U.S. Nuclear Regulatory Commission Operations Center Event Reports For 08/22/97 - 08/25/97 ** EVENT NUMBERS ** 32668 32763 32800 32801 32802 32803 32804 32805 32806 32807 32808 32809 32810 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 32668 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: WATERFORD REGION: 4 |NOTIFICATION DATE: 07/23/97 | |UNIT: [3] [ ] [ ] STATE: LA |NOTIFICATION TIME: 18:56 [ET]| |RX TYPE: [3] CE |EVENT DATE: 07/23/97 | +------------------------------------------------+EVENT TIME: 17:30[CDT]| |NRC NOTIFIED BY: BECKENDORF |LAST UPDATE DATE: 08/22/97 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BLAINE MURRAY RDO | |DUNE 73.71(b)(1) UNAUTHORIZED ENTRY | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 3 | N N 0 HOT SHUTDOWN | 0 HOT SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | UNAUTHORIZED ENTRY INTO THE PROTECTED AREA. IMMEDIATE COMPENSATORY MEASURES | | TAKEN UPON DISCOVERY. | | | | THE NRC RESIDENT INSPECTOR WILL BE NOTIFIED BY THE LICENSEE OF THIS EVENT. | | | | REFER TO THE HOO LOG FOR ADDITIONAL DETAILS. | | | | * RETRACTION ON 08/22/97 AT 1725EDT BY PHILLIP SNOWDEN TAKEN BY MACKINNON * | | | | THE LICENSEE IS RETRACTING THIS EVENT BASED UPON THE GUIDANCE FROM GENERIC | | LETTER 91-03, "REPORTING OF SAFEGUARDS EVENTS." THERE WAS NO MALEVOLENT | | INTENT, NOTHING ADVERSE RESULTED FROM THE DELAY IN TAKING COMPENSATORY | | MEASURES, AND APPROPRIATE MEASURES TO PRECLUDE SIMILAR CONDITIONS HAVE BEEN | | (OR WILL BE) TAKEN. THE LICENSEE IS MAKING THIS A LOGGABLE EVENT. R4DO | | (BILL JOHNSON) NOTIFIED. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED OF THIS EVENT BY THE LICENSEE. | +------------------------------------------------------------------------------+ !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 32763 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: FERMI REGION: 3 |NOTIFICATION DATE: 08/14/97 | |UNIT: [2] [ ] [ ] STATE: MI |NOTIFICATION TIME: 16:07 [ET]| |RX TYPE: [2] GE-4 |EVENT DATE: 08/14/97 | +------------------------------------------------+EVENT TIME: 12:50[EDT]| |NRC NOTIFIED BY: GROFF |LAST UPDATE DATE: 08/22/97 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |ROGER LANKSBURY RDO | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 2 | N Y 96 POWER OPERATION | 96 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | ISOLATION OF TORUS WATER MANAGEMENT SYSTEM | | | | THE FOLLOWING IS TEXT OF A FACSIMILE SUBMITTED BY THE LICENSEE: | | | | "AT 1250 ON 8/14/97, AUTOMATIC ISOLATION OF THE PRIMARY CONTAINMENT | | OUTBOARD ISOLATION VALVES FOR THE TORUS WATER MANAGEMENT SYSTEM OCCURRED. | | THIS IS BELIEVED TO HAVE OCCURRED AS A RESULT OF AN INVALID SIGNAL OF TORUS | | SUMP LEVEL HIGH-HIGH. THIS WAS NOT A PREPLANNED ISOLATION. THE VALVES | | CLOSED DUE TO LOSS OF POWER TO [THE] SUMP LOGIC WHICH WAS DEENERGIZED WHILE | | DISCONNECTING WIRES TO REPAIR/REPLACE A TERMINAL BLOCK DURING MAINTENANCE | | ACTIVITIES. INVESTIGATION OF THIS EVENT IS UNDERWAY INCLUDING WHETHER THE | | SUMP LEVEL SIGNAL IS AN ESF [ENGINEERED SAFETY FEATURE] SIGNAL." | | | | THE NRC RESIDENT INSPECTOR HAS BEEN INFORMED BY THE LICENSEE. | | | | * * RETRACTION AT 1455 EDT ON 08/22/97 BY JEFF GROFF TAKEN BY MACKINNON * * | | | | FURTHER INVESTIGATION IDENTIFIED THAT THE ISOLATION OF THE TORUS WATER | | MANAGEMENT SYSTEM OCCURRED BECAUSE OF AN INVALID HIGH-HIGH SUMP LEVEL-TORUS | | AREA WHICH, AS DESCRIBED IN THE FERMI 2 UPDATED FINAL SAFETY ANALYSIS | | REPORT, IS NOT CONSIDERED AN ACTUATION OF THE ESF RELATED FUNCTION OF THESE | | VALVES. THIS EVENT IS NOT REPORTABLE SINCE NO ESF ACTUATION OCCURRED. R3DO | | (MIKE JORDAN) NOTIFIED. | | | | THE NRC RESIDENT INSPECTOR WILL BE NOTIFIED OF THIS EVENT BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 32800 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: RIVER BEND REGION: 4 |NOTIFICATION DATE: 08/22/97 | |UNIT: [1] [ ] [ ] STATE: LA |NOTIFICATION TIME: 03:51 [ET]| |RX TYPE: [1] GE-6 |EVENT DATE: 08/22/97 | +------------------------------------------------+EVENT TIME: 00:26[CDT]| |NRC NOTIFIED BY: JIM BOYLE |LAST UPDATE DATE: 08/22/97 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |WILLIAM JOHNSON RDO | |ARPS 50.72(b)(2)(ii) RPS ACTUATION | | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | A/R Y 93 POWER OPERATION | 0 HOT SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | GENERATOR TRIP - REACTOR SCRAM | | | | THE MAIN GENERATOR TRIPPED AT 0026 FOR UNKNOWN REASONS CAUSING A REACTOR | | SCRAM. ALL CONTROL RODS FULLY INSERTED. NO ELECTRICAL BUSES WERE LOST AND | | THE PLANT IS STABLE IN MODE THREE. REACTOR WATER LEVEL IS BEING MAINTAINED | | BY THE MAIN FEED SYSTEM AND STEAM IS BEING DUMPED TO THE MAIN CONDENSER AS | | NECESSARY TO REMOVE DECAY HEAT. | | | | DURING THE INITIAL TRANSIENT THE SUPPRESSION POOL CLEANUP SYSTEM ISOLATED | | AT REACTOR WATER LEVEL THREE. | | | | THE PLANT WILL REMAIN IN MODE THREE WHILE THE CAUSE OF THE GENERATOR TRIP | | IS INVESTIGATED. THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 32801 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: FAIRVIEW HEALTH SYSTEM |NOTIFICATION DATE: 08/22/97 | | CITY: CLEVLAND REGION: 3 |NOTIFICATION TIME: 14:40 [ET]| | COUNTY: CUYAHOGA STATE: OH |EVENT DATE: 10/18/94 | |LICENSE#: 34-01869-01 AGREEMENT: N |EVENT TIME: 15:40[EDT]| | DOCKET: |LAST UPDATE DATE: 08/22/97 | | +-----------------------------+ | |PERSON ORGANIZATION| | |MIKE JORDAN RDO | | |Dr COOL (NMSS) EO | +------------------------------------------------+ | |NRC NOTIFIED BY: R URBAN | | |HQ OPS OFFICER: JOHN MacKINNON | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MEDICAL MISADMINISTRATION DISCOVERED BY NRC REGION 3 INSPECTORS | | | | NRC REGION 3 PERFORMED AN INSPECTION OF FAIRVIEW HEALTH SYSTEM LOCATED IN | | CLEVELAND, OH, LAST FEBRUARY AND DISCOVERED A MEDICAL MISADMINISTRATION | | THAT HAD TAKEN PLACE AT THE LUTHERAN HOSPITAL LOCATED IN CLEVELAND, OHIO | | (LUTHERAN HOSPITAL IS UNDER THE FAIRVIEW HEALTH SYSTEM LICENSE). THE | | MEDICAL MISADMINISTRATION OCCURRED ON OCTOBER 18, 1994, AT 1540 EDT. A | | PATIENT WAS TO BE GIVEN 2mCi OF IODINE-131 FOR A WHOLE BODY SCAN BUT | | PATIENT WAS GIVEN 3.2mCi OF IODINE-131. THE PATIENT DID NOT RECEIVE ANY | | ADVERSE HEALTH EFFECTS FROM THIS MEDICAL MISADMINISTRATION. NRC REGION 3 | | IS FOLLOWING UP THE MEDICAL MISADMINISTRATION EVENT. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 32802 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SUMMER REGION: 2 |NOTIFICATION DATE: 08/22/97 | |UNIT: [1] [ ] [ ] STATE: SC |NOTIFICATION TIME: 15:00 [ET]| |RX TYPE: [1] W-3-LP |EVENT DATE: 08/22/97 | +------------------------------------------------+EVENT TIME: 11:08[EDT]| |NRC NOTIFIED BY: JIM PROPER |LAST UPDATE DATE: 08/22/97 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |TOM DECKER RDO | |HFIT 26.73 FITNESS FOR DUTY | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | LICENSED REACTOR OPERATOR TERMINATED AFTER POSITIVE RESULTS TO A RANDOM | | DRUG TEST. | | | | ON 08/19/97, A LICENSED REACTOR OPERATOR WAS GIVEN A RANDOM DRUG TEST. ON | | 08/22/97, THE LICENSED REACTOR OPERATOR WAS CONFIRMED POSITIVE. THE | | OPERATOR'S SECURITY BADGE WAS IMMEDIATELY PURGED AND PLANT SECURITY WAS | | NOTIFIED. THE EMPLOYEE WAS TERMINATED. THE LICENSEE IS REVIEWING THE WORK | | PERFORMED BY THE TERMINATED LICENSED REACTOR OPERATOR. | | | | THE NRC RESIDENT INSPECTOR WILL BE NOTIFIED BY THE LICENSEE OF THIS EVENT. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 32803 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PILGRIM REGION: 1 |NOTIFICATION DATE: 08/22/97 | |UNIT: [1] [ ] [ ] STATE: MA |NOTIFICATION TIME: 15:13 [ET]| |RX TYPE: [1] GE-3 |EVENT DATE: 08/22/97 | +------------------------------------------------+EVENT TIME: 13:51[EDT]| |NRC NOTIFIED BY: BRAIN SULLIVAN |LAST UPDATE DATE: 08/23/97 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |NIEL DELLA GRECA RDO | |AINA 50.72(b)(2)(iii)(A) POT UNABLE TO SAFE SD | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | REACTOR CORE ISOLATION COOLING (RCIC) SYSTEM DECLARED INOPERABLE DUE TO | | ERRATIC INDICATIONS FROM THE RCIC PUMP DISCHARGE FLOW TRANSMITTER. | | | | DURING ROUTINE CONTROL ROOM OBSERVATIONS, REACTOR OPERATORS NOTICED THAT | | THE RCIC PUMP DISCHARGE FLOW INDICATION INTERMITTENTLY JUMPED FROM 0 gpm TO | | 100 gpm. THE LICENSEE DECLARED RCIC INOPERABLE AND ENTERED TECHNICAL | | SPECIFICATION 3.5 (14 DAYS TO RESTORE RCIC TO SERVICE OR SHUTDOWN). THE | | LICENSEE THINKS THAT AIR IN THE SENSING LINES TO FT-1360-4 IS CAUSING THE | | INTERMITTENT INDICATIONS. THE LICENSEE HAS A WORK REQUEST TO CORRECT THIS | | PROBLEM. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED OF THIS EVENT BY THE LICENSEE. | | | | * * * UPDATE AT 1112 ON 8/23/97 BY SULLIVAN, TAKEN BY WEAVER * * * | | RCIC SYSTEM RESTORED AT 1110. THE LICENSEE WILL INFORM THE NRC RESIDENT | | INSPECTOR. THE HOO NOTIFIED THE R1DO (BILL RULAND). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 32804 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: UNIV. OF CINCINNATI HOSPITAL |NOTIFICATION DATE: 08/22/97 | | CITY: CINCINNATI REGION: 3 |NOTIFICATION TIME: 18:00 [ET]| | COUNTY: STATE: OH |EVENT DATE: 08/22/97 | |LICENSE#: 34-06903-05 AGREEMENT: N |EVENT TIME: 16:00[EDT]| | DOCKET: |LAST UPDATE DATE: 08/22/97 | | +-----------------------------+ | |PERSON ORGANIZATION| | |MIKE JORDAN RDO | | |FRED COMBS (NMSS) EO | +------------------------------------------------+ | |NRC NOTIFIED BY: VICTORIA MORRIS | | |HQ OPS OFFICER: JOHN MacKINNON | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THREE IODINE-125 SEEDS POSSIBLY MISSING. | | | | THE RADIATION SAFETY OFFICER FOR THE UNIVERSITY OF CINCINNATI HOSPITAL | | RELAYED THE FOLLOWING INFORMATION. | | | | ON 08/19/97, A PATIENT AT THE UNIVERSITY OF CINCINNATI HOSPITAL (LOCATED AT | | 234 GOODMAN STREET) RECEIVED 37 IODINE-125 SEEDS TO HIS BRAIN TO CONTROL A | | BRAIN TUMOR. THE TOTAL ACTIVITY OF EACH SEED IS 0.7 mCi. WHILE INSERTING | | THE SEEDS INTO THE PATIENT'S BRAIN, PRESSURE FROM THE TUMOR CAUSED ONE SEED | | TO DROP ONTO THE FLOOR AND FIVE SEEDS TO GO INTO A SUCTION TUBE. A | | RADIATION SURVEY OF THE AREA DID NOT FIND ANY OTHER SEEDS. | | | | ON 08/22/97, THE PATIENT WAS X-RAYED TO FIND OUT HOW MANY IODINE-125 SEEDS | | HAD BEEN INSERTED INTO THE PATIENT. THEY FOUND THAT THE PATIENT HAD 37 | | IODINE-125 SEEDS IN HIS BRAIN. THE COMPANY (UNKNOWN) WHICH DELIVERED THE | | IODINE-125 SEEDS SAID THAT THEY DELIVERED 100 SEEDS. UPON PERFORMING AN | | INVENTORY ON THE NUMBER OF IODINE-125 SEEDS (NOT USED) THE HOSPITAL | | DISCOVERED THAT THEY HAD 54 IODINE-125 SEEDS INSTEAD OF THE 57 SEEDS | | EXPECTED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 32805 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: LASALLE REGION: 3 |NOTIFICATION DATE: 08/22/97 | |UNIT: [1] [2] [ ] STATE: IL |NOTIFICATION TIME: 18:52 [ET]| |RX TYPE: [1] GE-5,[2] GE-5 |EVENT DATE: 08/22/97 | +------------------------------------------------+EVENT TIME: 15:35[CDT]| |NRC NOTIFIED BY: JAY HOUSTON |LAST UPDATE DATE: 08/22/97 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MIKE JORDAN 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 N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | 2 | N N 0 REFUELING | 0 REFUELING | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | LEAK DETECTION SYSTEM AREA AND DIFFERENTIAL TEMPERATURES ASSUME INCORRECT | | STEAM FLASH RATE. | | | | PROBLEM IDENTIFICATION FORM (PIF) L1997-04896 IDENTIFIED THAT CALCULATIONS | | THAT FORM THE BASIS FOR THE LEAK DETECTION AREA TEMPERATURE AND | | DIFFERENTIAL TEMPERATURE NEEDED TO BE COMPLETED WITH THE CORRECT STEAM | | FLASH RATE. IT HAS BEEN DETERMINED THAT THE CALCULATION FOR THE REACTOR | | WATER CLEANUP SYSTEM HEAT EXCHANGER AREA TEMPERATURE AND DIFFERENTIAL | | TEMPERATURE HIGH ISOLATION, WHILE NOT COMPLETE, INDICATES THAT THE | | TECHNICAL SPECIFICATION TRIP SETPOINT WILL OCCUR AT A LEAKAGE RATE ABOVE | | THE DESIGN BASIS LEAKAGE OF 25 gpm. THIS HAS BEEN DOCUMENTED IN PIF | | L1997-05315. THE CALCULATION FOR THE RCIC EQUIPMENT ROOM, RCIC STEAM LINE | | TUNNEL, AND THE RHR EQUIPMENT AREA TEMPERATURES AND DIFFERENTIAL | | TEMPERATURES WILL ALSO BE REVISED AND THE RESULTS OF THOSE CALCULATIONS | | WILL BE ADDRESSED IN THE LICENSING EVENT REPORT. | | | | THE LEAKAGE DETECTION SYSTEM IS NOT REQUIRED TO BE OPERABLE IN CURRENT | | PLANT OPERATING CONDITIONS. THE SYSTEM HAS BEEN DECLARED INOPERABLE AND | | ENTERED INTO THE STATIONS DEGRADED EQUIPMENT LOG. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED OF THIS EVENT BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 32806 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: COOK REGION: 3 |NOTIFICATION DATE: 08/22/97 | |UNIT: [1] [2] [ ] STATE: MI |NOTIFICATION TIME: 19:43 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 08/22/97 | +------------------------------------------------+EVENT TIME: 18:56[EDT]| |NRC NOTIFIED BY: CHERBA |LAST UPDATE DATE: 08/22/97 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MIKE JORDAN RDO | |AUNA 50.72(b)(1)(ii)(A) UNANALYZED COND OP | | |ACNC 50.72(b)(1)(ii)(C) COND OUTSIDE EOPS | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | INSTRUMENTATION INDICATIONS USED TO DETERMINE WHEN RWST TO CONTAINMENT | | SWITCH OVER IS REQUIRED MAY NOT HAVE BEEN CORRECT TO PREVENT VORTEXING IN | | THE CONTAINMENT RECIRCULATION SUMP. | | | | DURING THE EVALUATION OF A PROPOSED PROCEDURE CHANGE THAT AFFECTS SWITCH | | OVER FROM THE RWST TO THE CONTAINMENT SUMP DURING A LOCA, IT WAS DETERMINED | | THAT THE INSTRUMENTATION INDICATIONS USED TO DETERMINE WHEN THE SWITCH OVER | | IS REQUIRED MAY NOT HAVE BEEN CORRECT TO PREVENT VORTEXING IN THE | | CONTAINMENT RECIRCULATION SUMP. | | | | TO ADDRESS THIS SITUATION, PROCEDURES ASSOCIATED WITH THE SWITCH OVER (ON | | BOTH UNITS) HAVE BEEN CONSERVATIVELY CHANGED TO ACCOMMODATE THE RELATED | | INSTRUMENT INACCURACIES. THESE CHANGES ASSURE ADEQUATE RWST WATER IS IN | | CONTAINMENT BEFORE SWITCH OVER TO ELIMINATE CONCERNS THAT VORTEXING WOULD | | OCCUR IN THE CONTAINMENT SUMP AFTER SWITCH OVER. | | | | THE PROBLEM IS THAT THE RWST WATER LEVEL INDICATORS ARE CONNECTED TO THE | | SUCTION LINE THAT GOES TO THE RHR PUMPS. DUE TO THE FLOW IN THESE LINES, | | THE INDICATED WATER LEVEL AT WHICH THE SWITCH OVER WOULD BE INITIATED WOULD | | BE LESS THAN THE ACTUAL WATER LEVEL OF THE RWST (THE LICENSEE WOULD BE | | PUTTING LESS WATER INTO THE CONTAINMENT THAN EXPECTED). ALSO, THE LICENSEE | | SAID THAT THEY HAD SOME INACCURACIES ASSOCIATED WITH THEIR CONTAINMENT SUMP | | INSTRUMENTATION. THE LICENSEE ADJUSTED THE CONTAINMENT SUMP INDICATION TO | | ASSURE THAT THEY HAVE AN ADEQUATE VOLUME IN THE CONTAINMENT TO PREVENT | | VORTEXING. THE LICENSEE RELIES UPON TWO INDICATIONS FOR SWITCH OVER; RWST | | WATER LEVEL AND CONTAINMENT WATER LEVEL. | | | | THIS SITUATION WAS DETERMINED TO BE POTENTIALLY REPORTABLE AFTER DISCUSSION | | WITH LICENSING PERSONNEL. THE SITUATION WILL BE FURTHER REEVALUATED AND | | UPDATES MAY BE FORTHCOMING. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED OF THIS EVENT BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 32807 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BYRON REGION: 3 |NOTIFICATION DATE: 08/22/97 | |UNIT: [ ] [2] [ ] STATE: IL |NOTIFICATION TIME: 23:34 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 08/22/97 | +------------------------------------------------+EVENT TIME: 22:30[CDT]| |NRC NOTIFIED BY: PETER KNARR |LAST UPDATE DATE: 08/23/97 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MIKE JORDAN RDO | |ASHU 50.72(b)(1)(i)(A) PLANT S/D REQD BY TS | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N Y 100 POWER OPERATION | 99 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | TECHNICAL SPECIFICATION SHUTDOWN ENTERED DUE TO MAINTENANCE ON TRAIN "B" | | SOLID STATE PROTECTION SYSTEM (SSPS) 48 VOLT POWER SUPPLY. | | | | A TECHNICAL SPECIFICATION REQUIRED SHUTDOWN WAS INITIATED AS THE RESULT OF | | MAINTENANCE ON THE TRAIN "B" SSPS 48 VOLT POWER SUPPLY. IN SUPPORT OF THE | | MAINTENANCE ACTIVITY, TRAIN "B" SSPS WAS PLACED IN TEST AND THE TRAIN "B" | | REACTOR TRIP BYPASS BREAKER WAS RACKED IN AND CLOSED. AS A RESULT OF THESE | | ACTIVITIES, TECHNICAL SPECIFICATION 3.3.1.12.(b), REACTOR TRIP BREAKER | | INOPERABLE, REQUIRES THAT THE UNIT BE IN HOT STANDBY WITHIN 6 HOURS. | | REPAIRS ARE EXPECTED TO TAKE 2 HOURS. THE UNIT IS CURRENTLY RAMPING DOWN AT | | 0.5 MEGAWATTS PER MINUTE. THE RAMP WILL BE SECURED WHEN REPAIRS ARE | | COMPLETED AND SSPS AND THE TRAIN "B" REACTOR TRIP BYPASS BREAKER RESTORED | | TO NORMAL. | | | | ALL ECCS SYSTEMS AND EMERGENCY DIESEL GENERATORS ARE FULLY OPERABLE IF | | NEEDED. THE ELECTRICAL GRID IS STABLE. | | | | THE NRC RESIDENT INSPECTOR WILL BE NOTIFIED BY THE LICENSEE OF THIS EVENT. | | | | * * * UPDATE AT 0108 ON 8/23/97 BY KNARR, TAKEN BY WEAVER * * * | | | | REPAIRS HAVE BEEN COMPLETED ON THE "B" TRAIN SOLID STATE PROTECTION SYSTEM. | | THE LCO HAS BEEN EXITED. POWER HAD BEEN REDUCED TO 98%. THE HOO NOTIFIED | | THE R3DO (MIKE JORDAN). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 32808 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: CLINTON REGION: 3 |NOTIFICATION DATE: 08/23/97 | |UNIT: [1] [ ] [ ] STATE: IL |NOTIFICATION TIME: 12:28 [ET]| |RX TYPE: [1] GE-6 |EVENT DATE: 08/23/97 | +------------------------------------------------+EVENT TIME: 09:40[CDT]| |NRC NOTIFIED BY: JIM SCHOTTEL |LAST UPDATE DATE: 08/23/97 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MIKE JORDAN 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | WESTINGHOUSE 4160 VOLT BREAKER LUBRICATION PROBLEM DISCOVERED. | | | | THE CLINTON POWER STATION HAS RECENTLY EXPERIENCED TWO FAILURES OF | | WESTINGHOUSE 4160 VOLT BREAKERS. THESE FAILURES HAVE BEEN ANALYZED TO | | DETERMINE A PROBABLE CAUSE. AS A RESULT OF THESE FAILURES, CORRECTIVE | | MAINTENANCE WAS INSTITUTED FOR ALL OF THE REMAINING WESTINGHOUSE 4160 VOLT | | BREAKERS (75 BREAKERS). WHILE PERFORMING THIS MAINTENANCE ON OTHER | | WESTINGHOUSE BREAKERS, CONDITIONS SIMILAR TO THE TWO FAILED BREAKERS WERE | | DETECTED. ALTHOUGH THE LICENSEE HAS NOT HAD ANY FAILURES ON THESE | | ADDITIONAL BREAKERS, THESE CONDITIONS COULD BE INDICATIVE OF PRECURSORS | | WITH THE POTENTIAL FOR FUTURE FAILURES. THE LICENSEE CONSIDERS THIS TO BE | | A SERIOUS DEGRADATION OF THE SAFETY RELATED ELECTRICAL SYSTEM. | | | | IT APPEARS THAT THE BREAKERS HAVE INADEQUATE LUBRICATION IN THE UPPER PART | | OF THE BREAKER MECHANISM WHERE THE CONTACTS ARE LOCATED. ACCORDING TO THE | | VENDOR MANUAL THESE BREAKERS ARE SUPPOSED TO BE LIFE TIME COMPONENTS THAT | | DO NOT REQUIRE ANY MAINTENANCE BY THE OWNER UNLESS WORK IS PERFORMED ON THE | | BREAKER CONTACTS. A LICENSEE ANALYSIS HAS SHOWN THAT THE LUBRICATION IN | | THE BREAKERS AGES WITH TIME AND ALSO THAT THE BREAKER SPRING ALIGNMENT AND | | SPRING STRENGTH CHANGE OVER TIME. | | | | ALL THESE BREAKERS ARE LOCATED IN THE AUXILIARY BUILDING. THE AUXILIARY | | BUILDING IS AIR CONDITIONED AND THE AUXILIARY BUILDING TEMPERATURE IS | | MAINTAINED IN 70s. | | | | THE DIVISION 1 AND DIVISION 2 ELECTRICAL SYSTEMS ARE AFFECTED BY THE | | BREAKER PROBLEM SINCE THEY BOTH USE WESTINGHOUSE 4160 VOLT BREAKERS. THE | | DIVISION 3 ELECTRICAL SYSTEM DOES NOT UTILIZE THESE TYPE OF BREAKERS AND IS | | OPERABLE. | | | | THE REACTOR WATER CLEANUP SYSTEM COULD BE USED TO MAINTAIN INVENTORY USING | | THE BALANCE OF PLANT POWER SUPPLY. IF OFFSITE POWER IS LOST, THE | | DIVISION 3 (HIGH PRESSURE CORE SPRAY) PUMP COULD BE USED. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED OF THIS EVENT BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 32809 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: ZION REGION: 3 |NOTIFICATION DATE: 08/23/97 | |UNIT: [1] [2] [ ] STATE: IL |NOTIFICATION TIME: 14:22 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 08/23/97 | +------------------------------------------------+EVENT TIME: 11:50[CDT]| |NRC NOTIFIED BY: D NOLDIN |LAST UPDATE DATE: 08/23/97 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MIKE JORDAN RDO | |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 N 0 REFUELING | 0 REFUELING | | 2 | N N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | RESIDUAL HEAT REMOVAL (RHR) SYSTEM CONSIDERED INOPERABLE DUE TO THE "1A" | | SERVICE WATER PUMP BEING DECLARED INOPERABLE DURING A PLANNED SURVEILLANCE | | TEST. | | | | AT 1150 CDT IT WAS DETERMINED THAT COOLING WATER FLOW TO THE "1A" SERVICE | | WATER PUMP UPPER MOTOR BEARING WAS INSUFFICIENT TO MAINTAIN PUMP | | OPERABILITY (THE LICENSEE SAID THAT THEY HAVE SOME TYPE OF BLOCKAGE IN ITS | | LINE AND THAT THEY ARE INVESTIGATING THE PROBLEM). THE 111 DC BUS IS ALSO | | INOPERABLE FOR THE PERFORMANCE OF TECHNICAL STAFF SURVEILLANCE TEST | | 15.6.38(C) (STATION BATTERY SERVICE TEST). THE "1B" EMERGENCY DIESEL IS | | INOPERABLE BECAUSE OF OVERHAUL. | | | | THIS COMBINATION OF INOPERABLE EQUIPMENT RESULTS IN ALL THREE SERVICE WATER | | PUMPS BEING INOPERABLE WHICH IN TURN RENDERS THE ENTIRE SERVICE WATER | | SYSTEM INOPERABLE (SERVICE WATER PUMPS "1B" & "1C" ARE STILL "AVAILABLE" | | BECAUSE THEY ARE CURRENTLY BEING SUPPLIED BY OFFSITE POWER). | | THIS CONDITION ALSO RENDERS THE COMPONENT COOLING WATER SYSTEM INOPERABLE | | AS SERVICE WATER IS ONE OF ITS SUPPORT SYSTEMS. UNIT 2 RHR IS ALSO | | CONSIDERED INOPERABLE AS COMPONENT COOLING IS ITS SUPPORT SYSTEM. ALL | | COMPONENTS EXCEPT THE "1B" EMERGENCY DIESEL GENERATOR AND THE "1A" SERVICE | | WATER PUMP ARE AVAILABLE. THE 111 DC BUS IS EXPECTED TO BE RETURNED TO AN | | OPERABLE STATUS BY 1400 CDT. THE TEST IS COMPLETED AND THE LICENSEE IS | | CLOSING OUT THE PAPER WORK FOR THE SURVEILLANCE TEST. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED OF THIS EVENT BY THE LICENSEE. | | | | ***UPDATE ON 08/23/97 @ 1545EDT BY NOLDIN TAKEN BY MACKINNON*** | | | | AT 1430 CDT THE 111 DC BUS WAS RESTORED TO SERVICE WHICH MAKES THE "1A" | | EMERGENCY DIESEL GENERATOR OPERABLE AND THE "1B" SERVICE WATER PUMP | | OPERABLE. THEREFORE RHR IS NOW FULLY OPERABLE. R3DO (MIKE JORDAN) NOTIFIED. | | | | THE NRC RESIDENT INSPECTOR WILL BE NOTIFIED BY THE LICENSEE OF THIS UPDATE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 32810 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: INDIAN POINT REGION: 1 |NOTIFICATION DATE: 08/23/97 | |UNIT: [2] [ ] [ ] STATE: NY |NOTIFICATION TIME: 17:18 [ET]| |RX TYPE: [2] W-4-LP,[3] W-4-LP |EVENT DATE: 08/23/97 | +------------------------------------------------+EVENT TIME: 16:25[EDT]| |NRC NOTIFIED BY: CORNAZ |LAST UPDATE DATE: 08/23/97 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BILL RULAND RDO | |ARPS 50.72(b)(2)(ii) RPS ACTUATION | | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 2 | A/R Y 100 POWER OPERATION | 0 HOT STANDBY | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | REACTOR TRIPPED FROM 100% POWER DUE TO SINGLE LOOP LOSS OF FLOW SIGNAL. NO | | REACTOR COOLANT PUMPS TRIPPED. | | | | THE UNIT WAS STABLE AT 100% POWER WITH NO EVOLUTIONS IN PROGRESS. THE | | CENTRAL CONTROL ROOM RECEIVED THE "SINGLE LOOP LOSS OF FLOW" FIRST OUT | | ANNUNCIATOR FOLLOWED BY A REACTOR TRIP. ALL RODS FULLY INSERTED INTO THE | | CORE. EMERGENCY PROCEDURE E-0 WAS ENTERED AND EXITED AFTER A NORMAL TRIP | | WAS VERIFIED. BOTH MOTOR DRIVEN AUXILIARY FEEDWATER PUMPS AUTOMATICALLY | | STARTED ON LOW STEAM GENERATOR WATER LEVEL. THE AUXILIARY FEEDWATER PUMPS | | ARE MAINTAINING PROPER STEAM GENERATOR WATER LEVELS. THE STEAM DUMP BYPASS | | CONTROL SYSTEM OPERATED PROPERLY AND IS MAINTAINING Tave AT A NO LOAD | | TEMPERATURE OF 547ø F. ALL EMERGENCY CORE COOLING SYSTEMS AND THE | | EMERGENCY DIESEL GENERATORS ARE FULLY OPERABLE. THE ELECTRICAL GRID IS | | STABLE. | | | | A REVIEW OF THE SEQUENCE OF EVENTS RECORDER SHOWED AN OPEN SIGNAL FROM THE | | "23" REACTOR COOLANT PUMP BREAKER WHICH RECLOSED AND CLEARED (REACTOR TRIP | | SIGNAL COMES OFF THE AUXILIARY CONTACTS ON THE REACTOR COOLANT PUMP TRIP | | BREAKER). ALL REACTOR COOLANT PUMPS REMAINED IN SERVICE THROUGHOUT THE | | EVENT. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED BY THE LICENSEE OF THIS EVENT. | +------------------------------------------------------------------------------+