U.S. Nuclear Regulatory Commission Operations Center Event Reports For 08/22/96 - 08/23/96 ** EVENT NUMBERS ** 30793 30908 30909 30910 30911 30912 30913 30914 30915 +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30793 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MILLSTONE REGION: 1 |NOTIFICATION DATE: 07/27/96 | |UNIT: [ ] [ ] [3] STATE: CT |NOTIFICATION TIME: 10:56 [ET]| |RX TYPE: [1] GE-3,[2] CE,[3] W-4-LP |EVENT DATE: 07/27/96 | +------------------------------------------------+EVENT TIME: 10:44[EDT]| |NRC NOTIFIED BY: RON ROTHGEB |LAST UPDATE DATE: 08/23/96 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JOHN MCFADDEN RDO | |AOUT 50.72(b)(1)(ii)(B) OUTSIDE DESIGN BASIS | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | | | | | 3 | N N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | REACTOR PLANT CLOSED COOLING WATER SYSTEM PIPING TO REACTOR COOLANT PUMP | | (RCP) "C" EXCEEDED ASME CODE SECTION 3 APPENDIX F LIMIT IN 1993. | | | | IN JULY 1993, LICENSEE DETERMINED (PRIOR TO LICENSEE'S FOURTH REFUELING | | OUTAGE) THAT FOR A SHORT TIME PERIOD THE RETURN TEMPERATURE OF THE REACTOR | | PLANT CLOSED COOLING WATER SYSTEM (CCW) FOR RCP "C" HAD EXCEEDED ITS ASME | | SECTION 3 APPENDIX F ALLOWABLE LIMITS (PIPING STRESS ANALYSIS). DURING THE | | REFUELING OUTAGE ALL FOUR RCP'S WERE REPLACED. DURING AN HISTORICAL REVIEW | | THE LICENSEE DETERMINED THAT RCP "C" TURNING VANE CAP SCREWS CAME LOOSE | | WHICH ALLOWED REACTOR COOLANT WATER AT NORMAL OPERATING TEMPERATURE TO FLOW | | INTO RCP "C" THERMAL BARRIER HEAT EXCHANGER. THIS OVERHEATED THE REACTOR | | PLANT CLOSED COOLING WATER PIPING SECTION FOR RCP "C". REACTOR PLANT CLOSED | | COOLING WATER SYSTEM PIPING FOR RCP "C" WAS HEATED TO 205ø F (ASME SECTION | | 3 APPENDIX F ALLOWABLE LIMIT IS 165ø F). LICENSEE WILL PERFORM A REANALYSIS | | OF THE REACTOR PLANT CLOSED COOLING WATER SYSTEM TO RCP "C" WHICH EXCEEDED | | ITS ASME SECTION 3 APPENDIX F LIMIT AND CORRECT ANY PROBLEM BEFORE STARTUP. | | LICENSEE NOTIFIED STATE AND LOCAL OFFICIALS OF THIS EVENT. | | | | THE NRC RESIDENT WAS NOTIFIED BY THE LICENSEE OF THIS EVENT. | | | | ****UPDATE AT 1358 ON 8/22/96 FROM KEN BURTON RECEIVED BY HENRY BAILEY**** | | | | THIS EVENT HAS BEEN RETRACTED BASED UPON SUBSEQUENT PIPING STRESS ANALYSIS. | | THE LICENSEE NOTIFIED THE RESIDENT INSPECTOR. DR. ROBERT BORES, R1DO, WAS | | NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30908 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PRAIRIE ISLAND REGION: 3 |NOTIFICATION DATE: 08/22/96 | |UNIT: [1] [2] [ ] STATE: MN |NOTIFICATION TIME: 04:02 [ET]| |RX TYPE: [1] W-2-LP,[2] W-2-LP |EVENT DATE: 08/22/96 | +------------------------------------------------+EVENT TIME: 00:42[CDT]| |NRC NOTIFIED BY: BILL MATHER |LAST UPDATE DATE: 08/22/96 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |LEWIS MILLER 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 100 POWER OPERATION | 100 POWER OPERATION | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | # 22 DIESEL COOLING WATER SAFEGUARDS PUMP AUTOSTARTED | | | | DURING A SURVEILLANCE TEST FOR # 12 DIESEL COOLING WATER SAFEGUARDS PUMP, # | | 12 & # 21 COOLING WATER PUMPS WERE RUNNING SUPPLYING LOOP "A" & "B" COOLING | | WATER HEADERS. THE CONTROL ROOM OPERATOR NOTICED THAT A STEP IN THE | | SURVEILLANCE TEST PROCEDURE HAD BEEN MISSED WHICH REQUIRED A VALVE TO BE | | CLOSED TO ISOLATE "A" & "B" COOLING WATER HEADERS PRIOR TO STARTING # 12 | | DIESEL PUMP. AFTER DISCUSSING THE MISSED STEP WITH CONTROL ROOM SUPERVISOR, | | THEY DECIDED TO CLOSE THE HEADER ISOLATION VALVE. WHEN THE ISOLATION VALVE | | CLOSED "B" HEADER PRESSURE DROPPED BELOW THE SETPOINT FOR # 22 DIESEL | | COOLING WATER PUMP AND IT AUTOSTARTED. THE PUMP HAS BEEN SECURED. | | | | THE NRC RESIDENT INSPECTOR WAS INFORMED OF THIS EVENT BY THE LICENSEE. | | | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30909 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: INDIAN POINT REGION: 1 |NOTIFICATION DATE: 08/22/96 | |UNIT: [2] [ ] [ ] STATE: NY |NOTIFICATION TIME: 04:55 [ET]| |RX TYPE: [2] W-4-LP,[3] W-4-LP |EVENT DATE: 08/22/96 | +------------------------------------------------+EVENT TIME: 03:57[EDT]| |NRC NOTIFIED BY: MANSELL |LAST UPDATE DATE: 08/22/96 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BOB BORES RDO | |ARPS 50.72(b)(2)(ii) RPS ACTUATION | | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 2 | A/R Y 20 POWER OPERATION | 0 HOT STANDBY | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | TURBINE TRIP/REACTOR TRIP ON HIGH STEAM GENERATOR WATER LEVEL. | | | | STEAM GENERATORS #21, #22, & #24 WATER LEVEL CONTROL SYSTEMS HAD BEEN | | SUCCESSFULLY TRANSFERRED FROM MANUAL CONTROL TO AUTOMATIC CONTROL AND A | | REACTOR OPERATOR WAS IN THE PROCESS OF TRANSFERRING STEAM GENERATOR # 23 | | WATER LEVEL CONTROL SYSTEM FROM MANUAL CONTROL TO AUTOMATIC CONTROL. DURING | | THE TRANSFER OF STEAM GENERATOR # 23 WATER LEVEL CONTROL SYSTEM FROM MANUAL | | TO AUTOMATIC CONTROL STEAM GENERATOR # 23 WATER LEVEL INCREASED TO 73% (ON | | NARROW RANGE INDICATION). THIS CAUSED A TURBINE TRIP/REACTOR TRIP SIGNAL ON | | HIGH STEAM GENERATOR WATER LEVEL. ALL RODS FULLY INSERTED INTO THE CORE. | | BOTH MOTOR DRIVEN AND THE TURBINE DRIVEN AUXILIARY FEEDWATER PUMPS | | AUTOMATICALLY STARTED ON LOW STEAM GENERATOR WATER LEVEL (8% ON NARROW | | RANGE). THE TURBINE DRIVEN AUXILIARY FEEDWATER PUMP HAS BEEN SECURED AND | | STEAM GENERATOR WATER LEVEL IS BEING MAINTAINED BY THE MOTOR DRIVEN | | AUXILIARY FEEDWATER PUMPS. NO PORVs OR CODE SAFETY VALVES ON THE PRIMARY OR | | THE SECONDARY SIDE OF THE PLANT OPENED. LICENSEE IS CURRENTLY INVESTIGATING | | WHY STEAM GENERATOR # 23 WATER LEVEL INCREASED TO 73%. REACTOR COOLANT | | TEMPERATURE IS SLOWLY INCREASING TO Tave NO LOAD TEMPERATURE OF 547ø F | | (CURRENT REACTOR COOLANT TEMPERATURE IS 540ø F). STEAM DUMP BYPASS CONTROL | | SYSTEM IS OPERATING PROPERLY. PLANT STARTUP WILL BE GREATER THAN 24 HOURS | | FROM THE TIME OF THIS EVENT. | | | | THE NRC RESIDENT INSPECTOR WILL BE INFORMED OF THIS EVENT BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |FUEL CYCLE FACILITY | |EVENT NUMBER: 30910 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: COMBUSTION ENGINEERING INC. |NOTIFICATION DATE: 08/22/96 | | RXTYPE: URANIUM FUEL FABRICATION |NOTIFICATION TIME: 09:04 [ET]| |COMMENTS: LEU CONVERSION (UF6 to UO2) |EVENT DATE: 08/22/96 | | COMMERCIAL LWR FUEL |EVENT TIME: 07:55[CDT]| | |LAST UPDATE DATE: 08/22/96 | | CITY: HEMATITE REGION: 3 +-----------------------------+ | COUNTY: JEFFERSON STATE: MO |PERSON ORGANIZATION| |LICENSE#: SNM-33 AGREEMENT: N |LEWIS MILLER RDO | | DOCKET: 07000036 |FRED COMBS (NMSS) EO | +------------------------------------------------+JERRY ROTH NMSS | |NRC NOTIFIED BY: PHILLIP WEAVER |FRANK CONGEL (IRD) AEOD | |HQ OPS OFFICER: JOHN MacKINNON |AUSTIN FEMA | +------------------------------------------------+CIBOCH FEMA | |EMERGENCY CLASS: ALERT | | |10 CFR SECTION: | | |AAEC 50.72(a)(1)(i) EMERGENCY DECLARED | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | ALERT DECLARED DUE TO A FIRE OUTSIDE AND BEHIND BUILDING #240. NO | | RADIOACTIVITY INVOLVED. | | | | THE LICENSEE DECLARED AN ALERT CLASSIFICATION BECAUSE IT ACTUATED THE | | EMERGENCY EVACUATION ALARM DUE TO A CHEMICAL FIRE OUTSIDE BUILDING #240. | | THE CHEMICALS INVOLVED WERE NITRIC ACID AND POTASSIUM HYDROXIDE. THE | | LICENSEE THINKS THAT IMPROPER MIXING OF THE CHEMICALS CAUSED THEM TO REACT | | AND CAUSE THE FIRE. FLAMES FROM THE FIRE REACHED HEIGHTS OF 15 FEET. THE | | FIRE TOOK PLACE IN THE BOIL DOWN TANK BEHIND BUILDING #240. THE LARGE | | FLAMES WERE EXTINGUISHED AT 0758 CDT, AND THE SMOLDERING FLAMES WERE | | EXTINGUISHED BY 0844 CDT BY THE LOCAL FIRE DEPARTMENT. NOBODY WAS AFFECTED | | BY THE FUMES FROM THE CHEMICALLY INDUCED FIRE. ALL NON-EMERGENCY PERSONNEL | | WERE EVACUATED TO THE ONSITE EMERGENCY RESPONSE FACILITY (APPROXIMATELY 200 | | PEOPLE). ONE PERSON EVACUATING ONE OF THE ONSITE BUILDINGS SLIGHTLY | | INJURED HIS BACK. NO RADIOACTIVE MATERIALS WERE INVOLVED IN THIS EVENT. | | THE URANIUM HEXAFLUORIDE CONVERSION PROCESS WAS SHUTDOWN AT 0806 CDT. THE | | ALERT CLASSIFICATION WAS DOWNGRADED TO AN UNUSUAL EVENT CLASSIFICATION AT | | 0812 CDT. THE UNUSUAL EVENT CLASSIFICATION WAS TERMINATED AT 0844 CDT WHEN | | THE LOCAL FIRE DEPARTMENT INFORMED THE LICENSEE THAT THE FIRE IN THE BOIL | | DOWN TANK HAD BEEN EXTINGUISHED. THE EVACUATION FOR PLANT PERSONNEL WAS | | TERMINATED AT 0853 CDT. THE LICENSEE STATED THAT PEOPLE OFFSITE WOULD NOT | | BE AFFECTED FROM THE FUMES THAT WERE GENERATED BY THE ONSITE CHEMICAL FIRE. | | THE LICENSEE FURTHER STATED THAT PEOPLE OFFSITE MIGHT SMELL SOME AMMONIA | | FUMES, BUT IT WOULD NOT HARM THEM IN ANY WAY. | | | | NRC REGION 3 (G. SHEAR), NRC PUBLIC AFFAIRS (BILL BEECHER), DOE (CHUCK | | CLAUS), EPA (Mrs MOORE), USDA (LINDA LEWIS), AND HHS (Ms SNOW) WERE | | NOTIFIED OF THIS EVENT BY THE NRC OPERATIONS CENTER. | | | | * * * 1500 AUGUST 22, 1996, UPDATE BY TROCINE * * * | | | | A COMMISSIONERS' ASSISTANTS' BRIEFING WAS CONDUCTED AT 1500 ON AUGUST 22, | | 1996, IN ORDER TO DISCUSS THIS ISSUE. THE FOLLOWING BRIEFING NOTIFICATIONS | | WERE MADE (*INDICATES OFFICE DID NOT PARTICIPATE): AEOD (*ROSSI); ERB | | (BAILEY AND *BARRETT); CHAIRMAN JACKSON (HOLIAN); COMMISSIONER ROGERS | | (SORENSEN); COMMISSIONER DICUS (LUBENAU); EDO (SHAFFER AND STABLEIN); NMSS | | EO (*F. COMBS); R3DO (*LANKSBURY); PAO (BEECHER); CAO (T. COMBS); SECY | | (HART); STATE (DROGGITIS); IP (UPSHAW); BRIEFER (SHEAR); REGION 3 | | (CANIANO); NMSS (Dr. PAPERIELLO); NMSS (*ROTH); AND AEOD (TREFETHEN). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30911 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PERRY REGION: 3 |NOTIFICATION DATE: 08/22/96 | |UNIT: [1] [ ] [ ] STATE: OH |NOTIFICATION TIME: 13:05 [ET]| |RX TYPE: [1] GE-6 |EVENT DATE: 08/21/96 | +------------------------------------------------+EVENT TIME: 15:00[EDT]| |NRC NOTIFIED BY: RUSS KEARNEY |LAST UPDATE DATE: 08/22/96 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |ROGER LANKSBURY 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 +------------------------------------------------------------------------------+ | OMISSION OF LOGIC CONTACTS FOLLOWING THE REVISION OF TWO SURVEILLANCE | | PROCEDURES | | | | DURING THE YELLOW LINE REVIEW OF TWO INSTRUMENT SURVEILLANCE PROCEDURES | | ASSOCIATED WITH THE NUMAC LEAK DETECTION MODULE CALIBRATION, THE LICENSEE | | IDENTIFIED THAT CONTACTS WERE OMITTED FROM TESTING IN THE FOLLOWING | | DIVISION 1 AND 2 LOGICS: REACTOR CORE ISOLATION COOLING LOGIC, REACTOR | | WATER CLEANUP ISOLATION LOGIC, AND RESIDUAL HEAT REMOVAL ISOLATION LOGIC. | | TWO OR THREE CONTACTS IN EACH OF THESE LOGICS WERE NOT TESTED DUE TO | | INADEQUATE SURVEILLANCE PROCEDURES. THE APPLICABLE PROCEDURES HAD BEEN | | RE-WRITTEN AS A RESULT OF A PLANT DESIGN CHANGE DURING REFUELING OUTAGE #5 | | (SPRING 1996). THIS DESIGN CHANGE REPLACED THE EXISTING RILEY LEAK | | DETECTION SYSTEM WITH A NUMAC LEAK DETECTION SYSTEM, AND THE PROCEDURE | | REVISIONS OMITTED THE TESTING OF TWO OR THREE CONTACTS IN EACH OF THE | | REFERENCED LOGICS. | | | | AS A RESULT OF THIS CONDITION, TECHNICAL SPECIFICATION SURVEILLANCE | | REQUIREMENT 3.0.3 WAS ENTERED AT 1630 ON AUGUST 20, 1996. (THIS NEW AND | | IMPROVED TECHNICAL SPECIFICATION REQUIREMENT ALLOWS UP TO 24 HOURS FOR THE | | COMPLETION OF THE REQUIRED TESTING.) FOLLOWING REVISION OF THE APPLICABLE | | PROCEDURES AND SATISFACTORILY TESTING OF THE OMITTED CONTACTS, TECHNICAL | | SPECIFICATION 3.0.3 WAS EXITED AT 1241 ON AUGUST 21, 1996. THE LICENSEE'S | | REPORTABILITY REVIEW WAS COMPLETED AT 1500 ON AUGUST 21, 1996, AND THE | | LICENSEE MADE THIS 24-HOUR EVENT NOTIFICATION IN ACCORDANCE WITH OPERATING | | LICENSE CONDITION 2.F AT 1305 ON AUGUST 22, 1996. | | | | THE LICENSEE NOTIFIED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30912 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: VERMONT YANKEE REGION: 1 |NOTIFICATION DATE: 08/22/96 | |UNIT: [1] [ ] [ ] STATE: VT |NOTIFICATION TIME: 16:07 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 08/22/96 | +------------------------------------------------+EVENT TIME: 15:45[EDT]| |NRC NOTIFIED BY: DENNIS MAY |LAST UPDATE DATE: 08/22/96 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |ROBERT BORES RDO | |AOUT 50.72(b)(1)(ii)(B) OUTSIDE DESIGN BASIS | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 90 POWER OPERATION | 90 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | IDENTIFICATION OF A THREE-INCH GAP IN THE FIRE BARRIER WRAPPING AROUND A | | CABLE TRAY IN THE REACTOR BUILDING | | | | DURING THE PERFORMANCE OF A FIRE BARRIER SURVEILLANCE ON AUGUST 15, 1996, | | THE LICENSEE IDENTIFIED A THREE-INCH GAP IN A FIRE BARRIER. THE | | QUESTIONABLE FIRE BARRIER WAS MADE OF 3M-INTERAM-E-54A MATERIAL WHICH WAS | | WRAPPED AROUND A CABLE TRAY LOCATED IN THE REACTOR BUILDING. THE CABLE | | TRAY CONTAINED CABLES THAT COULD AFFECT THE UNIT'S SAFETY SYSTEMS. THE | | LICENSEE HAS NOT ENTERED ANY TECHNICAL SPECIFICATION LIMITING CONDITIONS | | FOR OPERATION AS A RESULT OF THE IDENTIFICATION OF THIS ISSUE, AND THE | | CAUSE OF THE FIRE BARRIER GAP IS UNDER INVESTIGATION. | | | | THE LICENSEE DETERMINED THAT THIS EVENT WAS REPORTABLE TODAY. | | | | THE LICENSEE PLANS TO NOTIFY THE NRC RESIDENT INSPECTOR AND THE STATE OF | | VERMONT DEPARTMENT OF PUBLIC SERVICE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 30913 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: UNITY HOSPITAL |NOTIFICATION DATE: 08/22/96 | | CITY: FRIDLEY REGION: 3 |NOTIFICATION TIME: 16:24 [ET]| | COUNTY: ANOKA STATE: MN |EVENT DATE: 08/21/96 | |LICENSE#: 22-12614-01 AGREEMENT: N |EVENT TIME: 15:30[CDT]| | DOCKET: |LAST UPDATE DATE: 08/22/96 | | +-----------------------------+ | |PERSON ORGANIZATION| | |LEWIS MILLER RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: RICHARD WU | | |HQ OPS OFFICER: LEIGH TROCINE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | UNDER-DOSE OF CESIUM-137 DUE TO THE USE OF A LONGER APPLICATOR AT UNITY | | HOSPITAL IN FRIDLEY, MINNESOTA | | | | THE LICENSEE REPORTED A MEDICAL MISADMINISTRATION INVOLVING AN UNDER-DOSE | | OF CESIUM-137. A PHYSICIAN PRESCRIBED A 2,500-CENTIGRAY DOSE VIA A VAGINAL | | CESIUM-137 IMPLANT. (THE CESIUM-137 SOURCES HAD AN ACTIVITY OF 71.85 | | MILLICURIES.) AS PRESCRIBED, THE TWO SOURCES WERE LOADED AT 1140 CDT ON | | AUGUST 19, 1996, AND THE SOURCES WERE REMOVED AT 1340 CDT ON AUGUST 20, | | 1996. HOWEVER, THE ACTUAL DOSE RECEIVED WAS 1,186 CENTIGRAYS. APPARENTLY, | | THE LICENSEE UTILIZED A 3-CENTIMETER CAPSULE OVOID APPLICATOR TO IMPLANT | | THE SOURCES IN LIEU OF A 2-CENTIMETER CAPSULE OVOID APPLICATOR, AND THE | | DOSE TO THE INTENDED SURFACE AREA WAS REDUCED DUE TO THE ADDED LENGTH OF | | THE APPLICATOR. | | | | THE LICENSEE DETERMINED THAT THERE WAS NO ADDITIONAL RISK TO THE PATIENT. | | IN ADDITION, THE PHYSICIAN IS SATISFIED WITH THE DOSE AND DOES NOT PLAN TO | | ADMINISTER AN ADDITIONAL TREATMENT. THE PATIENT WAS INFORMED BY THE | | PHYSICIAN. | | | | THE LICENSEE IDENTIFIED THIS DISCREPANCY AT 1530 CDT ON AUGUST 21, 1996. | | THE PROBLEM WAS INVESTIGATED, AND THE LICENSEE DETERMINED HOW THE PROBLEM | | OCCURRED TODAY. THE LICENSEE ALSO CONFIRMED THAT THIS EVENT QUALIFIED AS A | | MEDICAL MISADMINISTRATION TODAY JUST PRIOR TO THE EVENT NOTIFICATION. | | | | THE LICENSEE PLANS TO SUBMIT A 15-DAY WRITTEN REPORT TO THE NRC. (REFER TO | | THE HOO LOG FOR THE LICENSEE ADDRESS AND FOR SITE CONTACT NAMES AND | | TELEPHONE NUMBERS.) | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30914 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MAINE YANKEE REGION: 1 |NOTIFICATION DATE: 08/22/96 | |UNIT: [1] [ ] [ ] STATE: ME |NOTIFICATION TIME: 16:25 [ET]| |RX TYPE: [1] CE |EVENT DATE: 08/22/96 | +------------------------------------------------+EVENT TIME: 15:00[EDT]| |NRC NOTIFIED BY: JERRY MAYBEN |LAST UPDATE DATE: 08/22/96 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |ROBERT BORES 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 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | OFFSITE NOTIFICATION REGARDING STEEL PLATE STOCK MATERIAL DELIVERED TO THE | | PLANT THAT WAS 50 TO 150 COUNTS PER MINUTE ABOVE BACKGROUND | | | | THE LICENSEE HAD STEEL PLATE STOCK MATERIAL DELIVERED TO THE PLANT AND | | LATER DETERMINED THAT IT WAS 50 TO 150 COUNTS PER MINUTE ABOVE BACKGROUND. | | THE STOCK MATERIAL WAS 1/4-INCH STEEL PLATE MEASURING 48 INCHES BY 96 | | INCHES. TWO PLATES WERE IDENTIFIED AND TRACED TO THE SAME PURCHASE ORDER. | | THE MANUFACTURER WAS GULF STATES. | | | | THE LICENSEE HAS SINCE LABELLED THIS MATERIAL AND HAS ROPED IT OFF. IN | | ADDITION, AN ACCOUNTING OF STOCK USED IN THE PLANT IS ONGOING. | | | | THIS ISSUE WAS IDENTIFIED WHEN A PLANT MECHANIC TOOK A PIECE OF ONE OF | | THESE PLATES INTO THE HOT SIDE TO WORK. WHEN THE MECHANIC BROUGHT THE | | PIECE BACK OUT AND FRISKED IT, MONITOR ALARMS ALERTED THE MECHANIC AND | | HEALTH PHYSICS PERSONNEL TO THE PROBLEM. LICENSEE PERSONNEL SUBSEQUENTLY | | TRACED THIS PIECE BACK TO THE STOCK MATERIAL LOCATED IN THE WAREHOUSE. | | | | THE LICENSEE ALSO DISCOVERED THAT TWO ROUND PIECES HAD PREVIOUSLY BEEN CUT | | OUT OF THE STOCK MATERIAL IN QUESTION. THE LICENSEE CURRENTLY BELIEVES | | THAT THESE PIECES MAY HAVE BEEN USED AS BLANK FLANGES. AN EFFORT TO | | ACCOUNT FOR THIS MATERIAL IS ONGOING. | | | | THE LICENSEE NOTIFIED THE NRC RESIDENT INSPECTOR AND AN OFFSITE STATE | | AGENCY. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30915 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: HOPE CREEK REGION: 1 |NOTIFICATION DATE: 08/22/96 | |UNIT: [1] [ ] [ ] STATE: NJ |NOTIFICATION TIME: 20:47 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 08/22/96 | +------------------------------------------------+EVENT TIME: 18:30[EDT]| |NRC NOTIFIED BY: JESSE PIKE |LAST UPDATE DATE: 08/22/96 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |ROBERT BORES 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 +------------------------------------------------------------------------------+ | QUESTIONABLE ALLOWABLE OUT-OF-SERVICE TIMES SPECIFIED IN THE TECHNICAL | | SPECIFICATIONS BASED ON CONCERNS WITH THE SAFETY EVALUATION THAT WAS USED | | FOR A LICENSE CHANGE | | | | ON AUGUST 16, 1996, THE LICENSEE REPORTED CONCERNS RELATIVE TO CROSS-TYING | | SAFETY AUXILIARY COOLING SYSTEM (SACS) SUBSYSTEMS. (REFER TO EVENT #30886 | | FOR ADDITIONAL INFORMATION.) THAT REPORT INDICATED THAT ENGINEERING | | REVIEWS WERE CONTINUING, AND THE LICENSEE IDENTIFIED AN ADDITIONAL CONCERN | | AS A RESULT OF THOSE CONTINUING ENGINEERING REVIEWS. | | | | THE NEW CONCERN INVOLVED THE BASIS FOR EXTENDED ALLOWABLE OUT-OF-SERVICE | | TIMES FOR ONE SERVICE WATER PUMP, ONE SACS PUMP, THE 'C' EMERGENCY DIESEL | | GENERATOR (EDG), AND THE 'D' EDG. THESE EXTENDED ALLOWABLE OUT-OF-SERVICE | | TIMES WERE APPROVED IN AMENDMENT #75 TO THE HOPE CREEK TECHNICAL | | SPECIFICATIONS. LICENSEE ENGINEERING PERSONNEL ARE CONTINUING TO REVIEW | | THIS ISSUE, AND THE LICENSEE IS IN THE PROCESS OF ESTABLISHING THE | | APPROPRIATE ACTIONS TO BE TAKEN IN THE EVENT THAT ANY OF THE AFFECTED | | EQUIPMENT BECOMES INOPERABLE. ALL SERVICE WATER PUMPS, SACS PUMPS, AND | | EDGs ARE FULLY OPERABLE AT THIS TIME. | | | | THE LICENSEE NOTIFIED THE NRC RESIDENT INSPECTOR AND THE LOWER ALLOWAYS | | CREEK TOWNSHIP. | +------------------------------------------------------------------------------+