U.S. Nuclear Regulatory Commission Operations Center Event Reports For 12/18/96 - 12/19/96 ** EVENT NUMBERS ** 31365 31463 31464 31471 31472 31473 31474 31475 31476 31477 31478 31479 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 31365 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: RIVER BEND REGION: 4 |NOTIFICATION DATE: 11/21/96 | |UNIT: [1] [ ] [ ] STATE: LA |NOTIFICATION TIME: 11:59 [ET]| |RX TYPE: [1] GE-6 |EVENT DATE: 11/21/96 | +------------------------------------------------+EVENT TIME: 08:00[CST]| |NRC NOTIFIED BY: VERNON CARLSON |LAST UPDATE DATE: 12/18/96 | |HQ OPS OFFICER: STEVE SANDIN +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |WILLIAM JOHNSON RDO | |AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | GE NUCLEAR ENERGY NOTIFIED THE LICENSEE OF AN ERROR IN A COMPUTER CODE USED | | TO CALCULATE THE PEAK CLAD TEMPERATURE. | | | | "ON NOVEMBER 21, 1996 GE INFORMED RIVER BEND STATION (RBS) OF AN INPUT | | ERROR IN THE GEGAP CODE. THE GEGAP CODE IS USED TO CALCULATE FUEL PELLET | | TO FUEL CLADDING HEAT TRANSFER THAT IS INPUT TO SAFE/REFLOOD CODE THAT | | CALCULATES THE PEAK CLAD TEMPERATURE (PCT) FOR RBS TO DETERMINE CONFORMANCE | | WITH EMERGENCY CORE COOLING SYSTEM (ECCS) PERFORMANCE CRITERIA IN | | 10CFR50.46. GE HAS DETERMINED THAT THIS INPUT ERROR WILL INCREASE THE PCT | | BY APPROXIMATELY 15øF. THE CURRENT LICENSING BASIS PCT FOR RBS IS 2189øF. | | THEREFORE THIS INPUT ERROR WOULD LIKELY CAUSE THE PCT FOR RBS TO BE OVER | | 2200øF WHICH IS THE ACCEPTANCE CRITERIA IN 10CFR50.46. THE IMMEDIATE | | ACTION TAKEN WAS VERIFICATION THAT CURRENT MAPRAT VALUE IS BELOW 0.97. THIS | | CONDITION IS BEING REPORTED AS A CONDITION THAT ALONE COULD HAVE PREVENTED | | THE MAPLHGR SAFETY FUNCTION OF MAINTAINING THE FUEL PCT BELOW 2200øF. | | THEREFORE, THIS CONDITION IS REPORTABLE UNDER 10 CFR 50.72 (b)(2)(iii)(D)." | | | | "THIS ERROR APPLIES TO PLANTS THAT CURRENTLY USE SAFE/REFLOOD ECCS | | METHODOLOGY AND HAVE GE11 FUEL. THE ERROR AFFECTS THE CALCULATION OF FUEL | | PELLET DENSIFICATION AS A FUNCTION OF EXPOSURE. FUEL PELLET DENSIFICATION | | AFFECTS THE HEAT TRANSFER BETWEEN THE FUEL AND THE CLADDING. HEAT TRANSFER | | BETWEEN THE FUEL AND CLADDING IS AN IMPORTANT PARAMETER IN CALCULATING PCT. | | THIS AFFECT ON PCT CAN BE OFFSET BY ADMINISTRATIVELY CONTROLLING MAPLHGR | | LIMITS. THIS IS ACCOMPLISHED BY APPLYING A PENALTY ON MAPRAT. GE HAS | | STATED THAT A 1% PENALTY IN MAPRAT WILL CAUSE THE CALCULATED PCT TO REDUCE | | BY ABOUT 15øF AND RECOMMENDS THAT RBS APPLY A 3% ADMINISTRATIVE PENALTY. | | THIS WILL ENSURE AMPLE MARGIN (~45øF) TO THE 2200øF LIMIT TO ACCOUNT FOR | | THE 15øF INCREASE." | | | | "GE DID NOT GIVE DETAILS OF THE NATURE OF THE ERROR OR ITS POTENTIAL CAUSE. | | THE IMMEDIATE ACTION TAKEN WAS VERIFICATION WITH REACTOR ENGINEERING THAT | | CURRENT MAPRAT VALUE IS BELOW 0.97, CURRENTLY LESS THAN 0.90." | | | | "RBS INTENDS TO ADMINISTRATIVELY CONTROL MAPRAT TO 0.97 (3% PENALTY | | RESULTING IN ABOUT 45øF) TO PROTECT PCT UNTIL FURTHER LONG TERM ACTIONS ARE | | TAKEN." | | | | THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | | | | * * * UPDATE AT 1606 ON 12/18/96 BY JULIUS CLARK ENTERED BY JOLLIFFE * * * | | | | AFTER AN ADDITIONAL REVIEW OF THE ABOVE ISSUE, GENERAL ELECTRIC HAS | | DETERMINED THAT THE EFFECT OF THE INPUT ERROR IN THE GEGAP CODE WAS OFFSET | | BY INPUT CONSERVATISMS IN THE ECCS LOCA ANALYSIS AND THAT A REDUCTION IN | | MARGIN IN THE MAPLHGR LIMITS DETERMINED THAT THE ACTUAL PCT TEMPERATURE | | FOR RIVER BEND REMAINS BELOW THE CURRENT LICENSING BASIS. | | | | BASED ON THIS ADDITIONAL INFORMATION RECEIVED FROM GE, THE ABOVE | | CONDITION HAS NOW BEEN DETERMINED TO NOT BE A CONDITION THAT ALONE | | COULD HAVE PREVENTED THE MAPLHGR SAFETY FUNCTION FROM MAINTAINING THE | | FUEL PCT BELOW 2200øF. THEREFORE, THIS CONDITION IS NOT REPORTABLE | | UNDER 10CFR50.72(b)(2)(iii)(D). | | | | THUS, THE LICENSEE DESIRES TO RETRACT THIS EVENT. | | | | THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | | | | THE HOO NOTIFIED THE R4DO (LINDA HOWELL). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 31463 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SAINT LUCIE REGION: 2 |NOTIFICATION DATE: 12/17/96 | |UNIT: [1] [2] [ ] STATE: FL |NOTIFICATION TIME: 12:12 [ET]| |RX TYPE: [1] CE,[2] CE |EVENT DATE: 12/17/96 | +------------------------------------------------+EVENT TIME: 10:30[EST]| |NRC NOTIFIED BY: DAVE WILLIAMS |LAST UPDATE DATE: 12/19/96 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |KEN BARR RDO | |APRE 50.72(b)(2)(vi) OFFSITE NOTIFICATION | | | |BILL BEECHER PAO | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | - RETIRED FPL EMPLOYEE VISITING THE PLANT SITE DIED OF A HEART ATTACK - | | | | A RETIRED FLORIDA POWER & LIGHT COMPANY EMPLOYEE VISITING THE PLANT SITE | | COLLAPSED FROM AN APPARENT HEART ATTACK. ONSITE MEDICAL PERSONNEL | | RESPONDED, PERFORMED CPR, AND REQUESTED OFFSITE ASSISTANCE. | | | | THE INDIVIDUAL WAS TRANSPORTED OFFSITE TO A LOCAL HOSPITAL FOR MEDICAL | | TREATMENT AND WAS LATER PRONOUNCED DEAD AT THE HOSPITAL. | | | | THE LICENSEE MAY ISSUE A PRESS RELEASE. | | | | THE LICENSEE NOTIFIED LOCAL OFFICIALS AND THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 31464 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: INDIAN POINT REGION: 1 |NOTIFICATION DATE: 12/17/96 | |UNIT: [ ] [3] [ ] STATE: NY |NOTIFICATION TIME: 16:16 [ET]| |RX TYPE: [2] W-4-LP,[3] W-4-LP |EVENT DATE: 12/17/96 | +------------------------------------------------+EVENT TIME: 14:00[EST]| |NRC NOTIFIED BY: TOM McKEE |LAST UPDATE DATE: 12/19/96 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MOHAMED SHANBAKY RDO | |APRE 50.72(b)(2)(vi) OFFSITE NOTIFICATION | | |NOCM COMM ASST BRIEF | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 3 | N Y 97 POWER OPERATION | 97 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - NONCONTAMINATED INJURED PLANT EMPLOYEE TRANSPORTED TO OFFSITE HOSPITAL - | | | | AT 1400, THE LICENSEE DISCOVERED A PLANT EMPLOYEE UNCONSCIOUS IN A SECURED | | (FENCED-IN) HIGH VOLTAGE AREA. THE INDIVIDUAL HAD ENTERED THE FENCED-IN | | AREA TO PERFORM A TRANSFORMER OIL TEST. THE LICENSEE ADMINISTERED FIRST | | AID ONSITE AND DURING TRANSPORT OF THE INJURED INDIVIDUAL TO AN OFFSITE | | HOSPITAL. THE INDIVIDUAL IS NOT CONTAMINATED AND HIS STATUS WAS UNKNOWN | | AT THE TIME OF THE CALL. THE LICENSEE IS INVESTIGATING THIS SITUATION. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | | | | *** UPDATE AT 1754 ON 12/17/96, BY DAVE MOHR ENTERED BY DICK JOLLIFFE *** | | | | THE INDIVIDUAL WAS PRONOUNCED DEAD AT THE HOSPITAL AT 1715. | | | | THE LICENSEE NOTIFIED THE NEW YORK STATE DEPARTMENT OF LABOR AND THE NRC | | RESIDENT INSPECTOR AND ISSUED A PRESS RELEASE. THE HOO NOTIFIED R1DO | | (SHANBAKY). | | | | * * * AT 1900 ON 12/17/96, COMMISSIONERS ASSISTANTS BRIEFING HELD * * * | | | | PARTICIPANTS INCLUDED AEOD (JORDAN); NRR EO (CHAFFEE, MATHEWS); NMSS EO | | (COOL); STATE PROGRAMS (BANGART); CONGRESSIONAL AFFAIRS (MADDEN); EDO | | (DROUIN); COMM McGAFFIGAN (BEALL); COMM ROGERS (SORENSEN); COMM DICUS | | (LUBENAU); REGION 1 (COWGILL, BARKLEY, CRLENJAK). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |GENERAL INFORMATION or OTHER | |EVENT NUMBER: 31471 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: C&D CHARTER POWER SYSTEMS |NOTIFICATION DATE: 12/18/96 | | CITY: CONSHOHOCKEN REGION: 1 |NOTIFICATION TIME: 07:50 [ET]| | COUNTY: STATE: PA |EVENT DATE: 12/18/96 | |LICENSE#: AGREEMENT: N |EVENT TIME: 00:00[EST]| | DOCKET: |LAST UPDATE DATE: 12/18/96 | | +-----------------------------+ | |PERSON ORGANIZATION| | | | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: DR. L.S. HOLDEN (VIA FAX) | | |HQ OPS OFFICER: STEVE SANDIN | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |CCCC 21.21 UNSPECIFIED PARAGRAPH | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | C&D POWER SYSTEMS, INC. LOCATED AT WASHINGTON AND CHERRY STREETS IN | | CONSHOHOCKEN, PA. FAXED A PART 21 NOTIFICATION INVOLVING THE RESULTS OF AN | | ANALYSIS PERFORMED ON A CHARGER RETURNED BY PSE&G. THE ANALYSIS CONCLUDED | | THAT THE WELDS ON THE WELD NUT HOLDING THE FILTER ASSEMBLY PANEL WERE NOT | | TO SPECIFICATION AND COULD RESULT IN FAILURE UNDER SEISMIC STRESS. SIMILAR | | CHARGERS IDENTIFIED BY SERIAL NUMBER WERE DELIVERED TO PSE&G AND NORTHERN | | STATES POWER. C&D POWER SYSTEMS PLANS TO INFORM THE ABOVE CUSTOMERS OF THE | | DEFECTIVE WELD NUT AND TO PROVIDE A REPAIR PROCEDURE IF DEFECTS ARE | | IDENTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |TRANSPORTATION EVENT | |EVENT NUMBER: 31472 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: CIS-US, INC, BEDFORD, MA |NOTIFICATION DATE: 12/18/96 | | CITY: BEDFORD REGION: 1 |NOTIFICATION TIME: 12:26 [ET]| | COUNTY: STATE: MA |EVENT DATE: 12/17/96 | |LICENSE#: 20-20973-01 AGREEMENT: N |EVENT TIME: 21:00[EST]| | DOCKET: 03022172 |LAST UPDATE DATE: 12/18/96 | | +-----------------------------+ | |PERSON ORGANIZATION| | |HEHL & KINNEMAN, R1 RDO | | |DON COOL, NMSS EO | +------------------------------------------------+CONGEL & BARRETT AEOD | |NRC NOTIFIED BY: MARK THORKILDSEN |KATHRYN EBNER DOT | |HQ OPS OFFICER: DICK JOLLIFFE |KEVIN MOORE DOE | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NTRA TRANSPORTATION EVENT | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - PACKAGE CONTAINING IODINE-131 FELL FROM FEDEX TRUCK NEAR BEDFORD, MA - | | | | AT ABOUT 2100 ON 12/17/96, A SHIPPING PACKAGE CONTAINING APPROXIMATELY | | 2.5 MILLICURIES OF IODINE-131 FELL FROM A FEDERAL EXPRESS TRUCK NEAR THE | | INTERSECTION OF ROUTES 4, 225, AND 128 NEAR BEDFORD, MA. | | | | THE REAR DOORS OF THE TRUCK APPARENTLY HAD NOT BEEN CLOSED TIGHTLY AND CAME | | OPEN DURING TRANSPORT. THE PACKAGE WAS RETRIEVED BY A MOTORIST WHO TOOK | | THE PACKAGE TO HIS HOME IN NEW HAMPSHIRE. THE MOTORIST NOTIFIED CIS-US, | | THE SHIPPER, WHO RETRIEVED THE PACKAGE ON 12/18/96. THE PACKAGE WAS NOT | | DAMAGED, AND THERE WAS NO CONTAMINATION. | | | | THE COMMONWEALTH OF MASSACHUSETTS AND THE STATE OF NEW HAMPSHIRE OFFICIALS | | HAVE BEEN CONTACTED BY NRC REGION 1 AND ARE ASSISTING IN THE EVALUATION OF | | THIS EVENT. | | | | REGION 1 ISSUED PRELIMINARY NOTIFICATION #PN1-96-092 ON THIS EVENT. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 31473 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: COOPER REGION: 4 |NOTIFICATION DATE: 12/18/96 | |UNIT: [1] [ ] [ ] STATE: NE |NOTIFICATION TIME: 13:39 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 12/18/96 | +------------------------------------------------+EVENT TIME: 11:40[CST]| |NRC NOTIFIED BY: FRED SCHIZAS |LAST UPDATE DATE: 12/18/96 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |LINDA HOWELL 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 SYSTEM INOPERABLE DUE TO INOPERABLE HPCI FLOW INDICATING CONTROLLER- | | | | DURING A TECH SPEC SURVEILLANCE TEST OF THE HPCI SYSTEM, THE HPCI SYSTEM | | DID NOT MEET THE TEST ACCEPTANCE FLOW RATE OF 3700 TO 3800 GPM. THE TEST | | FLOW RATE ACHIEVED DURING THE TEST WAS 3650 TO 3850 GPM. AT 1140 (CST), | | THE LICENSEE DECLARED THE HPCI SYSTEM INOPERABLE DUE TO AN INOPERABLE | | HPCI FLOW INDICATING CONTROLLER #HPCI-FIC-108. THE LICENSEE IS | | REPAIRING/REPLACING THE CONTROLLER. | | | | TECH SPEC LCO A/S 4.5.C.2 REQUIRES THE LICENSEE TO VERIFY THE OTHER | | EMERGENCY CORE COOLING SYSTEMS ARE OPERABLE AND TO RESTORE THE HPCI SYSTEM | | TO OPERABLE STATUS WITHIN 7 DAYS OR PLACE THE PLANT IN AT LEAST A COLD | | SHUTDOWN CONDITION WITHIN THE NEXT 24 HOURS. THE LICENSEE VERIFIED THAT | | THE RCIC SYSTEM, | | BOTH LPCI SUBSYSTEMS, AND BOTH CORE SPRAY SUBSYSTEMS WERE OPERABLE AND | | IS VERIFYING THAT THE ADS LOGIC IS OPERABLE. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 31474 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BROWNS FERRY REGION: 2 |NOTIFICATION DATE: 12/18/96 | |UNIT: [ ] [2] [3] STATE: AL |NOTIFICATION TIME: 14:19 [ET]| |RX TYPE: [1] GE-4,[2] GE-4,[3] GE-4 |EVENT DATE: 12/18/96 | +------------------------------------------------+EVENT TIME: 01:00[CST]| |NRC NOTIFIED BY: BYRAN BOOHER |LAST UPDATE DATE: 12/18/96 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |CHUCK CASTO 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | 3 | N Y 99 POWER OPERATION | 99 POWER OPERATION | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | TECHNICAL SPECIFICATION LIMITING CONDITION FOR OPERATION ENTRY DUE TO | | INOPERABLE BATTERY CHARGERS | | | | AFTER COMPLETING A SCHEDULED BATTERY DISCHARGE SURVEILLANCE ON 250-VOLT | | MAIN BANK BATTERY #2, THE NORMAL AND SPARE BATTERY CHARGERS WERE FOUND TO | | BE INOPERABLE. WHEN THE NORMAL CHARGER WAS PLACED IN SERVICE, IT FAILED TO | | BUILD VOLTAGE. THE SPARE CHARGER WAS THEN PLACED IN SERVICE, AND IT FAILED | | AFTER APPROXIMATELY 3 HOURS (MOTOR AMPS WERE FLUCTUATING). THE NORMAL | | CHARGER WAS OPERATING PROPERLY PRIOR TO REMOVING IT FROM SERVICE FOR THE | | BATTERY DISCHARGE TEST. | | | | BOTH UNIT 2 AND UNIT 3 REMAIN IN 7-DAY LIMITING CONDITIONS FOR OPERATION | | WHICH WERE ENTERED FOR THE BATTERY DISCHARGE TEST. TROUBLESHOOTING AND | | PARTS PROCUREMENT CONTINUE FOR BOTH CHARGERS AT THIS TIME. DC | | MOTOR-OPERATED VALVE TESTING HAS BEEN SUSPENDED UNTIL THE BATTERY IS | | RETURNED TO SERVICE, AND HPCI DISCHARGE VALVE 2-FCV-73-44 HAS BEEN OPENED | | TO LIMIT LOADING ON MAIN BANK BATTERY #3 IN THE EVENT OF A LOSS OF COOLANT | | ACCIDENT. | | | | THIS EVENT NOTIFICATION IS A 24-HOUR REPORT IN ACCORDANCE WITH TECHNICAL | | SPECIFICATION 3.9.B.7. | | | | THE LICENSEE PLANS TO NOTIFY THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 31475 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: FITZPATRICK REGION: 1 |NOTIFICATION DATE: 12/18/96 | |UNIT: [1] [ ] [ ] STATE: NY |NOTIFICATION TIME: 14:36 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 12/18/96 | +------------------------------------------------+EVENT TIME: 12:00[EST]| |NRC NOTIFIED BY: STEVE CAROLIN |LAST UPDATE DATE: 12/18/96 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MOHAMED SHANBAKY RDO | |AINC 50.72(b)(2)(iii)(C) POT UNCNTRL RAD REL | | |AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 HOT SHUTDOWN | 0 HOT SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | DESIGN ERROR IN OFFGAS SYSTEM COULD HAVE AFFECTED CONSEQUENCES OF | | POSTULATED FUEL DAMAGE ACCIDENTS | | | | THE FOLLOWING IS TEXT OF A FACSIMILE SUBMITTED BY THE LICENSEE: | | "ON DECEMBER 13, 1996, A QUESTION WAS RAISED ABOUT AN APPARENT DESIGN ERROR | | IN THE OFFGAS SYSTEM THAT HAS EXISTED SINCE PLANT CONSTRUCTION. OFFGAS FLOW | | CAN BYPASS THE 30 MINUTE HOLDUP LINE AND OFFGAS HEPA FILTERS VIA DRAIN | | CONNECTIONS COMMON TO BOTH OFFGAS AND THE TURBINE GENERATOR STEAM PACKING | | EXHAUSTER DISCHARGE LINE TO THE PLANT STACK IF OFFGAS ISOLATION VALVE | | 01-107AOV-100 IS CLOSED. BASED UPON FURTHER REVIEW ON DECEMBER 18, IT HAS | | BEEN DETERMINED THAT THE APPARENT DESIGN ERROR IS REPORTABLE. | | | | AS A RESULT, ACCIDENTS SUCH AS CONTROL ROD DROP, WHICH CAN CAUSE FUEL | | DAMAGE AND WHICH ARE, IN PART, INTENDED TO BE MITIGATED BY ISOLATION OF THE | | OFFGAS 30 MINUTE HOLDUP LINE, COULD CAUSE RADIOACTIVITY TO BE RELEASED TO | | THE ENVIRONMENT FROM THE ELEVATED PLANT STACK RELEASE POINT (WHICH IS ALSO | | MONITORED FOR RADIATION) DUE TO THE PATH WHICH COULD BYPASS THE 30 MINUTE | | HOLDUP AND HEPA FILTERS. | | | | THE APPARENT DESIGN ERROR WAS CORRECTED PRIOR TO PLANT STARTUP ON DECEMBER | | 18, 1996 BY INSTALLATION OF A CHECK VALVE IN THE COMMON DRAIN PIPING WHICH | | PREVENTS FLOW FROM THE OFFGAS 30 MINUTE HOLDUP LINE TO THE TURBINE | | GENERATOR STEAM PACKING EXHAUSTER DISCHARGE LINE." | | | | THE NRC RESIDENT INSPECTOR HAS BEEN INFORMED OF THIS EVENT BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 31476 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: PIEDMONT HOSPITAL, ATLANTA, GA |NOTIFICATION DATE: 12/18/96 | | CITY: ATLANTA REGION: 2 |NOTIFICATION TIME: 15:00 [ET]| | COUNTY: FULTON STATE: GA |EVENT DATE: 12/18/96 | |LICENSE#: AGREEMENT: Y |EVENT TIME: 08:00[EST]| | DOCKET: |LAST UPDATE DATE: 12/18/96 | | +-----------------------------+ | |PERSON ORGANIZATION| | |KENNETH BARR RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: TOM HILL | | |HQ OPS OFFICER: BOB STRANSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AGREEMENT STATE REPORT REGARDING EXPOSURE OF PHYSICIST WHILE REPAIRING HDR | | AFTERLOADER. | | | | THE FOLLOWING INFORMATION WAS SUBMITTED VIA FACSIMILE BY THE STATE OF | | GEORGIA: | | | | "JUST BEFORE 8:00 AM, THE HOSPITAL PHYSICIST ATTEMPTED TO REPAIR A HDR | | LIMIT SWITCH THAT WAS GIVING A FAULT SIGNAL. WHEN THE SWITCH WAS | | DISCONNECTED, THE STARTER MOTOR WAS ENERGIZED AND BACKED THE SOURCE CABLE | | AND SOURCE OUT OF SHIELDED STORAGE. WHEN THE MOTOR WAS ENERGIZED THE | | PHYSICIST STATED THAT HE TURNED TO OBSERVE THE PRIME ALERT AND IT STARTED | | FLASHING. HE EXITED THE ROOM, OBTAINED SELF READING DOSIMETRY, AND USING A | | RADIATION SURVEY INSTRUMENT, HE REENTERED THE ROOM AND, HANDLING THE 'COLD' | | END OF THE CABLE, PLACED THE SOURCE IN THE MANUFACTURER SUPPLIED EMERGENCY | | STORAGE CONTAINER. THE PHYSICIST CHECKED THE UNIT FOR CONTAMINATION AS AN | | INDICATOR OF THE SOURCE HAVING BEEN BREACHED UPON EXIT OF THE UNIT. NO | | CONTAMINATION WAS FOUND. THE SUPPLIER HAS BEEN CONTACTED TO REPAIR THE | | UNIT, LOAD A NEW SOURCE, AND RETRIEVE THE OLD SOURCE. THESE ACTIONS ARE | | EXPECTED TO OCCUR ON FRIDAY DECEMBER 20, 1996. THE SOURCE IN THE EMERGENCY | | STORAGE CONTAINER IS STORED IN A SECURE LOCATION. THE PHYSICIST ESTIMATES | | HIS RADIATION EXPOSURE AS LESS THAN 50 mREM. THE SELF READING DOSIMETER | | RECORDED 14 mREM WHILE PLACING THE SOURCE IN THE SHIELDED CONTAINER. THE | | FILM BADGE IS TO BE SENT FOR EMERGENCY ANALYSIS." | | | | THE STATE OF GEORGIA HAS ALREADY CONTACTED NRC REGION 2 REGARDING THIS | | EVENT. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 31477 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: CLINTON REGION: 3 |NOTIFICATION DATE: 12/18/96 | |UNIT: [1] [ ] [ ] STATE: IL |NOTIFICATION TIME: 15:15 [ET]| |RX TYPE: [1] GE-6 |EVENT DATE: 12/17/96 | +------------------------------------------------+EVENT TIME: 14:30[CST]| |NRC NOTIFIED BY: MATT STOOKEY |LAST UPDATE DATE: 12/18/96 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: | | |CCCC 21.21 UNSPECIFIED PARAGRAPH | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 REFUELING | 0 REFUELING | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | -CRD SYSTEM INOP DUE TO INCORRECT TORQUE VALUE OF CRD HCU HOLD DOWN BOLTS- | | | | ON 11/19/96, WITH THE PLANT IN A REFUELING OUTAGE, THE LICENSEE IDENTIFIED | | THAT THE TORQUE VALUES SPECIFIED BY GENERAL ELECTRIC FOR THE 3/8-INCH HOLD | | DOWN BOLTS FOR THE CONTROL ROD DRIVE (CRD) HYDRAULIC CONTROL UNITS (HCUs) | | EXCEEDED THE MINIMUM YIELD STRENGTH OF THE BOLT MATERIAL. THIS CAUSED THE | | CRD HCUs TO BE INOPERABLE BECAUSE THE TORQUE VALUE DID NOT MEET SEISMIC | | QUALIFICATION REQUIREMENTS FOR RESTRAINING THE CRD HCUs DURING A DESIGN | | BASIS EARTHQUAKE. THE CRD HCU OPERATION WOULD ONLY BE AFFECTED IF A | | SEISMIC EVENT WERE TO OCCUR DURING PLANT OPERATION. | | | | THERE ARE SEVEN 3/8-INCH BOLTS IN EACH OF THE 145 CRD HCUs FOR A TOTAL OF | | 1015 BOLTS. THESE BOLTS ATTACH THE GENERAL ELECTRIC SUPPLIED CRD HCUs TO | | STRUCTURAL STEEL SUPPORTS IN THE CONTAINMENT BUILDING WHICH WERE DESIGNED | | BY SARGENT AND LUNDY ENGINEERING, THE ARCHITECT ENGINEER FOR THE | | CONSTRUCTION OF THE POWER STATION. THIS CONDITION HAS EXISTED SINCE | | INITIAL LICENSING OF THE PLANT IN 1987. | | | | ALL OF THE 3/8-INCH CRD HCU HOLD DOWN BOLTS HAVE BEEN REPLACED WITH NEW | | BOLTS AND RETORQUED TO THE PROPER VALUE. A SAMPLE OF THE 3/8-INCH BOLTS | | THAT WERE REMOVED FROM THE CRD HCUs WILL BE TESTED TO DETERMINE WHETHER OR | | NOT THEY WOULD HAVE BEEN ABLE TO WITHSTAND A DESIGN BASIS EARTHQUAKE WHILE | | INSTALLED ON THE CRD HCUs. | | | | THIS 10 CFR PART 21 REPORT ONLY APPLIES TO THE CLINTON POWER STATION. | | | | IN ADDITION, THE LICENSEE HAS SUBMITTED LER #96-018 AND HAS INFORMED THE | | NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 31478 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: MORRISTOWN MEMORIAL HOSPITAL |NOTIFICATION DATE: 12/18/96 | | CITY: MORRISTOWN REGION: 1 |NOTIFICATION TIME: 16:04 [ET]| | COUNTY: MORRIS STATE: NJ |EVENT DATE: 12/18/96 | |LICENSE#: AGREEMENT: N |EVENT TIME: 12:30[EST]| | DOCKET: |LAST UPDATE DATE: 12/18/96 | | +-----------------------------+ | |PERSON ORGANIZATION| | |MOHAMED SHANBAKY RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: DR. SWAYNE | | |HQ OPS OFFICER: LEIGH TROCINE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MEDICAL MISADMINISTRATION (INJECTION OF THE WRONG ISOTOPE) AT MORRISTOWN | | MEMORIAL HOSPITAL LOCATED IN MORRISTOWN, NEW JERSEY, DUE TO HUMAN ERROR. | | | | AT APPROXIMATELY 1230 EST, A PATIENT RECEIVED 6.3 mCi OF HUMAN | | MACRO-AGGREGATED ALBUMIN (MAA) IN LIEU OF THE PRESCRIBED RE-INJECTION OF 1 | | mCi OF THALLIUM. THE SYRINGES WERE LABELLED CORRECTLY, AND THE LICENSEE | | BELIEVES THAT THIS EVENT OCCURRED DUE TO HUMAN ERROR. THE AMOUNT OF MAA | | INJECTED WAS THE TYPICAL DOSE THAT IS USED FOR A LUNG SCAN, AND THE | | LICENSEE DOES NOT BELIEVE THAT THERE WILL BE ANY ADVERSE EFFECTS TO THE | | PATIENT. THE LICENSEE ALSO DOES NOT BELIEVE THAT THERE WAS AN | | OVEREXPOSURE. THE REFERRING PHYSICIAN HAS BEEN INFORMED AND PLANS TO | | NOTIFY THE PATIENT. THE LICENSEE PLANS TO HAVE THE PATIENT RETURN TOMORROW | | TO DELAY SCAN THE PATIENT FOR THE REST OF THE THALLIUM SCAN AND WINDOW OUT | | THE REMAINING LUNG ACTIVITY. | | | | THE LICENSEE PLANS TO FILL OUT AND FILE A DIAGNOSTIC NRC MISADMINISTRATION | | REPORT FORM. (REFER TO THE HOO LOG FOR A SITE CONTACT TELEPHONE NUMBER.) | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 31479 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: MERCY HOSPITAL, MINNEAPOLIS, MN |NOTIFICATION DATE: 12/18/96 | | CITY: MINNEAPOLIS REGION: 3 |NOTIFICATION TIME: 19:02 [ET]| | COUNTY: STATE: MN |EVENT DATE: 12/18/96 | |LICENSE#: AGREEMENT: N |EVENT TIME: 11:30[CST]| | DOCKET: |LAST UPDATE DATE: 12/18/96 | | +-----------------------------+ | |PERSON ORGANIZATION| | |B.J. HOLT RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: DICK WU, RSO | | |HQ OPS OFFICER: DICK JOLLIFFE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NONR OTHER UNSPEC REQMNT | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - MERCY HOSPITAL RECEIVED CONTAMINATED PACKAGE FROM SYNCOR, INC - | | | | AT 1130 (CST), MERCY HOSPITAL, LOCATED IN MINNEAPOLIS, MN, RECEIVED A | | PACKAGE CONTAINING 25 mCi OF Tc-99m FROM SYNCOR, INC, OF ST PAUL, MN. SWIPE | | TESTS OF THE OUTSIDE OF THE PACKAGE RECEIVED AT MERCY HOSPITAL INDICATED | | 300,000 DPM (5 MR/HR ON CONTACT); THE DOT LIMIT IS 22,000 DPM. MERCY | | HOSPITAL LAB TECHNICIANS OPENED THE PACKAGE, REMOVED THE UNDAMAGED | | CONTENTS, AND CALLED SYNCOR TO RETRIEVE THE PACKAGE. | | | | THE MERCY HOSPITAL RADIATION SAFETY OFFICER STATED THAT THIS IS THE THIRD | | CONTAMINATED PACKAGE THAT HAS BEEN RECEIVED FROM SYNCOR IN THE LAST TWO | | MONTHS. | | | | THE RSO HAS BEEN IN CONTACT WITH REGION 3 (JAMES CAMERON). | | | | THE LICENSEE REPORTED THIS EVENT IN ACCORDANCE WITH 10 CFR 20.1906. | +------------------------------------------------------------------------------+