U.S. Nuclear Regulatory Commission Operations Center Event Reports For 11/25/97 - 11/26/97 ** EVENT NUMBERS ** 33163 33307 33308 33309 33310 33311 33312 33313 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33163 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: GINNA REGION: 1 |NOTIFICATION DATE: 10/28/97 | |UNIT: [1] [ ] [ ] STATE: NY |NOTIFICATION TIME: 15:14 [ET]| |RX TYPE: [1] W-2-LP |EVENT DATE: 10/28/97 | +------------------------------------------------+EVENT TIME: 12:30[EST]| |NRC NOTIFIED BY: DOUGLAS J. GOMEZ |LAST UPDATE DATE: 11/25/97 | |HQ OPS OFFICER: STEVE SANDIN +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JOHN KINNEMAN 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 REFUELING | 0 REFUELING | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | FUEL DESIGN CRITERIA MAY NOT BE MET FOR WESTINGHOUSE TWICE BURNED IFBA | | FUEL. | | | | "ROCHESTER GAS & ELECTRIC PERSONNEL WERE NOTIFIED BY REPRESENTATIVES OF | | WESTINGHOUSE ELECTRIC CORPORATION THAT CERTAIN LIMITS ESTABLISHED IN THE | | CURRENTLY LICENSED PAD CODE FOR FUEL ROD DESIGN MAY HAVE BEEN EXCEEDED. THE | | WESTINGHOUSE CRITERIA EXCEEDED IS ROD INTERNAL PRESSURE WHICH AFFECTS THE | | ASSUMPTION THAT THE FUEL PELLET TO CLAD GAP SHALL NOT REOPEN OVER THE FUEL | | ASSEMBLY LIFETIME. IN ADDITION, THE 17% CLAD OXIDATION LIMIT AS DESCRIBED | | IN 10CFR50.46 MAY ALSO HAVE BEEN IMPACTED. IT IS OUR UNDERSTANDING THAT | | NRC REPRESENTATIVES HAVE PREVIOUSLY BEEN APPRAISED OF THIS CONDITION ON A | | GENERIC BASIS BY WESTINGHOUSE PERSONNEL." | | | | THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | | | | HOO NOTE: SEE EVENT #33160, 33161, 33164 TO 33170, AND 33172. | | | | * * * UPDATE AT 1029 ON 11/25/97 FROM PETERSON TAKEN BY STRANSKY * * * | | | | THE LICENSEE IS RETRACING THIS NOTIFICATION. THE FOLLOWING IS TEXT FROM A | | FACSIMILE SUBMITTED BY THE LICENSEE: | | | | "WESTINGHOUSE HAS PERFORMED A COMPREHENSIVE SAFETY ASSESSMENT WHICH | | CONSIDERED THE POTENTIAL FOR GAP REOPENING IN OPERATING CORES. WESTINGHOUSE | | HAS CONCLUDED THAT GAP REOPENING WILL NOT LEAD TO FUEL ROD FAILURE. GAP | | REOPENING DOES NOT NECESSARILY CAUSE THE 17% MAXIMUM CLADDING OXIDATION | | CRITERION TO BE EXCEEDED (OTHER CONDITIONS MUST ALSO BE PRESENT). SINCE | | GAP REOPENING DOES NOT LEAD TO FUEL ROD FAILURES AND SINCE PREVIOUSLY | | ANALYZED DESIGN BASIS ACCIDENT SCENARIOS REMAIN BOUNDING, WESTINGHOUSE | | CONCLUDES THAT GAP REOPENING IS OF LOW SAFETY SIGNIFICANCE. | | | | ADDITIONAL ANALYSES ARE PLANNED TO CONFIRM THAT ALL THIRD OR MORE CYCLE | | FUEL CONTINUES TO BE BOUNDED BY SECOND CYCLE FUEL. IF THESE ANALYSES | | INDICATE THAT CRITERIA WILL BE EXCEEDED, REPORTABILITY UNDER 10 CFR 50.72 | | AND 10 CFR 50.73 WILL BE REEVALUATED. | | | | THE LICENSEE HAS INFORMED THE NRC SENIOR RESIDENT INSPECTOR." | | | | THE OPERATIONS OFFICER NOTIFIED R1DO (JOHANSEN). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 33307 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: VIRGINIA BEACH GENERAL HOSPITAL |NOTIFICATION DATE: 11/25/97 | | CITY: VIRGINIA BEACH REGION: 2 |NOTIFICATION TIME: 08:23 [ET]| | COUNTY: NORFOLK STATE: VA |EVENT DATE: 11/21/97 | |LICENSE#: 45-11035-01 AGREEMENT: N |EVENT TIME: 00:00[EST]| | DOCKET: |LAST UPDATE DATE: 11/25/97 | | +-----------------------------+ | |PERSON ORGANIZATION| | |AL BELISLE RDO | | |FRED COMBS, NMSS EO | +------------------------------------------------+ | |NRC NOTIFIED BY: MAZZOCCO | | |HQ OPS OFFICER: BOB STRANSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MEDICAL MISADMINISTRATION. | | | | ON 11/21/97, AN ONCOLOGIST PRESCRIBED A THYROID FUNCTION TEST (100æCi OF | | I-131) FOR A 75 YEAR OLD FEMALE. DUE TO A MISCOMMUNICATION, THE PATIENT | | WAS ADMINISTERED A 5 mCi DOSE OF I-131 FOR A WHOLE BODY SCAN. THE ERROR | | WAS DISCOVERED ON 11/24/97. THE ATTENDING PHYSICIAN WILL BE INFORMED OF | | THE ERROR; HOWEVER, THE LICENSEE DOES NOT BELIEVE THAT THE | | MISADMINISTRATION WILL HAVE AN ADVERSE EFFECT ON THE PATIENT. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33308 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: VERMONT YANKEE REGION: 1 |NOTIFICATION DATE: 11/25/97 | |UNIT: [1] [ ] [ ] STATE: VT |NOTIFICATION TIME: 09:09 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 11/25/97 | +------------------------------------------------+EVENT TIME: 06:48[EST]| |NRC NOTIFIED BY: EMPEY |LAST UPDATE DATE: 11/25/97 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JENNY JOHANSEN 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 84 POWER OPERATION | 0 HOT SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AUTOMATIC REACTOR SCRAM FROM 84% POWER AFTER MAIN GENERATOR RUNBACK. | | | | THE PLANT EXPERIENCED AN AUTOMATIC REACTOR SCRAM DUE TO AN APRM FLOW BIASED | | HIGH FLUX TRIP SIGNAL. WORKERS IN THE ELECTRICAL SWITCHYARD INADVERTENTLY | | CAUSED TWO BREAKERS TO TRIP, CAUSING VOLTAGE/CURRENT PERTURBATIONS AND A | | MAIN GENERATOR RUNBACK. CONTROL ROOM OPERATORS REDUCED RECIRCULATION FLOW | | TO APPROXIMATELY 26 Mlb/HR IN RESPONSE TO THE RUNBACK, DECREASING REACTOR | | THERMAL POWER TO 74-78% OF RATED. HOWEVER, LOSS OF FEEDWATER HEATING DUE | | TO THE TRANSIENT CAUSED REACTOR POWER TO INCREASE BEFORE OPERATORS COULD | | INSERT CONTROL RODS TO COMPENSATE. THE PLANT AUTOMATICALLY SCRAMMED WHEN | | REACTOR POWER INCREASED TO APPROXIMATELY 84%. ALL CONTROL RODS INSERTED | | COMPLETELY FOLLOWING THE SCRAM. | | | | FOLLOWING THE SCRAM, PRIMARY CONTAINMENT ISOLATION SYSTEM GROUPS 2, 3, 4, | | AND 5 ISOLATED DUE TO THE EXPECTED REACTOR WATER LEVEL DECREASE, AND THE | | STANDBY GAS TREATMENT SYSTEM AUTOMATICALLY STATED IN RESPONSE TO THE GROUP | | 3 (REACTOR BUILDING VENTILATION) ISOLATION. THE ISOLATIONS HAVE BEEN | | RESET. | | | | THE SWITCHYARD RING BUS HAS BEEN RESTORED, AND THE PLANT IS CURRENTLY | | STABLE IN CONDITION 3 (HOT SHUTDOWN). | | | | THE NRC RESIDENT INSPECTOR HAS BEEN INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33309 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: NINE MILE POINT REGION: 1 |NOTIFICATION DATE: 11/25/97 | |UNIT: [1] [ ] [ ] STATE: NY |NOTIFICATION TIME: 11:21 [ET]| |RX TYPE: [1] GE-2,[2] GE-5 |EVENT DATE: 11/25/97 | +------------------------------------------------+EVENT TIME: 09:00[EST]| |NRC NOTIFIED BY: JAMES KRONENBITTER |LAST UPDATE DATE: 11/25/97 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JENNY JOHANSEN 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 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | PRIMARY CONTAINMENT VENT AND PURGE ISOLATION. | | | | "WHILE PERFORMING TROUBLESHOOTING ON STACK MONITORING SYSTEM, A POWER SPIKE | | OCCURRED RESULTING IN A 'STACK ISOLATION' SIGNAL. THIS CAUSED THE CLOSURE | | OF THE PRIMARY CONTAINMENT VENT AND PURGE ISOLATION VALVES, AS DESIGNED. | | ALL SYSTEMS RESPONDED NORMALLY. CHEMISTRY CONFIRMED THE ACTUATION WAS | | INVALID AND SYSTEMS WERE RETURNED TO NORMAL." | | | | THE NRC RESIDENT INSPECTOR WILL BE INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33310 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: VERMONT YANKEE REGION: 1 |NOTIFICATION DATE: 11/25/97 | |UNIT: [1] [ ] [ ] STATE: VT |NOTIFICATION TIME: 14:22 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 11/25/97 | +------------------------------------------------+EVENT TIME: 11:15[EST]| |NRC NOTIFIED BY: EMPEY |LAST UPDATE DATE: 11/25/97 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JENNY JOHANSEN 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 HOT SHUTDOWN | 0 HOT SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | OFFSITE NOTIFICATION - ONE GALLON OIL SPILL IN THE CONNECTICUT RIVER. | | | | APPROXIMATELY ONE GALLON OF HYDRAULIC OIL WAS SPILLED INTO THE CONNECTICUT | | RIVER BY A DREDGE BARGE. THE LEAK HAS BEEN STOPPED. THE LICENSEE NOTIFIED | | THE NATIONAL RESPONSE CENTER, US COAST GUARD, VERMONT HAZMAT OFFICE, AND | | THE NEW HAMPSHIRE EMERGENCY MANAGEMENT AGENCY. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33311 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: INDIAN POINT REGION: 1 |NOTIFICATION DATE: 11/25/97 | |UNIT: [2] [ ] [ ] STATE: NY |NOTIFICATION TIME: 14:47 [ET]| |RX TYPE: [2] W-4-LP,[3] W-4-LP |EVENT DATE: 11/25/97 | +------------------------------------------------+EVENT TIME: 12:00[EST]| |NRC NOTIFIED BY: MIKE VASELY |LAST UPDATE DATE: 11/25/97 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JENNY JOHANSEN RDO | |APRE 50.72(b)(2)(vi) OFFSITE NOTIFICATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 2 | N N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | OFFSITE NOTIFICATION - TOOLS WITH FIXED CONTAMINATION ALLOWED OFFSITE. | | | | THE LICENSEE MAY MAKE A PRESS RELEASE REGARDING THREE HAND DRILLS AND | | A BAND SAW THAT HAD BEEN SENT TO A LOCAL SHOP FOR OVERHAUL. THE TOOLS | | WERE FOUND TO HAVE FIXED CONTAMINATION IN THE RANGE OF 300 TO 2000 CPM. | | THE TOOLS WERE ORIGINALLY STORED IN A CONTROLLED AREA AND THE LICENSEE | | IS INVESTIGATING HOW THE TOOLS FOUND THEIR WAY TO AN UNCONTROLLED AREA. | | THE CONTAMINATED DRILLS WERE DISCOVERED IN AN UNCONTROLLED AREA AFTER | | THEIR RETURN FROM THE SHOP. A SUBSEQUENT SURVEY OF THE SHOP DISCOVERED | | THE CONTAMINATED BAND SAW. NO LOOSE CONTAMINATION WAS FOUND IN THE SHOP. | | | | THE NRC RESIDENT INSPECTOR HAS BEEN NOTIFIED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33312 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MONTICELLO REGION: 3 |NOTIFICATION DATE: 11/25/97 | |UNIT: [1] [ ] [ ] STATE: MN |NOTIFICATION TIME: 16:32 [ET]| |RX TYPE: [1] GE-3 |EVENT DATE: 11/25/97 | +------------------------------------------------+EVENT TIME: 15:10[CST]| |NRC NOTIFIED BY: KEVIN PEDERSON |LAST UPDATE DATE: 11/25/97 | |HQ OPS OFFICER: DOUG WEAVER +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BRUCE BURGESS 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 | M/R Y 100 POWER OPERATION | 0 HOT SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MANUAL REACTOR SCRAM FROM 50% DUE TO LOSS OF BOTH H2 RECOMBINER SYSTEMS. | | | | BOTH HYDROGEN RECOMBINER SYSTEMS WERE LOST DUE TO AN ELECTRICAL FAULT AT | | APPROXIMATELY 1500 CST. THIS STARTED A SLOW DECREASE IN CONDENSER VACUUM | | AS THE AIR EJECTORS LOST EFFECTIVENESS. A RAPID POWER REDUCTION WAS | | COMMENCED BY REDUCING RECIRCULATION PUMP SPEED. AFTER CONFIRMING THAT | | THE HYDROGEN RECOMBINERS COULD NOT BE PROMPTLY RESTORED, OPERATORS MANUALLY | | SCRAMMED THE REACTOR FROM ABOUT 50% POWER. | | | | ALL CONTROL RODS INSERTED COMPLETELY EXCEPT CONTROL ROD 34-19 WHICH | | INSERTED TO THE 02 POSITION WHICH WAS THEN MANUALLY INSERTED. PRIMARY | | CONTAINMENT ISOLATION SYSTEM GROUP II AND GROUP III ISOLATIONS OCCURRED AT | | +9 INCHES REACTOR VESSEL WATER LEVEL. STEAM IS BEING DUMPED TO THE MAIN | | CONDENSER | | AS NECESSARY TO REMOVE DECAY HEAT. INVESTIGATION CONTINUES INTO THE CAUSE | | OF THE LOSS OF THE HYDROGEN RECOMBINER SYSTEMS. | | | | THE NRC RESIDENT INSPECTOR HAS BEEN NOTIFIED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 33313 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: US NAVY - BREMERTON NAVAL HOSPITAL |NOTIFICATION DATE: 11/25/97 | | CITY: BREMERTON REGION: 4 |NOTIFICATION TIME: 17:25 [ET]| | COUNTY: STATE: WA |EVENT DATE: 11/25/97 | |LICENSE#: 46-68095-11NP AGREEMENT: Y |EVENT TIME: 10:30[PST]| | DOCKET: |LAST UPDATE DATE: 11/25/97 | | +-----------------------------+ | |PERSON ORGANIZATION| | |CHARLES CAIN RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: LCDR POMERVILLE, US NAVY | | |HQ OPS OFFICER: DOUG WEAVER | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NMAT MATL IN UNCNTRL AREA | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | CONTAMINATED PACKAGE DELIVERED TO BREMERTON NAVAL HOSPITAL. | | | | A PACKAGE DELIVERED TO BREMERTON NAVAL HOSPITAL IN BREMERTON, WASHINGTON, | | HAD EXTERNAL CONTAMINATION OF 52,000 DPM/100 CMý OF Tc-99. THE PACKAGE | | CONTAINED 30 mCi OF Tc-99, BUT THE CONTAINER WAS NOT DAMAGED. | | | | THE PACKAGED CAME FROM AND WAS DELIVERED BY TACOMA CENTRAL PHARMACY OF | | TACOMA, WASHINGTON. CONTACT INFORMATION FOR THE HOSPITAL AND PHARMACY IS | | AVAILABLE IN THE HOO LOG. NO PERSONNEL CONTAMINATIONS OCCURRED AT THE | | HOSPITAL. THE PHARMACY WAS NOTIFIED IMMEDIATELY AFTER THE CONTAMINATION | | WAS DISCOVERED. | +------------------------------------------------------------------------------+