U.S. Nuclear Regulatory Commission Operations Center Event Reports For 09/19/97 - 09/22/97 ** EVENT NUMBERS ** 32798 32956 32961 32962 32963 32964 32965 32966 32967 32968 32969 32970 32971 32972 32973 +----------------------------------+ +-----------------------+ |GENERAL INFORMATION or OTHER | |EVENT NUMBER: 32798 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: UINTAH ENGINEERING INC. |NOTIFICATION DATE: 08/21/97 | | CITY: VERNAL REGION: 4 |NOTIFICATION TIME: 19:54 [ET]| | COUNTY: RICH STATE: UT |EVENT DATE: 08/21/97 | |LICENSE#: UT2400046 AGREEMENT: Y |EVENT TIME: 17:54[MDT]| | DOCKET: |LAST UPDATE DATE: 09/19/97 | | +-----------------------------+ | |PERSON ORGANIZATION| | |BILL JOHNSON RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: JULIE FELICE | | |HQ OPS OFFICER: JOHN MacKINNON | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | TROXLER MOISTURE DENSITY GAUGE MISSING | | | | THE STATE OF UTAH DIVISION OF RADIATION CONTROL PERFORMED AN INSPECTION OF | | UINTAH ENGINEERING INC., LOCATED AT P.O. BOX 1758, VERNAL, UTAH. A TROXLER | | MOISTURE GAUGE WAS FOUND MISSING. THE LICENSEE SAID THAT THEY HAD THE | | GAUGE DURING THE LAST THE TIME THEY WERE INSPECTED BY THE UTAH DIVISION OF | | RADIATION CONTROL IN APRIL OF 1993. THE STATE OF UTAH DIVISION OF | | RADIATION CONTROL ISSUED THEM A NOTICE OF VIOLATION FOR NOT HAVING THE | | GAUGE IN LATE APRIL OF THIS YEAR. UINTAH ENGINEERING INC. SAID THAT THEY | | HAD GIVEN THE GAUGE TO NUCLEAR TESTING SERVICES TO DESTROY THE GAUGE. UPON | | INVESTIGATION, THE UTAH DIVISION OF RADIATION CONTROL FOUND THAT NO RECORDS | | EXISTED AT NUCLEAR TESTING SERVICES OR WITH TROXLER SHOWING THAT THE GAUGE | | HAD BEEN GIVEN TO EITHER ONE THEM BY UINTAH ENGINEERING INC. THE UTAH | | DIVISION OF RADIATION CONTROL IS SENDING AN ORDER TO UINTAH ENGINEERING | | INC. REQUESTING THEM TO FIND THE GAUGE OR REPORT THE GAUGE MISSING TO THE | | POLICE. THE MODEL NUMBER OF THE MISSING GAUGE IS 2401, AND THE SOURCE | | SERIAL NUMBER IS 64-4500. THE GAUGE CONTAINED 7.4 mCi OF Cs-137 AND 50 mCi | | OF Am-241/Be. THE STATE OF UTAH HAS NOT ASSIGNED AN ORIGINAL ITEM NUMBER | | TO THIS EVENT. (REFER TO THE HOO LOG FOR TELEPHONE NUMBERS AND NAMES.) | | | | *** UPDATE ON 09/19/97 @ 1443 FROM FELICE TO GOULD *** THE UTAH DIVISION | | OF RADIATION PROTECTION HAS LOCATED THE MISSING TROXLER GAUGE AT A | | CALIFORNIA LICENSEE BY THE NAME OF HIGH DESERT TESTING IN APPLE VALLEY, | | CALIFORNIA. IT APPEARS TO HAVE BEEN TRANSFERRED TO THE CALIFORNIA LICENSEE | | IN 1991 FROM NUCLEAR TESTING SERVICES OF UTAH. THE UTAH DIVISION OF | | RADIATION RECEIVED CONFIRMATION BY FACSIMILE ON 09/16/97 FROM HIGH DESERT | | TESTING (CALIFORNIA LICENSE 5775-36) THAT THEY HAVE THE DEVICE. THE NRC | | OPERATIONS CENTER NOTIFIED THE R4DO (JOHNSON). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |GENERAL INFORMATION or OTHER | |EVENT NUMBER: 32956 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: BILL MILLER, INC, HENRYETTA, OK |NOTIFICATION DATE: 09/18/97 | | CITY: HENRYETTA REGION: 4 |NOTIFICATION TIME: 10:40 [ET]| | COUNTY: STATE: OK |EVENT DATE: 09/18/97 | |LICENSE#: AGREEMENT: N |EVENT TIME: 10:00[CDT]| | DOCKET: |LAST UPDATE DATE: 09/21/97 | | +-----------------------------+ | |PERSON ORGANIZATION| | |WILLIAM JOHNSON RDO | | |MICHAEL WEBER, NMSS EO | +------------------------------------------------+KATHLEEN SCHNEIDER OSP | |NRC NOTIFIED BY: BILL MILLER |JOSEPH GIITTER, AEOD IRD | |HQ OPS OFFICER: DICK JOLLIFFE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |BAB2 20.2201(a)(1)(ii) LOST/STOLEN LNM>10X | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - TRUCK CONTAINING INDUSTRIAL RADIOGRAPHY CAMERA STOLEN FROM OWNER - | | | | SOMETIME BETWEEN 1000 CDT ON 09/17/97 AND 0600 CDT ON 09/18/97, A TRUCK WAS | | STOLEN FROM THE PROPERTY OF BILL MILLER, INC., LOCATED IN HENRYETTA, OK. | | INSIDE THE TRUCK WAS AN INDUSTRIAL RADIOGRAPHY CAMERA (MANUFACTURER: | | INDUSTRIAL NUCLEAR COMPANY, MODEL NUMBER: IR-100, SERIAL NUMBER: 4194, | | SOURCE: 16 CURIES I-192, AND SERIAL NUMBER: 6782). THE TRUCK/CAMERA OWNER | | REPORTED THE THEFT TO THE TULSA COUNTY SHERIFF'S DEPARTMENT AND THE NRC | | REGION 4 OFFICE. | | | | *** UPDATE ON 09/21/97 AT 1942 EDT FROM MILLER TO GOULD *** THE STOLEN | | RADIOGRAPHY CAMERA WAS FOUND AT 1000 CDT ON 09/21/97. IT WAS FOUND BY A | | FISHERMAN IN TULSA, OK, NEAR THE ARKANSAS BRIDGE OFF THE ROAD JUST WEST OF | | THE ARKANSAS RIVER OFF I-44. THE CAMERA WAS NOT DAMAGED, AND THE SOURCE | | WAS INSIDE. THE POLICE DEPARTMENT WAS NOTIFIED, AND THE CAMERA WAS | | RETURNED TO THE LICENSEE AT 1145 CDT. THE NRC OPERATIONS CENTER NOTIFIED | | THE R4DO (JOHNSON), NMSS EO (WEBER), AND AEOD IRD (GIITTER). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 32961 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PALO VERDE REGION: 4 |NOTIFICATION DATE: 09/19/97 | |UNIT: [1] [ ] [ ] STATE: AZ |NOTIFICATION TIME: 14:49 [ET]| |RX TYPE: [1] CE,[2] CE,[3] CE |EVENT DATE: 09/19/97 | +------------------------------------------------+EVENT TIME: 11:00[MST]| |NRC NOTIFIED BY: RUSSELL STROUD |LAST UPDATE DATE: 09/19/97 | |HQ OPS OFFICER: STEVE SANDIN +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: | | |DDDD 73.71 UNSPECIFIED PARAGRAPH | | | |DWIGHT CHAMBERLAIN IAT | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | FALSIFIED PRE-EMPLOYMENT INFORMATION FOR AN INDIVIDUAL GRANTED ACCESS TO | | THE SITE WAS DISCOVERED. IMMEDIATE COMPENSATORY MEASURES WERE TAKEN UPON | | DISCOVERY. THE LICENSEE NOTIFIED THE REGION 4 OFFICE AND NRC RESIDENT | | INSPECTOR. (REFER TO THE HOO LOG FOR ADDITIONAL DETAILS.) | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 32962 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: HOPE CREEK REGION: 1 |NOTIFICATION DATE: 09/19/97 | |UNIT: [1] [ ] [ ] STATE: NJ |NOTIFICATION TIME: 15:15 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 09/19/97 | +------------------------------------------------+EVENT TIME: 13:05[EDT]| |NRC NOTIFIED BY: PRICE |LAST UPDATE DATE: 09/19/97 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |NIEL DELLA GRECA RDO | |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 N 0 REFUELING | 0 REFUELING | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE LICENSEE HAS DECLARED THE 'A' CORE SPRAY LOOP INJECTION PIPING | | INOPERABLE DUE TO A THROUGH-WALL WELD CRACK. | | | | THE LICENSEE IDENTIFIED A THROUGH-WALL WELD CRACK ON THE 'A' CORE SPRAY | | LOOP INJECTION PIPING AT THE REACTOR PRESSURE VESSEL NOZZLE. THE LEAK RATE | | FROM THE WELD IS APPROXIMATELY 60 DROPS PER MINUTE AND IS UNISOLABLE FROM | | THE REACTOR PRESSURE VESSEL (RPV). | | | | THE PLANT IS CURRENTLY IN A REFUELING OUTAGE, CONDITION 5, WITH THE RPV | | HEAD REMOVED. RPV WATER LEVEL IS BEING MAINTAINED AT THE VESSEL HEAD | | FLANGE (+218"), AND REACTOR COOLANT SYSTEM TEMPERATURE IS 102øF WITH THE | | 'A' RESIDUAL HEAT REMOVAL LOOP PROVIDING SHUTDOWN COOLING. | | | | WITH THE 'A' CORE SPRAY SUBSYSTEM INOPERABLE DUE TO THE WELD CRACK, THE | | PLANT IS BELOW THE REQUIRED MINIMUM OPERABLE EMERGENCY CORE COOLING SYSTEMS | | BUT IS IN COMPLIANCE WITH THE TECHNICAL SPECIFICATION REQUIRED ACTION | | STATEMENT OF SUSPENDING ALL OPERATIONS WITH THE POTENTIAL TO DRAIN THE RPV. | | THERE ARE CURRENTLY NO OPERATIONS IN PROGRESS THAT WOULD POTENTIALLY DRAIN | | THE RPV. | | | | THE NRC RESIDENT INSPECTOR WAS INFORMED BY THE LICENSEE. THE LICENSEE ALSO | | PLANS TO NOTIFY THE LOWER ALLOWAYS CREEK TOWNSHIP. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 32963 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: NINE MILE POINT REGION: 1 |NOTIFICATION DATE: 09/19/97 | |UNIT: [1] [ ] [ ] STATE: NY |NOTIFICATION TIME: 16:41 [ET]| |RX TYPE: [1] GE-2,[2] GE-5 |EVENT DATE: 09/15/97 | +------------------------------------------------+EVENT TIME: 02:10[EDT]| |NRC NOTIFIED BY: LUKACZYK |LAST UPDATE DATE: 09/19/97 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |NIEL DELLA GRECA 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 Y 100 POWER OPERATION | 0 COLD SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE PLANT WAS IN A 7-DAY LIMITING CONDITION FOR OPERATION (LCO) DUE TO A | | TUBE LEAK IN THE EMERGENCY CONDENSER. | | | | THE PLANT SHUTDOWN ON 9/15/97 WAS NOT DUE TO A TECHNICAL SPECIFICATION | | REQUIREMENT. IT WAS TO GATHER INFORMATION FOR THE REPAIR OF THE '122' | | EMERGENCY CONDENSER. THE REACTOR HAD TO BE SHUTDOWN IN ORDER TO BREAK | | SECONDARY CONTAINMENT TO PERFORM THE INSPECTION. IT WAS DETERMINED (ON | | 9/16/97 AT 1200) THAT THE REPAIR COULD NOT HAVE BEEN COMPLETED WITHIN THE | | 7-DAY LCO CLOCK WHICH STARTED ON 9/12/97 AT 0130 AND ENDED ON 9/19/97. | | THEREFORE, THE LICENSEE IS REPORTING THIS EVENT AS A TECHNICAL | | SPECIFICATION REQUIRED SHUTDOWN NOTIFICATION SINCE REPAIRS COULD NOT BE | | MADE WITHIN THE ALLOTTED TIME. | | | | THE NRC RESIDENT INSPECTOR WAS INFORMED. | | | | SEE EVENT NUMBER 32973. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 32964 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: WOLF CREEK REGION: 4 |NOTIFICATION DATE: 09/19/97 | |UNIT: [1] [ ] [ ] STATE: KS |NOTIFICATION TIME: 16:58 [ET]| |RX TYPE: [1] W-4-LP |EVENT DATE: 09/19/97 | +------------------------------------------------+EVENT TIME: 15:20[CDT]| |NRC NOTIFIED BY: WALGREN |LAST UPDATE DATE: 09/19/97 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |WILLIAM JOHNSON RDO | |NLTR LICENSEE 24 HR REPORT | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | THE PLANT HAS DETERMINED THAT PREVIOUS USES OF THE FIRE PROTECTION SYSTEM | | PUMPS FOR NON-FIRE PROTECTION PURPOSES HAVE RESULTED IN A REDUCTION OF FIRE | | PROTECTION CAPABILITY. | | | | TESTING PERFORMED ON 9/19/97 PROVIDED RESULTS WHICH INDICATE THAT | | HISTORICAL USES OF THE FIRE PROTECTION SYSTEM PUMPS FOR NON-FIRE PROTECTION | | PURPOSES HAVE RESULTED IN A REDUCTION OF FIRE PROTECTION CAPABILITY IN BOTH | | SAFETY AND NON-SAFETY RELATED AREAS OF THE PLANT. THIS DEGRADATION, | | HOWEVER, WOULD NOT HAVE AFFECTED THE ABILITY TO ACHIEVE AND MAINTAIN THE | | PLANT IN A SAFE SHUTDOWN CONDITION. WITH RESPECT TO PROTECTION OF SAFETY | | RELATED EQUIPMENT, TESTING FOR AN IDENTIFIED SCENARIO HAS DEMONSTRATED THAT | | EITHER AUTOMATIC OR MANUAL SUPPRESSION WOULD REMAIN FUNCTIONAL IN THE | | REQUIRED AREAS. IN NON-SAFETY RELATED AREAS, CERTAIN USES OF THE FIRE PUMP | | WOULD RESULT IN THE INABILITY OF THE FIRE SUPPRESSION SYSTEM TO CONTAIN | | CERTAIN FIRES; HOWEVER, THESE FIRES WOULD NOT PREVENT ACHIEVING AND | | MAINTAINING SAFE SHUTDOWN. ALTHOUGH THE ABILITY TO ACHIEVE AND MAINTAIN | | SAFE SHUTDOWN OF THE PLANT IN THE EVENT OF A FIRE IS CONTINUED, THE | | LICENSEE CONSIDERS THIS CONDITION TO CONSTITUTE A SIGNIFICANT REDUCTION IN | | THE LEVEL OF FIRE PROTECTION AND A VIOLATION OF LICENSE CONDITION | | 2.C(5)(a). THE FIRE PROTECTION SYSTEM IS FULLY OPERABLE, AND THE CURRENT | | PRACTICE IS TO NOT USE IT FOR NON-FIRE PROTECTION PURPOSES. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 32965 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: RIVER BEND REGION: 4 |NOTIFICATION DATE: 09/20/97 | |UNIT: [1] [ ] [ ] STATE: LA |NOTIFICATION TIME: 03:14 [ET]| |RX TYPE: [1] GE-6 |EVENT DATE: 09/19/97 | +------------------------------------------------+EVENT TIME: 22:15[CDT]| |NRC NOTIFIED BY: GEORGE TURNER |LAST UPDATE DATE: 09/20/97 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |WILLIAM JOHNSON RDO | |APRE 50.72(b)(2)(vi) OFFSITE NOTIFICATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 REFUELING | 0 REFUELING | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | OFFSITE NOTIFICATION OF A TRANSFORMER OIL SPILL OUTSIDE THE PROTECTED AREA | | | | A TRANSFORMER LOCATED IN THE LICENSEE'S 3,208-ACRE OWNER CONTROLLED AREA | | HAD AN INTERNAL FAULT WHICH RESULTED IN MECHANICAL DAMAGE AND A SUBSEQUENT | | OIL LEAK. THE LICENSEE ESTIMATED THAT 5,000 GALLONS OF TRANSFORMER OIL | | LEAKED FROM THE TRANSFORMER ONTO THE GROUND IN THE TRANSFORMER YARD. THE | | TRANSFORMER IS NOT DIRECTLY AFFILIATED WITH THE NUCLEAR POWER PLANT'S | | POWER. IT IS LOCATED OUTSIDE THE PROTECTED AREA AND IS DISTANT FROM THE | | NUCLEAR SITE. | | | | OIL RECOVERY EFFORTS ARE CURRENTLY ONGOING. GROUND EXCAVATION MACHINES ARE | | AVAILABLE TO RECOVER THE SOIL, AND VACUUM TRUCKS HAVE BEEN ORDERED TO THE | | SITE. | | | | THE LICENSEE NOTIFIED THE NRC RESIDENT INSPECTOR, U.S. NATIONAL RESPONSE | | CENTER, LOUISIANA DEPARTMENT OF ENVIRONMENTAL QUALITY, LOUISIANA DEPARTMENT | | OF PUBLIC SAFETY, STATE POLICE, WEST FELICIANA PERISH LOCAL EMERGENCY | | PLANNING COMMITTEE, WATER WORKS WARNING NETWORK, AND U.S. ENVIRONMENTAL | | PROTECTION AGENCY. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |GENERAL INFORMATION or OTHER | |EVENT NUMBER: 32966 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: RUSH-PRES.-ST. LUKE'S M.C. |NOTIFICATION DATE: 09/20/97 | | CITY: CHICAGO REGION: 3 |NOTIFICATION TIME: 09:47 [ET]| | COUNTY: STATE: IL |EVENT DATE: 09/17/97 | |LICENSE#: IL-01766-01 AGREEMENT: Y |EVENT TIME: 14:00[CDT]| | DOCKET: |LAST UPDATE DATE: 09/20/97 | | +-----------------------------+ | |PERSON ORGANIZATION| | |BRUCE JORGENSEN RDO | | |MICHAEL WEBER, NMSS EO | +------------------------------------------------+ | |NRC NOTIFIED BY: BRUCE SANZA | | |HQ OPS OFFICER: LEIGH TROCINE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE ILLINOIS DEPARTMENT OF NUCLEAR SAFETY NOTIFIED THE NRC (VIA ELECTRONIC | | MAIL) OF A REPORTABLE BRACHYTHERAPY EVENT (MISADMINISTRATION) INVOLVING | | PATIENT INTERVENTION AT RUSH-PRES.-ST. LUKE'S M.C. LOCATED IN CHICAGO, | | ILLINOIS. | | | | THE FOLLOWING TEXT IS A CONVERSATION BETWEEN THE LICENSEE (GLENN SULLIVAN) | | AND THE STATE (BRUCE SANZA) DOCUMENTED BY THE ILLINOIS DEPARTMENT OF | | NUCLEAR SAFETY ON SEPTEMBER 18, 1997: | | | | "[THE] CALLER[, GLENN SULLIVAN,] REPORTED THAT A BRACHYTHERAPY PATIENT | | REMOVED HER FLETCHER SUIT AFTER LITTLE MORE THAN TWO HOURS OF A PLANNED | | 21-HOUR TREATMENT. THE GYNECOLOGICAL TREATMENT INVOLVED FIVE [CESIUM]-137 | | SOURCES WITH A TOTAL ACTIVITY OF 163 mCi. THE TREATMENT BEGAN ON SEPTEMBER | | 17 AT NOON, AND THE NURSE NOTICED AT [1400 CDT] THAT THE PATIENT HAD | | REMOVED THE APPLICATOR. RADIATION SAFETY AND ONCOLOGY WERE CALLED | | IMMEDIATELY, AND THE SOURCES WERE IN STORAGE AND ACCOUNTED FOR BY [1500 | | CDT]. THE PHYSICIAN DECIDED NOT TO CONTINUE THE TREATMENT, AND THE PATIENT | | WAS INFORMED. FURTHER DETAILS ARE TO BE PROVIDED IN THE 15-DAY WRITTEN | | REPORT REQUIRED BY REGULATION." | | | | (REFER TO THE HOO LOG FOR CONTACT TELEPHONE NUMBERS.) | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |FUEL CYCLE FACILITY | |EVENT NUMBER: 32967 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PADUCAH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 09/20/97 | | RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 12:14 [ET]| |COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 09/19/97 | | 6903 ROCKLEDGE DRIVE |EVENT TIME: 13:42[CDT]| | BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 09/20/97 | | CITY: PADUCAH REGION: 3 +-----------------------------+ | COUNTY: McCRACKEN STATE: KY |PERSON ORGANIZATION| |LICENSE#: GDP-1 AGREEMENT: Y |BRUCE JORGENSEN RDO | | DOCKET: 0707001 |MICHAEL WEBER, NMSS EO | +------------------------------------------------+ | |NRC NOTIFIED BY: HALICKS | | |HQ OPS OFFICER: CHAUNCEY GOULD | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |OCBA 76.120(c)(2)(i) ACCID MT EQUIP FAILS | | |OCBB 76.120(c)(2)(ii) EQUIP DISABLED/FAILS | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE LICENSEE HAS DECLARED ALL 32 FREEZER-SUBLIMERS INOPERABLE IN BUILDINGS | | C-331, C-333, C-335, AND C-337. (24-HOUR REPORT) | | | | ON 9/19/97 AT 1342 CDT, IT WAS DETERMINED THAT THE RECIRCULATING COOLING | | WATER (RCW) PUMPS ON THE FREEZER-SUBLIMERS COULD NOT BE VERIFIED TO BE | | RUNNING IN MODES WHERE THEY WERE REQUIRED TO SUPPORT THE OPERABILITY OF THE | | HIGH-HIGH WEIGHT TRIP SAFETY SYSTEM (TECHNICAL SPECIFICATION REQUIREMENT | | 2.4.3.1). THIS SAFETY SYSTEM IS USED TO PREVENT TOO MUCH UF6 MATERIAL FROM | | BEING ADDED TO THE FREEZER-SUBLIMERS, WHICH ARE VESSELS USED TO STORE THIS | | MATERIAL. AS A RESULT OF THE INVESTIGATION OF AN EARLIER EVENT (REFER TO | | EVENT #32909 DATED 9/11/97), A VISUAL CHECK WAS CONDUCTED OF EACH | | FREEZER-SUBLIMER RCW PUMP TO VERIFY OPERATION OF THE PUMP. BASED ON THIS | | CHECK, THREE ADDITIONAL RCW PUMPS WERE FOUND NOT TO BE RUNNING WHEN | | REQUIRED. WHEN THIS WAS DISCOVERED, IT APPEARED THAT PADUCAH MAY HAVE A | | GENERIC PROBLEM. AS A RESULT, ALL 32 FREEZER-SUBLIMERS WERE DECLARED | | INOPERABLE AT 1705 CDT AT 9/19/97, AND PADUCAH PLACED THE SYSTEMS IN A SAFE | | MODE PENDING ENGINEERING EVALUATION. THE PLANT IS STILL OPERATING IN THIS | | CONDITION. | | | | THE NRC RESIDENT INSPECTOR WAS INFORMED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 32968 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SOUTH TEXAS REGION: 4 |NOTIFICATION DATE: 09/20/97 | |UNIT: [1] [ ] [ ] STATE: TX |NOTIFICATION TIME: 15:17 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 09/20/97 | +------------------------------------------------+EVENT TIME: 11:45[CDT]| |NRC NOTIFIED BY: BOWMAN |LAST UPDATE DATE: 09/20/97 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |WILLIAM JOHNSON RDO | |NLTR LICENSEE 24 HR REPORT | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 REFUELING | 0 REFUELING | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE LICENSEE DISCOVERED THAT THE '1C' STEAM GENERATOR SAFETY VALVES HAVE | | RESTRICTED FULL FLOW CAPACITY. | | | | DURING A REVIEW OF THE CALCULATIONS USED IN ESTABLISHING THE SAFETY VALVE | | SETPOINTS FOR '1C' STEAM GENERATOR SAFETY VALVES 'PSV-7430A' AND | | 'PSV-7430B,' IT WAS DETERMINED THAT ALLOWANCES FOR THERMAL GROWTH WERE NOT | | INCLUDED. THIS RESULTED IN A RESTRICTED FULL FLOW CAPACITY WHERE EACH | | VALVE WOULD ONLY PASS 93% OF THE REQUIRED STEAM FLOW. THIS CONDITION | | EXISTED WHILE THE UNIT WAS CONDUCTING POWER OPERATIONS AND RESULTED IN | | OPERATION IN NON-COMPLIANCE WITH TECHNICAL SPECIFICATION 3.7.1.1, ACTION | | STATEMENT a. THE UNIT IS NOT IN ANY LIMITING CONDITION FOR OPERATION | | ACTION STATEMENT. THE ENGINEERING DEPARTMENT IS CURRENTLY WORKING ON | | CORRECTIVE ACTION FOR THIS CONDITION. | | | | THE NRC RESIDENT INSPECTOR WILL BE NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 32969 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: TURKEY POINT REGION: 2 |NOTIFICATION DATE: 09/20/97 | |UNIT: [3] [4] [ ] STATE: FL |NOTIFICATION TIME: 17:28 [ET]| |RX TYPE: [3] W-3-LP,[4] W-3-LP |EVENT DATE: 09/20/97 | +------------------------------------------------+EVENT TIME: 16:26[EDT]| |NRC NOTIFIED BY: CRAIG MOWREY |LAST UPDATE DATE: 09/20/97 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |KERRY LANDIS RDO | |APRE 50.72(b)(2)(vi) OFFSITE NOTIFICATION |MICHAEL WEBER, NMSS EO | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 N 0 REFUELING | 0 REFUELING | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | OFFSITE NOTIFICATION OF CONTAMINATED WELDING EQUIPMENT RECEIVED AT THE SITE | | (REFER TO EVENT NUMBERS 32912 AND 32934 FOR ADDITIONAL OCCURRENCES.) | | | | WHILE SURVEYING WELDING EQUIPMENT ARRIVING ON SITE FOR THE CURRENT UNIT 4 | | REFUELING OUTAGE, PLANT PERSONNEL DISCOVERED LOW LEVELS OF CONTAMINATION ON | | THE EQUIPMENT. THE OWNER OF THE EQUIPMENT IS NOT LICENSED TO RECEIVE | | BYPRODUCT MATERIAL. THE SURVEY IS NOT YET COMPLETE; HOWEVER, FIXED | | CONTAMINATION DISCOVERED SO FAR VARIES FROM 6,000 TO 61,000 DISINTEGRATIONS | | PER MINUTE WHEN MEASURED IN A SMALL ARTICLES MONITOR. SMEARABLE | | CONTAMINATION WAS DISCOVERED ON FAN BLADES AND INSIDE THE FAN HOUSING | | (INSIDE THE WELDING MACHINES) AT ABOUT 60 TO 400 DISINTEGRATIONS PER MINUTE | | PER 100 SQUARE CENTIMETERS (COUNTED WITH AN MDA SCALER). THERE HAS BEEN NO | | SMEARABLE CONTAMINATION FOUND ON EXTERNAL SURFACES OR ON THE PALLETS | | CARRYING THE MATERIAL. THE MATERIAL WAS TRANSPORTED TO TURKEY POINT INSIDE | | A STANDARD CLOSED SHIPPING VAN WHICH AT THIS POINT HAS NOT BEEN DETERMINED | | TO BE CONTAMINATED. | | | | THE LICENSEE HAS NOTIFIED THE OWNER OF THE EQUIPMENT AND THE STATE OF | | FLORIDA, DEPARTMENT OF HEALTH, BUREAU OF RADIATION CONTROL. THE LICENSEE | | ALSO PLANS TO NOTIFY THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 32970 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PERRY REGION: 3 |NOTIFICATION DATE: 09/21/97 | |UNIT: [1] [ ] [ ] STATE: OH |NOTIFICATION TIME: 06:15 [ET]| |RX TYPE: [1] GE-6 |EVENT DATE: 09/21/97 | +------------------------------------------------+EVENT TIME: 04:53[EDT]| |NRC NOTIFIED BY: BRIAN STETSON |LAST UPDATE DATE: 09/21/97 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BRUCE JORGENSEN 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 N 0 REFUELING | 0 REFUELING | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | UNEXPECTED REACTOR WATER LEVEL LOW SIGNAL RESULTING IN LOW PRESSURE COOLANT | | INJECTION INITIATION SIGNALS WITH NO ACTUAL INJECTION INTO THE VESSEL | | | | AT 0453, THE UNIT RECEIVED AN UNEXPECTED REACTOR WATER LEVEL LOW (LEVEL 1) | | SIGNAL ON DIVISION 2 WHICH RESULTED IN LOW PRESSURE COOLANT INJECTION 'B' | | AND 'C' INITIATION SIGNALS. (THIS WAS NOT AN ACTUAL LOW LEVEL. IT WAS A | | SPIKE ON ONE OF THE REFERENCE LEGS.) AT THE TIME, THE DIVISION 2 DIESEL | | GENERATOR, LOW PRESSURE COOLANT INJECTION 'B,' AND LOW PRESSURE COOLANT | | INJECTION 'C' WERE IN THE SECURED STATUS FOR PREPLANNED MAINTENANCE DUE TO | | THE CURRENT REFUELING OUTAGE. AUTOMATIC STARTS OCCURRED ON THE DIVISION 2 | | EMERGENCY SERVICE WATER PUMP AND THE DIVISION 2 CLOSED COOLING WATER PUMP. | | THE STUB BUS (EX-12) OFF OF DIVISION 2 SAFETY BUS EH-12 ALSO STRIPPED ON | | UNDERVOLTAGE. IN ADDITION, ISOLATIONS OCCURRED ON THE NUCLEAR CLOSED | | COOLING WATER TO THE FUEL POOL COOLING AND CLEANUP HEAT EXCHANGERS, FLOW | | THROUGH THE FUEL POOL COOLING AND CLEANUP FILTER DEMINERALIZERS, AND | | NUCLEAR CLOSED COOLING WATER TO THE CONTROL COMPLEX CHILLED WATER CHILLERS. | | THESE ISOLATIONS INVOLVED NON-SAFETY RELATED COOLING SUPPLIES. EMERGENCY | | COOLING SUPPLIES ARE STILL AVAILABLE. DECAY HEAT REMOVAL WAS NOT LOST, AND | | THERE WAS NO ACTUAL INJECTION INTO THE REACTOR VESSEL. ALL SYSTEMS | | FUNCTIONED AS REQUIRED AS A RESULT OF THIS SIGNAL, AND NOTHING WAS UNUSUAL | | OR NOT UNDERSTOOD. | | | | THE LICENSEE ENTERED THE APPROPRIATE OFF-NORMAL INSTRUCTIONS AND IS IN THE | | PROCESS OF RECOVERING THE PLANT AT THIS TIME. THE LICENSEE ATTRIBUTED THIS | | EVENT TO INSTRUMENT TECHNICIANS WORKING ON THE REFERENCE LEGS OFF OF THE | | VESSEL. | | | | THE LICENSEE PLANS TO NOTIFY THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 32971 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: DUANE ARNOLD REGION: 3 |NOTIFICATION DATE: 09/21/97 | |UNIT: [1] [ ] [ ] STATE: IA |NOTIFICATION TIME: 15:52 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 09/21/97 | +------------------------------------------------+EVENT TIME: 13:43[CDT]| |NRC NOTIFIED BY: CHAISSON |LAST UPDATE DATE: 09/21/97 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BRUCE JORGENSEN 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 +------------------------------------------------------------------------------+ | THE PLANT HAD A GROUP 5 ISOLATION OF THE REACTOR WATER CLEANUP SYSTEM. | | | | THIS OCCURRED DURING THE REMOVAL OF THE SYSTEM FROM SERVICE FOR MAINTENANCE | | AND TESTING. THE ISOLATION WAS DUE TO A DIFFERENTIAL FLOW ISOLATION | | SIGNAL. THE RETURN FLOW INDICATOR IS PEGGED DOWN SCALE WHICH MAY HAVE BEEN | | DUE TO A PERTURBATION IN THE SYSTEM. THE LICENSEE IS STILL INVESTIGATING | | THE CAUSE OF THE ISOLATION BUT SUSPECTS IT COULD BE A FLOW METER PROBLEM. | | THE LICENSEE ALSO VERIFIED THAT THERE IS NO SYSTEM LEAKAGE. THE ISOLATION | | SIGNAL HAS NOT YET BEEN RESET. | | | | THE NRC RESIDENT INSPECTOR HAS BEEN NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 32972 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: DIABLO CANYON REGION: 4 |NOTIFICATION DATE: 09/22/97 | |UNIT: [1] [ ] [ ] STATE: CA |NOTIFICATION TIME: 04:16 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 09/22/97 | +------------------------------------------------+EVENT TIME: 00:17[PDT]| |NRC NOTIFIED BY: RICHARD WILLETT |LAST UPDATE DATE: 09/22/97 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: | | |DDDD 73.71 UNSPECIFIED PARAGRAPH | | | | , REG 4 IAT | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | ONE-HOUR SECURITY REPORT | | | | THE LICENSEE DISCOVERED THAT COMPENSATORY MEASURES FOR A DEGRADED VITAL | | AREA BARRIER HAD BEEN CHANGED AND WERE NO LONGER ADEQUATE. IMMEDIATE | | COMPENSATORY MEASURES WERE TAKEN UPON DISCOVERY. (REFER TO THE HOO LOG FOR | | ADDITIONAL DETAILS.) | | | | THE LICENSEE PLANS TO NOTIFY THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 32973 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: NINE MILE POINT REGION: 1 |NOTIFICATION DATE: 09/22/97 | |UNIT: [1] [ ] [ ] STATE: NY |NOTIFICATION TIME: 06:00 [ET]| |RX TYPE: [1] GE-2,[2] GE-5 |EVENT DATE: 09/22/97 | +------------------------------------------------+EVENT TIME: 02:15[EDT]| |NRC NOTIFIED BY: D. BIERBRAUER |LAST UPDATE DATE: 09/22/97 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: | | |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 | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | TUBE LEAKS DISCOVERED ON EMERGENCY CONDENSERS 111 AND 112. | | | | | | FOLLOWING A CONFIRMED TUBE LEAK ON EMERGENCY CONDENSER 122, HYDROSTATIC | | TESTING OF EMERGENCY CONDENSERS 111 AND 112 WAS CONDUCTED TO CONFIRM THE | | INTEGRITY OF THE TUBING. DURING THE HYDROSTATIC TESTING, IT WAS DISCOVERED | | BOTH EMERGENCY CONDENSERS 111 AND 112 HAD TUBES LEAKS. ENGINEERING IS | | CURRENTLY EVALUATING CORRECTIVE ACTIONS. | | | | THEN NRC RESIDENT INSPECTOR WAS NOTIFIED OF THIS EVENT BY THE LICENSEE. | | | | SEE EVENT NUMBER 32963. | +------------------------------------------------------------------------------+