14/96 | | +-----------------------------+ | |PERSON ORGANIZATION| | |N/A RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: WOODRUFF (NRC REGION 2) | | |HQ OPS OFFICER: BOB STRANSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE STATE OF NORTH CAROLINA NOTIFIED NRC REGION 2 ON 3/14/96 REGARDING A | | MEDICAL MISADMINISTRATION WHICH OCCURRED AT A STATE REGULATED FACILITY. | | | | A PATIENT RECEIVED AN UNPRESCRIBED DOSE OF 90 TO 130 cGy (RAD) TO THE RIGHT | | CHEEK DUE TO THE USE OF AN INCORRECT SIZED CATHETER WITH A BRACHYTHERAPY | | DEVICE. THE PATIENT WAS PRESCRIBED TO RECEIVE A TWO-PART RADIATION THERAPY | | TO THE BRONCHUS OF 1200 cGy (600 cGy PER TREATMENT) USING AN OMNITRON HDR | | BRACHYTHERAPY DEVICE WITH A 170GBq (4.6 Ci) IR-192 SOURCE. THE SOURCE WAS | | TO BE PLACED USING A 150-CM LONG CATHETER, BUT A 100-CM CATHETER WAS USED | | INSTEAD. THE PATIENT'S RIGHT EYE ALSO RECEIVED A DOSE OF 35 TO 45 cGy. | | THE PHYSICIAN NOTIFIED THE PATIENT OF THE MISADMINISTRATION. THE STATE IS | | CONDUCTING AN INVESTIGATION OF THIS EVENT, AND EXPECTS TO HAVE INSPECTORS | | ONSITE TOMORROW MORNING. THE N.C. STATE DIVISION OF RADIATION PROTECTION | | WILL PROVIDE UPDATES TO NRC REGION 2. NRC REGION 2 MANAGEMENT IS AWARE OF | | THIS EVENT, AND IS PREPARING A PRELIMINARY NOTIFICATION. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30112 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: OYSTER CREEK REGION: 1 |NOTIFICATION DATE: 03/14/96 | |UNIT: [1] [ ] [ ] STATE: NJ |NOTIFICATION TIME: 20:05 [ET]| |RX TYPE: [1] GE-2 |EVENT DATE: 03/14/96 | +------------------------------------------------+EVENT TIME: 15:45[EST]| |NRC NOTIFIED BY: CIGANIK |LAST UPDATE DATE: 03/14/96 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BARKLEY RDO | |NLTR LICENSEE 24 HR REPORT | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | LICENSEE DISCOVERED THAT TWO SECONDARY CONTAINMENT ISOLATION VALVES DO NOT | | HAVE SURVEILLANCE TESTING REQUIREMENTS. | | | | WHILE RETURNING TWO SECONDARY CONTAINMENT ISOLATION VALVES TO SERVICE, THE | | LICENSEE DISCOVERED THAT THESE VALVES DO NOT HAVE ANY SURVEILLANCE TEST | | REQUIREMENTS ASSOCIATED WITH THEM. THESE VALVES ARE LOCATED IN THE | | NITROGEN SUPPLY LINE TO THE DRYWELL VENTILATION SYSTEM, AND ARE ONLY OPENED | | WHEN THE DRYWELL IS BEING PURGED PRIOR TO PERSONNEL ENTRY. THE VALVES ARE | | LOCATED IN SERIES WITH TWO PRIMARY CONTAINMENT ISOLATION VALVES. THE | | LICENSEE STATED THAT SEVERAL YEARS AGO, A MODIFICATION WAS PERFORMED TO ADD | | AUTOMATIC CLOSURE OF THE SECONDARY CONTAINMENT ISOLATION VALVES ON THE | | ASSOCIATED CONTAINMENT ISOLATION LOGIC, BUT THAT SURVEILLANCE TESTING | | PROCEDURES FOR THESE VALVES WERE NOT DEVELOPED AT THAT TIME. OYSTER CREEK | | TECHNICAL SPECIFICATION SECTION 4.5.R.2 REQUIRES THAT TESTING BE PERFORMED | | FOR SECONDARY CONTAINMENT ISOLATION VALVES. | | | | THE LICENSEE HAS DISABLED THESE VALVES UNTIL TESTING CAN BE PERFORMED. THE | | NRC RESIDENT INSPECTOR HAS BEEN INFORMED BY THE LICENSEE. | | | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30113 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: QUAD CITIES REGION: 3 |NOTIFICATION DATE: 03/15/96 | |UNIT: [1] [ ] [ ] STATE: IL |NOTIFICATION TIME: 05:56 [ET]| |RX TYPE: [1] GE-3,[2] GE-3 |EVENT DATE: 03/15/96 | +------------------------------------------------+EVENT TIME: 03:40[CST]| |NRC NOTIFIED BY: ED KLUNDT |LAST UPDATE DATE: 03/15/96 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |WAYNE KROPP 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 +------------------------------------------------------------------------------+ | ESF ACTUATION | | | | WHILE HANGING A TAGOUT, THE LICENSEE CAUSED A REACTOR BUILDING VENTILATION | | ISOLATION AND STANDBY GAS TREATMENT START. A UNIT 1 CHANNEL "A" RPS | | BREAKER WAS OPENED AS PART OF THE TAGOUT AND CAUSED THE ESF ACTUATION. THE | | RESPONSE WAS CORRECT FOR THE BREAKER THAT WAS OPENED, BUT WAS NOT EXPECTED. | | THE LICENSEE IS INVESTIGATING A POSSIBLE ERROR IN THE DEVELOPMENT OR | | EXECUTION OF THE TAGOUT. | | | | ALL SYSTEMS WERE RESTORED WITHIN ABOUT 30 MINUTES. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+