U.S. Nuclear Regulatory Commission Operations Center Event Reports For 05/30/96 - 05/31/96 ** EVENT NUMBERS ** 30465 30513 30563 30564 30565 30566 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30465 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MAINE YANKEE REGION: 1 |NOTIFICATION DATE: 05/14/96 | |UNIT: [1] [ ] [ ] STATE: ME |NOTIFICATION TIME: 13:32 [ET]| |RX TYPE: [1] CE |EVENT DATE: 05/14/96 | +------------------------------------------------+EVENT TIME: 13:00[EDT]| |NRC NOTIFIED BY: PETE EBERT |LAST UPDATE DATE: 05/30/96 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |ANIELLO DELLA GRECA 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 +------------------------------------------------------------------------------+ | DISCOVERY THAT INTERLOCKS WHICH PREVENT THE YARD CRANE FROM TRANSPORTING | | HEAVY LOADS OVER THE SPENT FUEL POOL MAY NOT BE FUNCTIONAL | | | | AT 1200, THE CONTROL ROOM WAS NOTIFIED BY THE ENGINEERING DEPARTMENT THAT | | THE INTERLOCKS WHICH PREVENT THE YARD CRANE FROM TRANSPORTING HEAVY LOADS | | OVER THE SPENT FUEL POOL DO NOT APPEAR TO BE FUNCTIONAL. THE YARD CRANE | | INTERLOCKS ARE DESIGNED TO ALLOW ACCESS TO THE SPENT FUEL CASK LAYDOWN AREA | | BUT PREVENT CARRYING HEAVY LOADS OVER SPENT FUEL POOL UNLESS A BYPASS KEY | | DISABLES THE INTERLOCK CIRCUIT. THE DESIGN DEFECT HAS BEEN IN EXISTENCE | | SINCE INITIAL PLANT OPERATION. | | | | A MAJOR OVERHAUL OF THE YARD CRANE IS JUST BEING COMPLETED, AND THE CRANE | | VENDOR WAS IN THE PROCESS OF PREPARING A POST-MAINTENANCE FUNCTIONAL TEST | | PLAN WHEN THE DESIGN DEFECT WAS DISCOVERED. AN ENGINEERING REVIEW OF THE | | WIRING SCHEMATICS CONFIRMED THE VENDOR'S INITIAL CONCLUSION. UPON FINAL | | REASSEMBLY OF THE CRANE, A TEST OF THE INTERLOCK CIRCUIT WILL BE CONDUCTED | | TO VERIFY THE EXISTENCE OF THE DEFECT. AT 1300, AFTER REVIEW OF THE | | APPLICABLE DESIGN DOCUMENTS AND ADMINISTRATIVE CONTROLS, THE EVENT WAS | | CONSIDERED TO BE REPORTABLE TO THE NRC. AS FAR AS IS KNOWN BY THE | | LICENSEE, AT NO TIME HAS A HEAVY LOAD BEEN PLACED OVER SPENT FUEL AS A | | RESULT OF THIS DESIGN DEFECT. | | | | THE LICENSEE WILL NOTIFY THE NRC RESIDENT INSPECTOR. | | | | * * * UPDATE ON 5/30/96 AT 1117 EDT FROM EBERT TAKEN BY KARSCH * * * | | THE LICENSEE IS RETRACTING THIS EVENT. THEY DETERMINED THAT THE CRANE | | INTERLOCKS WOULD HAVE WORKED TO PREVENT MOVEMENT OF THE HEAVY LOADS AS | | REQUIRED. THE INTERLOCKS WERE TESTED IN 1975 AFTER THEY WERE INSTALLED, | | BUT ARE NOT RETESTED PERIODICALLY. THE CRANE IS UNDERGOING OVERHAUL AND | | WILL BE RETESTED PRIOR TO USE. THE LICENSEE WILL INFORM THE NRC RESIDENT | | INSPECTOR. R1DO (HOLODY) NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30513 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: CRYSTAL RIVER REGION: 2 |NOTIFICATION DATE: 05/21/96 | |UNIT: [3] [ ] [ ] STATE: FL |NOTIFICATION TIME: 14:20 [ET]| |RX TYPE: [3] B&W-L-LP |EVENT DATE: 05/20/96 | +------------------------------------------------+EVENT TIME: 12:00[EDT]| |NRC NOTIFIED BY: BILL BANDHAUER |LAST UPDATE DATE: 05/30/96 | |HQ OPS OFFICER: RUDY KARSCH +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |CHRIS CHRISTENSEN RDO | |NINF INFORMATION ONLY | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 3 | N Y 70 POWER OPERATION | 70 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | LARGE BREAK LOSS OF COOLANT ACCIDENT (LOCA) ANALYSIS ASSUMPTION ERROR | | | | A RECENT REVIEW OF AN EXISTING EMERGENCY CORE COOLING SYSTEM CALCULATION | | REVEALED AN ASSUMPTION ERROR IN THE LARGE BREAK LOCA ANALYSIS. THE | | ASSUMPTION ERROR INVOLVED THE EXTENT OF FUEL GRID PLASTIC DEFORMATION | | DURING A LARGE BREAK LOCA. CORRECTION OF THE ASSUMPTION ERROR WOULD RESULT | | IN EXCEEDING THE CLAD TEMPERATURE LIMIT OF 2,200øF USING THE CONVENTIONAL | | GUILLOTINE-BREAK MODEL. USING LEAK-BEFORE-BREAK MODELING FOR LOCA ANALYSIS | | (WITH CORRECT ASSUMPTIONS ON GRID DEFORMATION) WILL PROVIDE MARGIN TO AVOID | | EXCEEDING THE 2,200øF CLAD LIMIT. THE UPDATED ANALYSIS IS BEING PERFORMED | | BY THE BABCOCK AND WILCOX OWNERS GROUP. | | | | THE LICENSEE NOTIFIED THE NRC RESIDENT INSPECTOR. (REFER TO RELATED EVENT | | NUMBERS 30500, 30504, AND 30521.) | | | | NOTE: THIS EVENT WAS RE-RELEASED DUE TO EXTENSIVE REVISIONS TO THE EVENT | | TEXT. | | | | ****UPDATE @ 1140 EDT 05/30/96 BY NEUMAN TAKEN BY MACKINNON*** | | | | LICENSEE CHANGED THE WORD "WOULD" IN THE THIRD SENTENCE TO "COULD". THE | | THIRD SENTENCE NOW READS, "CORRECTION OF THE ASSUMPTION ERROR COULD RESULT | | IN EXCEEDING THE CLAD TEMPERATURE LIMIT OF 2,200øF USING CONVENTIONAL | | GUILLOTINE-BREAK MODEL". R2DO (TOM DECKER) NOTIFIED. | | | | THE NRC RESIDENT INSPECTOR WILL BE INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30563 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: CLINTON REGION: 3 |NOTIFICATION DATE: 05/30/96 | |UNIT: [1] [ ] [ ] STATE: IL |NOTIFICATION TIME: 04:12 [ET]| |RX TYPE: [1] GE-6 |EVENT DATE: 05/30/96 | +------------------------------------------------+EVENT TIME: 00:20[CDT]| |NRC NOTIFIED BY: GREG HALVERSON |LAST UPDATE DATE: 05/30/96 | |HQ OPS OFFICER: RUDY KARSCH +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MICHAEL J. JORDAN 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 +------------------------------------------------------------------------------+ | THE REACTOR WATER CLEANUP (RWCU) SYSTEM MAY BE INOPERABLE BECAUSE THE HEAT | | EXCHANGER (HX) TEMPERATURE INSTRUMENTS MAY BE INOPERABLE. THE RWCU HX WAS | | PLACED IN STANDBY AND THE ACCESS PLUG TO THE RWCU HX ROOM WAS REMOVED. | | REMOVING THE RWCU HX ACCESS PLUG RENDERED THE DELTA T AND AMBIENT TEMP | | INSTRUMENTS INOPERABLE BECAUSE THE ROOM WAS NO LONGER AN ENCLOSED AREA. | | PLACING THE RWCU HX IN STANDBY RATHER THAN ISOLATING IT BECAME A VIOLATION | | OF TECH SPEC 3.3.6.1 AFTER THE TWO HOUR LCO EXPIRED. THE LICENSEE INFORMED | | THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30564 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PERRY REGION: 3 |NOTIFICATION DATE: 05/30/96 | |UNIT: [1] [ ] [ ] STATE: OH |NOTIFICATION TIME: 08:26 [ET]| |RX TYPE: [1] GE-6 |EVENT DATE: 05/30/96 | +------------------------------------------------+EVENT TIME: 06:15[EDT]| |NRC NOTIFIED BY: RUSS KEARNEY |LAST UPDATE DATE: 05/30/96 | |HQ OPS OFFICER: RUDY KARSCH +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MICHAEL J. JORDAN 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 | A/R Y 100 POWER OPERATION | 0 HOT SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | REACTOR SCRAM DUE TO GENERATOR LOCKOUT. | | | | THE LICENSEE WAS CLOSING 13.8 KV CIRCUIT BREAKER #L1108, THE FEEDER TO 480 | | VOLT TRANSFORMER #LF1C, WHEN #LF1C FAILED. THE RESULTING TRANSIENT CAUSED | | A SUDDEN PRESSURE LOCKOUT OF THE UNIT TRANSFORMER. THE UNIT TRANSFORMER | | LOCKOUT CAUSED A TRIP OF THE MAIN GENERATOR, A TURBINE TRIP AND A REACTOR | | SCRAM. ALL CONTROL RODS INSERTED FULLY. DECAY HEAT REMOVAL IS VIA THE | | TURBINE BYPASS VALVES TO THE MAIN CONDENSER. THE LICENSEE ANTICIPATES | | RESTART ON 06/01/96. THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 30565 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: BRIDGEPORT RADIOLOGY ASSOC. |NOTIFICATION DATE: 05/30/96 | | CITY: TRUMBULL REGION: 1 |NOTIFICATION TIME: 16:31 [ET]| | COUNTY: FAIRFIELD STATE: CT |EVENT DATE: 05/23/96 | |LICENSE#: 06-16869-01 AGREEMENT: N |EVENT TIME: 12:00[EDT]| | DOCKET: |LAST UPDATE DATE: 05/30/96 | | +-----------------------------+ | |PERSON ORGANIZATION| | |DAN HOLODY RDO | | |BOB PIERSON (NMSS) EO | +------------------------------------------------+ | |NRC NOTIFIED BY: DAVE WHISKO (RSO) | | |HQ OPS OFFICER: JOHN MacKINNON | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | TODAY BRIDGEPORT RADIOLOGY ASSOCIATES LOCATED AT 15 CORPORATE DRIVE, | | TRUMBULL, CT., NOTIFIED THEIR RADIATION SAFETY OFFICER (RSO) THAT A | | MEDICAL MISADMINISTRATION HAD OCCURRED AT THEIR ESTABLISHMENT ON 05/23/96. | | | | THE RSO SAID THAT HE WAS INFORMED BY BRIDGEPORT RADIOLOGY ASSOCIATES THAT A | | MEDICAL MISADMINISTRATION HAD TAKEN PLACE AT THE ESTABLISHMENT ON 05/23/96. | | A PATIENT WAS SUPPOSED TO HAVE RECEIVED ~ 25 mcuries OF Tc-99M-MDP FOR A | | BONE SCAN. A MEDICAL TECHNOLOGIST DID NOT READ HIS INSTRUCTIONS CORRECTLY | | AND INJECTED THE PATIENT WITH ~ 25 mcuries OF Tc-99M. THE PATIENT'S HEALTH | | WAS NOT AFFECTED BY THIS ERROR. THE PATIENT WAS VERBALLY NOTIFIED OF THE | | MISTAKE BY THE TECHNOLOGIST ON 05/24/96, AND WAS THEN GIVEN ~ 25 mcuries OF | | Tc-99M-MDP. THE PHYSICIAN FOR THE PATIENT WAS VERBALLY NOTIFIED OF THE | | ERROR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30566 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MONTICELLO REGION: 3 |NOTIFICATION DATE: 05/30/96 | |UNIT: [1] [ ] [ ] STATE: MN |NOTIFICATION TIME: 17:16 [ET]| |RX TYPE: [1] GE-3 |EVENT DATE: 05/30/96 | +------------------------------------------------+EVENT TIME: 14:10[CDT]| |NRC NOTIFIED BY: DUANE BISTODEAU |LAST UPDATE DATE: 05/30/96 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MICHAEL JORDAN 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 | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE LICENSEE RECEIVED AN UNEXPECTED GROUP 2 ISOLATION (CONTAINMENT SAMPLING | | SYSTEM & REACTOR SAMPLING SYSTEM) DURING PERFORMANCE OF MAINTENANCE ON | | CHANNEL "A" OF THE REACTOR BUILDING EXHAUST PLENUM RADIATION MONITOR. | | | | DURING PERFORMANCE OF MAINTENANCE ON CHANNEL "A" OF THE REACTOR BUILDING | | EXHAUST PLENUM RADIATION MONITOR THE ASSOCIATED POWER SUPPLY FUSE WAS | | REMOVED. THE REMOVAL OF THE FUSE CAUSED A COINCIDENT VOLTAGE SPIKE ON | | CHANNEL "A" SPENT FUEL POOL RADIATION MONITOR, RESULTING IN A HIGH | | RADIATION TRIP FOLLOWED BY A GROUP 2 ISOLATION. THE CHANNEL "A" REACTOR | | BUILDING MONITOR AND CHANNEL "A" SPENT FUEL POOL RADIATION MONITOR SHARE A | | COMMON POWER SUPPLY. THE SPENT FUEL POOL RADIATION MONITOR TRIP AND GROUP | | 2 ISOLATION WERE RESET. ALL SYSTEMS WERE RESTORED AND WERE RETURNED TO | | SERVICE. | | | | THE NRC RESIDENT INSPECTOR WILL BE INFORMED BY THE LICENSEE OF THIS EVENT. | +------------------------------------------------------------------------------+