U.S. Nuclear Regulatory Commission Operations Center Event Reports For 05/31/96 - 06/03/96 ** EVENT NUMBERS ** 30476 30565 30567 30568 30569 30570 30571 30572 30573 30574 30575 +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30476 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MILLSTONE REGION: 1 |NOTIFICATION DATE: 05/16/96 | |UNIT: [1] [ ] [ ] STATE: CT |NOTIFICATION TIME: 15:11 [ET]| |RX TYPE: [1] GE-3,[2] CE,[3] W-4-LP |EVENT DATE: 05/16/96 | +------------------------------------------------+EVENT TIME: 14:50[EDT]| |NRC NOTIFIED BY: LATZ |LAST UPDATE DATE: 05/31/96 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |ANIELLO DELLA GRECA RDO | |ADAS 50.72(b)(2)(i) DEG/UNANALYZED COND | | |AINA 50.72(b)(2)(iii)(A) POT UNABLE TO SAFE SD | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | THE LICENSEE REPORTED A CONDITION WHERE THE TURBINE STOP VALVE AND TURBINE | | CONTROL VALVE CLOSURE SCRAM SIGNALS WOULD BE BYPASSED WHEN REQUIRED TO BE | | OPERABLE BY TECHNICAL SPECIFICATION. | | | | THIS CONDITION WOULD OCCUR WHEN A REQUEST FOR LOAD REDUCTION IS MADE, | | REACTOR POWER IS REDUCED AND IN ADDITION THEY OPENED THEIR BYPASS VALVES TO | | BYPASS STEAM TO THE CONDENSER. THE TURBINE SCRAM BYPASS SIGNAL COMES FROM | | FIRST STAGE PRESSURE AND TECH SPECS REQUIRE CORE THERMAL POWER TO BE LESS | | THAN 50%. BECAUSE THE INITIATING SIGNAL FOR BYPASS COMES FROM FIRST STAGE | | PRESSURE WHEN THEY OPEN THE BYPASS VALVES THE FIRST STAGE PRESSURE COULD BE | | LESS THAN 50% WHICH CAUSES THE SCRAM BYPASS TO COME IN, BUT THERMAL POWER | | COULD STILL BE GREATER THAN 50%. THE INVESTIGATION WAS INITIATED BECAUSE OF | | GE INFORMATION LETTER #423. THEY PLAN TO CORRECT THEIR PROCEDURES TO | | PREVENT THIS CONDITION FROM OCCURRING. THE RI, STATE AND LOCAL AGENCIES | | WERE NOTIFIED. | | | | *** UPDATE @ 1409 EDT, 05/31/96 BY Mr. KUFFEL TAKEN BY MACKINNON *** | | | | THE LICENSEE IS RETRACTING THE 10 CFR 50.72 (b)(2)(i) PART OF THIS REPORT | | AFTER THEIR DESIGN ANALYSIS GROUP SAID THAT THIS EVENT WAS FOUND TO BE | | BOUNDED BY THEIR EXISTING TRANSIENT ANALYSIS AND THAT THEY COULD NOT FIND | | THIS EVENT HAPPENING IN THE PAST ON MILLSTONE UNIT 1. THE NRC RESIDENT | | INSPECTOR WILL BE INFORMED OF THIS EVENT BY THE LICENSEE. R1DO (HOLODY) | | NOTIFIED. | +------------------------------------------------------------------------------+ !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |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: 05/31/96 | | +-----------------------------+ | |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. | | | | * * * UPDATE ON 5/31/96 AT 1047 EDT FROM WISHKO TAKEN BY KARSCH * * * | | THE LICENSEE IS RETRACTING THIS EVENT. IT DOES NOT MEET THE REPORTING | | REQUIREMENT THRESHOLD. THE PATIENT'S WHOLE BODY DOSE DID NOT EXCEED THE 5 | | REM LIMIT. R1DO (HOLODY) NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |GENERAL INFORMATION or OTHER | |EVENT NUMBER: 30567 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: SUNRISE ENGINEERING INC. |NOTIFICATION DATE: 05/31/96 | | CITY: DRAPER REGION: 4 |NOTIFICATION TIME: 12:10 [ET]| | COUNTY: SALT LAKE STATE: UT |EVENT DATE: 05/30/96 | |LICENSE#: UT-1400313 AGREEMENT: Y |EVENT TIME: 17:30[MDT]| | DOCKET: |LAST UPDATE DATE: 05/31/96 | | +-----------------------------+ | |PERSON ORGANIZATION| | |GARY SANBORN RDO | | |FRED COMBS (NMSS) EO | +------------------------------------------------+ | |NRC NOTIFIED BY: JULIE FELICE | | |HQ OPS OFFICER: JOHN MacKINNON | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | JULIE FELICE OF THE UTAH DIVISION OF RADIATION CONTROL RECEIVED A REPORT | | FROM THE RADIATION SAFETY OFFICER (RSO), FOR SUNRISE ENGINEERING INC., THAT | | A TROXLER MOISTURE DENSITY GAUGE HAD BEEN STOLEN ON 05/30/96 AT 1730 EDT. | | | | THE RSO FOR SUNRISE ENGINEERING INC., LOCATED IN FILLMORE, UTAH, REPORTED | | THAT A TROXLER MOISTURE DENSITY GAUGE HAD BEEN STOLEN FROM THE BACK OF ONE | | OF THEIR PICKUP TRUCKS LOCATED AT THEIR DRAPER, UTAH OFFICE. THE TROXLER | | MOISTURE DENSITY GAUGE HAD BEEN CHAINED AND LOCKED IN THE BACK OF THE | | PICKUP TRUCK. SOMEONE USED A CHAIN CUTTER TO STEAL THE TROXLER MOISTURE | | DENSITY GAUGE. THE MODEL # OF THE DENSITY GAUGE IS 3430 AND ITS SERIAL # | | IS 23008. THE SOURCES IN THE GAUGE WERE 8 mCi OF Cs-137 (SERIAL # FOR THE | | CESIUM SOURCE IS 75-4813), AND 40 mCi OF Am(241)-Be (SERIAL # FOR THE | | Am(241)-Be SOURCE IS 47-18815). LICENSEE NOTIFIED THE SALT LAKE CITY | | POLICE DEPARTMENT OF THE STOLEN TROXLER MOISTURE DENSITY GAUGE AND THE | | POLICE CASE # FOR THIS THEFT IS 96-71082. THE UTAH DIVISION OF RADIATION | | CONTROL WILL TRY TO HAVE THE LOCAL NEWS STATIONS ANNOUNCE THAT A TROXLER | | MOISTURE DENSITY GAUGE WAS STOLEN. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30568 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MAINE YANKEE REGION: 1 |NOTIFICATION DATE: 05/31/96 | |UNIT: [1] [ ] [ ] STATE: ME |NOTIFICATION TIME: 18:19 [ET]| |RX TYPE: [1] CE |EVENT DATE: 05/31/96 | +------------------------------------------------+EVENT TIME: 16:00[EDT]| |NRC NOTIFIED BY: BOB HATHAWAY |LAST UPDATE DATE: 05/31/96 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |DAN HOLODY 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 90 POWER OPERATION | 90 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE 10 CFR 100 LIMITS COULD HAVE BEEN EXCEEDED DURING A STEAM GENERATOR | | TUBE RUPTURE (SGTR) WITH A COINCIDENT LOSS OF CONDENSER VACUUM. | | | | DURING A RECENT REVIEW OF THE ASSUMPTIONS USED IN THEIR EMERGENCY OPERATING | | PROCEDURES VERIFICATION ANALYSIS,IT WAS DETERMINED THAT ACTUAL TIMES TO | | PERFORM CERTAIN FUNCTIONS VARY FROM THE ANALYSIS ASSUMPTIONS. SPECIFICALLY, | | FOR A SGTR EVENT WITH COINCIDENT LOSS OF CONDENSER VACUUM (WHICH IS A MAINE | | YANKEE DESIGN BASIS EVENT), THE ACTUAL TIME TO ISOLATE THE RUPTURED STEAM | | GENERATOR (SG) IS NOW ASSUMED TO TAKE 20 MINUTES. THIS IS A 15 MINUTE | | INCREASE OVER THE PREVIOUS ASSUMPTION. | | | | THE INCREASE IN THE TIME REQUIRED IS BASED ON THE ENVIRONMENTAL CONDITIONS | | THAT WOULD EXIST IN THE MAIN STEAM AND VALVE HOUSE DURING THE POSTULATED | | EVENT. BLOW BACK FROM THE MAIN STEAM SAFETY VALVES, WHICH WOULD BE LIFTING | | DUE TO THE LOSS OF CONDENSER VACUUM, WOULD CREATE A RADIOACTIVE STEAM | | ENVIRONMENT. THUS, FOR A SGTR, WITH A COINCIDENT LOSS OF CONDENSER VACUUM, | | THE INITIATION OF THE COOLDOWN WOULD BE DELAYED. THE DELAY CONSISTS OF THE | | TIME IT WOULD TAKE AN EQUIPMENT OPERATOR TO DON PROTECTIVE CLOTHING AND | | CLOSE THE MANUAL STOP CHECK VALVE IN THE LINE FROM THE RUPTURED SG TO THE | | DECAY HEAT RELEASE HEADER. DURING THIS DELAY, BREAK FLOW LEAKING INTO THE | | RUPTURED SG WILL SIGNIFICANTLY DECREASE THE MARGIN TO SG OVERFILL, AND | | CAUSE THE MAIN STEAM SAFETY VALVE IN THE RUPTURED SG TO CYCLE ADDITIONAL | | TIMES. | | | | AS A RESULT OF THIS EXTENDED ISOLATION TIME, THE POTENTIAL EXISTS THAT A | | SGTR EVENT, WITH COINCIDENT LOSS OF CONDENSER VACUUM COULD RESULT IN AN | | OVERFILL OF THE RUPTURED SG. THIS COULD LEAD TO AN OFF-SITE DOSE IN EXCESS | | OF 10 CFR 100 LIMITS. | | | | THE FOLLOWING IMMEDIATE ACTION HAS BEEN TAKEN. MAINE YANKEE HAS PUT IN | | PLACE AN ADMINISTRATIVE RESTRICTION TO LIMIT THE REACTOR COOLANT SYSTEM | | IODINE CONCENTRATION TO LESS THAN 10% OF THE TECHNICAL SPECIFICATION 3.2 | | (REACTOR COOLANT SYSTEM ACTIVITY LIMITS). THE TECHNICAL SPECIFICATION | | LIMIT IS 1.0 æCi/ml DOSE EQUIVALENT IODINE. THE ADMINISTRATIVE LIMIT IS | | 0.1 æCi/ml DOSE EQUIVALENT IODINE. BASED ON ENGINEERING JUDGMENT, IMPOSING | | THIS RESTRICTION WILL ENSURE THAT THE 10 CFR 100 LIMITS WILL NOT BE | | EXCEEDED EVEN IF THE RUPTURED SG OVERFILLS. | | | | LONGER TERM ACTIONS INCLUDE ENHANCEMENTS TO THE SGTR PROCEDURE TO REDUCE | | THE LIKELIHOOD OF OVERFILL AND POSSIBLE HARDWARE CHANGES TO REDUCE THE | | ISOLATION TIME TO 5 MINUTES AS ORIGINALLY ASSUMED. | | | | LICENSEE WILL NOTIFY THE STATE OF THIS EVENT NOTIFICATION. THE NRC | | RESIDENT INSPECTOR WAS INFORMED OF THIS EVENT BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30569 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: DRESDEN REGION: 3 |NOTIFICATION DATE: 05/31/96 | |UNIT: [ ] [2] [ ] STATE: IL |NOTIFICATION TIME: 22:09 [ET]| |RX TYPE: [1] GE-1,[2] GE-3,[3] GE-3 |EVENT DATE: 05/31/96 | +------------------------------------------------+EVENT TIME: 20:38[CDT]| |NRC NOTIFIED BY: STEVE VERCELLI |LAST UPDATE DATE: 05/31/96 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |M JORDAN 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 | M/R Y 45 POWER OPERATION | 0 HOT SHUTDOWN | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MANUAL REACTOR SCRAM PERFORMED DUE TO REACTOR VESSEL WATER LEVEL | | DECREASING. | | | | OPERATORS INITIATED A MANUAL REACTOR SCRAM WHEN REACTOR VESSEL WATER LEVEL | | STARTED DROPPING. REACTOR VESSEL WATER LEVEL STARTED DROPPING FROM ITS | | NORMAL LEVEL OF + 30" WHILE ENGINEERING PERSONNEL WHERE PERFORMING PROCESS | | TUNING ON THE REACTOR FEEDWATER LEVEL CONTROL SYSTEM (BAILEY) ON THE BACKUP | | COMPUTER. AN OPERATOR TOOK MANUAL CONTROL OF THE REACTOR FEEDWATER SYSTEM | | PUMPS BUT WAS UNABLE TO STOP THE DOWNWARD TREND OF THE REACTOR VESSEL WATER | | LEVEL AND THE REACTOR WAS MANUALLY SCRAMMED. REACTOR VESSEL WATER LEVEL | | HAD DECREASED TO + 18" WHEN THE MANUAL REACTOR SCRAM WAS PERFORMED. THE | | LOWEST REACTOR VESSEL WATER LEVEL, AS READ ON THE MEDIUM REACTOR VESSEL | | VESSEL WATER LEVEL INDICATION, WAS 0". ALL CONTROL RODS FULLY INSERTED | | INTO THE CORE. GROUP 2 (PRIMARY CONTAINMENT ISOLATION) AND GROUP 3 (REACTOR | | WATER CLEANUP ISOLATION & SHUTDOWN COOLING ISOLATION) ISOLATIONS WERE | | RECEIVED BUT THE SHUTDOWN COOLING SYSTEM ISOLATION VALVES WERE ALREADY | | ISOLATED. NO ELECTROMATIC SAFETY RELIEF VALVES OPENED AND STEAM IS BEING | | DUMPED TO THE MAIN CONDENSER VIA THE TURBINE BYPASS SYSTEM. ALL EMERGENCY | | CORE COOLING SYSTEMS & THE EMERGENCY DIESEL GENERATORS ARE OPERABLE. | | THE LICENSEE IS INVESTIGATING THIS EVENT. | | | | THE NRC RESIDENT INSPECTOR WAS INFORMED OF THIS EVENT BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30570 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BEAVER VALLEY REGION: 1 |NOTIFICATION DATE: 05/31/96 | |UNIT: [1] [ ] [ ] STATE: PA |NOTIFICATION TIME: 22:27 [ET]| |RX TYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 05/31/96 | +------------------------------------------------+EVENT TIME: 21:14[EDT]| |NRC NOTIFIED BY: C HYNES |LAST UPDATE DATE: 05/31/96 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |DAN HOLODY RDO | |ARPS 50.72(b)(2)(ii) RPS ACTUATION | | |AESF 50.72(b)(2)(ii) ESF ACTUATION |PETE ESELGROTH REG1 | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | A/R Y 100 POWER OPERATION | 0 HOT STANDBY | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AUTOMATIC REACTOR TRIP DURING TRAIN "B" TESTING OF THE SOLID STATE | | PROTECTION SYSTEM (SSPS). | | | | THE LICENSEE WAS PERFORMING SSPS TRAIN "B" TESTING, PER OST 1.1.12. | | AN OPERATOR WAS IN THE PROCESS OF TESTING THE TURBINE AND MAIN FEEDWATER | | PUMP TRIP CIRCUIT. THE TESTING METHODOLOGY HAS THE OPERATOR ACTUATE A | | BLOCK RELAY PRIOR TO ENERGIZING THE OUTPUT RELAY, AND THE OPERATOR THEN | | DEPRESSES THE WHITE TEST LAMPS TO VERIFY THE SLAVE RELAY HAS PICKED UP. | | UPON DEPRESSING THE FIRST TURBINE TRIP TEST PUSH BUTTON, THE TURBINE | | TRIPPED, WHICH GENERATED A REACTOR TRIP. ALL RODS FULLY INSERTED INTO THE | | CORE. | | | | THE ONLY ITEM NOT UNDERSTOOD, BESIDES THE MAIN TURBINE TRIPPING, IS THE | | AUTOSTART OF THE # 2 EMERGENCY DIESEL GENERATOR (THE LICENSEE THINKS THAT | | THE EDG STARTED ON A SPURIOUS UNDERVOLTAGE SIGNAL). THE DIESEL STARTED BUT | | DID NOT LOAD. THE 4KV BUS REMAINED ENERGIZED AT ALL TIMES. BOTH MAIN | | FEEDWATER PUMPS WERE SECURED DUE TO RELIEF VALVE RV-SV-111B LIFTING. THE | | TURBINE DRIVEN AND BOTH MOTOR DRIVEN AUXILIARY FEEDWATER PUMPS STARTED ON | | LOW LOW STEAM GENERATOR WATER LEVEL. THE TURBINE DRIVEN AUXILIARY | | FEEDWATER PUMP WAS SECURED AND STEAM GENERATOR WATER LEVEL IS BEING | | MAINTAINED BY THE MOTOR DRIVEN AUXILIARY FEEDWATER PUMPS. STEAM DUMP | | BYPASS CONTROL SYSTEM IS OPERATING PROPERLY. | | | | ALL EMERGENCY CORE COOLING SYSTEMS AND THE EMERGENCY DIESEL GENERATORS ARE | | OPERABLE. THE LICENSEE IS INVESTIGATING THIS EVENT. | | | | THE NRC RESIDENT INSPECTOR WILL BE INFORMED BY THE LICENSEE OF THIS EVENT. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30571 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: CRYSTAL RIVER REGION: 2 |NOTIFICATION DATE: 05/31/96 | |UNIT: [3] [ ] [ ] STATE: FL |NOTIFICATION TIME: 23:02 [ET]| |RX TYPE: [3] B&W-L-LP |EVENT DATE: 05/31/96 | +------------------------------------------------+EVENT TIME: 21:25[EDT]| |NRC NOTIFIED BY: IVAN WILSON |LAST UPDATE DATE: 05/31/96 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |TOM DECKER 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 3 | A/R Y 100 POWER OPERATION | 0 HOT STANDBY | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | REACTOR TRIP OCCURRED DURING TURBINE EHC TRIP SOLENOID TESTS. | | | | REACTOR TRIP OCCURRED DURING TURBINE EHC SOLENOID VALVE TESTS. IT APPEARS | | THAT THE TURBINE CONTROL VALVES CLOSED DURING EHC VALVE TESTING. THE | | REACTOR TRIPPED DUE TO HIGH REACTOR COOLANT SYSTEM PRESSURE. NORMAL | | REACTOR COOLANT PRESSURE IS 2155 psig. THE HIGHEST REACTOR COOLANT | | PRESSURE DURING THE TRANSIENT WAS 2350 psig. ALL RODS FULLY INSERTED INTO | | THE CORE. BOTH EMERGENCY FEEDWATER PUMPS STARTED ON LOW ONCE THROUGH STEAM | | GENERATOR (OTSG) WATER LEVEL. OTSG ATMOSPHERIC VALVES OPENED AND CLOSED | | DURING THIS TRANSIENT. ONE TURBINE BYPASS VALVE (MSV-11) ON THE "B" OTSG | | MAY NOT HAVE OPERATED PROPERLY DURING THE TRANSIENT (LICENSEE WAS NOT SURE | | IF THE VALVE HAD OPENED). ALSO, OTSG "B" ATMOSPHERIC VALVE (MSV-33) RESET | | AT A LOWER THAN NORMAL SETPOINT. THE VALVE SHOULD RESET AT APPROXIMATELY | | 1000 psig BUT IT RESET BETWEEN 950 psig AND 990 psig. THEREFORE, THE | | LICENSEE IS MAINTAINING REACTOR COOLANT TEMPERATURE AT 498øF INSTEAD OF AT | | 555øF. LICENSEE IS INVESTIGATING THE ABOVE NOTED PROBLEMS. ALL EMERGENCY | | CORE COOLING SYSTEMS AND THE EMERGENCY DIESEL GENERATORS ARE OPERABLE. | | | | THE NRC RESIDENT INSPECTOR WAS INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30572 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: THREE MILE ISLAND REGION: 1 |NOTIFICATION DATE: 06/01/96 | |UNIT: [1] [ ] [ ] STATE: PA |NOTIFICATION TIME: 06:18 [ET]| |RX TYPE: [1] B&W-L-LP,[2] B&W-L-LP |EVENT DATE: 06/01/96 | +------------------------------------------------+EVENT TIME: 05:20[EDT]| |NRC NOTIFIED BY: BRANTLEY |LAST UPDATE DATE: 06/01/96 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |DANIEL HOLODY RDO | |DDDD 73.71 UNSPECIFIED PARAGRAPH | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | POTENTIAL TAMPERING WITH SECURITY EQUIPMENT | | | | IMMEDIATE COMPENSATORY ACTIONS HAVE BEEN TAKEN. SEE HOO LOG FOR DETAILS. | | THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | | | | *** UPDATE @ 1243 EDT 06/01/96, BY GOODRICH TAKEN BY MACKINNON *** | | | | THIS EVENT REPORT IS BEING RETRACTED AFTER FURTHER REVIEW AND INVESTIGATION | | OF THIS EVENT. THE INVESTIGATION SHOWED THAT THERE WAS NO DELIBERATE ACT | | OF TAMPERING OR SABOTAGE INVOLVED. THEREFORE, THIS EVENT IS BEING | | RETRACTED. THE NRC RESIDENT INSPECTOR WAS INFORMED. R1DO (DAN HOLODY) | | NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30573 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: FERMI REGION: 3 |NOTIFICATION DATE: 06/02/96 | |UNIT: [2] [ ] [ ] STATE: MI |NOTIFICATION TIME: 05:29 [ET]| |RX TYPE: [2] GE-4 |EVENT DATE: 06/02/96 | +------------------------------------------------+EVENT TIME: 04:36[EDT]| |NRC NOTIFIED BY: MAREK |LAST UPDATE DATE: 06/02/96 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MICHAEL J. JORDAN 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 2 | N Y 93 POWER OPERATION | 78 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | TECH SPEC REQUIRED SHUTDOWN | | | | PRIOR TO THIS EVENT, ONE TRAIN (DIV II) OF THE CONTROL ROOM HVAC SYSTEM WAS | | INOPERABLE FOR SCHEDULED MAINTENANCE. DURING THE PERFORMANCE OF THIS | | MAINTENANCE IT WAS IDENTIFIED THAT A DAMPER NEEDED REPAIR. THIS IN TURN | | REQUIRED DIV I OF THE CONTROL ROOM HVAC SYSTEM TO BE PLACED IN THE | | RECIRCULATION MODE. PRIOR TO THE ACCUMULATION OF 720 HOURS IN THE | | RECIRCULATION MODE, THE FILTER PERFORMANCE TEST IS REQUIRED. THIS TEST | | REQUIRED THAT THE DIV I CONTROL ROOM TRAIN ALSO BE DECLARED INOPERABLE. | | | | SINCE THE LICENSEE WAS UNABLE TO COMPLETE THE TESTING IN THE REQUIRED TIME, | | THEY HAVE ENTERED A SIX HOUR SHUTDOWN TECH SPEC ACTION STATEMENT. TECH | | SPEC ACTION STATEMENT 3.7.2.b.1. REQUIRES THE PLANT BE IN HOT SHUTDOWN IN 6 | | HOURS IF BOTH DIVISIONS OF CENTRAL CONTROL ROOM HVAC ARE INOPERABLE. AT | | 0436, A POWER REDUCTION WAS INITIATED IN ACCORDANCE WITH THE TECH SPEC | | ACTION STATEMENT. TESTING IS IN PROGRESS AND IS EXPECTED TO BE COMPLETED | | SATISFACTORILY PRIOR TO 0800, WHICH IS THE DEADLINE TO BE IN HOT SHUTDOWN | | PER TECH SPEC 3.7.2.b.1. | | | | UPON SATISFACTORY PERFORMANCE TEST COMPLETION, ACTION b.1 CAN BE EXITED AND | | ACTION b.2 CONTINUED (7 DAY LCO WHICH EXPIRES AT 0615 ON 6/4/96). THE | | LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | | | | * * * UPDATE AT 0938 ON 6/2/96 BY COSEO TAKEN BY WEAVER * * * | | AT 0748, THE TESTING WAS COMPLETED SATISFACTORILY AND TECH SPEC ACTION | | STATEMENT 3.7.2.B.1 WAS EXITED. THE 7 DAY LCO WAS RESUMED ON DIVISION II | | CCHVAC IAW TECH SPEC 3.7.2.B.2. THE LICENSEE WILL INFORM THE NRC RESIDENT | | INSPECTOR. THE HOO NOTIFIED THE R3DO (JORDAN). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30574 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: FARLEY REGION: 2 |NOTIFICATION DATE: 06/02/96 | |UNIT: [1] [ ] [ ] STATE: AL |NOTIFICATION TIME: 05:51 [ET]| |RX TYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 06/02/96 | +------------------------------------------------+EVENT TIME: 01:00[CDT]| |NRC NOTIFIED BY: LERO |LAST UPDATE DATE: 06/02/96 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |THOMAS DECKER 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 +------------------------------------------------------------------------------+ | ESF ACTUATION - ACTUATION OF THE "B" TRAIN SEQUENCER | | | | DURING THE PERFORMANCE OF THE 1000 KW LOAD REJECT TEST ON THE "1B" EDG, AN | | UNKNOWN FAILURE LED TO THE ACTUATION OF THE "B" TRAIN SEQUENCER. ALL | | EQUIPMENT RESPONDED AS EXPECTED. THE "B" TRAIN COMPONENT COOLING WATER | | PUMP AND CHARGING PUMP WERE ALREADY IN SERVICE WHEN THIS EVENT OCCURRED. | | | | THE LICENSEE BELIEVES THAT THE FAILURE OF A TEST RELAY CAUSED THE SEQUENCER | | ACTUATION, AND THIS IS BEING INVESTIGATED. THE SEQUENCER IS CONSIDERED | | OPERABLE. THIS ACTUATION SHOULD NOT HAVE OCCURRED BECAUSE OF A JUMPER | | INSTALLED DURING THE TEST PROCEDURE. THE PROPER INSTALLATION OF THE JUMPER | | HAS BEEN VERIFIED. | | | | ALL EQUIPMENT NOT RUNNING AT THE TIME OF THE EVENT HAS BEEN RETURNED TO ITS | | STANDBY CONDITION. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 30575 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: WASHINGTON NUCLEAR REGION: 4 |NOTIFICATION DATE: 06/02/96 | |UNIT: [2] [ ] [ ] STATE: WA |NOTIFICATION TIME: 19:14 [ET]| |RX TYPE: [2] GE-5 |EVENT DATE: 06/02/96 | +------------------------------------------------+EVENT TIME: 14:09[PDT]| |NRC NOTIFIED BY: STEVE BERRY |LAST UPDATE DATE: 06/02/96 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |GARY SANBORN RDO | |AMED 50.72(b)(2)(v) OFFSITE MEDICAL | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 2 | N N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | CONTAMINATED CONTRACT HEALTH PHYSICIST (HP) TAKEN TO KADLEC HOSPITAL | | LOCATED IN RICHLAND, WA. | | | | AT 1327 PDT, THE CONTROL ROOM RECEIVED A REPORT THAT A CONTRACT HP, WHO WAS | | DECONTAMINATING THE REACTOR CAVITY, WAS IN NEED OF EMERGENCY MEDICAL | | ATTENTION DUE TO A HEART ATTACK. DUE TO THE SEVERITY OF HIS CONDITION THE | | CONTAMINATED HP WAS TRANSPORTED OFF SITE IN AN AMBULANCE TO THE KADLEC | | HOSPITAL LOCATED IN RICHLAND, WA. THE CONTRACT HP HAD 1000 COUNTS PER | | MINUTE (CPM) OF RADIOACTIVE CONTAMINATION ON ONE SIDE OF HIS HEAD, 200-300 | | CPM OF RADIOACTIVE CONTAMINATION ON THE ON THE OTHER SIDE OF HIS HEAD, AND | | 300 TO 500 CPM OF RADIOACTIVE CONTAMINATION ON HIS PROTECTIVE CLOTHING. | | LICENSEE'S HP ACCOMPANIED THE CONTRACT HP TO THE HOSPITAL. THE HOSPITAL | | REPORTED LATER THAT THE MAN HAD DIED. | | A SURVEY OF THE AMBULANCE FOUND NO RADIOACTIVE CONTAMINATION. | | LICENSEE WILL NOTIFY THE WASHINGTON STATE OF LABOR AND INDUSTRIES OF THIS | | EVENT AND ALSO ISSUE A PRESS RELEASE. | | | | THE NRC RESIDENT INSPECTOR WAS INFORMED BY THE LICENSEE OF THIS EVENT. | +------------------------------------------------------------------------------+