U.S. Nuclear Regulatory Commission Operations Center Event Reports For 12/16/97 - 12/17/97 ** EVENT NUMBERS ** 33413 33414 33415 33416 33417 33418 33419 +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33413 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: COOPER REGION: 4 |NOTIFICATION DATE: 12/16/97 | |UNIT: [1] [ ] [ ] STATE: NE |NOTIFICATION TIME: 01:47 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 12/15/97 | +------------------------------------------------+EVENT TIME: 21:16[CST]| |NRC NOTIFIED BY: TERRY RATZLAFF |LAST UPDATE DATE: 12/16/97 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |GARY SANBORN RDO | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | |AINB 50.72(b)(2)(iii)(B) POT RHR INOP | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 - HPCI ISOLATION CAUSED BY OPERATOR ERROR | | | | WHILE PERFORMING A HPCI SURVEILLANCE PROCEDURE, HPCI STEAM LINE SPACE | | TEMPERATURE SWITCH FUNCTIONAL TEST, THE INCORRECT TEST SWITCH (FOR THE "B" | | CHANNEL TEMPERATURE SWITCHES RATHER THAN THE "C" CHANNEL ) WAS PLACED IN | | THE TEST POSITION BY A NON-LICENSED OPERATOR. FOLLOWING THE PERFORMANCE OF | | THE SUBSEQUENT STEP, WHICH ENERGIZED THE HEATING ELEMENTS ADJACENT TO TWO | | TEMPERATURE SWITCHES, AN INVALID HIGH SPACE TEMPERATURE SIGNAL WAS | | GENERATED, RESULTING IN THE AUTOMATIC CLOSURE OF THE HPCI STEAM LINE | | ISOLATION VALVES. | | | | HPCI WAS DECLARED INOPERABLE FOLLOWING THE CLOSURE OF THE VALVES. UPON | | HEARING AN ADJACENT RELAY OPERATE, THE OPERATOR RE-CHECKED THE SWITCH | | POSITION AND LOCATED THE INCORRECTLY POSITIONED SWITCH. UPON REPORTING THE | | CONDITION TO THE CONTROL ROOM, THE OPERATORS PERFORMING THE TEST WERE | | DIRECTED TO RESTORE THE SWITCHES TO THE NORMAL LINEUP, AND THE HEATING | | ELEMENTS ADJACENT TO THE SWITCHES BEING TESTED WERE DE-ENERGIZED. THE HPCI | | ISOLATION WAS RESET, AND THE STEAM SUPPLY RESTORED TO STANDBY STATUS. HPCI | | WAS DECLARED OPERABLE AS 2145. RCIC AND LOW PRESSURE ECCS SYSTEMS WERE | | VERIFIED OPERABLE IN ACCORDANCE WITH TECH SPECS. ADS WAS NOT DEMONSTRATED | | OPERABLE DUE TO THE SHORT TIME HPCI WAS ISOLATED. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33414 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SEABROOK REGION: 1 |NOTIFICATION DATE: 12/16/97 | |UNIT: [1] [ ] [ ] STATE: NH |NOTIFICATION TIME: 11:13 [ET]| |RX TYPE: [1] W-4-LP |EVENT DATE: 12/16/97 | +------------------------------------------------+EVENT TIME: 10:34[EST]| |NRC NOTIFIED BY: RON McINTIRE |LAST UPDATE DATE: 12/16/97 | |HQ OPS OFFICER: FANGIE JONES +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JAMES NOGGLE RDO | |ASHU 50.72(b)(1)(i)(A) PLANT S/D REQD BY TS | | |NLCO TECH SPEC LCO A/S | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 HOT SHUTDOWN | 0 HOT SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | TS 3.0.3 SHUTDOWN REQUIRED DUE TO LOSS OF BOTH UNITS OF CONTROL ROOM A/C. | | | | DURING REPAIRS ON TRAIN B CONTROL ROOM AIR CONDITIONING (A/C) UNIT, THE | | REDUNDANT TRAIN "A" CONTROL ROOM A/C UNIT TRIPPED. TECHNICAL SPECIFICATION | | (TS) 3.0.3 WAS ENTERED, DUE TO BOTH TRAINS BEING INOPERABLE, AND PLANT | | TEMPERATURE REDUCTION WAS STARTED TO PLACE THE UNIT IN MODE 5. | | | | THE TRAIN "A" UNIT HAS BEEN RESTARTED AND PARTIAL COOLING HAS BEEN | | RESTORED. INVESTIGATION IS UNDERWAY TO DETERMINE THE CAUSE OF THE TRAIN "A" | | TRIP. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33415 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: POINT BEACH REGION: 3 |NOTIFICATION DATE: 12/16/97 | |UNIT: [1] [2] [ ] STATE: WI |NOTIFICATION TIME: 11:49 [ET]| |RX TYPE: [1] W-2-LP,[2] W-2-LP |EVENT DATE: 12/16/97 | +------------------------------------------------+EVENT TIME: 10:00[CST]| |NRC NOTIFIED BY: JIM KNORR |LAST UPDATE DATE: 12/16/97 | |HQ OPS OFFICER: FANGIE JONES +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BRUCE JORGENSEN RDO | |AUNA 50.72(b)(1)(ii)(A) UNANALYZED COND OP | | |ADAS 50.72(b)(2)(i) DEG/UNANALYZED COND | | |NLCO TECH SPEC LCO A/S | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 98 POWER OPERATION | 98 POWER OPERATION | | 2 | N N 0 HOT SHUTDOWN | 0 HOT SHUTDOWN | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | LOSS OF BOTH TRAINS OF CONTAINMENT SPRAY DURING PAST INSERVICE TESTING. | | | | THE LICENSEE DISCOVERED, DURING THE INVESTIGATION OF THE USE OF A DEDICATED | | OPERATOR (NRC INFORMATION NOTICE 97-78), THAT DURING INSERVICE TESTING OF | | THE CONTAINMENT SPRAY (CS) SYSTEM, THE SODIUM HYDROXIDE (NaOH) SYSTEM WAS | | ISOLATED FROM BOTH TRAINS OF CS. THE TECHNICAL SPECIFICATIONS (TS) REQUIRE | | BOTH TRAINS OF CS TO BE OPERABLE WITH A PROVISION FOR A 72 HOUR ACTION | | STATEMENT SHUTDOWN FOR ONE TRAIN INOPERABLE. THE TS REQUIRE A UNIT | | SHUTDOWN WITH BOTH TRAINS INOPERABLE. THE INSERVICE TESTING PROCEDURES | | HAVE TESTED THE AUTOMATIC ISOLATION VALVES ON THE NaOH ADDITION CAPABILITY | | ONE VALVE AT A TIME, SHUTTING THE COMMON UPSTREAM MANUAL ISOLATION VALVE | | DURING THE TEST. THE SHUTTING OF THE UPSTREAM MANUAL ISOLATION VALVE | | RENDERED BOTH TRAINS INOPERABLE. IN THE PAST THE LICENSEE HAS TAKEN CREDIT | | FOR A DEDICATED OPERATOR STANDING BY TO REOPEN THE MANUAL ISOLATION VALVE | | IF NEEDED. THE LICENSEE IS REVISING THE PROCEDURES TO ENSURE THE | | PERFORMANCE OF THE TESTING IS DONE ONLY DURING TIME THE CS SYSTEM IS NOT | | REQUIRED TO BE OPERABLE. THIS WAS REPORTED AS AN UNANALYZED CONDITION, | | POTENTIALLY COMPROMISING PLANT SAFETY. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33416 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BEAVER VALLEY REGION: 1 |NOTIFICATION DATE: 12/16/97 | |UNIT: [ ] [2] [ ] STATE: PA |NOTIFICATION TIME: 13:03 [ET]| |RX TYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 12/16/97 | +------------------------------------------------+EVENT TIME: 13:00[EST]| |NRC NOTIFIED BY: GEORGE STOROLIS |LAST UPDATE DATE: 12/16/97 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JAMES NOGGLE RDO | |ASHU 50.72(b)(1)(i)(A) PLANT S/D REQD BY TS | | |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 +------------------------------------------------------------------------------+ | UNIT SHUTDOWN DUE TO INABILITY TO MEET SINGLE FAILURE CRITERION REGARDING | | CONTROL ROOM EMERGENCY VENTILATION SYSTEM. | | | | THE UNIT HAS BEEN IN A 7-DAY ACTION TECHNICAL SPECIFICATION STATEMENT DUE | | TO THE INOPERABILITY OF ONE TRAIN OF THE CONTROL ROOM EMERGENCY VENTILATION | | SYSTEM. [HOO NOTE: SEE EN 33409] SUBSEQUENTLY, BOTH TRAINS OF THE CONTROL | | ROOM EMERGENCY VENTILATION SYSTEM HAVE BEEN DECLARED INOPERABLE DUE TO THE | | INABILITY OF THE SYSTEM TO MEET THE SINGLE FAILURE CRITERION. AT 1300 EST, | | THE LICENSEE COMMENCED A POWER REDUCTION OF UNIT 2, WITH THE INTENTION OF | | TAKING THE UNIT TO COLD SHUTDOWN. THIS ISSUE ALSO AFFECTS UNIT 1, WHICH IS | | ALREADY IN COLD SHUTDOWN. | | | | THE LICENSEE HAS FORMED A MULTIDISCIPLINARY TEAM TO EVALUATE THE CONTROL | | ROOM EMERGENCY VENTILATION SYSTEM AND RECOMMEND CORRECTIVE ACTIONS. THE NRC | | RESIDENT INSPECTOR HAS BEEN INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 33417 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: MEDCENTRAL HEALTH SYSTEM |NOTIFICATION DATE: 12/16/97 | | CITY: MANSFIELD REGION: 3 |NOTIFICATION TIME: 15:17 [ET]| | COUNTY: RICHLAND STATE: OH |EVENT DATE: 12/16/97 | |LICENSE#: 34-02007-02 AGREEMENT: N |EVENT TIME: 00:00[EST]| | DOCKET: |LAST UPDATE DATE: 12/16/97 | | +-----------------------------+ | |PERSON ORGANIZATION| | |BRUCE JORGENSEN RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: ANGELA SCOTT | | |HQ OPS OFFICER: BOB STRANSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MEDICAL MISADMINISTRATION | | | | A PATIENT RECEIVED 5 COBALT-60 TREATMENTS (900 RADS TOTAL) AND WAS THEN | | REASSESSED BY THE PHYSICIAN. AT THAT TIME, THE PHYSICIAN REVISED THE ORDER | | TO REQUIRE AN ADDITIONAL 5 TREATMENTS OF THE SAME AREA, ALONG WITH 5 | | TREATMENTS OF ANOTHER NEARBY AREA. THE TREATMENTS TO THE SECOND AREA WERE | | ADMINISTERED, BUT THE TECHNICIANS DID NOT RECOGNIZE THE CHANGE TO THE | | TREATMENT ORDER FOR THE FIRST AREA, SO THESE TREATMENTS WERE NOT | | ADMINISTERED. THE ERROR WAS DISCOVERED ON 12/16/97. THE PHYSICIAN WAS | | CONTACTED, AND DECIDED NOT TO ADMINISTER THE MISSED TREATMENTS. | | | | THE LICENSEE HAS ALREADY CONTACTED NRC REGION 3 REGARDING THIS ISSUE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33418 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: FITZPATRICK REGION: 1 |NOTIFICATION DATE: 12/16/97 | |UNIT: [1] [ ] [ ] STATE: NY |NOTIFICATION TIME: 15:38 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 12/16/97 | +------------------------------------------------+EVENT TIME: 14:16[EST]| |NRC NOTIFIED BY: D. SQUIRES |LAST UPDATE DATE: 12/16/97 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JAMES NOGGLE RDO | |AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION | | |NLCO TECH SPEC LCO A/S | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | HPCI SYSTEM INOPERABLE | | | | THE HIGH PRESSURE COOLANT INJECTION (HPCI) SYSTEM HAS BEEN DECLARED | | INOPERABLE DUE TO THE INABILITY TO PROPERLY RESEAT A LOGIC CARD AFTER | | TESTING. THE HPCI HIGH AREA TEMPERATURE SIGNAL TRIP UNIT (23MTU-217B) WOULD | | NOT RESEAT. THE LICENSEE HAS ENTERED A 7-DAY LIMITING CONDITION FOR | | OPERATION (LCO) DUE TO THE INOPERABILITY OF HPCI. | | | | IN ADDITION, TABLE 3.2-1, ACTION 3.F OF THE PLANT TECHNICAL SPECIFICATIONS | | REQUIRES THAT THE LICENSEE VERIFY THE CLOSURE OF VALVES ASSOCIATED WITH | | CONTAINMENT PENETRATIONS MONITORED BY THE AREA TEMPERATURE LOGIC. HPCI | | VALVES 23MOV16, 23MOV57 AND 23MOV60 WERE VERIFIED CLOSED BY THE LICENSEE. | | | | THE NRC RESIDENT INSPECTOR HAS BEEN INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |FUEL CYCLE FACILITY | |EVENT NUMBER: 33419 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PADUCAH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 12/16/97 | | RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 23:05 [ET]| |COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 12/16/97 | | 6903 ROCKLEDGE DRIVE |EVENT TIME: 18:45[CST]| | BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 12/16/97 | | CITY: PADUCAH REGION: 3 +-----------------------------+ | COUNTY: McCRACKEN STATE: KY |PERSON ORGANIZATION| |LICENSE#: GDP-1 AGREEMENT: Y |BRUCE JORGENSEN RDO | | DOCKET: 0707001 |SUSAN SHANKMAN EO | +------------------------------------------------+RICHARD BARRETT IRD | |NRC NOTIFIED BY: W. HALICKS | | |HQ OPS OFFICER: BOB STRANSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NBNL RESPONSE-BULLETIN | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | 4-HOUR NRC BULLETIN 91-01 REPORT | | | | WHILE PERFORMING WALKDOWNS IN RESPONSE TO A PREVIOUS NUCLEAR CRITICALITY | | SAFETY (NCS) EVENT (SEE EN 33392), TEN 55-GALLON DRUMS OF CONTAMINATED | | PARTS (COMPRESSOR SHAFT SEAL COMPONENTS) WERE FOUND IN THE SEAL CAGE IN THE | | C-337 PROCESS BUILDING. VISUAL INSPECTION OF THE CONTENTS OF TWO OF THE | | DRUMS REVEALED THAT THE PARTS HAD SOME SURFACE URANIUM CONTAMINATION. THESE | | DRUMS WERE NOT STORED IN ACCORDANCE WITH WITH A DOCUMENTED NCS EVALUATION | | AND APPROVAL. | | | | THE FOLLOWING INFORMATION WAS SUBMITTED VIA FACSIMILE: | | | | "SAFETY SIGNIFICANCE OF EVENTS: | | THE PHYSICAL CHARACTERISTICS OF THE SEAL SUBCOMPONENTS DO NOT READILY | | SUPPORT LARGE ACCUMULATIONS OF URANIUM BEARING MATERIAL. THE SEAL | | SUBCOMPONENTS DO NOT CONTAIN LARGE CAVITIES THAT WOULD FACILITATE HOLDUP OF | | FISSILE MATERIAL. THEREFORE, TYPICAL SEALS WOULD CONTAIN ONLY A DUSTING OF | | URANIUM BEARING MATERIAL. DUE TO THE INABILITY OF THE SEAL TO CONTAIN LARGE | | AMOUNTS OF URANIUM, THE RATIO OF FISSILE MATERIAL TO METAL WOULD BE | | EXPECTED TO BE VERY LOW. FOR INSTANCE, A LARGE DRUM OF SEAL COMPONENTS | | COULD CONTAIN AS MUCH AS A THOUSAND POUNDS OF METAL AND ONLY A FEW POUNDS | | OF FISSILE MATERIAL. BASED ON THE EXTREMELY SMALL AMOUNT OF URANIUM ON THE | | SEAL PARTS, THE SAFETY SIGNIFICANCE OF THIS EVENT IS VERY LOW. | | | | POTENTIAL CRITICALITY PATHWAYS INVOLVED: | | IN ORDER FOR A CRITICALITY TO OCCUR AS A RESULT OF THIS EVENT, FISSILE | | MATERIAL IN QUANTITIES FAR EXCEEDING TYPICAL SEAL COMPONENT HOLDUP WOULD | | HAVE TO BE REPEATEDLY CONSOLIDATED IN THE UNSAFE VOLUME CONTAINERS. | | | | CONTROLLED PARAMETERS: | | THIS EVENT REPRESENTS AN UNAPPROVED FISSILE MATERIAL OPERATION. SEALS WERE | | DISASSEMBLED AND THE PARTS WERE PLACED INTO 55-GALLON CONTAINERS WITHOUT | | CLEANING THEM AND/OR PLACING THEM IN AN APPROVED CONTAINER. | | | | ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL: | | THE TOTAL AMOUNT OF FISSILE MATERIAL IN THE DRUMS IS UNKNOWN. THE | | ENRICHMENT IS LESS THAN 2 WEIGHT PERCENT U-235. THE EXPECTED FORM OF | | MATERIAL IS UO2F2 OR POSSIBLE UFx HOLDUP. | | | | NUCLEAR CRITICALITY SAFETY CONTROL OR SYSTEM AND DESCRIPTION OF FAILURES: | | DRUMS CONTAINING POTENTIALLY FISSILE MATERIAL WERE NOT STORED IN ACCORDANCE | | WITH A DOCUMENTED NCS EVALUATION AND APPROVAL. | | | | CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEM AND WHEN EACH WAS IMPLEMENTED: | | THE AFFECTED AREAS WERE EVACUATED, SECURED AND POSTED. NCS CONTINUES TO | | EVALUATE THE CONFIGURATION IN ORDER TO DEVELOP APPROPRIATE GUIDANCE FOR | | ESTABLISHING DOUBLE CONTINGENCY AND ENSURING A SAFE CONFIGURATION EXISTS." | | | | THE NRC RESIDENT INSPECTOR HAS BEEN INFORMED. | +------------------------------------------------------------------------------+