U.S. Nuclear Regulatory Commission Operations Center Event Reports For 03/05/98 - 03/06/98 ** EVENT NUMBERS ** 33690 33834 33835 33836 33837 33838 33839 33840 33841 33842 33843 33844 33845 33846 33847 33848 33849 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33690 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: OCONEE REGION: 2 |NOTIFICATION DATE: 02/10/98 | |UNIT: [ ] [2] [ ] STATE: SC |NOTIFICATION TIME: 20:48 [ET]| |RX TYPE: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP |EVENT DATE: 02/10/98 | +------------------------------------------------+EVENT TIME: 17:00[EST]| |NRC NOTIFIED BY: NORTH |LAST UPDATE DATE: 03/05/98 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |ROBERT HAAG RDO | |AINC 50.72(b)(2)(iii)(C) POT UNCNTRL RAD REL | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE LICENSEE DISCOVERED AN OPEN PATHWAY FROM CONTAINMENT TO THE | | ENVIRONMENT. | | | | THE OPEN PATHWAY FROM CONTAINMENT TO THE ENVIRONMENT WOULD HAVE BEEN | | ISOLATED BY AN ENGINEERED SAFEGUARDS SIGNAL WHICH WOULD HAVE OCCURRED AT | | 3 PSIG REACTOR BUILDING PRESSURE OR 1,600 PSIG RCS PRESSURE. THIS PATHWAY | | EXISTED FROM 1100 TO 1400 ON 02/10/98 DURING A SETUP FOR TESTING OF THE | | CONTAINMENT HYDROGEN RECOMBINER SYSTEM. MAINTENANCE PERSONNEL STARTED TO | | HOOK UP THE HYDROGEN RECOMBINER PRIOR TO ISOLATING THE VALVES. THIS | | RESULTED IN THE OPEN PATH. DURING THIS TIME, IT DOES NOT APPEAR THAT AN | | UNMONITORED RELEASE OCCURRED BASED ON AN INCREASE IN REACTOR BUILDING | | PRESSURE (REACTOR BUILDING PRESSURE WAS LESS THAN ATMOSPHERIC PRESSURE) | | WHEN THE BLIND FLANGES WERE REMOVED TO CONNECT THE HYDROGEN RECOMBINER | | SKID. | | | | THE HYDROGEN RECOMBINER IS CONNECTED VIA FLANGES LOCATED OUTSIDE THE | | REACTOR BUILDING. THE PIPING TO THIS FLANGE EXITS THE REACTOR BUILDING | | THROUGH TWO VALVES IN SERIES, AND EACH VALVE RECEIVES AN ENGINEERED | | SAFEGUARDS SIGNAL. THE RETURN PIPING TO THE REACTOR BUILDING ALSO HAS TWO | | VALVES IN SERIES WHICH ALSO RECEIVE AN ENGINEERED SAFEGUARDS SIGNAL. THESE | | CONTAINMENT ISOLATION VALVES AND THE ASSOCIATED ENGINEERED SAFEGUARDS | | SIGNALS REMAINED OPERABLE THROUGHOUT THE EVENT. THE EVENT IS STILL BEING | | INVESTIGATED. | | | | THE NRC RESIDENT INSPECTOR WAS INFORMED BY THE LICENSEE. | | | | * * * UPDATE AT 1621 ON 03/05/98 FROM LOWERY RECEIVED BY TROCINE * * * | | | | THE LICENSEE IS RETRACTING THIS EVENT NOTIFICATION SINCE, AFTER FURTHER | | REVIEW, IT DOES NOT MEET THE REPORTABILITY REQUIREMENTS OF 10 CFR 50.72. | | THE LICENSEE CONFIRMED THAT THERE WAS NO UNMONITORED RELEASE. THE REACTOR | | BUILDING PRESSURE WAS LESS THAN ATMOSPHERIC PRESSURE DURING THE TIME PERIOD | | THE PATHWAY EXISTED. IN ADDITION, THE ENGINEERED SAFEGUARD FUNCTION OF THE | | CONTAINMENT ISOLATION REMAINED FULLY OPERATIONAL. THIS EVENT ALONE COULD | | NOT HAVE PREVENTED THE FULFILLMENT OF THE SAFETY FUNCTION OF STRUCTURES | | (THE REACTOR BUILDING) OR SYSTEMS (REACTOR BUILDING ENGINEERED SAFEGUARDS | | ISOLATION) THAT ARE NEEDED TO CONTROL THE RELEASE OF RADIOACTIVE MATERIAL. | | | | THE LICENSEE NOTIFIED THE NRC RESIDENT INSPECTOR. THE NRC OPERATIONS | | CENTER NOTIFIED THE R2DO (BELISLE). | +------------------------------------------------------------------------------+ !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33834 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: ZION REGION: 3 |NOTIFICATION DATE: 03/05/98 | |UNIT: [1] [2] [ ] STATE: IL |NOTIFICATION TIME: 02:53 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 03/05/98 | +------------------------------------------------+EVENT TIME: 00:59[CST]| |NRC NOTIFIED BY: LANE OBEREMBT |LAST UPDATE DATE: 03/05/98 | |HQ OPS OFFICER: STEVE SANDIN +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |RONALD GARDNER RDO | |DDDD 73.71 UNSPECIFIED PARAGRAPH | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 REFUELING | 0 REFUELING | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | A SAFEGUARDS SYSTEM DEGRADATION RELATED TO PERIMETER MONITORING OCCURRED. | | IMMEDIATE COMPENSATORY MEASURES WERE TAKEN UPON DISCOVERY. (REFER TO THE | | HOO LOG FOR DETAILS.) | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | | | | * * * UPDATE AT 1625 ON 03/05/97 FROM WILLIAMS RECEIVED BY TROCINE * * * | | | | FURTHER INVESTIGATION AND ASSESSMENT REVEALED THAT THERE WAS NO SAFEGUARDS | | SYSTEM DEGRADATION. THEREFORE, THE LICENSEE WISHES TO RETRACT THIS EVENT | | NOTIFICATION REPORT. | | | | THE LICENSEE PLANS TO INFORM THE NRC RESIDENT INSPECTOR. THE NRC | | OPERATIONS CENTER NOTIFIED THE R3DO (GARDNER). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |OTHER NUCLEAR MATERIAL | |EVENT NUMBER: 33835 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: USAF RADIOISOTOPE COMMITTEE |NOTIFICATION DATE: 03/05/98 | | CITY: REGION: 1 |NOTIFICATION TIME: 08:06 [ET]| | COUNTY: STATE: MA |EVENT DATE: 02/04/98 | |LICENSE#: 42-23539-01AF AGREEMENT: Y |EVENT TIME: 14:30[EST]| | DOCKET: 03028641 |LAST UPDATE DATE: 03/05/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |RONALD BELLAMY RDO | | |DON COOL, NMSS EO | +------------------------------------------------+TOM STETKA RDO | |NRC NOTIFIED BY: CAPT. JULIE COLEMAN |FEMA, DOE, DOA, HHS FAX | |HQ OPS OFFICER: STEVE SANDIN |EPA, DOT (NRC) FAX | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |BAB2 20.2201(a)(1)(ii) LOST/STOLEN LNM>10X | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | FOUR MISSING MAG COMPASSES EACH CONTAINING 120 mCi OF TRITIUM | | | | ON 02/04/98 AT 1430 EST, AN AIR FORCE REPRESENTATIVE AT HANSCOM AIR FORCE | | BASE, WHICH IS LOCATED 1 HOUR WEST OF BOSTON, MASSACHUSETTS, NOTIFIED THE | | AIR FORCE MEDICAL OPERATIONS AGENCY (OFFICE OF THE SURGEON GENERAL) THAT | | FOUR MAG COMPASSES (NSN 6605-00-151-5337) FROM THE CLINIC READINESS SECTION | | WERE FOUND TO BE MISSING DURING A ROUTINE ANNUAL SURVEY. EACH COMPASS | | CONTAINS 120 mCi OF TRITIUM. THESE COMPASSES ARE USED APPROXIMATELY ONCE A | | YEAR DURING ANNUAL CONTINUING MEDICAL READINESS TRAINING. WHEN NOT IN USE | | THEY ARE STORED WITH OTHER MEDICAL READINESS SUPPLIES. A SUBSEQUENT | | EXHAUSTIVE SEARCH DID NOT LOCATE THEM. THE LICENSEE BELIEVES THAT THE | | COMPASSES ARE PROBABLY MISPLACED. THERE IS NO SUSPECTED EXPOSURE | | ASSOCIATED WITH THIS INCIDENT. (REFER TO THE HOO LOG FOR A LICENSEE | | CONTACT TELEPHONE NUMBER.) | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 33836 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: FAIRVIEW UNIVERSITY MEDICAL CENTER |NOTIFICATION DATE: 03/05/98 | | CITY: MINNEAPOLIS REGION: 3 |NOTIFICATION TIME: 11:12 [ET]| | COUNTY: HENNAPIN STATE: MN |EVENT DATE: 03/04/98 | |LICENSE#: 22-0187-46 AGREEMENT: N |EVENT TIME: 09:20[CST]| | DOCKET: |LAST UPDATE DATE: 03/05/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |RONALD GARDNER RDO | | |DON COOL, NMSS EO | +------------------------------------------------+ | |NRC NOTIFIED BY: ERIC EASTWOLD | | |HQ OPS OFFICER: STEVE SANDIN | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MEDICAL MISADMINISTRATION DUE TO EARLY REMOVAL OF A Cs-137 IMPLANT AT | | FAIRVIEW UNIVERSITY MEDICAL CENTER (THERAPEUTIC RADIOLOGY RADIATION | | ONCOLOGY DEPARTMENT) LOCATED IN MINNEAPOLIS, MINNESOTA | | | | ON 03/04/98, A Cs-137 SOURCE WAS REMOVED FROM A FEMALE PATIENT UNDERGOING | | TREATMENT FOR CERVICAL CANCER. A 54-HOUR EXPOSURE WAS PRESCRIBED; HOWEVER, | | THE IMPLANT WAS REMOVED AFTER 42 HOURS DUE TO A TRANSCRIPTION ERROR BY A | | RESIDENT PHYSICIAN. (THE TIME OF 9:20 p.m. ON 03/04/97 WAS INCORRECTLY | | TRANSCRIBED AS 9:20 a.m.) THE ATTENDING PHYSICIAN IN CONSULTATION WITH THE | | REFERRING PHYSICIAN DECIDED THAT THE PATIENT WOULD NOT BE NOTIFIED OF THE | | UNDEREXPOSURE IN THAT THE TREATMENT WAS FOR PALLIATIVE PURPOSES. THERE IS | | NO REMEDIAL CARE REQUIRED. THE LICENSEE HAS BOTH THE PRESCRIBED AND ACTUAL | | EXPOSURE INFORMATION AVAILABLE. (REFER TO THE HOO LOG FOR THE LICENSEE'S | | STREET ADDRESS AND TELEPHONE NUMBER.) | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33837 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SAINT LUCIE REGION: 2 |NOTIFICATION DATE: 03/05/98 | |UNIT: [1] [ ] [ ] STATE: FL |NOTIFICATION TIME: 15:10 [ET]| |RX TYPE: [1] CE,[2] CE |EVENT DATE: 03/05/98 | +------------------------------------------------+EVENT TIME: 14:35[EST]| |NRC NOTIFIED BY: JAMES HURCHALLA |LAST UPDATE DATE: 03/05/98 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |AL BELISLE RDO | |AOUT 50.72(b)(1)(ii)(B) OUTSIDE DESIGN BASIS | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | TWO OUTSIDE-DESIGN-BASIS CONDITIONS FOR FIRE PROTECTION FEATURES: UNIT 1 | | POWER-OPERATED RELIEF VALVES (PORV) AND THE '1A' CHARGING PUMP | | | | THE FOLLOWING TEXT IS A PORTION OF A FACSIMILE RECEIVED FROM THE LICENSEE: | | | | "AT 1435, A DETERMINATION WAS MADE OF REPORTABILITY UNDER 10 CFR 50.72 FOR | | A DEGRADED CONDITION - OUTSIDE DESIGN BASIS FOR FIRE PROTECTION FEATURES." | | "SECTION III.G OF APPENDIX 'R' (FIRE PROTECTION OF SAFE SHUTDOWN | | CAPABILITY) REQUIRES THAT FIRE PROTECTION FEATURES BE PROVIDED TO PROTECT | | ONE TRAIN OF SAFE SHUTDOWN EQUIPMENT FROM FIRE DAMAGE. CONTRARY TO THIS | | REQUIREMENT, TWO CONDITIONS HAVE BEEN DISCOVERED ON UNIT 1 WHERE SUCH | | PROTECTION DOES NOT EXIST. | | | | "CONDITION 1 CONCERNS THE LACK OF PROTECTION FOR THE UNIT 1 PORVs TO | | PRECLUDE THEIR SPURIOUS OPERATION DURING A POSTULATED FIRE. THE UNIT 1 | | APPENDIX 'R' DESIGN REQUIRES THAT THE CABLES FOR THE PORVs BE PROTECTED | | FROM INTERACTION WITH OTHER CABLES THAT COULD CAUSE THEIR SPURIOUS OPENING. | | HOWEVER, FIELD WALKDOWNS INDICATE THAT A PORTION OF EACH PORV's POWER | | CABLING IS ROUTED IN A COMMON WIREWAY IN THE ELECTRICAL PENETRATION ROOMS. | | THIS CONFIGURATION MAKES THE PORVs SUSCEPTIBLE TO SPURIOUS OPERATION AS A | | RESULT OF THE POTENTIAL INTERACTION WITH OTHER POWER CABLES. | | | | "CONDITION 2 CONCERNS THE LACK OF PROTECTION FOR THE '1A' CHARGING PUMP IN | | FIRE AREA 'N' (CHARGING PUMP AREA). SPECIFICALLY, AN EXEMPTION WAS | | REQUESTED FOR THE CHARGING PUMPS WHICH REQUIRED THE POWER CABLE FOR THE | | '1A' CHARGING PUMP TO BE PROTECTED IN A ONE-HOUR FIRE BARRIER. FIELD | | INSPECTION INDICATES THAT THIS ONE-HOUR PROTECTION DOES NOT EXIST. AS A | | RESULT, REDUNDANT CHARGING PUMPS MAY NOT BE AVAILABLE FOR POSTULATED FIRES | | WITHIN THIS FIRE AREA. | | | | "AN OPERABILITY ASSESSMENT HAS BEEN PERFORMED FOR BOTH CONDITIONS, AND IT | | HAS BEEN CONCLUDED THAT UNIT 1 REMAINS OPERABLE. INTERIM COMPENSATORY | | ACTIONS HAVE BEEN IMPLEMENTED." | | | | THE LICENSEE NOTIFIED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |TRANSPORTATION EVENT | |EVENT NUMBER: 33838 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: NATIONAL RESPONSE CENTER |NOTIFICATION DATE: 03/05/98 | | CITY: INGLIS REGION: 2 |NOTIFICATION TIME: 15:12 [ET]| | COUNTY: LEVY STATE: FL |EVENT DATE: 03/05/98 | |LICENSE#: AGREEMENT: Y |EVENT TIME: 14:15[EST]| | DOCKET: |LAST UPDATE DATE: 03/05/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |AL BELISLE RDO | | |JOSEPHINE PICCONE EO | +------------------------------------------------+FRANK CONGEL, AEOD IRD | |NRC NOTIFIED BY: PETTY OFFICER SAVAGE |TOM TANNER DOE | |HQ OPS OFFICER: LEIGH TROCINE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NTRA TRANSPORTATION EVENT | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | TRAFFIC ACCIDENT INVOLVING A TRUCK TOWING A TRAILER CONTAINING AN | | IRIDIUM-192 SOURCE IN INGLIS, FLORIDA | | | | THE NATIONAL RESPONSE CENTER NOTIFIED THE NRC OPERATIONS CENTER OF A | | TRAFFIC ACCIDENT INVOLVING A TRUCK TOWING A TRAILER WITH A PORTABLE | | DARKROOM FACILITY WHICH CONTAINED AN IRIDIUM-192 SOURCE (INCIDENT REPORT | | #427071). THE ACCIDENT OCCURRED AT 1415 ON 03/05/98 IN INGLIS, FLORIDA, AT | | THE CORNER OF U.S. 19 AND HIGHWAY 121. THERE WAS NO DAMAGE TO THE VEHICLES | | OR TO THE SOURCE, AND THERE WERE NO PERSONNEL INJURIES. THERE WAS NO | | RELEASE OF RADIOACTIVE MATERIAL. | | | | THE NATIONAL RESPONSE CENTER NOTIFIED THE ENVIRONMENTAL PROTECTION AGENCY, | | REGION IV, AND PLANS TO NOTIFY THE ENVIRONMENTAL PROTECTION AGENCY OFFICE | | OF AIR AND RADIATION. PER A FACSIMILE RECEIVED BY THE NATIONAL RESPONSE | | CENTER, THE HIGHWAY PATROL AND THE STATE WERE ALSO NOTIFIED. THIS | | FACSIMILE ALSO REFERENCED FLORIDA POWER CORPORATION AS THE ORGANIZATION OF | | THE REPORTING PARTY AND THE SUSPECTED RESPONSIBLE PARTY, AND IT ALSO | | REFERENCED THE STATE GOVERNMENT AS THE TYPE OF ORGANIZATION. (REFER TO THE | | HOO LOG FOR A CONTACT NAME AND TELEPHONE NUMBER.) | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 33839 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: DR. JOSE COLON |NOTIFICATION DATE: 03/05/98 | | CITY: MANATI REGION: 2 |NOTIFICATION TIME: 15:20 [ET]| | COUNTY: STATE: PR |EVENT DATE: 08/23/94 | |LICENSE#: 52-25113-02 AGREEMENT: N |EVENT TIME: 00:00[AT ]| | DOCKET: |LAST UPDATE DATE: 03/05/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |AL BELISLE RDO | | |JOSEPHINE PICCONE EO | +------------------------------------------------+ | |NRC NOTIFIED BY: DR. JOSE COLON | | |HQ OPS OFFICER: LEIGH TROCINE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | TWO MEDICAL MISADMINISTRATIONS INVOLVING STRONTIUM-90 OCCURRED IN 1994 AT | | THE DR. JOSE COLON FACILITY IN MANATI, PUERTO RICO. | | | | TWO MEDICAL MISADMINISTRATIONS (ONE UNDERDOSE AND ONE OVERDOSE) WERE | | IDENTIFIED AS A RESULT OF AN ONGOING NRC AUDIT. BOTH OF THESE INCIDENTS | | INVOLVED THE RECEIPT OF BETA RADIATION FROM A STRONTIUM-90 SOURCE AS PART | | OF PTERIGUIUM (EYE) SURGERY. ON 09/27/94, THE PRESCRIBED DOSE WAS 1,500 | | RADs OVER A PERIOD OF 30 SECONDS, AND THE RECEIVED DOSE WAS 1,000 RADs OVER | | A PERIOD OF 21 SECONDS. ON 08/23/94, THE PRESCRIBED DOSE WAS 1,000 RADs | | OVER A PERIOD OF 20 SECONDS, AND THE RECEIVED DOSE WAS 1,500 RADs OVER A | | PERIOD OF 30 SECONDS. THE LICENSEE STATED THAT THIS WAS WELL BELOW THE | | MINIMUM DOSE OF 2,000 RADs. THE LICENSEE ALSO STATED THAT BOTH INDIVIDUALS | | WERE NOTIFIED AND THAT THERE WERE NO ANTICIPATED ADVERSE HEALTH AFFECTS AS | | A RESULT OF THESE MISADMINISTRATIONS. (REFER TO THE HOO LOG FOR THE | | LICENSEE'S ADDRESS AND TELEPHONE NUMBER.) | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33840 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: COOK REGION: 3 |NOTIFICATION DATE: 03/05/98 | |UNIT: [1] [ ] [ ] STATE: MI |NOTIFICATION TIME: 15:22 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 03/05/98 | +------------------------------------------------+EVENT TIME: 12:00[EST]| |NRC NOTIFIED BY: RUSS STEVENS |LAST UPDATE DATE: 03/05/98 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |RONALD GARDNER 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 +------------------------------------------------------------------------------+ | CONTAINMENT LINER PITTING WAS FOUND (WHILE THE REACTOR WAS SHUTDOWN), WHICH | | IF IT HAD BEEN FOUND WHILE THE REACTOR WAS OPERATING, WOULD HAVE RESULTED | | IN THE PLANT BEING IN AN UNANALYZED CONDITION. | | | | AS PART OF THE INVESTIGATION OF INFORMATION NOTICE 97-10, LINER PLATE | | CORROSION IN CONCRETE CONTAINMENTS, AN INSPECTION OF THE STEEL CONTAINMENT | | LINER IS UNDERWAY. THE INSPECTION OF THE LINER, LOCATED AT THE BOTTOM OF | | THE CONTAINMENT NEAR WHERE THE VERTICAL SECTION OF THE LINER JOINS THE | | HORIZONTAL SECTION, HAS IDENTIFIED THAT THE CONTAINMENT LINER IS PITTED. | | THE ALLOWABLE DEPTH OF ANY PIT IS SPECIFIED TO BE 0.125 INCHES. PITTING | | HAS BEEN IDENTIFIED WHICH EXCEEDS THE ALLOWABLE DEPTH WITH A MAXIMUM | | MEASURED PIT DEPTH OF 0.171 INCHES. | | | | THE SPECIFIC CORROSION MECHANISM HAS NOT YET BEEN DETERMINED. HOWEVER, THE | | SEAL BETWEEN LINER AND THE CONCRETE SLAB HAS DETERIORATED, WHICH INDICATES | | A POTENTIAL FOR MOISTURE INTRUSION OR A SEAL MATERIAL INTERACTION. THE | | LICENSEE STATED THAT INSPECTIONS OF THE SEAL AREA WILL CONTINUE. AN | | ENGINEERING EVALUATION IS IN PROGRESS. REPAIR PLANS ARE UNDER DEVELOPMENT | | TO RETURN THE LINER TO ITS DESIGN BASIS. INSPECTION OF THE UNIT 2 LINER IS | | UNDERWAY AND PITTING HAS BEEN IDENTIFIED, BUT NONE OF THE PITTING HAS YET | | TO EXCEED THE ALLOWABLE DEPTH. | | | | THE LICENSEE NOTIFIED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33841 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: POINT BEACH REGION: 3 |NOTIFICATION DATE: 03/05/98 | |UNIT: [ ] [2] [ ] STATE: WI |NOTIFICATION TIME: 15:30 [ET]| |RX TYPE: [1] W-2-LP,[2] W-2-LP |EVENT DATE: 03/05/98 | +------------------------------------------------+EVENT TIME: 14:09[CST]| |NRC NOTIFIED BY: ROSSEAU |LAST UPDATE DATE: 03/05/98 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |RONALD GARDNER 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 | 97 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO AN INOPERABLE COMPONENT | | COOLING WATER (CCW) SYSTEM | | | | AT 1325 CST, THE UNIT ENTERED TECHNICAL SPECIFICATION 15.3.0 BASED ON | | DECLARING THE UNIT 2 CCW SYSTEM INOPERABLE. THE CCW SYSTEM WAS DECLARED | | INOPERABLE DUE TO AN ENGINEERING EVALUATION OF JET IMPINGEMENT CONCERNS | | FROM A PRESSURIZER SURGE LINE LEAK ON THE 4-INCH CCW PIPING INSIDE THE | | REACTOR COOLANT PUMP CUBICLE. THE LICENSEE COMMENCED A SHUTDOWN OF UNIT 2 | | AT 1409 CST. UNIT 1 IS DEFUELED. THE LICENSEE STATED THAT THIS CONDITION | | WILL BE LOOKED AT IN UNIT 1; HOWEVER, THE PIPING CONFIGURATIONS ARE | | DIFFERENT. | | | | THE LICENSEE NOTIFIED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 33842 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: ATHENS REGIONAL MEDICAL CENTER |NOTIFICATION DATE: 03/05/98 | | CITY: ATHENS REGION: 2 |NOTIFICATION TIME: 15:31 [ET]| | COUNTY: STATE: GA |EVENT DATE: 03/04/98 | |LICENSE#: GA-4-1 AGREEMENT: Y |EVENT TIME: 00:00[EST]| | DOCKET: |LAST UPDATE DATE: 03/05/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |AL BELISLE RDO | | |JOSEPHINE PICCONE EO | +------------------------------------------------+FRANK CONGEL, AEOD IRD | |NRC NOTIFIED BY: ELIZABETH L. DRINNON | | |HQ OPS OFFICER: LEIGH TROCINE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AGREEMENT STATE REPORT OF A MEDICAL MISADMINISTRATION AT ATHENS REGIONAL | | MEDICAL CENTER LOCATED IN ATHENS, GEORGIA | | | | THE FOLLOWING INFORMATION WAS RECEIVED VIA FACSIMILE FROM THE STATE OF | | GEORGIA'S DEPARTMENT OF NATURAL RESOURCES, ENVIRONMENTAL PROTECTION | | DIVISION, RADIATION PROTECTION DEPARTMENT (ELIZABETH L. DIVISION): | | | | "[A] PATIENT WAS TO RECEIVE A SECOND FRACTION TREATMENT BY HDR [HIGH DOSE | | RATE REMOTE AFTER-LOADER BRACHYTHERAPY] TO [THE] URETHRA. THE FIRST | | FRACTION HAD GONE PERFECTLY ACCORDING TO [THE] PHYSICIST. THE PATIENT HAD | | A CATHETER IN PLACE FOR THE HDR TREATMENT. THE DAY THE PATIENT CAME IN FOR | | THE SECOND FRACTION, SHE HAD THE HDR CATHETER IN PLACE IN THE URETHRA, AND | | A SECOND CATHETER HAD BEEN SURGICALLY PLACED IN THE BLADDER FOR AN | | UNRELATED PROCEDURE. WHEN THE TRIAL RUN WAS MADE FOR THE SECOND FRACTION, | | THE PHYSICIAN SAID EVERYTHING LOOKED LIKE IT WAS SUPPOSED TO ON THE FILM | | WITH THE HDR CATHETER IN PLACE. THEY HOOKED UP THE HDR FOR THE ACTUAL | | PROCEDURE AND GAVE THE PATIENT THE SECOND FRACTION. WHEN THEY STARTED TO | | REMOVE THE HDR CATHETER, THEY FOUND THE URETHRA CATHETER THEY WERE SUPPOSED | | TO USE UNDER THE PATIENT'S LEG. THEY HAD ACCIDENTALLY PLACED THE HDR IN | | THE BLADDER CATHETER. THE INTENDED TREATMENT SITE WAS ESTIMATED TO RECEIVE | | LESS THAN 25 RADs FROM THE INADVERTENT TREATMENT WHICH WAS APPROXIMATELY | | 10-15 CM FROM THE INTENDED TREATMENT SITE. THE TOTAL TREATMENT WILL BE | | APPROXIMATELY 3,000 RADs ONCE ALL FRACTIONS HAVE BEEN DELIVERED. THE | | PHYSICIAN AND THE PATIENT WERE INFORMED OF THE MISADMINISTRATION. THE | | PATIENT WAS RETREATED AT THE CORRECT SITE ON THE SAME DAY. | | | | "THE LICENSEE WILL SUBMIT A WRITTEN REPORT OF THE INCIDENT WITHIN 15 DAYS | | (MARCH 18). THEY KNOW THEY HAVE TO GIVE A WRITTEN REPORT TO THE PATIENT. | | FINAL DOSE CALCULATIONS WILL BE INCLUDED IN THE FINAL REPORT." | | | | THE ISOTOPE INVOLVED WAS IRIDIUM-192, AND THE AMOUNT OF ACTIVITY INVOLVED | | WAS 3.55 CURIES. THE DATE OF THE EVENT WAS MARCH 4, 1998, AND THE DATE | | THAT THIS EVENT WAS REPORTED TO THE STATE RCP WAS MARCH 5, 1998. THERE | | WERE NO OTHER LICENSEES INVOLVED. | | | | (REFER TO THE HOO LOG FOR THE LICENSEE'S ADDRESS AND FOR A STATE CONTACT | | TELEPHONE NUMBER.) | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33843 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PALISADES REGION: 3 |NOTIFICATION DATE: 03/05/98 | |UNIT: [1] [ ] [ ] STATE: MI |NOTIFICATION TIME: 15:41 [ET]| |RX TYPE: [1] CE |EVENT DATE: 03/05/98 | +------------------------------------------------+EVENT TIME: 14:45[EST]| |NRC NOTIFIED BY: ROBERT VINCENT |LAST UPDATE DATE: 03/05/98 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |RONALD GARDNER RDO | |AOUT 50.72(b)(1)(ii)(B) OUTSIDE DESIGN BASIS | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | MANUAL ACTIONS TO SUPPORT EMERGENCY CORE COOLING SYSTEM (ECCS) RESPONSE TO | | A POSTULATED SMALL BREAK LOSS OF COOLANT ACCIDENT (LOCA) MAY NOT HAVE BEEN | | ADEQUATELY DEFINED. | | | | A REVIEW OF HIGH PRESSURE (HP) AIR SYSTEM OPERATION NEEDED TO SUPPORT ECCS | | RESPONSE TO A POSTULATED SMALL BREAK LOCA HAS LED TO A CONCERN THAT | | REQUIRED OPERATOR ACTIONS ARE NOT ADEQUATELY DEFINED IN OPERATING | | PROCEDURES. SOME MANUAL ACTIONS ARE REQUIRED TO ASSURE HP AIR AVAILABILITY | | FOR A RANGE OF SMALL BREAK LOCAs. THESE ACTIONS MUST BE TAKEN PRIOR TO | | DRAINING THE SAFETY INJECTION AND REFUELING WATER TANK (SOURCE OF ECCS | | WATER) TO ASSURE THAT ECCS PUMP SUCTIONS WILL SUCCESSFULLY SWITCH TO THE | | CONTAINMENT SUMP. MANUAL ACTIONS ARE PERMITTED BY PLANT DESIGN BASES. | | BECAUSE THE OPERATING PROCEDURES LACK DEFINITIVE GUIDANCE, THERE MAY BE A | | SIGNIFICANT PROBABILITY THAT OPERATORS WILL FAIL TO TAKE THE NEEDED ACTIONS | | IN THE REQUIRED TIME. THE TIME REQUIRED TO COMPLETE ACTIONS WOULD RANGE | | FROM A MINIMUM OF APPROXIMATELY 1 HOUR FOR LARGE BREAKS TO MANY HOURS AS | | THE BREAKS GET SMALLER. SINCE THE FAILURE TO TAKE NECESSARY MANUAL ACTIONS | | COULD JEOPARDIZE THE ECCS FUNCTION, THIS SITUATION COULD BE VIEWED AS A | | POTENTIAL CONDITION OUTSIDE THE DESIGN BASIS. | | | | IMMEDIATE ACTION HAS BEEN TAKEN TO PROVIDE GUIDANCE TO OPERATING SHIFTS. | | THIS GUIDANCE IS ADEQUATE TO ENSURE ECCS EQUIPMENT OPERABILITY. PROCEDURE | | ENHANCEMENTS ARE IN PROGRESS, AND THE LICENSEE STATED THAT THEY WILL BE | | MADE PROMPTLY. | | | | THE LICENSEE HAS NOTIFIED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |GENERAL INFORMATION or OTHER | |EVENT NUMBER: 33844 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: COGEMA MINING, INC |NOTIFICATION DATE: 03/05/98 | | CITY: REGION: 4 |NOTIFICATION TIME: 16:50 [ET]| | COUNTY: CAMPBELL STATE: WY |EVENT DATE: 03/05/98 | |LICENSE#: SUA-1341 AGREEMENT: N |EVENT TIME: 14:50[MST]| | DOCKET: |LAST UPDATE DATE: 03/05/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |TOM STETKA RDO | | |JOSEPHINE PICCONE EO | +------------------------------------------------+JOE HOLONICH NMSS | |NRC NOTIFIED BY: JOHN VASELIN | | |HQ OPS OFFICER: LEIGH TROCINE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NLTR LICENSEE 24 HR REPORT | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | COGEMA MINING, INC., REPORTED A PERIMETER MONITOR WELL IN EXCURSION STATUS | | AT THE CHRISTENSEN MINE LOCATED 100 MILES NORTHEAST OF CASPER, WYOMING. | | | | PERIMETER MONITOR WELL 6MW46 WAS FOUND TO BE IN EXCURSION STATUS. CHLORIDE | | WAS 22.5 MILLIGRAMS PER LITER, AND THE LIMIT WAS 20.6 MILLIGRAMS PER LITER. | | ALKALINITY WAS 282.4 MILLIGRAMS PER LITER, AND THE LIMIT WAS 89.2 | | MILLIGRAMS PER LITER. THERE HAS BEEN NO URANIUM DETECTED. | | | | SOME OVER-INJECTION WAS DISCOVERED IN THE AREA. THE LICENSEE IS IN THE | | PROCESS OF OVER-RECOVERING TO CORRECT THE EXCURSION. THE LICENSEE ASSESSED | | THE RISK TO BE MINIMAL. | | | | THIS EVENT WAS REPORTED IN ACCORDANCE WITH LICENSEE CONDITIONS 28 AND 29. | | | | (REFER TO THE HOO LOG FOR A COGEMA CONTACT TELEPHONE NUMBER.) | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |OTHER NUCLEAR MATERIAL | |EVENT NUMBER: 33845 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: DUPONT CORPORATION |NOTIFICATION DATE: 03/05/98 | | CITY: LOS ANGELES, CA REGION: 4 |NOTIFICATION TIME: 18:14 [ET]| | COUNTY: STATE: CA |EVENT DATE: 03/03/98 | |LICENSE#: AGREEMENT: Y |EVENT TIME: 18:00[PST]| | DOCKET: |LAST UPDATE DATE: 03/05/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |TOM STETKA RDO | | |JOSEPHINE PICCONE EO | +------------------------------------------------+FRANK CONGEL, AEOD IRD | |NRC NOTIFIED BY: DONALD BUNN - STATE OF CA |TED DUNCAN DOE | |HQ OPS OFFICER: LEIGH TROCINE |RUTHERFORD DOT | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AGREEMENT STATE REPORT - A SHIPMENT OF THALLIUM-201 WAS DAMAGED AT THE LOS | | ANGELES INTERNATIONAL AIRPORT. | | | | A SHIPMENT CONTAINING 54-MILLICURIES OF THALLIUM-201 WAS BEING TRANSPORTED | | FROM THE DUPONT CORPORATION IN MASSACHUSETTS. THE SHIPMENT FELL OFF A | | TRANSPORTER IN THE LOS ANGELES INTERNATIONAL AIRPORT AND WAS RUN OVER BY A | | VEHICLE. THE CONTAINER WAS RUPTURED. AN INSPECTOR FROM THE STATE OF | | CALIFORNIA WENT TO THE SCENE, TOOK READINGS, AND BARRICADED THE AREA. THERE | | WERE NO READINGS AVAILABLE AT THE TIME OF THIS EVENT NOTIFICATION. NO ONE | | WAS REPORTED TO BE CONTAMINATED. THE AREA IS STILL BARRICADED, AND DUPONT | | IS SCHEDULED TO CLEANUP THE AREA. | | | | THE NRC OPERATIONS CENTER NOTIFIED THE FOLLOWING FEDERAL AGENCIES OF THIS | | EVENT VIA FACSIMILE: FEDERAL EMERGENCY MANAGEMENT AGENCY, DEPARTMENT OF | | ENERGY, DEPARTMENT OF AGRICULTURE, DEPARTMENT OF HEALTH AND HUMAN SERVICES, | | ENVIRONMENTAL PROTECTION AGENCY, AND DEPARTMENT OF TRANSPORTATION (VIA THE | | NATIONAL RESPONSE CENTER). (REFER TO THE HOO LOG FOR A STATE CONTACT | | TELEPHONE NUMBER.) | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33846 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BEAVER VALLEY REGION: 1 |NOTIFICATION DATE: 03/05/98 | |UNIT: [1] [ ] [ ] STATE: PA |NOTIFICATION TIME: 18:42 [ET]| |RX TYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 03/05/98 | +------------------------------------------------+EVENT TIME: 17:48[EST]| |NRC NOTIFIED BY: JEFF SHIPE |LAST UPDATE DATE: 03/05/98 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |RONALD BELLAMY 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 +------------------------------------------------------------------------------+ | DISCOVERY THAT CAPACITORS COULD NOT BE GUARANTEED TO WITHSTAND THE | | CONSEQUENCES OF A DESIGN BASIS SEISMIC EVENT WITHOUT BEING FLUSH MOUNTED | | AND THAT VIBRATION OR FAILURE OF THESE CAPACITORS DURING A SEISMIC EVENT | | WOULD HAVE DISABLED THE INPUT SIGNALS FOR VALVE ISOLATION OF PIPING (DURING | | A HIGH ENERGY LINE BREAK) FOR THE STEAM GENERATOR BLOWDOWN AND AUXILIARY | | STEAM SUPPLY SYSTEMS | | | | THE FOLLOWING TEXT IS A PORTION OF A FACSIMILE RECEIVED FROM THE LICENSEE: | | | | "CONDITION REPORT 980219 IDENTIFIED AN EQUIPMENT QUALIFICATION CONCERN WITH | | REPLACEMENT CAPACITORS FOR TEMPERATURE SWITCHES. THESE TEMPERATURE | | SWITCHES PROVIDE SIGNAL INPUTS FOR ISOLATION VALVES IN THE STEAM GENERATOR | | (SG) BLOWDOWN AND AUXILIARY STEAM SUPPLY SYSTEMS, DURING A HIGH ENERGY LINE | | BREAK (HELB), [AND THEY] WERE NOT FLUSH MOUNTED TO THE CIRCUIT BOARDS AS | | REQUIRED BY THE CURRENT MANUFACTURER IN ORDER TO MEET THE CONSEQUENCES OF A | | DESIGN BASIS SEISMIC EVENT AS SPECIFIED IN [FINAL SAFETY ANALYSIS REPORT | | (FSAR)] APPENDIX D.1. THE CAPACITORS' USEFUL LIFE IS 5 YEARS, AND [THEY] | | HAD BEEN REPLACED WITH CAPACITORS FROM ANOTHER APPENDIX-B APPROVED VENDOR | | WHOSE CAPACITOR SIZE WAS SLIGHTLY LARGER THAN THE ORIGINAL MANUFACTURER'S | | CAPACITOR. THE PHYSICAL SIZE OF THE CAPACITORS HAD NECESSITATED IMPROPER | | INSTALLATION SINCE THEY WOULD NOT FLUSH MOUNT FIT ON THE CIRCUIT BOARD. | | THIS CONDITION HAS EXISTED FOR THE LAST 5 YEARS. THE CURRENT MANUFACTURER | | COULD NOT GUARANTEE THE CAPACITOR'S ABILITY TO SURVIVE A DESIGN BASIS | | SEISMIC EVENT (SPECIFIED IN FSAR APPENDIX D.1) WITHOUT BEING FLUSH MOUNTED. | | | | "ACCORDINGLY, THIS CONDITION IS BEING REPORTED UNDER 10 CFR 50.72(b)(2)(i) | | FOR [BEAVER VALLEY POWER STATION] UNIT 1 SINCE THE CAPACITORS COULD NOT BE | | GUARANTEED TO WITHSTAND THE CONSEQUENCES OF A DESIGN BASIS SEISMIC EVENT | | WITHOUT BEING FLUSH MOUNTED. CONSEQUENT VIBRATION OR FAILURE OF THE | | CAPACITORS DURING A SEISMIC EVENT WOULD HAVE DISABLED THE INPUT SIGNALS FOR | | THE VALVE ISOLATION OF PIPING DURING HELB FOR THE SG BLOWDOWN AND AUXILIARY | | STEAM SUPPLY SYSTEMS. ADDITIONALLY, THE CONTROL ROOM OPERATORS WOULD NOT | | HAVE BEEN ABLE TO EVALUATE OR TAKE APPROPRIATE ACTION AFTER A HELB HAD | | OCCURRED BASED UPON THE UNAVAILABILITY OF THE REQUIRED TEMPERATURE READINGS | | PROVIDED BY THE TEMPERATURE SWITCHES. | | | | "THIS CONDITION HAS BEEN CORRECTED IN THE FIELD FOR UNIT 1. THIS CONDITION | | HAS BEEN REVIEWED AND ANALYZED FOR UNIT 2, AND [IT WAS] FOUND NOT TO BE | | APPLICABLE." | | | | THE LICENSEE NOTIFIED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33847 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: COOK REGION: 3 |NOTIFICATION DATE: 03/05/98 | |UNIT: [1] [2] [ ] STATE: MI |NOTIFICATION TIME: 18:51 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 03/05/98 | +------------------------------------------------+EVENT TIME: 16:10[EST]| |NRC NOTIFIED BY: RANDY PTACEK |LAST UPDATE DATE: 03/05/98 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |RONALD GARDNER 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 | | 2 | N N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | FAILURE TO MAINTAIN THE CONTAINMENT RECIRCULATION SUMP 1/4-INCH RETENTION | | REQUIREMENT | | | | A 1/4-INCH PARTICULATE RETENTION REQUIREMENT FOR THE CONTAINMENT | | RECIRCULATION SUMP WAS NOT PROPERLY ESTABLISHED IN 1979 FOLLOWING SUMP | | MODIFICATIONS. ON MARCH 5, 1998, WHILE ASSESSING THE SIGNIFICANCE OF | | DEBRIS FOUND IN THE UNIT 1 ICE CONDENSER ICE MELT SYSTEM FILTER, A PATHWAY | | FOR THE DEBRIS WAS IDENTIFIED. | | | | THE ICE CONDENSER MAIN DRAIN LINES HAVE A SMALLER SEPARATE DRAIN FOR MINOR | | LEAKAGE WHICH CONNECTS THE ICE CONDENSER TO INSIDE THE CONTAINMENT SUMP. | | THE CONTAINMENT SUMP CONNECTS TO THE RECIRCULATION SUMP; THEREFORE, THE | | DRAIN LINE BYPASSED THE SCREENS AT THE ENTRANCE OF THE RECIRCULATION SUMP. | | THIS BYPASS FLOWPATH REPRESENTS A CONDITION OUTSIDE THE PLANT'S DESIGN | | BASIS FOR MAINTAINING THE 1/4-INCH PARTICULATE RETENTION REQUIREMENT. | | | | ACTIONS HAVE BEEN INITIATED TO INVESTIGATE THIS EVENT AND DETERMINE | | APPROPRIATE CORRECTIVE ACTIONS RELATIVE TO THE BYPASS FLOWPATH. | | | | THE LICENSEE HAS NOTIFIED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |FUEL CYCLE FACILITY | |EVENT NUMBER: 33848 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 03/05/98 | | RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 19:58 [ET]| |COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 03/05/98 | | 6903 ROCKLEDGE DRIVE |EVENT TIME: 16:04[EST]| | BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 03/05/98 | | CITY: PIKETON REGION: 3 +-----------------------------+ | COUNTY: PIKE STATE: OH |PERSON ORGANIZATION| |LICENSE#: GDP-2 AGREEMENT: N |RONALD GARDNER RDO | | DOCKET: 0707002 |JOSEPHINE PICCONE EO | +------------------------------------------------+FRANK CONGEL, AEOD IRD | |NRC NOTIFIED BY: STEVE MAY | | |HQ OPS OFFICER: LEIGH TROCINE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NBNL RESPONSE-BULLETIN | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | NRC BULLETIN 91-01 RESPONSE (4-HOUR REPORT) - LOSS OF THE DOUBLE | | CONTINGENCY FOR A LARGE BOX CONTAINING CONTAMINATED SCRAP METAL | | | | AT 1604 ON MARCH 5, 1998, IT WAS DISCOVERED THAT THE DOUBLE CONTINGENCY WAS | | LOST FOR A B-25 BOX CONTAINING CONTAMINATED SCRAP METAL. THE BOX WAS | | LOCATED IN THE XT-847 WAREHOUSE, AND IT WAS REPORTED TO BE THE SIZE OF A | | DUMPSTER. REQUIREMENTS 1.A, 1.B, AND 1.D WERE LOST. REQUIREMENT 1.A | | STATED THAT THE WASTES ARE TO BE DRY. REQUIREMENT 1.B STATED THAT THERE | | ARE TO BE NO VISIBLE AMOUNTS OF URANIUM PLACED IN THE CONTAINER. | | REQUIREMENT 1.D STATED THAT IF THE ITEMS ARE FROM A RADIOLOGICAL AREA, THEN | | THE SUPERVISOR'S (OR DESIGNEE'S) CONCURRENCE THAT THE WASTE MEETS ALL OF | | THE ABOVE ITEMS IS REQUIRED. | | | | SAFETY SIGNIFICANCE: CONTAMINATED METAL ITEMS ARE ACCUMULATED IN UNSAFE | | GEOMETRY CONTAINERS THROUGHOUT THE PLANT SITE. THE ITEMS PLACED INTO THESE | | CONTAINERS ARE REQUIRED TO BE VISIBLY INSPECTED FOR URANIUM-BEARING | | MATERIAL AND TO ENSURE THAT THEY ARE DRY (WITH NO LIQUIDS PRESENT). THE | | CONTAINER IN QUESTION WAS FOUND TO CONTAIN ITEMS WHICH VIOLATED ONE OR THE | | OTHER NUCLEAR CRITICALITY SAFETY APPROVAL CONTROL. | | | | POTENTIAL CRITICALITY PATHWAYS: IF ITEMS WITH SUFFICIENT AMOUNTS OF | | URANIUM-BEARING MATERIAL WERE PLACED IN A CONTAMINATED METAL WASTE | | CONTAINER IN CONJUNCTION WITH AN ADEQUATE AMOUNT OF MODERATING MATERIAL | | (OIL OR WATER), THE MODERATED MATERIAL COULD ACCUMULATE IN AN UNSAFE | | CONFIGURATION. | | | | CONTROL PARAMETERS: MASS IS THE PRIMARY PARAMETER BEING CONTROLLED. | | MODERATION AND INTERACTION ARE THE OTHER PARAMETERS BEING CONTROLLED. | | | | ESTIMATED AMOUNT OF ENRICHMENT: THE MASS ON/IN THE PIGTAIL (ONE OF THE | | ITEMS FOUND IN THE B-25 BOX) WAS ESTIMATED TO BE APPROXIMATELY 7.6 GRAMS OF | | URANIUM-235. THIS WAS DETERMINED THROUGH NON-DESTRUCTIVE ASSAY METHODS | | BASED ON A BOX LABELLING 2 PROBLEM REPORT. THIS IS SIGNIFICANTLY LESS THAN | | THE MAXIMUM SAFE MASS AT 100 WEIGHT PERCENT ENRICHMENT OF 350 GRAMS OF | | URANIUM-235. IN ADDITION, THE ITEM WITH LIQUID ON OR IN IT WAS A DIFFERENT | | ITEM. THE PIGTAIL WAS OBSERVED TO BE DRY. | | | | NUCLEAR CRITICALITY SAFETY CONTROLS: THE REQUIREMENT THAT ONLY ITEMS WITH | | NO VISIBLE URANIUM-BEARING MATERIAL BE PLACED IN THE B-25 BOX WAS VIOLATED. | | ANOTHER REQUIREMENT THAT ALL WASTE PLACED IN THE BOX BE DRY WAS ALSO | | VIOLATED. | | | | CORRECTIVE ACTIONS: BOTH ITEMS WERE REMOVED FROM THE B-25 BOX AND SPACED A | | MINIMUM OF TWO FEET FROM EACH OTHER AND OTHER URANIUM-BEARING ITEMS. THESE | | ACTIONS WERE PERFORMED UPON DISCOVERY OF THE ITEMS. | | | | ALL SYSTEMS FUNCTIONED AS REQUIRED, AND THERE WAS NOTHING THAT WAS UNUSUAL | | OR NOT UNDERSTOOD. THERE WAS NO RELEASE OF HAZARDOUS RADIOACTIVE MATERIAL, | | AND THERE WERE NO RADIOACTIVE/RADIOLOGICAL CONTAMINATION EXPOSURES AS A | | RESULT OF THIS EVENT. | | | | PORTSMOUTH PLANS TO NOTIFY THE NRC RESIDENT INSPECTOR AND THE SITE | | DEPARTMENT OF ENERGY REPRESENTATIVE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 33849 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BYRON REGION: 3 |NOTIFICATION DATE: 03/06/98 | |UNIT: [1] [ ] [ ] STATE: IL |NOTIFICATION TIME: 02:06 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 03/05/98 | +------------------------------------------------+EVENT TIME: 23:40[CST]| |NRC NOTIFIED BY: DONALD McDERMOTT |LAST UPDATE DATE: 03/06/98 | |HQ OPS OFFICER: STEVE SANDIN +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |RONALD GARDNER RDO | |ARPS 50.72(b)(2)(ii) RPS ACTUATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | M/R N 0 HOT STANDBY | 0 HOT STANDBY | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MANUAL REACTOR TRIP INITIATED DURING CONTROL ROD SURVEILLANCE TESTING DUE | | TO LOSS OF COMMUNICATION. | | | | "DURING THE CONDUCT OF CONTROL ROD TESTING PER SURVEILLANCE PROCEDURE | | 1-BVS-1.3.4-1b, THE NSO MANUALLY INITIATED A REACTOR TRIP DUE TO A LOSS OF | | VERBAL COMMUNICATIONS WITH TESTING PERSONNEL. | | | | "ALL RODS INSERTED NORMALLY. | | | | "THE NSOs ACTION FOR LOSS OF VERBAL COMMUNICATIONS WAS DISCUSSED AS PART OF | | THE PRETEST BRIEF AND INCLUDED A REACTOR TRIP AS PROPER ACTION." | | | | THE CONTROL RODS UNDER TEST AT THE TIME WAS CONTROL BANK "B" (8 CONTROL | | RODS). THE DEFECTIVE SOUND POWERED PHONES WERE REPLACED AND CONTROL | | TESTING RESUMED AT 0020CST. THE LICENSEE WILL INFORM THE NRC RESIDENT | | INSPECTOR. | +------------------------------------------------------------------------------+