U.S. Nuclear Regulatory Commission Operations Center Event Reports For 01/13/97 - 01/14/97 ** EVENT NUMBERS ** 31478 31581 31582 31583 31584 31585 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 31478 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: MORRISTOWN MEMORIAL HOSPITAL |NOTIFICATION DATE: 12/18/96 | | CITY: MORRISTOWN REGION: 1 |NOTIFICATION TIME: 16:04 [ET]| | COUNTY: MORRIS STATE: NJ |EVENT DATE: 12/18/96 | |LICENSE#: AGREEMENT: N |EVENT TIME: 12:30[EST]| | DOCKET: |LAST UPDATE DATE: 01/13/97 | | +-----------------------------+ | |PERSON ORGANIZATION| | |MOHAMED SHANBAKY RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: DR. SWAYNE | | |HQ OPS OFFICER: LEIGH TROCINE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MEDICAL MISADMINISTRATION (INJECTION OF THE WRONG ISOTOPE) AT MORRISTOWN | | MEMORIAL HOSPITAL LOCATED IN MORRISTOWN, NEW JERSEY, DUE TO HUMAN ERROR. | | | | AT APPROXIMATELY 1230 EST, A PATIENT RECEIVED 6.3 mCi OF HUMAN | | MACRO-AGGREGATED ALBUMIN (MAA) IN LIEU OF THE PRESCRIBED RE-INJECTION OF 1 | | mCi OF THALLIUM. THE SYRINGES WERE LABELLED CORRECTLY, AND THE LICENSEE | | BELIEVES THAT THIS EVENT OCCURRED DUE TO HUMAN ERROR. THE AMOUNT OF MAA | | INJECTED WAS THE TYPICAL DOSE THAT IS USED FOR A LUNG SCAN, AND THE | | LICENSEE DOES NOT BELIEVE THAT THERE WILL BE ANY ADVERSE EFFECTS TO THE | | PATIENT. THE LICENSEE ALSO DOES NOT BELIEVE THAT THERE WAS AN | | OVEREXPOSURE. THE REFERRING PHYSICIAN HAS BEEN INFORMED AND PLANS TO | | NOTIFY THE PATIENT. THE LICENSEE PLANS TO HAVE THE PATIENT RETURN TOMORROW | | TO DELAY SCAN THE PATIENT FOR THE REST OF THE THALLIUM SCAN AND WINDOW OUT | | THE REMAINING LUNG ACTIVITY. | | | | THE LICENSEE PLANS TO FILL OUT AND FILE A DIAGNOSTIC NRC MISADMINISTRATION | | REPORT FORM. (REFER TO THE HOO LOG FOR A SITE CONTACT TELEPHONE NUMBER.) | | | | * * * UPDATE 1202 1/13/97 FROM J. TRIVINAR TAKEN BY STRANSKY * * * | | | | THE LICENSEE IS RETRACTING THIS NOTIFICATION. UPON FURTHER REVIEW OF THE | | REPORTING REQUIREMENTS, THE LICENSEE HAS DETERMINED THAT THIS EVENT IS NOT | | REPORTABLE. NOTIFIED R1DO (WHITE). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |GENERAL INFORMATION or OTHER | |EVENT NUMBER: 31581 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: BASF |NOTIFICATION DATE: 01/13/97 | | CITY: REGION: 2 |NOTIFICATION TIME: 14:37 [ET]| | COUNTY: STATE: NC |EVENT DATE: 01/13/97 | |LICENSE#: AGREEMENT: Y |EVENT TIME: 13:00[EST]| | DOCKET: |LAST UPDATE DATE: 01/13/97 | | +-----------------------------+ | |PERSON ORGANIZATION| | |CHRISTENSEN RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: HIGHTOWER | | |HQ OPS OFFICER: BOB STRANSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AGREEMENT STATE REPORT | | | | THE NC STATE DIVISION OF RADIATION PROTECTION NOTIFIED THE OPERATIONS | | CENTER THAT BASF, A NORTH CAROLINA LICENSEE, DISCOVERED THE LOSS OF TWO | | 8mCi Ni-63 SOURCES. THE LICENSEE BELIEVES THAT THE SOURCES WERE REMOVED | | FROM SOME EQUIPMENT THAT BASF DONATED TO WAKE TECHNICAL COLLEGE IN DECEMBER | | OF 1996. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 31582 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SEABROOK REGION: 1 |NOTIFICATION DATE: 01/13/97 | |UNIT: [1] [ ] [ ] STATE: NH |NOTIFICATION TIME: 15:17 [ET]| |RX TYPE: [1] W-4-LP |EVENT DATE: 01/13/97 | +------------------------------------------------+EVENT TIME: 14:55[EST]| |NRC NOTIFIED BY: M. DAVID |LAST UPDATE DATE: 01/13/97 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |WHITE RDO | |AUNA 50.72(b)(1)(ii)(A) UNANALYZED COND OP | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 FOR PIPING FAILURE DURING ACCIDENT CONDITIONS | | | | WHILE CONDUCTING ENGINEERING EVALUATIONS IN RESPONSE TO NRC GL 96-06, THE | | LICENSEE HAS IDENTIFIED THAT PIPING INSIDE CONTAINMENT ADJACENT TO THE SI | | SYSTEM TEST RETURN LINE COULD BECOME OVERPRESSURIZED DURING CERTAIN DESIGN | | BASIS ACCIDENTS AND CHALLENGE THE INTEGRITY OF CONTAINMENT ISOLATION VALVE | | SI-V-70. ASSUMING A SINGLE FAILURE OF THE OUTBOARD ISOLATION VALVE, THIS | | FAILURE COULD PERMIT CONTAINMENT BYPASS. | | | | THE LICENSEE HAS OPENED THE AFFECTED VALVE, AND REPORTED THAT CONTINUED | | OPERATION WAS PERMITTED BY THE PLANT TECHNICAL SPECIFICATIONS WITH ONLY THE | | OUTBOARD VALVE CLOSED. THE NRC RESIDENT INSPECTOR HAS BEEN INFORMED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 31583 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: POINT BEACH REGION: 3 |NOTIFICATION DATE: 01/13/97 | |UNIT: [ ] [2] [ ] STATE: WI |NOTIFICATION TIME: 16:25 [ET]| |RX TYPE: [1] W-2-LP,[2] W-2-LP |EVENT DATE: 01/13/97 | +------------------------------------------------+EVENT TIME: 13:30[CST]| |NRC NOTIFIED BY: HENNIG |LAST UPDATE DATE: 01/13/97 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BURGESS RDO | |ADAS 50.72(b)(2)(i) DEG/UNANALYZED COND | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N N 0 REFUELING | 0 REFUELING | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | POTENTIAL FOR COMMON MODE FAILURE OF DC ELECTRICAL BUSES DUE TO FAILURE OF | | MOLDED-CASE CIRCUIT BREAKERS TO CLEAR FAULT | | | | THE FOLLOWING IS TEXT OF A FACSIMILE SUBMITTED BY THE LICENSEE: | | | | "DURING FURTHER ANALYSIS FOR OPERABILITY OF DC MOLDED CASE CIRCUIT | | BREAKERS, ENGINEERING DETERMINED THAT CABLE ROUTING OF NON-SAFETY RELATED | | CONTROL CIRCUITS FOR ROD DRIVE MOTOR GENERATORS HAS BOTH NON-SAFETY TRAINS | | (A & B) IN THE SAME RACEWAY. THE MOLDED CASE CIRCUIT BREAKERS ARE TO | | PROVIDE ISOLATION BOUNDARY BETWEEN THE SAFETY RELATED DC BUSES AND THE | | DOWNSTREAM CABLING. HOWEVER, THERE HAS BEEN A HISTORY OF PREVIOUS FAILURES | | OF THESE TYPE BREAKERS TO ISOLATE A FAULT ON A HIGH OVERCURRENT BY THE | | MAGNETIC TRIP ELEMENT. SINCE THE ROUTING OF THE ROD DRIVE MG CONTROL | | CIRCUIT IS SUCH THAT A COMMON FAULT COULD RESULT IN AN OVERCURRENT | | CONDITION WHICH IS ABOVE THE RATING OF THE THERMAL TRIP ELEMENTS, THESE | | BREAKERS COULD POTENTIALLY NOT CLEAR A FAULT CONDITION. OUR CONSERVATIVE | | ANALYSIS WHERE NEITHER BREAKER WOULD OPEN WOULD RESULT IN THE DC BUSES' | | SUPPLY FUSES OPENING, AND DEENERGIZING OF THE SAFETY RELATED LOADS ON THE | | BUSES (D-19 AND D-22). THIS WOULD REMOVE CAPABILITY TO SHUT EITHER MAIN | | STEAM ISOLATION VALVE (2MS-2017 AND 2MS-2018) OR TO ACTUATE EITHER TRAIN OF | | ENGINEERED SAFETY FEATURES (EFSAS). | | | | THE SAME CONDITION HAS BEEN EVALUATED ON UNIT 1 TO NOT EXIST. FOR UNIT 2, | | ONE BREAKER THAT FEEDS THE 'A' TRAIN ROD DRIVE MG CONTROL CIRCUIT (D22-06) | | HAS BEEN OPENED TO ELIMINATE THE POTENTIAL FOR A COMMON FAULT TO CAUSE | | FAILURES IN BOTH SAFETY RELATED TRAINS OF SAFEGUARDS EQUIPMENT." | | | | THE NRC RESIDENT INSPECTOR HAS BEEN INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 31584 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: LASALLE REGION: 3 |NOTIFICATION DATE: 01/13/97 | |UNIT: [1] [2] [ ] STATE: IL |NOTIFICATION TIME: 18:55 [ET]| |RX TYPE: [1] GE-5,[2] GE-5 |EVENT DATE: 01/13/97 | +------------------------------------------------+EVENT TIME: 16:00[CST]| |NRC NOTIFIED BY: SCHAIBLE |LAST UPDATE DATE: 01/13/97 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BURGESS RDO | |ADAS 50.72(b)(2)(i) DEG/UNANALYZED COND | | |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 N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | 2 | N N 0 REFUELING | 0 REFUELING | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | CONTROL ROOM RADIATION MONITOR LOGIC DOES NOT MEET SINGLE-FAILURE CRITERIA | | | | THE FOLLOWING IS TEXT OF A FACSIMILE SUBMITTED BY THE LICENSEE: | | | | "ON JANUARY 13, 1997 AT 1600 CST, IT WAS DETERMINED THAT A CONDITION | | EXISTED IN THE CONTROL ROOM VENTILATION SYSTEM THAT RESULTED IN THE PLANT | | BEING IN AN UNANALYZED CONDITION. AN ENGINEERING REVIEW WAS RECENTLY DONE | | ON MODIFICATIONS PERFORMED ON THE CONTROL ROOM VENTILATION SYSTEM IN JULY | | OF 1993 IN WHICH THE LOGIC AND WIRING OF THE CONTROL ROOM VENTILATION | | INTAKE RADIATION MONITORS HAD BEEN CHANGED TO PREVENT SPURIOUS ACTUATIONS. | | THE ENGINEERING EVALUATION DETERMINED THAT THE CHANGED CONTROL ROOM | | RADIATION MONITOR LOGIC DID NOT MEET THE SINGLE FAILURE CRITERIA REQUIRED | | BY THE SAFETY EVALUATION REPORT. IN ADDITION, THE MODIFICATION RESULTED IN | | AN UNREVIEWED SAFETY QUESTION BECAUSE THE LOGIC INCREASED THE NUMBER OF | | MONITORS REQUIRED TO INITIATE THE TRIP LOGIC AND MAY THEREFORE HAVE | | INCREASED THE PROBABILITY OF FAILURE OF EQUIPMENT IMPORTANT TO SAFETY. | | | | UNIT 1 IS CURRENTLY IN COLD SHUTDOWN AND UNIT 2 IS CURRENTLY DEFUELED. THE | | CONTROL ROOM VENTILATION SYSTEM IS CONSIDERED INOPERABLE AT THIS TIME DUE | | TO DESIGN DEFICIENCIES WITH THE SYSTEM FOR MAINTAINING REQUIRED SYSTEM | | POSITIVE PRESSURE WITH RESPECT TO ITS SURROUNDING AREAS. THE INOPERABILITY | | OF THE CONTROL ROOM VENTILATION SYSTEM WAS PREVIOUSLY REPORTED. THE | | RADIATION MONITORS ARE NOT REQUIRED TO BE OPERABLE IN THE CURRENT PLANT | | CONDITION." | | | | THE NRC RESIDENT INSPECTOR HAS BEEN INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 31585 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MILLSTONE REGION: 1 |NOTIFICATION DATE: 01/13/97 | |UNIT: [ ] [ ] [3] STATE: CT |NOTIFICATION TIME: 19:05 [ET]| |RX TYPE: [1] GE-3,[2] CE,[3] W-4-LP |EVENT DATE: 01/13/97 | +------------------------------------------------+EVENT TIME: 18:45[EST]| |NRC NOTIFIED BY: KULTERMAN |LAST UPDATE DATE: 01/13/97 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |WHITE 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 +------------------------------------------------------------------------------+ | POTENTIAL FOR WATER HAMMER TO DAMAGE CONTAINMENT RECIRCULATION SPRAY SYSTEM | | | | THE LICENSEE HAS IDENTIFIED A DEFICIENCY IN THE PIPING DESIGN OF THE | | CONTAINMENT RECIRCULATION SPRAY SYSTEM. SPECIFICALLY, A WATER HAMMER COULD | | OCCUR IF THE ASSOCIATED PUMP IS OPERATED, STOPPED, THEN RESTARTED, DUE TO | | LOOP SEALS IN THE VERTICAL PIPING ASSOCIATED WITH THIS SYSTEM. THIS | | CONDITION COULD OCCUR WHEN THE SYSTEM IS BEING USED IN EITHER THE | | CONTAINMENT SPRAY OR RCS COLD LEG RECIRCULATION MODE. THE NRC RESIDENT | | INSPECTOR HAS BEEN INFORMED OF THIS EVENT BY THE LICENSEE. | +------------------------------------------------------------------------------+