U.S. Nuclear Regulatory Commission Operations Center Event Reports For 09/23/96 - 09/24/96 ** EVENT NUMBERS ** 31045 31046 31047 31048 31049 +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 31045 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: DEPARTMENT OF VETERANS AFFAIRS |NOTIFICATION DATE: 09/23/96 | | CITY: MEMPHIS REGION: 2 |NOTIFICATION TIME: 15:01 [ET]| | COUNTY: SHELBY STATE: TN |EVENT DATE: 09/23/96 | |LICENSE#: 41-00119-08 AGREEMENT: Y |EVENT TIME: 12:00[EDT]| | DOCKET: |LAST UPDATE DATE: 09/23/96 | | +-----------------------------+ | |PERSON ORGANIZATION| | |THOMAS DECKER RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: C. BRANNON | | |HQ OPS OFFICER: BOB STRANSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MEDICAL MISADMINISTRATION AT VA MEDICAL CENTER IN MEMPHIS, TN | | | | A PATIENT WAS INADVERTENTLY GIVEN A SECOND 20 mCi DOSE OF Tc-99m AS PART OF | | A BONE SCAN. THE PATIENT HAD ARRIVED SEVERAL HOURS EARLY FOR HIS | | APPOINTMENT, AND HAD BEEN INJECTED WITH A 20 mCi DOSE OF Tc-99m. TWO HOURS | | LATER (THE TIME OF HIS SCHEDULED APPOINTMENT), HE RETURNED TO HAVE THE SCAN | | READ. HOWEVER, INSTEAD OF READING THE SCAN, THE TECHNICIAN INJECTED THE | | PATIENT WITH A SECOND 20 mCi DOSE OF Tc-99m. THE LICENSEE PLANS TO CONTACT | | THE NRC REGION 2 OFFICE REGARDING THIS EVENT. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 31046 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: VERMONT YANKEE REGION: 1 |NOTIFICATION DATE: 09/23/96 | |UNIT: [1] [ ] [ ] STATE: VT |NOTIFICATION TIME: 16:23 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 09/23/96 | +------------------------------------------------+EVENT TIME: 15:30[EDT]| |NRC NOTIFIED BY: HENRIQUEZ |LAST UPDATE DATE: 09/23/96 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |ANDERSON RDO | |AINB 50.72(b)(2)(iii)(B) POT RHR INOP | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 REFUELING | 0 REFUELING | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | INCORRECTLY SPECIFIED LIMIT SWITCH SETTINGS COULD PREVENT CERTAIN | | INTERLOCKS FROM BEING COMPLETED, CAUSING LOSS OF SAFETY SYSTEMS. | | | | ON 09/07/96, WHILE STARTING THE "D" RHR PUMP FOR SHUTDOWN COOLING, THE | | INTERLOCK TO PREVENT STARTING OF THE PUMP DID NOT PICK UP WHEN VALVE | | V10-15D WAS OPENED. THE CAUSE OF THE FAILURE WAS AN INCORRECTLY SPECIFIED | | LIMIT SWITCH ROTOR SETTING. THE LICENSEE REPORTED THAT IN 1995 A PLANT | | MODIFICATION WAS PERFORMED TO CHANGE NUMEROUS TWO-ROTOR LIMIT SWITCH | | CONTROL CIRCUITS TO FOUR-ROTOR CIRCUITS. IN THIS INSTANCE, BOTH LIMIT | | SWITCH ROTORS #! & #3 WERE SET TO THE SAME SETTING, WITH THE SAME | | TOLERANCE. WHEN THE VALVE WAS OPENED, ROTOR #1 STOPPED VALVE TRAVEL BEFORE | | ROTOR #3 MADE UP CONTACTS TO PERMIT THE START OF THE RHR PUMP. | | | | THE LICENSEE REPORTED THAT NINE OTHER MOTOR OPERATED VALVES (EIGHT IN THE | | RHR AND ONE IN THE RCIC SYSTEM) COULD BE AFFECTED IN A SIMILAR MANNER. THE | | NRC RESIDENT INSPECTOR WILL BE INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 31047 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: DEPARTMENT OF VETERANS AFFAIRS |NOTIFICATION DATE: 09/23/96 | | CITY: BOSTON REGION: 1 |NOTIFICATION TIME: 16:36 [ET]| | COUNTY: SUFFOLK STATE: MA |EVENT DATE: 09/23/96 | |LICENSE#: 20-00671-02 AGREEMENT: N |EVENT TIME: 00:00[EDT]| | DOCKET: |LAST UPDATE DATE: 09/23/96 | | +-----------------------------+ | |PERSON ORGANIZATION| | |ANDERSON RDO | | |GREEVES EO | +------------------------------------------------+PAPARILLO NMSS | |NRC NOTIFIED BY: M. WALSH |CONGEL AEOD | |HQ OPS OFFICER: BOB STRANSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NTRA TRANSPORTATION EVENT | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE LICENSEE MEASURED EXCESSIVE DOSE READINGS FROM A PACKAGE DELIVERED FROM | | THE NEW ENGLAND MEDICAL CENTER. | | | | THE VA MEDICAL CENTER IN BOSTON, MA REPORTED THAT A PACKAGE DELIVERED FROM | | THE NEW ENGLAND MEDICAL CENTER WAS SURVEYED WITH READINGS IN EXCESS OF | | USDOT SHIPPING LIMITS. THE PACKAGE WAS READING APPROXIMATELY 400 mR/HR ON | | CONTACT, AND 40mR/HR AT 1 METER. THE PACKAGE WAS BROUGHT TO THE VA MEDICAL | | CENTER BY TAXI, WITH A PHYSICIST FROM THE NEMC ACTING AS COURIER. THE | | LICENSEE HAS CONTACTED THE NEW ENGLAND MEDICAL CENTER REGARDING THIS EVENT, | | AND PLANS TO CONTACT NRC REGION I. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 31048 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: CLINTON REGION: 3 |NOTIFICATION DATE: 09/23/96 | |UNIT: [1] [ ] [ ] STATE: IL |NOTIFICATION TIME: 21:20 [ET]| |RX TYPE: [1] GE-6 |EVENT DATE: 09/23/96 | +------------------------------------------------+EVENT TIME: 01:09[CDT]| |NRC NOTIFIED BY: PAUL NAUYALIS |LAST UPDATE DATE: 09/23/96 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |PATRICK HILAND RDO | |ARPS 50.72(b)(2)(ii) RPS ACTUATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | M/R N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MANUAL REACTOR SCRAM TO INSERT IMMOVABLE CONTROL ROD DUE TO RC&IS FAILURE | | | | WITH THE UNIT IN COLD SHUTDOWN, CONTROL ROD 28-29 BECAME IMMOVABLE AT | | POSITION 28 DUE TO A LOCKUP OF THE ROD CONTROL AND INFORMATION SYSTEM | | (RC&IS). LICENSEE ATTEMPTS TO RESET THE RC&IS RESULTED IN A BLOWN FUSE IN | | THE POWER SUPPLY. OPERATORS MOVED THE MODE SELECTOR SWITCH FROM 'REFUEL' | | TO 'SHUTDOWN' IN ORDER TO INSERT A REACTOR SCRAM SIGNAL AND INSERT THE | | CONTROL ROD. FOLLOWING THE REACTOR SCRAM, THE CONTROL ROD MOVED FROM | | POSITION 28 TO POSITION 00 (FULLY INSERTED). NO OTHER CONTROL RODS WERE | | WITHDRAWN AT THE TIME OF THE EVENT. | | | | THE LICENSEE HAS DETERMINED THAT THE RC&IS LOCKUP WAS CAUSED BY SEVERAL | | TRANSPONDER CARDS THAT ARE NOT FUNCTIONING PROPERLY. ADDITIONALLY, THE | | LICENSEE BELIEVES THAT THE BLOWN FUSE MAY BE THE RESULT OF A FAULTY RESET | | SWITCH. THE LICENSEE DETERMINED THAT THIS EVENT WAS REPORTABLE AT 1755 CDT | | 9/23/96. THE NRC RESIDENT INSPECTOR HAS BEEN INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 31049 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: TURKEY POINT REGION: 2 |NOTIFICATION DATE: 09/24/96 | |UNIT: [3] [ ] [ ] STATE: FL |NOTIFICATION TIME: 03:52 [ET]| |RX TYPE: [3] W-3-LP,[4] W-3-LP |EVENT DATE: 09/24/96 | +------------------------------------------------+EVENT TIME: 03:11[EDT]| |NRC NOTIFIED BY: KRIS MILLER |LAST UPDATE DATE: 09/24/96 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |THOMAS DECKER RDO | |ASHU 50.72(b)(1)(i)(A) PLANT S/D REQD BY TS | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 3 | N Y 100 POWER OPERATION | 65 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | TWO CONTROL RODS HAVE DROPPED INTO THE CORE | | | | ONE CONTROL ROD (F-12) FROM BANK "C" DROPPED INTO THE CORE AT 0255. WHILE | | FOLLOWING THE OFF NORMAL PROCEDURE FOR A DROPPED ROD, A SECOND ROD (K-4) | | DROPPED AT 0311. THE SECOND ROD WAS ALSO FROM BANK "C". BANK "C" IS A | | CONTROL BANK. THIS PLACED THE UNIT IN A SIX HOUR SHUTDOWN LCO. THE UNIT | | IS CURRENTLY BEING BORATED OFF LINE. ONCE POWER IS SUFFICIENTLY REDUCED | | AND THE MAIN TURBINE TRIPPED, THE CONTROL RODS WILL BE FULLY INSERTED. | | | | THE CAUSE OF THE DROPPED RODS IS NOT KNOWN, BUT IS UNDER INVESTIGATION. | | | | THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+