U.S. Nuclear Regulatory Commission Operations Center Event Reports For 01/09/97 - 01/10/97 ** EVENT NUMBERS ** 31508 31561 31562 31563 31564 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 31508 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: COOPER REGION: 4 |NOTIFICATION DATE: 12/24/96 | |UNIT: [1] [ ] [ ] STATE: NE |NOTIFICATION TIME: 20:47 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 12/24/96 | +------------------------------------------------+EVENT TIME: 16:00[CST]| |NRC NOTIFIED BY: DOUG HITZEL |LAST UPDATE DATE: 01/09/97 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |GENE BATES 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 +------------------------------------------------------------------------------+ | INDICATION OF AN 8-SECOND STANDBY GAS TREATMENT TRAIN 'A' START AND RUN. | | | | AT APPROXIMATELY 1600 CST ON DECEMBER 24, 1996, DURING THE INVESTIGATION OF | | A STANDBY GAS TREATMENT SYSTEM AUTOMATIC REACTOR BUILDING DIFFERENTIAL | | PRESSURE CONTROL VALVE PROBLEM, THE LICENSEE IDENTIFIED AN INDICATION OF A | | STANDBY GAS TREATMENT TRAIN 'A' START AND RUN FOR APPROXIMATELY 8 SECONDS | | AT APPROXIMATELY 1703 CST ON DECEMBER 23, 1996. THIS ANOMALY WAS | | IDENTIFIED AS RELAY ACTUATIONS DURING A REVIEW OF DATA FROM THE PLANT | | MANAGEMENT INFORMATION SYSTEM COMPUTER. THIS IS POSSIBLY DUE TO A LOOSE | | CONNECTION IN STANDBY GAS TREATMENT/REACTOR BUILDING ISOLATION LOGIC RELAYS | | PC-REL-ISO1AX (SYSTEM 'A' ISOLATION RELAY) AND PC-REL-ISO2AX (SYSTEM 'A' | | ISOLATION RELAY). THESE RELAYS FAIL SAFE UPON A LOSS OF POWER, AND A | | POSSIBLE LOOSE CONNECTION WOULD CAUSE THE ISOLATION LOGIC TO ACTUATE. | | | | THE LICENSEE IS REPORTING THIS ISSUE AS A CONSERVATIVE MEASURE DUE TO THE | | LOGIC TIE TO VALVES REC-MO-711MV (NORTH CRITICAL LOOP COOLING SUPPLY FOR | | EMERGENCY CORE COOLING SYSTEMS) AND SW-MO-650MV (RESIDUAL HEAT REMOVAL HEAT | | EXCHANGER 'A' OUTLET). THIS LOGIC INCLUDES A 30-SECOND TIME DELAY FOR | | VALVE REC-MO-711MV ACTUATION (OPENING). HOWEVER, SINCE THE INITIATION | | SIGNAL WAS ONLY PRESENT FOR APPROXIMATELY 8 SECONDS, THIS ACTUATION DID NOT | | OCCUR. HAD THE INITIATION BEEN PRESENT FOR 30 SECONDS, VALVE REC-MO-711MV | | ACTUATION WOULD HAVE OCCURRED. THE CAUSE OF THIS CONDITION IS CURRENTLY | | UNDER INVESTIGATION. | | | | THE LICENSEE NOTIFIED THE NRC RESIDENT INSPECTOR. | | | | *** RETRACTION BY MARK KAUL ON 01/09/97 @ 1423 EDT TAKEN BY MACKINNON *** | | | | THE FOLLOWING IS TEXT EXCERPTED FROM A FACSIMILE SUBMITTED BY THE LICENSEE: | | | | "SBGT TRAIN "A" WAS ACTUATED ON AN INVALID SIGNAL IN THAT NONE OF THE | | ACTUAL PLANT CONDITIONS OR PARAMETERS SATISFYING THE SPECIFIC ESF ACTUATION | | WERE DETERMINED TO BE PRESENT. WHILE VARIOUS VALVES AND OTHER EQUIPMENT HAD | | ALSO RECEIVED ACTUATION SIGNALS DURING THIS EVENT, NONE HAD RECEIVED THE | | SIGNALS FOR A DURATION WHICH WOULD RESULT IN THE ACTUATION OF OTHER ESF | | SYSTEMS/SUBSYSTEMS. THE EXACT CAUSE OF THE INVALID SIGNAL HAS NOT YET BEEN | | DETERMINED; HOWEVER, TROUBLESHOOTING AS TO THE ORIGIN OF THE INVALID SIGNAL | | IS CONTINUING. CURRENTLY, THE SIGNAL IS BEING ATTRIBUTED TO A SUSPECTED | | NONCONFORMING CONDITION OF THE SGT/REACTOR BUILDING ISOLATION LOGIC FOR | | SBGT TRAIN "A". | | | | THE DISTRICT HAS DETERMINED THAT THE ONLY ESF SYSTEM/SUBSYSTEM TO ACTUATE | | DURING THIS EVENT IS THE SBGT TRAIN "A". AS SUCH, 10 CFR 50.72(b)(ii)(B) | | ALLOWS LICENSEES, IN PART, TO NOT REPORT CERTAIN ESF ACTUATIONS PROVIDED 1) | | THE ACTUATION IS INVALID, AND 2) INVOLVES ONLY THE LISTED ESFs IN THIS | | REGULATION. BOTH OF THESE CONDITIONS HAD BEEN SATISFIED IN THAT THE | | ACTUATION OF THE SBGT TRAIN "A" WAS INVALID, AND THAT THE ESF INVOLVED ONLY | | THE REACTOR BUILDING VENTILATION SYSTEM (REFERENCE 50.72(b)(2)(ii)(B)(iii). | | THE STATEMENTS OF CONSIDERATION PROVIDED IN VOLUME 57 FEDERAL REGISTER PAGE | | 41378, EFFECTIVE 10/13/92, EXPLICITLY STATES THAT "THE ACTUATION OF THE | | STANDBY GAS TREATMENT SYSTEM FOLLOWING AN INVALID ACTUATION OF THE REACTOR | | BUILDING VENTILATION SYSTEM IS ALSO EXEMPTED FROM REPORTING." THEREFORE, | | THE CONDITIONS OF 10 CFR 50.72(b)(2)(ii)(B) FOR AN INVALID SIGNAL INVOLVING | | ONE OF THE SPECIFICALLY LISTED ESFs HAD BEEN SATISFIED, AND THE ENS | | NOTIFICATION OF 12/24/96 IS RETRACTED. R4DO (CHRIS VANDENBURGH) NOTIFIED." | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED OF THIS EVENT BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 31561 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: INDIAN POINT REGION: 1 |NOTIFICATION DATE: 01/09/97 | |UNIT: [2] [ ] [ ] STATE: NY |NOTIFICATION TIME: 14:16 [ET]| |RX TYPE: [2] W-4-LP,[3] W-4-LP |EVENT DATE: 01/09/97 | +------------------------------------------------+EVENT TIME: 03:45[EST]| |NRC NOTIFIED BY: SANTINI |LAST UPDATE DATE: 01/09/97 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |HAROLD GRAY RDO | |NLTR LICENSEE 24 HR REPORT | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | ISOLATION OF FIRE PROTECTION HEADERS | | | | THE FOLLOWING TEXT IS FROM A FACSIMILE SENT BY THE LICENSEE: | | | | "AT 0345 01/09/97 TAG OUT 96-N-6022 WAS APPLIED FOR WORK ORDER 94-73911 TO | | REPAIR 12 FMBP (FIRE MAIN BOOSTER PUMP) PRESSURE GAUGE TO STOP A LEAK-BY. | | THE TAG OUT REMOVED 12 FMBP FROM SERVICE WHICH NECESSITATED ENTRY INTO A 7 | | DAY ADMINISTRATIVE ACTION STATEMENT PER SAO 703 AND THE FIRE PROTECTION | | PROGRAM PLAN TABLE D.1-1 ITEM 2. IN ADDITION TO ISOLATING 12 FMBP, VALVE | | FP-1 WAS CLOSED AS PART OF THE TAG OUT. THIS HAD THE EFFECT OF ISOLATING | | THE DIESEL FIRE PUMP FROM THE INSIDE (TURBINE HALL) FIRE PROTECTION HEADER | | AND ISOLATING 11 FMBP FROM THE OUTSIDE HEADER. THIS RESULTED IN AN ENTRY | | INTO ADDITIONAL ADMINISTRATION REQUIREMENTS PER SAO 703 REV 8 ADDENDUM 1 | | ITEM 2B REQUIREMENTS WHICH INCLUDES ESTABLISHING AN ALTERNATE FIRE | | PROTECTION SYSTEM WITHIN 24 HRS. BOTH THE INSIDE AND OUTSIDE HEADERS HAD A | | HIGH PRESSURE FIRE WATER SOURCE AVAILABLE VIA 11 FMBP AND THE DIESEL FIRE | | PUMP. SEPARATION OF THE HEADERS RESULTS IN A CONDITION WHERE 11 FMBP FEEDS | | THE INSIDE HEADER AND THE DIESEL FIRE PUMP FEEDS THE OUTSIDE HEADER. AT NO | | TIME WAS EITHER HEADER WITHOUT A HIGH PRESSURE WATER SUPPLY." | | | | THE IMMEDIATE ACTIONS OF THE LICENSEE WERE TO REMOVE TAG 96-N-6022, PLACE | | 12 FMBP IN SERVICE, AND RECONNECT THE INNER AND OUTER HEADERS. THE LICENSEE | | PLANS TO CONTACT THE NRC REGION 1 OFFICE REGARDING THIS EVENT. | | | | THE NRC RESIDENT INSPECTOR WILL BE NOTIFIED OF THIS EVENT. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 31562 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: ALTOONA HOSPITAL |NOTIFICATION DATE: 01/09/97 | | CITY: ALTOONA REGION: 1 |NOTIFICATION TIME: 15:40 [ET]| | COUNTY: STATE: PA |EVENT DATE: 01/09/97 | |LICENSE#: 37-11826-01 AGREEMENT: N |EVENT TIME: 13:00[EST]| | DOCKET: |LAST UPDATE DATE: 01/09/97 | | +-----------------------------+ | |PERSON ORGANIZATION| | |HAROLD GRAY RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: DR. VINCE | | |HQ OPS OFFICER: JOHN MacKINNON | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THREE POSSIBLE MEDICAL MISADMINISTRATIONS DISCOVERED DURING A QUALITY | | MANAGEMENT PROGRAM AUDIT. | | | | THREE PATIENTS WERE GIVEN WHOLE BODY SCANS FOR THYROID CANCER. THE PATIENTS | | WERE SUPPOSED TO RECEIVE 3 mCi OF SODIUM IODIDE (I-131) BEFORE THE WHOLE | | BODY SCAN WAS PERFORMED. DURING A QUALITY MANAGEMENT PROGRAM AUDIT, THE | | LICENSEE DISCOVERED THAT, ON 6/24/96, A PATIENT RECEIVED ONLY 77% OF THE | | PRESCRIBED DOSE, AND ON 7/25/96 AND 9/19/96, PATIENTS RECEIVED 76% OF THE | | PRESCRIBED DOSES. THESE UNDERDOSES OF I-131 POSE NO MEDICAL THREAT TO THE | | PATIENTS. | | | | THE PATIENTS AND THEIR DOCTORS WILL BE INFORMED OF THE ABOVE INFORMATION BY | | THE ALTOONA HOSPITAL MEDICAL STAFF. THE RADIATION SAFETY OFFICER STATED | | THAT GOOD IMAGES OF THE PATIENTS COULD BE OBTAINED EVEN WITH THE 24% | | UNDERDOSE OF I-131. THE LICENSEE HAS ALREADY REPORTED THIS EVENT TO NRC | | REGION 1 (JIM DWYER). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 31563 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SEABROOK REGION: 1 |NOTIFICATION DATE: 01/09/97 | |UNIT: [1] [ ] [ ] STATE: NH |NOTIFICATION TIME: 17:07 [ET]| |RX TYPE: [1] W-4-LP |EVENT DATE: 01/09/97 | +------------------------------------------------+EVENT TIME: 17:00[EST]| |NRC NOTIFIED BY: FREEMAN |LAST UPDATE DATE: 01/09/97 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |HAROLD GRAY 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 100 POWER OPERATION | 100 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | FLOODING DESIGN BASES FOR THE PROBABLE MAXIMUM HURRICANE MAY BE EXCEEDED. | | | | THE LICENSEE HAS DETERMINED THAT THE SEABROOK STATION UFSAR DESIGN BASIS | | FOR HURRICANE INDUCED FLOODING MAY BE EXCEEDED DURING THE PROBABLE MAXIMUM | | HURRICANE (PMH). THE FLOODING DESIGN BASIS, WHICH IS DOCUMENTED IN SECTION | | 2.4 OF THE UFSAR, SPECIFIES THAT FLOOD LEVELS ASSOCIATED WITH THE PMH ARE | | AT ELEVATION 21' MEAN SEA LEVEL (MSL). THE ELEVATION OF DOOR SILLS IN | | SAFETY RELATED BUILDINGS IS 21.5', WHICH IS HIGHER THAN THE DESIGN BASIS | | FLOOD LEVEL CURRENTLY SPECIFIED IN THE UFSAR. DURING A SITE WALKDOWN | | CONDUCTED IN SUPPORT OF AN ONGOING DESIGN BASIS REVIEW, THE LICENSEE | | DETERMINED THAT THE ADDITION OF CONCRETE CURBING/STEEL PLATES AT THE | | PROTECTED AREA PERIMETER AND CONSTRUCTION OF NEW BUILDINGS WERE NOT | | EVALUATED AS TO THEIR IMPACT ON THE SITE FLOODING ANALYSIS. A PRELIMINARY | | REVISION OF THE SITE FLOODING ANALYSIS HAS DETERMINED THAT THESE STRUCTURES | | WILL IMPEDE THE OUTFLOW OF WATER FROM VARIOUS LOCATIONS ON THE SITE, | | CREATING AN INCREASE IN THE MAXIMUM FLOOD ELEVATION TO APPROXIMATELY 21.7'. | | THE REVISED FLOOD LEVEL OF 21.7' EXCEEDS THE DOOR SILL ELEVATION TO 21.5' | | FOR SAFETY RELATED BUILDINGS (THE DOORS TO THE PRIMARY AUXILIARY BUILDING, | | SERVICE WATER PUMP HOUSE, & FUEL STORAGE BUILDING). | | | | THE LICENSEE HAS DETERMINED THAT THERE IS NO IMMEDIATE SAFETY CONCERN | | ASSOCIATED WITH THIS CONDITION AND THAT NO IMMEDIATE PHYSICAL CHANGES ARE | | REQUIRED DUE TO THE EXTREMELY LOW PROBABILITY OF THE OCCURRENCE OF A PMH. | | THE HURRICANE SEASON IN THE NORTHEASTERN UNITED STATES IS JUNE 1st TO | | NOVEMBER 1st. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED OF THIS EVENT BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 31564 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: POINT BEACH REGION: 3 |NOTIFICATION DATE: 01/09/97 | |UNIT: [1] [ ] [ ] STATE: WI |NOTIFICATION TIME: 23:36 [ET]| |RX TYPE: [1] W-2-LP,[2] W-2-LP |EVENT DATE: 01/09/97 | +------------------------------------------------+EVENT TIME: 20:15[CST]| |NRC NOTIFIED BY: MIELKE |LAST UPDATE DATE: 01/09/97 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |LEWIS MILLER RDO | |AINC 50.72(b)(2)(iii)(C) POT UNCNTRL RAD REL | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | LIQUID TRAPPED IN ISOLATED SECTIONS OF PIPING COULD EXPAND UNDER ELEVATED | | POST ACCIDENT TEMPERATURES AND OVERPRESSURIZE CONTAINMENT PENETRATIONS | | CAUSING THEIR FAILURE. | | | | WHILE PERFORMING EVALUATIONS ON PIPING SYSTEM CONTAINMENT PENETRATIONS PER | | GENERIC LETTER 96-06, IT WAS DISCOVERED THAT THERE IS A POTENTIAL TO | | OVERPRESSURIZE THE UNIT 1 SEAL RETURN PIPING (SEAL RETURN FROM THE REACTOR | | COOLANT PUMP). THIS POTENTIAL COULD EXIST SHOULD BOTH CONTAINMENT ISOLATION | | VALVES BE SHUT COINCIDENT WITH A DESIGN BASIS LARGE BREAK LOCA WHICH COULD | | HEAT THE TRAPPED LIQUID, AND OVERPRESSURIZE THE PIPE. | | | | BASED ON THIS SCENARIO, THE CONTAINMENT WAS DECLARED INOPERABLE, AND A | | ONE-HOUR LCO WAS ENTERED PER TECH SPEC 15.3.6.A.1.a.(1). THIS LCO WAS | | EXITED WHEN ONE OF THE SEAL RETURN CONTAINMENT ISOLATION VALVES WAS TAGGED | | OPEN, WHICH EFFECTIVELY REMOVED THE OVERPRESSURIZATION POTENTIAL. A | | FOUR-HOUR LCO WAS THEN ENTERED PER TECH SPEC 15.3.6.A.1.b(1)(a) PER AN | | INOPERABLE CONTAINMENT ISOLATION VALVE. | | | | AN ENGINEERING ANALYSIS HAS BEEN PERFORMED WHICH SHOWS THAT THE | | INSTALLATION OF THERMAL INSULATION ON THE SECTION OF PIPE IN QUESTION WILL | | REMOVE THE OVERPRESSURIZATION CONCERN. THIS INSULATION WORK IS UNDER WAY | | AND INSULATION WILL BE IN-PLACE IN ORDER TO EXIT THE 4 HOUR LCO. A PROMPT | | OPERABILITY DETERMINATION OF THIS CONDITION WILL BE COMPLETED WITHIN 24 | | HOURS. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED OF THIS EVENT BY THE LICENSEE. | +------------------------------------------------------------------------------+