U.S. Nuclear Regulatory Commission Operations Center Event Reports For 07/06/98 - 07/07/98 ** EVENT NUMBERS ** 34373 34476 34477 34478 34479 34480 34481 34482 34483 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |FUEL CYCLE FACILITY | |EVENT NUMBER: 34373 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 06/09/98 | | RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 18:09 [ET]| |COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 06/08/98 | | 6903 ROCKLEDGE DRIVE |EVENT TIME: 22:29[EDT]| | BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 07/06/98 | | CITY: PIKETON REGION: 3 +-----------------------------+ | COUNTY: PIKE STATE: OH |PERSON ORGANIZATION| |LICENSE#: GDP-2 AGREEMENT: N |THOMAS KOZAK RDO | | DOCKET: 0707002 |JOE HOLONICH, NMSS EO | +------------------------------------------------+ | |NRC NOTIFIED BY: LARSON | | |HQ OPS OFFICER: CHAUNCEY GOULD | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |OCBA 76.120(c)(2)(i) ACCID MT EQUIP FAILS | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | A SURVEILLANCE ON AN AUTOCLAVE WAS PERFORMED WITH UN-CALIBRATED PRESSURE | | GAUGES. | | | | IT WAS DETERMINED THAT UN-CALIBRATED PRESSURE GAUGES HAVE BEEN USED TO | | PERFORM A TECHNICAL SPECIFICATION REQUIRED SURVEILLANCE ON THE AUTOCLAVE'S | | SHELL HIGH PRESSURE RELIEF SYSTEM (A SAFETY SYSTEM). THESE GAUGES MEASURE | | THE PRESSURE IN THE PIPE BETWEEN THE AUTOCLAVE RUPTURE DISC AND RELIEF | | VALVE, AND THEY MUST BE CHECKED AT THE BEGINNING OF EACH HEATING CYCLE. | | | | THE PRESSURE CHECK IS USED TO ASSURE THE INTEGRITY OF THE RUPTURE DISC AND | | THAT THERE IS NOT AN UNWANTED PRESSURE BUILDUP BETWEEN THE DISC AND RELIEF | | VALVE REDUCING THE DIFFERENTIAL PRESSURE ACROSS THE DISC. THIS REDUCTION | | OF PRESSURE DIFFERENTIAL ACROSS THE DISC WOULD INCREASE THE ULTIMATE | | BURSTING PRESSURE OF THE DISC, POSSIBLY INCREASING THE DISC'S RUPTURE | | PRESSURE ABOVE THE MAXIMUM ALLOWABLE WORKING PRESSURE OF THE AUTOCLAVE | | VESSEL. | | | | THE AUTOCLAVES HAVE BEEN MADE INOPERABLE. THERE WAS NO LOSS OF | | HAZARDOUS/RADIOACTIVE MATERIAL OR RADIOACTIVE/RADIOLOGICAL CONTAMINATION | | EXPOSURE AS A RESULT OF THIS EVENT. | | | | PORTSMOUTH PERSONNEL NOTIFIED THE NRC RESIDENT INSPECTOR AND PLAN TO NOTIFY | | THE DEPARTMENT OF ENERGY SITE REPRESENTATIVE. | | | | * * * UPDATE AT 1611 ON 07/06/98 FROM KURT SISLER TO TROCINE * * * | | | | THE FOLLOWING TEXT IS A PORTION OF A FACSIMILE RECEIVED FROM PORTSMOUTH: | | | | "THIS [EVENT] NOTIFICATION IS BEING RETRACTED BASED ON AN ENGINEERING | | ASSESSMENT COMPLETED ON [06/30/98] THAT CONCLUDED THE AUTOCLAVE SHELL HIGH | | PRESSURE RELIEF SYSTEM WOULD HAVE PERFORMED ITS DESIGN FUNCTION. | | | | "THE PIs (PRESSURE INDICATORS) WITH A 0-200 PSIG RANGE OR A 0-150 PSIG | | RANGE HAVE BEEN REMOVED FROM ALL OPERATIONAL AUTOCLAVES, AND AS-FOUND | | CHECKS WERE DONE COMPARING PI READINGS TO A CALIBRATED GAUGE. ALL PIs WERE | | WITHIN THE AS-FOUND TOLERANCE OF 3% (6 PSIG OR 4.8 PSIG). THE MAJORITY OF | | THE PIs UNDERSTATED THE ACTUAL PRESSURE READINGS WHICH COULD HAVE CAUSED A | | [TECHNICAL SPECIFICATION REQUIREMENT] VIOLATION OF THE < OR = TO 2 PSIG | | SURVEILLANCE LIMIT. THE LARGEST DEVIATION WAS ON X-343 AUTOCLAVE #1 WHERE | | THE GAUGE READ 2.0 PSIG AT AN ACTUAL PRESSURE OF 4.8 PSIG. | | | | "CALIBRATED PIs WITH A 0-20 PSIG OR 0-30 PSIG RANGE HAVE BEEN INSTALLED ON | | ALL OPERATING AUTOCLAVES. IN ALL OPERABLE AUTOCLAVES, THESE PIs HAVE | | MAINTAINED A 0-PSIG READING, INDICATING THERE WERE NO LEAKS IN THE SYSTEM | | THAT MIGHT HAVE BEEN UNDETECTED BY THE LARGER SCALE PIs. | | | | "THE MAXIMUM ALLOWABLE WORKING PRESSURE (MAWP) VARIES DUE TO THE | | DIFFERENTIAL DIAMETER OF THE AUTOCLAVES. THE LOWEST MAWP IS 150 PSIG FOR | | THE 96-INCH X-344 AUTOCLAVES, AND THE HIGHEST MAWP IS 185 PSIG FOR THE | | 84-INCH X-343 AUTOCLAVES. THE ASME CODE (1995 ASME PRESSURE VESSEL CODE, | | SECTION VIII, DIVISION I, PART UG, GENERAL REQUIREMENTS) REQUIRES THAT OVER | | PRESSURE RELIEF BE PROVIDED BY A DEVICE STAMPED AT OR BELOW THE MAWP AND | | SIZED SUCH THAT THE SUBSEQUENT TRANSIENT PRESSURE WILL BE LIMITED [TO] A | | MAXIMUM OF 110% OF [THE] MAWP WHEN A SINGLE RELIEF PATH IS USED. ASME CODE | | ALLOWS RUPTURE DISKS TO HAVE A 5% TOLERANCE. THE PEAK AUTOCLAVE ACCIDENT | | PRESSURES IDENTIFIED IN THE ACCIDENT ANALYSES ARE BETWEEN 91 PSIG AND 95 | | PSIG (DEPENDING ON AUTOCLAVE SIZE) AND ARE SIGNIFICANTLY BELOW THE MAWP | | DISCUSSED ABOVE. | | | | "BASED ON THE ABOVE DISCUSSION, ADDING THE 5% RUPTURE DISK TOLERANCE | | ([APPROXIMATELY] 8 PSIG) TO THE MAXIMUM ACTUAL READING FOUND AT 2.0 PSIG | | READING (4.8) EQUALS [APPROXIMATELY] 13 PSIG, WHICH IS LESS THAN THE | | ALLOWABLE 10% ABOVE MAWP TOLERANCE (15-16.5 PSIG). SINCE THE LACK OF PI | | CALIBRATION DID NOT VIOLATE THE SAFETY BASIS OF THE AUTOCLAVE SYSTEM, THE | | EVENT HAS BEEN DETERMINED NOT REPORTABLE IN ACCORDANCE WITH THE SAFETY | | ANALYSIS REPORT, SECTION 6.9, TABLE 6.9-1, J(1). | | | | "ALL AUTOCLAVES NOT REQUIRING FURTHER MAINTENANCE HAVE HAD THE PIs REPLACED | | AND [HAVE BEEN] RETURNED TO SERVICE." | | | | PORTSMOUTH PERSONNEL NOTIFIED THE NRC RESIDENT INSPECTOR AND THE DEPARTMENT | | OF ENERGY SITE REPRESENTATIVE. THE NRC OPERATIONS OFFICER NOTIFIED THE | | R3DO (GARDNER) AND NMSS EO (HICKEY). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34476 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SEQUOYAH REGION: 2 |NOTIFICATION DATE: 07/06/98 | |UNIT: [1] [2] [ ] STATE: TN |NOTIFICATION TIME: 04:21 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 07/06/98 | +------------------------------------------------+EVENT TIME: 01:02[EDT]| |NRC NOTIFIED BY: JEFF EPPERSON |LAST UPDATE DATE: 07/06/98 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |ROBERT HAAG RDO | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AUXILIARY BUILDING VENTILATION ISOLATION DUE TO HIGH NOBLE GAS LEVELS | | | | AN AUXILIARY BUILDING ISOLATION (ABI) OCCURRED AFTER RECEIPT OF A VALID | | HIGH RADIATION SIGNAL FROM THE PARTICULATE CHANNEL OF THE AUXILIARY | | BUILDING EXHAUST RADIATION MONITOR (0-RM-90-101A). ALL SYSTEMS OPERATED | | PROPERLY FOLLOWING THE ABI, AND BOTH TRAINS OF THE AUXILIARY BUILDING GAS | | TREATMENT SYSTEM AUTOMATICALLY STARTED AS EXPECTED. THE AUXILIARY BUILDING | | HAS BEEN POSTED AS AN AIRBORNE CONTAMINATION AREA DUE TO HIGH NOBLE GAS | | LEVELS. | | | | THE LICENSEE HAS TENTATIVELY IDENTIFIED THE SOURCE OF THE GAS AS A BLOWN | | WATER SEAL IN A TRAP ON THE GAS VENT HEADER. THE WATER SEAL APPARENTLY BLEW | | DURING UNIT 1 VOLUME CONTROL TANK VENTING OPERATIONS AS A RESULT OF A | | MALFUNCTIONING WATER TRAP DRAIN VALVE. THIS AIR-OPERATED VALVE APPEARS TO | | HAVE STUCK PARTIALLY OPEN SINCE ITS LAST OPERATION, ALTHOUGH ITS HAND | | SWITCH WAS ALIGNED TO THE CLOSED POSITION. THE TRAP HAS BEEN MANUALLY | | ISOLATED TO ELIMINATE IT AS A SOURCE OF THE GAS. | | | | THE LICENSEE PLANS TO RESTORE THE AUXILIARY BUILDING VENTILATION SYSTEMS TO | | THEIR NORMAL ALIGNMENT AFTER THE HIGH RADIATION ALARM CLEARS AND THE | | LICENSEE CONFIRMS THAT THE SOURCE OF THE GAS HAS BEEN ISOLATED. AUXILIARY | | BUILDING AIRBORNE RADIATION LEVELS ARE THEN EXPECTED TO QUICKLY RETURN TO | | NORMAL LEVELS. | | | | THE NRC RESIDENT INSPECTOR WILL BE INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34477 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: RIVER BEND REGION: 4 |NOTIFICATION DATE: 07/06/98 | |UNIT: [1] [ ] [ ] STATE: LA |NOTIFICATION TIME: 10:09 [ET]| |RX TYPE: [1] GE-6 |EVENT DATE: 07/06/98 | +------------------------------------------------+EVENT TIME: 05:13[CDT]| |NRC NOTIFIED BY: G. TURNER |LAST UPDATE DATE: 07/06/98 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JOHN PELLET RDO | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | ISOLATION OF ANNULUS PRESSURE CONTROL SYSTEM | | | | THE ANNULUS PRESSURE CONTROL SYSTEM ISOLATED, AND THE ANNULUS MIXING AND | | STANDBY GAS TREATMENT SYSTEMS AUTOMATICALLY STARTED. THE LICENSEE BELIEVES | | THAT THE ISOLATION WAS CAUSED BY A LOW FLOW SIGNAL. THE LICENSEE IS STILL | | TROUBLESHOOTING THE SYSTEM. | | | | THE NRC RESIDENT INSPECTOR WILL BE INFORMED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |GENERAL INFORMATION or OTHER | |EVENT NUMBER: 34478 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: UNKNOWN |NOTIFICATION DATE: 07/06/98 | | CITY: ELIZABETH REGION: 1 |NOTIFICATION TIME: 10:26 [ET]| | COUNTY: STATE: NJ |EVENT DATE: 07/06/98 | |LICENSE#: AGREEMENT: N |EVENT TIME: : [EDT]| | DOCKET: |LAST UPDATE DATE: 07/06/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |JOHN KINNEMAN RDO | | |SCOTT MOORE/NMSS EO | +------------------------------------------------+FEMA, DOE, USDA, HHS FAX | |NRC NOTIFIED BY: BRIAN MALISZEWSKI |EPA, DOT (VIA NRC) FAX | |HQ OPS OFFICER: STEVE SANDIN | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NINF INFORMATION ONLY | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | ABANDONED SOURCE IDENTIFIED DURING PROPERTY RENOVATION. | | | | AN INDIVIDUAL WITH OENJ (ORION ELIZABETH NEW JERSEY) IDENTIFIED AN | | ABANDONED MOISTURE DENSITY GAUGE DURING RENOVATION OF PROPERTY LOCATED AT | | 1000 KAPKOWSKI, ELIZABETH, NEW JERSEY. PRELIMINARY RADIATION READINGS ARE | | APPROXIMATELY 3 mR/HR AT A DISTANCE OF 1 FT. CAUTION TAPE EXTENDING | | APPROXIMATELY 10 FT IN RADIUS HAS BEEN ESTABLISHED TO PREVENT INADVERTENT | | PERSONNEL EXPOSURE. THE INDIVIDUAL BELIEVES THAT THE GAUGE MAY HAVE BEEN | | OWNED BY A NOW DEFUNCT COMPANY (WALSH) THAT DID WORK AT THIS LOCATION ABOUT | | A YEAR AGO. | | | | THE HOO NOTIFIED THE NEW JERSEY DEPARTMENT OF ENVIRONMENTAL PROTECTION | | (REPORT #98-07-06-1059-40). (SEE THE HOO LOG FOR CONTACT INFORMATION.) | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34479 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: COOK REGION: 3 |NOTIFICATION DATE: 07/06/98 | |UNIT: [1] [2] [ ] STATE: MI |NOTIFICATION TIME: 12:42 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 07/04/98 | +------------------------------------------------+EVENT TIME: 11:59[EDT]| |NRC NOTIFIED BY: MARK KELLY |LAST UPDATE DATE: 07/06/98 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |RONALD GARDNER RDO | |HFIT 26.73 FITNESS FOR DUTY | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | A CONTRACTOR SUPERVISOR TESTED POSITIVE FOR COCAINE USE DURING A RANDOM | | TEST. THE INDIVIDUAL'S ACCESS TO THE PLANT HAS BEEN TERMINATED. REFER TO | | THE HOO LOG FOR ADDITIONAL DETAILS. THE NRC RESIDENT HAS BEEN NOTIFIED BY | | THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34480 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: OCONEE REGION: 2 |NOTIFICATION DATE: 07/06/98 | |UNIT: [1] [2] [3] STATE: SC |NOTIFICATION TIME: 14:18 [ET]| |RX TYPE: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP |EVENT DATE: 07/06/98 | +------------------------------------------------+EVENT TIME: 13:30[EDT]| |NRC NOTIFIED BY: MIKE BAILEY |LAST UPDATE DATE: 07/06/98 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |ROBERT HAAG RDO | |ASHU 50.72(b)(1)(i)(A) PLANT S/D REQD BY TS | | |NLCO TECH SPEC LCO A/S | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | 3 | N Y 100 POWER OPERATION | 100 POWER OPERATION | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO INOPERABILITY OF THE | | PENETRATION ROOM VENTILATION SYSTEM | | | | THE FOLLOWING TEXT IS A PORTION OF A FACSIMILE RECEIVED FROM THE LICENSEE: | | | | "ON JULY 6, 1998, AT 1330, ALL THREE OCONEE UNITS ENTERED TECHNICAL | | SPECIFICATION (TS) 3.0 AFTER THE PENETRATION ROOM VENTILATION SYSTEM (PRVS) | | WAS DECLARED INOPERABLE DUE TO NOT LITERALLY MEETING THE PERIODIC | | SURVEILLANCE TESTING REQUIREMENTS OF TS 4.5.4.1.b.1. THIS PROBLEM OCCURRED | | AS A RESULT OF A MISINTERPRETATION OF THE TESTING REQUIREMENTS OF ANSI | | N510-1975. | | | | "ANSI N510-1975 REQUIRES THAT THE PITOT TUBE TRAVERSE FLOW MEASUREMENT | | METHOD BE USED FOR PRVS TS SURVEILLANCE. CURRENTLY, OCONEE USES AN ORIFICE | | PLATE FLOW MEASUREMENT METHOD IN THE PRVS TS SURVEILLANCE. OCONEE BELIEVED | | THAT THE ORIFICE PLATE FLOW MEASUREMENT METHOD MET THE TS SURVEILLANCE | | REQUIREMENTS. | | | | "ON JULY 6, 1998, VIA CORRESPONDENCE FROM THE NRC STAFF REGARDING A | | VIOLATION, OCONEE WAS INFORMED OF THE NRC STAFF'S INTERPRETATION OF ANSI | | N510-1975. THE STAFF'S INTERPRETATION IS THAT THE PITOT TUBE TRAVERSE FLOW | | MEASUREMENT METHOD MUST BE USED UNDER EXISTING PRVS FLOW AND DESIGN | | CONDITIONS TO ENSURE THE TS SURVEILLANCE REQUIREMENTS ARE MET. | | | | "ALTHOUGH THE PRVS HAS BEEN DECLARED INOPERABLE, THE PRVS IS CAPABLE OF | | PERFORMING ITS INTENDED FUNCTIONS. OCONEE WILL NEED TO HAVE ALL THREE | | UNITS IN HOT SHUTDOWN NO LATER THAN 0130 ON JULY 7, 1998. A REQUEST FOR | | ENFORCEMENT DISCRETION HAS BEEN MADE TO NRC HEADQUARTERS. | | | | "ADDITIONAL INFORMATION WILL BE PROVIDED IN THE LICENSEE EVENT REPORT." | | | | THE LICENSEE NOTIFIED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34481 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: CATAWBA REGION: 2 |NOTIFICATION DATE: 07/06/98 | |UNIT: [1] [2] [ ] STATE: SC |NOTIFICATION TIME: 16:13 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 07/06/98 | +------------------------------------------------+EVENT TIME: 13:00[EDT]| |NRC NOTIFIED BY: JACK BRISSON |LAST UPDATE DATE: 07/06/98 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |ROBERT HAAG RDO | |AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION | | |NLCO TECH SPEC LCO A/S | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | INOPERABLE CONTROL ROOM VENTILATION SYSTEM | | | | THE FOLLOWING TEXT IS A PORTION OF A FACSIMILE RECEIVED FROM THE LICENSEE: | | | | "ON JULY 6, 1998, OPERATIONS [PERSONNEL] QUESTIONED CONTROL ROOM | | PRESSURIZATION AS A RESULT OF LACK OF PRESSURE UPON OPENING THE CONTROL | | ROOM DOOR. A PERFORMANCE TEST WAS CONDUCTED ON THE OPERATING 'B' TRAIN OF | | THE CONTROL ROOM VENTILATION SYSTEM. THE TEST IDENTIFIED A LOW PRESSURE | | CONDITION. SUBSEQUENT WALKDOWN OF THE SYSTEM DISCOVERED A BACKDRAFT DAMPER | | NOT PROPERLY SECURED IN THE CLOSED POSITION. THIS DAMPER IS THE 'A' TRAIN | | BACKDRAFT DAMPER ON THE SUCTION OF THE AIR HANDLING UNIT, AND [IT] WAS | | REQUIRED TO BE CLOSED TO PROVIDE A PRESSURE BOUNDARY FOR THE CONTROL ROOM | | DURING MAINTENANCE ON THE 'A' TRAIN CONTROL ROOM VENTILATION SYSTEM. | | | | "THE 'A' TRAIN CONTROL ROOM VENTILATION SYSTEM HAD PREVIOUSLY BEEN REMOVED | | FROM SERVICE FOR MAINTENANCE. | | | | "THE POSITION OF THE DAMPER CAUSED THE 'B' TRAIN CONTROL ROOM VENTILATION | | SYSTEM TO ALSO BE INOPERABLE. WITH BOTH TRAINS OF [THE] CONTROL ROOM | | VENTILATION SYSTEM INOPERABLE, THE UNIT ENTERED TECHNICAL SPECIFICATION | | 3.0.3. THE BACKDRAFT DAMPER WAS CLOSED, THEREBY RESTORING THE 'B' TRAIN TO | | OPERABLE STATUS, AND [TECHNICAL SPECIFICATION] 3.0.3 WAS EXITED [WITHIN 16 | | MINUTES]. | | | | "A FORMAL ROOT CAUSE INVESTIGATION INTO THE CAUSE OF THE DAMPER POSITION | | HAS BEEN INITIATED. | | | | "THIS CONDITION HAS BEEN CLASSIFIED AS A SINGLE CAUSE OF CONDITION (OPEN | | BACKDRAFT DAMPER) THAT ALONE COULD HAVE PREVENTED THE FULFILLMENT OF THE | | SAFETY FUNCTION OF A SYSTEM NEEDED TO ... MITIGATE THE CONSEQUENCES OF AN | | ACCIDENT. THIS CONDITION IS REPORTABLE UNDER 10 CFR 50.72(b)(2)(iii)." | | | | THE UNIT IS CURRENTLY IN A 7-DAY LIMITING CONDITION FOR OPERATION BECAUSE | | THE 'A' TRAIN OF THE CONTROL ROOM VENTILATION SYSTEM REMAINED OUT OF | | SERVICE FOR MAINTENANCE. | | | | THE LICENSEE NOTIFIED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 34482 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: WILLIAM BEAUMONT HOSPITAL |NOTIFICATION DATE: 07/06/98 | | CITY: ROYAL OAK REGION: 3 |NOTIFICATION TIME: 17:11 [ET]| | COUNTY: OAKLAND STATE: MI |EVENT DATE: 01/29/98 | |LICENSE#: 21-01333-01 AGREEMENT: N |EVENT TIME: : [EDT]| | DOCKET: |LAST UPDATE DATE: 07/06/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |RONALD GARDNER RDO | | |JOHN HICKEY/NMSS EO | +------------------------------------------------+KEVIN RAMSEY/NMSS IMOB | |NRC NOTIFIED BY: CHERYL SCHULTZ | | |HQ OPS OFFICER: LEIGH TROCINE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |CDEG 21.21(c)(3)(i) DEFECTS/NONCOMPLIANCE | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | POTENTIAL GENERIC IMPLICATIONS OF A SAFETY SYSTEM FAILURE - FAILURE OF A | | NUCLETRON HIGH DOSE RATE MICROSELECTRON UNIT (VERSION 1) TO DETECT THE | | ABSENCE OF AN APPLICATOR IN FIVE CHANNELS DUE TO DIRTY OPTOPAIRS AT THE | | INDEXER PHASE OF THE HIGH DOSE RATE UNIT | | | | ON 01/29/98, WILLIAM BEAUMONT HOSPITAL (LOCATED IN ROYAL OAK, MICHIGAN) | | PERSONNEL IDENTIFIED A MALFUNCTION OF A NUCLETRON HIGH DOSE RATE | | MICROSELECTRON UNIT (VERSION 1) DURING A ROUTINE AUDIT OF THE QUALITY | | MANAGEMENT PROGRAM. THIS UNIT CONTAINS LESS THAN 10 CURIES OF IRIDIUM-192, | | AND IT IS USED FOR PATIENT CANCER TREATMENTS. | | | | ONE OF THE CHECKS DURING PERFORMANCE OF ROUTINE DAILY QUALITY CONTROL IS TO | | ENSURE THAT THE NUCLETRON HIGH DOSE RATE MICROSELECTRON UNIT CAN DETERMINE | | THE ABSENCE OF AN APPLICATOR. IN THE ABSENCE OF AN APPLICATOR, THE MACHINE | | WOULD DISPLAY ERROR CODE #14. ON 01/29/98, ALL OF THE CHANNELS WERE | | PROGRAMMED, BUT THE DEVICE FAILED TO DETECT THE ABSENCE OF AN APPLICATOR | | (MISSING TRANSFER TUBES) IN FIVE CHANNELS. THE LICENSEE CONTACTED THE | | VENDOR (NUCLETRON) IMMEDIATELY. THE VENDOR CONCLUDED THAT THE PROBLEM | | INVOLVED DIRTY OPTOPAIRS AT THE INDEXER PHASE OF THE HIGH DOSE RATE UNIT. | | THE VENDOR SERVICED THE UNIT ON 02/04/98. ONCE THE OPTOPAIRS WERE CLEANED, | | THE UNIT FUNCTIONED PERFECTLY. THE LICENSEE STATED THAT THERE HAVE BEEN NO | | ADDITIONAL FAILURES. THE LICENSEE ALSO STATED THAT A CONTRIBUTING FACTOR | | MAY HAVE BEEN THAT THE UNIT WAS LOCATED IN A AREA THAT WAS BEING RENOVATED, | | AND THERE MAY HAVE BEEN SOME ADDITIONAL DUST IN THE AREA. | | | | BECAUSE THE LICENSEE STILL HAD PATIENTS THAT NEEDED TREATMENT WHEN THE UNIT | | FAILED, THE UNIT'S FAILSAFE WAS BYPASSED. THE LICENSEE KNEW THAT THE HIGH | | DOSE RATE UNIT WOULD BE ABLE TO DETECT THE ABSENCE OF AN APPLICATOR THAT | | WAS ATTACHED TO THE END OF A TRANSFER TUBE. AS A RESULT, THE LICENSEE | | CONNECTED TRANSFER TUBES TO ALL OF THE CHANNELS. THEN, THERE WOULD BE NO | | WAY THAT THE SOURCE WOULD EXIT ANY OF THE TRANSFER CHANNELS (TUBES) WITHOUT | | AN APPLICATOR BEING IN PLACE INSIDE THE PATIENT. THEREFORE, THE SOURCE | | WOULD NOT GO OUT INTO THE AIR. THE LICENSEE STATED THAT THERE WERE NO | | REPORTABLE OR RECORDABLE EVENTS ASSOCIATED WITH THE MALFUNCTION (FAILURE TO | | DETECT AN APPLICATOR ASSEMBLY). | | | | THE LICENSEE PLANS TO SEND A LETTER TO NRC REGION 3 IN ORDER TO PROVIDE | | ADDITIONAL INFORMATION. THE LICENSEE ALSO PLANS TO NOTIFY NUCLETRON ABOUT | | THIS EVENT NOTIFICATION TO THE NRC. (REFER TO THE HOO LOG FOR A SITE | | CONTACT TELEPHONE NUMBER.) | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |FUEL CYCLE FACILITY | |EVENT NUMBER: 34483 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PADUCAH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 07/06/98 | | RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 23:00 [ET]| |COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 07/06/98 | | 6903 ROCKLEDGE DRIVE |EVENT TIME: 10:00[CDT]| | BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 07/06/98 | | CITY: PADUCAH REGION: 3 +-----------------------------+ | COUNTY: McCRACKEN STATE: KY |PERSON ORGANIZATION| |LICENSE#: GDP-1 AGREEMENT: Y |RONALD GARDNER RDO | | DOCKET: 0707001 |JOHN HICKEY/NMSS EO | +------------------------------------------------+ | |NRC NOTIFIED BY: RANDY BOSHELL | | |HQ OPS OFFICER: LEIGH TROCINE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NCFR NON CFR REPORT REQMNT | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | SAFETY SYSTEM ACTIVATION DUE TO A VALID SIGNAL (24-HOUR REPORT) | | | | AT 1000 CDT ON 07/06/98, A WATER INVENTORY CONTROL SYSTEM ACTIVATION | | OCCURRED ON THE C-337A POSITION #1 EAST AUTOCLAVE DUE TO A LOSS OF STEAM | | PRESSURE IN THE AUTOCLAVE. A CYLINDER WAS HEATING AT THE TIME OF THE | | ACTIVATION. THE SAFETY SYSTEM OPERATED AS REQUIRED TO ISOLATE THE STEAM | | SUPPLY SYSTEM BLOCK VALVE AND STEAM VENT HEADER FOR THE AUTOCLAVE. THE | | CONDENSATE DRAIN VALVE REMAINED OPEN AS REQUIRED TO ALLOW WATER TO DRAIN | | OUT. | | | | ALTHOUGH THE CAUSE OF THE LOSS OF STEAM PRESSURE IN THE AUTOCLAVE IS STILL | | UNDER INVESTIGATION, PRELIMINARY INVESTIGATIONS INDICATED THAT A STEAM | | PRESSURE CONTROLLER MAY HAVE BEEN PLACED IN MANUAL MODE FROM AUTOMATIC | | MODE. THEREFORE, WHEN THE SYSTEM REQUIRED ADDITIONAL STEAM, IT WAS NOT | | RECEIVED. | | | | THIS SAFETY SYSTEM ACTIVATION IS REPORTABLE TO THE NRC AS REQUIRED BY | | SAFETY ANALYSIS REPORT, SECTION 6.9, TABLE 1, CRITERIA J.2, SAFETY SYSTEM | | ACTUATION DUE TO A VALID SIGNAL. | | | | PADUCAH PERSONNEL NOTIFIED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+