U.S. Nuclear Regulatory Commission Operations Center Event Reports For 01/15/97 - 01/16/97 ** EVENT NUMBERS ** 31594 31595 31596 31597 31598 31599 31600 +----------------------------------+ +-----------------------+ |GENERAL INFORMATION or OTHER | |EVENT NUMBER: 31594 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: HILLIS-CARNES ENG. ASSOC. INC. |NOTIFICATION DATE: 01/15/97 | | CITY: WHEATON REGION: 1 |NOTIFICATION TIME: 10:46 [ET]| | COUNTY: MONTGOMERY STATE: MD |EVENT DATE: 01/14/97 | |LICENSE#: 19-30304-01 AGREEMENT: Y |EVENT TIME: 08:30[EST]| | DOCKET: |LAST UPDATE DATE: 01/15/97 | | +-----------------------------+ | |PERSON ORGANIZATION| | |DAVID SILK RDO | | |COOL EO | +------------------------------------------------+RICHARD BARRETT IRD | |NRC NOTIFIED BY: NELSON(STATE OF MARYLAND) | | |HQ OPS OFFICER: CHAUNCEY GOULD | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NINF INFORMATION ONLY | | |NAGR AGREEMENT STATE | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE MARYLAND DEPARTMENT OF THE ENVIRONMENT, AIR, AND RADIATION MANAGEMENT | | NOTIFIED THE NRC THAT A TROXLER MODEL-3440 MOISTER DENSITY GAUGE WAS STOLEN | | FROM HILLIS-CARNES ENGINEERING ASSOCIATES INC. OF ANNAPOLIS JUNCTION, MD. | | | | THIS TROXLER GAUGE WAS STOLEN FROM A STORAGE TRAILER LOCATED AT THE | | NORTHEAST HIGH SCHOOL CONSTRUCTION SITE IN WHEATON, MD. THE GAUGE | | CONTAINED 10 MILLICURIES OF CESIUM-137 AND 40 MILLICURIES OF AMERICIUM-241 | | BERYLLIUM. THE STATE HAS ISSUED PRESS RELEASES, BUT THE GAUGE HAS NOT YET | | BEEN RETURNED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 31595 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: TURKEY POINT REGION: 2 |NOTIFICATION DATE: 01/15/97 | |UNIT: [3] [4] [ ] STATE: FL |NOTIFICATION TIME: 12:46 [ET]| |RX TYPE: [3] W-3-LP,[4] W-3-LP |EVENT DATE: 01/15/97 | +------------------------------------------------+EVENT TIME: 09:00[EST]| |NRC NOTIFIED BY: EDDINGER |LAST UPDATE DATE: 01/15/97 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |VERRELLI 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 3 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | 4 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | POTENTIAL FOR INADEQUATE TESTING OF MSL ISOLATION FUNCTION | | | | THE FOLLOWING IS TEXT OF A FACSIMILE SUBMITTED BY THE LICENSEE: | | | | "DURING A REVIEW OF CIRCUITS AND SURVEILLANCES IN ACCORDANCE WITH GENERIC | | LETTER 96-01, FLORIDA POWER & LIGHT COMPANY DISCOVERED A COMBINATION OF | | APPROVED PROCEDURAL STEPS WHICH COULD HAVE ALLOWED INADEQUATE SURVEILLANCE | | TESTING OF THE MAIN STEAM LINE ISOLATION FUNCTION ON CONTAINMENT HIGH-HIGH | | PRESSURE. TECHNICAL SPECIFICATION TABLE 4.3-2, ITEM 4 (STEAM LINE | | ISOLATION), REQUIRES THAT A TRIP ACTUATING DEVICE OPERATIONAL TEST BE | | PERFORMED EACH REFUELING OUTAGE FOR MANUAL INITIATION (ITEM 4a) AND FOR | | CONTAINMENT HIGH PRESSURE COINCIDENT WITH HIGH-HIGH PRESSURE (ITEM 4c). | | | | PLANT PROCEDURES (3/4-OSP-072.1) PROVIDED TO SATISFY THE REQUIREMENTS OF | | ITEM 4a VERIFY THAT THE MAIN STEAM ISOLATION VALVE (MSIV) WILL SHUT ON | | MANUAL INITIATION BUT DO NOT VERIFY THAT EACH TRAIN WILL INDEPENDENTLY SHUT | | THE MSIV. PLANT PROCEDURES (3/4-OSP-203.1 AND 203.2) PROVIDED TO SATISFY | | THE REQUIREMENTS OF ITEM 4c VERIFY THAT EACH TRAIN WILL INDEPENDENTLY SHUT | | THE MSIV BUT CONTAIN A NOTE WHICH ALLOWS FOR MONITORING OF THE STATUS OF | | THE STEAM LINE ACTUATING RELAYS IF THE ISOLATION VALVES (MSIVs) ARE | | UNAVAILABLE. IF THE NOTE IS INVOKED FOR MORE THAN ONE OF THE SIX ACTUATING | | RELAYS (THREE MSIVs, EACH WITH TWO TRAINS), THE STEAM LINE ISOLATION | | FUNCTION WOULD NO LONGER BE PROVIDED TO SATISFY SINGLE FAILURE CRITERIA. | | | | THIS COMBINATION OF PROCEDURES CONSTITUTES A CONDITION WHICH ALONE COULD | | HAVE PREVENTED THE FULFILLMENT OF A SAFETY FUNCTION NEEDED TO MITIGATE THE | | CONSEQUENCES OF AN ACCIDENT AND IS THEREFORE REPORTABLE UNDER 10 CFR | | 50.72(b)(2)(iii). A REVIEW OF SURVEILLANCES PERFORMED SINCE THE LISTED | | PROCEDURE STEPS WERE APPROVED INDICATES THAT AT NO TIME WAS THE NOTE | | INVOKED FOR MORE THAN ONE OF THE STEAM LINE ACTUATING RELAYS." | | | | THE NRC RESIDENT INSPECTOR HAS BEEN INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |GENERAL INFORMATION or OTHER | |EVENT NUMBER: 31596 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: RICKER, ATKINSON, MCBEE & ASSOC |NOTIFICATION DATE: 01/15/97 | | CITY: TEMPE REGION: 4 |NOTIFICATION TIME: 14:00 [ET]| | COUNTY: STATE: AZ |EVENT DATE: 01/14/97 | |LICENSE#: 7-406 AGREEMENT: Y |EVENT TIME: 15:30[MST]| | DOCKET: |LAST UPDATE DATE: 01/15/97 | | +-----------------------------+ | |PERSON ORGANIZATION| | |TAPIA RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: C. CAIN (NRC REGION 4) | | |HQ OPS OFFICER: BOB STRANSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AGREEMENT STATE REPORT | | | | THE FOLLOWING IS TEXT OF A FACSIMILE SUBMITTED BY THE STATE: | | | | "ON JANUARY 11, 1997, AN ATTEMPT WAS MADE TO NOTIFY THE ARIZONA RADIATION | | REGULATORY AGENCY THAT A TROXLER MOISTURE/DENSITY GAUGE, MODEL 3430, S/N | | 26457, SEALED SOURCE NUMBERS 75-9560 AND 47-22903, WAS REMOVED FROM THE BED | | OF A TRUCK THAT WAS IN A PARKING LOT LOCATED AT 2820 E. MARCONI, IN | | PHOENIX, ARIZONA. DUE TO A PROBLEM WITH THE REPORTING SYSTEM, THE AGENCY | | WAS NOT NOTIFIED UNTIL JANUARY 14, 1997. THE DEVICE WAS REMOVED SOMETIME | | BETWEEN 4:00 PM JANUARY 10, 1997, AND 4:00 PM JANUARY 11, 1997. THE DEVICE | | CONTAINED 8 mCi OF Cs-137 AND 40 mCi OF Am-241/Be. THE PHOENIX POLICE | | DEPARTMENT IS INVESTIGATING THIS INCIDENT AS CASE #70-058314. THE AGENCY | | SENT AN INVESTIGATOR TO THE LICENSEE'S ADDRESS." | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 31597 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: CENTRE COMMUNITY HOSPITAL |NOTIFICATION DATE: 01/15/97 | | CITY: STATE COLLEGE REGION: 1 |NOTIFICATION TIME: 15:20 [ET]| | COUNTY: CENTRE STATE: PA |EVENT DATE: 12/20/96 | |LICENSE#: 37-13681-01 AGREEMENT: N |EVENT TIME: 00:00[EST]| | DOCKET: |LAST UPDATE DATE: 01/15/97 | | +-----------------------------+ | |PERSON ORGANIZATION| | |SILK RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: DR. NAGLE | | |HQ OPS OFFICER: BOB STRANSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MEDICAL MISADMINISTRATION | | | | ON 12/20/96, A PATIENT WAS BEING TREATED WITH AN Ir-192 HIGH DOSE RATE | | BRACHYTHERAPY FOR NASAL CANCER. THE TREATMENT PLAN CALLED FOR A DOSE OF 400 | | cGy TO BE DELIVERED TO THE TREATMENT AREA USING A CATHETER PLACED INSIDE AN | | APPLICATOR TUBE WITH THE APPLICATOR HELD IN PLACE BY A PLASTIC MASK. AFTER | | THE TREATMENT WAS ADMINISTERED, THE DOCTOR WAS REMOVING THE PLASTIC MASK | | AND APPLICATOR TUBE WHEN THE CATHETER DROPPED INTO THE PATIENT'S LAP. AT | | THAT TIME, THE MEDICAL PHYSICIST WAS UNABLE TO DETERMINE WHETHER THE | | CATHETER HAD BECOME DISLODGED BEFORE OR AFTER TREATMENT. THIS WAS 1 OF 11 | | TREATMENT FRACTIONS, AND THE OTHER FRACTIONS WERE ADMINISTERED WITHOUT | | INCIDENT. | | | | DURING FOLLOWUP VISITS TO THE HOSPITAL, THE DOCTOR NOTICED SOME REDDENING | | OF THE PATIENT'S SKIN INDICATING THAT THE CATHETER HAD INDEED BEEN | | DISLODGED BEFORE TREATMENT. THE LICENSEE ESTIMATES THAT LOCALIZED PORTIONS | | THE PATIENT'S SKIN MAY HAVE RECEIVED UP TO 3,000 cGy IF THE CATHETER HAD | | CONTACTED THE SKIN. | | | | THE LICENSEE HAS NOT CONTACTED NRC REGION I REGARDING THIS EVENT. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 31598 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: NINE MILE POINT REGION: 1 |NOTIFICATION DATE: 01/15/97 | |UNIT: [ ] [2] [ ] STATE: NY |NOTIFICATION TIME: 18:01 [ET]| |RX TYPE: [1] GE-2,[2] GE-5 |EVENT DATE: 01/15/97 | +------------------------------------------------+EVENT TIME: 17:15[EST]| |NRC NOTIFIED BY: R. ORZELL |LAST UPDATE DATE: 01/15/97 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |SILK 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | STANDBY GAS TREATMENT SYSTEM UNABLE TO FULFILL SAFETY FUNCTION. | | | | THE FOLLOWING IS TEXT OF A FACSIMILE SUBMITTED BY THE LICENSEE: | | | | "FROM 12/11/96 TO 12/13/96, NINE MILE POINT UNIT 2 STANDBY GAS TREATMENT | | SYSTEM WAS IN A CONDITION THAT COULD HAVE PREVENTED THE FULFILLMENT OF THE | | SAFETY FUNCTIONS OF STRUCTURES OR SYSTEMS NEEDED TO CONTROL THE RELEASE OF | | RADIOACTIVE MATERIAL. SPECIFICALLY BOTH STANDBY GAS TREATMENT SYSTEM DECAY | | HEAT REMOVAL VALVES WERE FAILED IN THE OPEN POSITION WHICH WOULD HAVE | | PREVENTED THE ABILITY TO MAINTAIN PHYSICAL SEPARATION OF THE STANDBY GAS | | TRAINS AS REQUIRED BY REG GUIDE 1.52. NINE MILE POINT UNIT 2 ENGINEERING IS | | CONTINUING TO EVALUATE THIS CONDITION." | | | | THE NRC RESIDENT INSPECTOR WILL BE INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 31599 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: NINE MILE POINT REGION: 1 |NOTIFICATION DATE: 01/15/97 | |UNIT: [ ] [2] [ ] STATE: NY |NOTIFICATION TIME: 19:15 [ET]| |RX TYPE: [1] GE-2,[2] GE-5 |EVENT DATE: 01/15/97 | +------------------------------------------------+EVENT TIME: 18:50[EST]| |NRC NOTIFIED BY: R. GREEN |LAST UPDATE DATE: 01/15/97 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |SILK RDO | |AOUT 50.72(b)(1)(ii)(B) OUTSIDE DESIGN BASIS | | |NLCO TECH SPEC LCO A/S | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | RCIC SYSTEM MAY NOT BE AVAILABLE FROM REMOTE SHUTDOWN PANEL. | | | | THE FOLLOWING IS TEXT OF A FACSIMILE SUBMITTED BY THE LICENSEE: | | | | "DURING A REVIEW OF APPENDIX R FIRE INDUCED HOT SHORTS AS DESCRIBED IN | | INFORMATION NOTICE 92-18, IT WAS DISCOVERED THAT CERTAIN RCIC SYSTEM MOVs | | ARE SUSCEPTIBLE AND THAT THE RCIC SYSTEM MAY NOT BE AVAILABLE FROM THE | | REMOTE SHUTDOWN PANEL. WITH RCIC NOT AVAILABLE IN THE APPENDIX R SCENARIO, | | THERE ARE CURRENTLY NO SPECIFIC OPERATING PROCEDURES TO ACHIEVE COLD | | SHUTDOWN. | | | | THE RCIC SYSTEM HAS BEEN DECLARED INOPERABLE FROM THE REMOTE SHUTDOWN PANEL | | AND TECHNICAL SPECIFICATION 3.3.7.4 HAS BEEN ENTERED TO REQUIRE RESTORATION | | IN 7 DAYS OR BE IN HOT SHUTDOWN WITHIN THE NEXT 12 HOURS. THIS NOTIFICATION | | IS BEING MADE AS WE ARE CURRENTLY UNABLE TO CONFIRM THAT WE ARE WITHIN OUR | | DESIGN BASIS FOR APPENDIX R." | | | | THE NRC RESIDENT INSPECTOR WILL BE INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |TRANSPORTATION EVENT | |EVENT NUMBER: 31600 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: UNKNOWN |NOTIFICATION DATE: 01/15/97 | | CITY: HUNTSVILLE REGION: 4 |NOTIFICATION TIME: 23:30 [ET]| | COUNTY: STATE: TX |EVENT DATE: 01/15/97 | |LICENSE#: AGREEMENT: Y |EVENT TIME: 00:00[CST]| | DOCKET: |LAST UPDATE DATE: 01/15/97 | | +-----------------------------+ | |PERSON ORGANIZATION| | |JOSEPH TAPIA, REG 4 RDO | | | | +------------------------------------------------+BRUCE BURGESS, REG 3 RDO | |NRC NOTIFIED BY: "ROBERT" |CHUCK CAIN REG4 | |HQ OPS OFFICER: CHAUNCEY GOULD | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NTRA TRANSPORTATION EVENT | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | A TRUCKING OPERATIONS MANAGER NOTIFIED THE NRC OF AN ACCIDENT BETWEEN TWO | | TRUCKS AT A TRUCK STOP IN HUNTSVILLE, TX. | | | | ONE OF THE TRUCKS INVOLVED IN THE ACCIDENT WAS PLACARDED. IT IS UNKNOWN | | WHAT THE TRUCK CONTAINED. THE PLACARDED TRUCK LEFT THE ACCIDENT SCENE. THE | | TRUCK BELONGING TO THE COMPANY WHICH THE INDIVIDUAL WORKED FOR APPARENTLY | | DID NOT CONTAIN ANY RADIOACTIVE MATERIAL. | | | | (REFER TO THE HOO LOG FOR CONTACT TELEPHONE NUMBERS.) | +------------------------------------------------------------------------------+