U.S. Nuclear Regulatory Commission Operations Center Event Reports For 10/08/98 - 10/09/98 ** EVENT NUMBERS ** 34805 34822 34889 34890 34891 34892 34893 34894 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |FUEL CYCLE FACILITY | |EVENT NUMBER: 34805 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 09/18/98 | | RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 17:20 [ET]| |COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 09/18/98 | | 6903 ROCKLEDGE DRIVE |EVENT TIME: 13:30[EDT]| | BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 10/08/98 | | CITY: PIKETON REGION: 3 +-----------------------------+ | COUNTY: PIKE STATE: OH |PERSON ORGANIZATION| |LICENSE#: GDP-2 AGREEMENT: N |MONTE PHILLIPS RDO | | DOCKET: 0707002 |JOSE PICCONE, NMSS EO | +------------------------------------------------+JOSEPH GIITTER IRD | |NRC NOTIFIED BY: DALE NOEL | | |HQ OPS OFFICER: DICK JOLLIFFE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NBNL RESPONSE-BULLETIN | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - 4 HOUR NRC BULLETIN 91-01 REPORT - SPACING VIOLATION OF UH EQUIPMENT - | | | | ON 09/18/98, PLANT PERSONNEL DETERMINED THAT NUCLEAR CRITICALITY SAFETY | | APPROVAL NCSA PLANT-062.A00 WAS DEFICIENT IN THAT IT FAILED TO ANALYZE A | | CREDIBLE SCENARIO AND THEREFORE FAILED TO ESTABLISH THE CONTROLS NECESSARY | | TO MEET THE DOUBLE CONTINGENCY PRINCIPLE. | | | | A SPACING VIOLATION INVOLVING TWO PIECES OF PROCESS EQUIPMENT CLASSIFIED | | AS UNCOMPLICATED HANDLING (UH) EQUIPMENT BASED ON FAVORABLE GEOMETRY IN | | THE X-326 PROCESS BUILDING COULD RESULT IN AN UNSAFE CONDITION DEPENDENT | | ON SYSTEM CONDITION (i.e. REFLECTION AND DISTRIBUTION OF MATERIAL IN THE | | SYSTEM PIPING). THE NCSA RELIED ON CALCULATION #NCS-CALC-96-004 TO | | DEMONSTRATE SUBCRITICALITY IN THE EVENT OF A SPACING VIOLATION. THIS | | CALCULATION CONTAINED SEVERAL NONCONSERVATIVE ASSUMPTIONS. | | | | INTERACTION IS THE CONTROLLED CONTINGENCY PARAMETER. MODERATION OF THE | | MATERIAL IN THE PIPING AND THE MAXIMUM PIPE DIMENSIONS WERE MAINTAINED. | | THE OPERATING CASCADE IS LIMITED IN ENRICHMENT TO 20 WT% OF U-235. | | | | PENDING RESOLUTION OF THIS ISSUE, PLANT PERSONNEL ISSUED A STOP WORK NOTICE | | AT 1508 ON 09/18/98 TO PREVENT CLASSIFYING EQUIPMENT AS UH EQUIPMENT BASED | | ON FAVORABLE GEOMETRY IN THE X-326 PROCESS BUILDING. | | | | THERE WAS NO LOSS OF HAZARDOUS OR RADIOACTIVE MATERIAL NOR RADIOACTIVE OR | | RADIOLOGICAL CONTAMINATION EXPOSURE AS A RESULT OF THIS EVENT. | | | | PORTSMOUTH PERSONNEL NOTIFIED THE NRC RESIDENT INSPECTOR. | | | | * * * UPDATE AT 1927 ON 10/08/98 BY JOHN JORDAN TO JOLLIFFE * * * | | | | THE PORTSMOUTH GDP NUCLEAR SAFETY MANAGER DETERMINED THAT THE ABOVE EVENT | | REPORT WAS ERRONEOUS IN STATING THAT NCSA PLANT-062.A00 WAS DEFICIENT. | | | | PLANT PERSONNEL PERFORMED NUCLEAR CRITICALITY SAFETY CALCULATION | | #NCS-CALC-98-029 THAT VERIFIED THAT TWO 5-INCH DIAMETER PIPES CONTAINING | | 100% ENRICHED URANYL FLUORIDE WITH WATER OF HYDRATION IS SUBCRITICAL | | UNDER POSTULATED CONDITIONS OF REFLECTION AND MODERATION THAT COULD BE | | ENCOUNTERED BY PROCESS EQUIPMENT REMOVED FOR MAINTENANCE. | | | | THE CONTROLS IN THE CURRENT NCSA REMAIN VALID FOR CLASSIFYING EQUIPMENT | | REMOVED FROM THE CASCADE AS UH BASED ON GEOMETRY OF 5-INCH DIAMETER PIPE | | UP TO 10 FEET IN LENGTH AND ASSURING THAT DOUBLE CONTINGENCY IS MAINTAINED | | IN THE EVENT OF A SPACING UPSET INVOLVING PLACEMENT OF TWO SUCH PIPES | | ADJACENT TO EACH OTHER. | | | | THUS, PORTSMOUTH PERSONNEL DESIRE TO RETRACT THIS EVENT. | | | | PORTSMOUTH PERSONNEL NOTIFIED THE NRC RESIDENT INSPECTOR. | | | | THE NRC OPERATIONS OFFICER NOTIFIED R3DO TOM KOZAK & NMSS EO JOHN SURMEIER. | +------------------------------------------------------------------------------+ !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34822 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: CLINTON REGION: 3 |NOTIFICATION DATE: 09/22/98 | |UNIT: [1] [ ] [ ] STATE: IL |NOTIFICATION TIME: 15:41 [ET]| |RX TYPE: [1] GE-6 |EVENT DATE: 09/22/98 | +------------------------------------------------+EVENT TIME: 12:20[CDT]| |NRC NOTIFIED BY: MARSHALL FUNKHOUSER |LAST UPDATE DATE: 10/08/98 | |HQ OPS OFFICER: FANGIE JONES +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JAMES CREED RDO | |AINB 50.72(b)(2)(iii)(B) POT RHR INOP | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | UNANALYZED CONDITION THAT COULD LEAD TO FAILURE OF RHR SYSTEM | | | | DURING AN IMPACT ASSESSMENT FOR SINGLE LOOP OPERATION, THE SEISMIC REVIEWER | | OBSERVED THAT THE SEISMIC ANALYSIS FOR THE REACTOR RECIRCULATION (RR) | | SYSTEM SUCTION VALVES WAS ONLY FOR THE OPEN POSITION. THE CLOSED POSITION | | MAY BE NECESSARY FOR LOOP ISOLATION. SINGLE LOOP OPERATION IS ALLOWED IN | | MODES 1 AND 2 (SECTION 3.4.1 OF TECHNICAL SPECIFICATIONS). | | SINCE THE CLOSED POSITION IS POSSIBLE DURING OPERATION AND SINCE THE DESIGN | | REQUIREMENTS MANDATE THAT THE VALVE BE ANALYZED, THIS IS AN UNANALYZED | | CONDITION AND FAILURE OF THIS VALVE IS BEING CONSIDERED. | | | | THE RESIDUAL HEAT REMOVAL (RHR) SYSTEM SUCTION IS FROM THE RR SYSTEM | | SUCTION LINE PRIOR TO THE RR SUCTION ISOLATION VALVE. SINCE THE SEISMIC | | FAILURE OF THE RR SUCTION VALVES COULD RESULT IN LOSS OF RHR CAPABILITY, | | THIS NOTIFICATION IS MADE IN ACCORDANCE WITH 10 CFR 50.72. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | | | | * *RETRACTION ON 10/08/98 AT 1341EDT BY M HUDSON TAKEN BY MACKINNON* * | | | | SUBSEQUENT ANALYSIS HAS DETERMINED THAT THE SUCTION VALVES ARE SEISMICALLY | | QUALIFIED IN THE OPEN AND CLOSED POSITIONS. THEREFORE, CLINTON POWER | | STATION IS RETRACTING THIS EVENT. R3DO (TOM KOZAK) NOTIFIED. | | | | THE NRC RESIDENT IN WAS NOTIFIED OF THIS RETRACTION BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34889 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: FERMI REGION: 3 |NOTIFICATION DATE: 10/08/98 | |UNIT: [2] [ ] [ ] STATE: MI |NOTIFICATION TIME: 03:19 [ET]| |RX TYPE: [2] GE-4 |EVENT DATE: 10/08/98 | +------------------------------------------------+EVENT TIME: 02:30[EDT]| |NRC NOTIFIED BY: STEVE MAREK |LAST UPDATE DATE: 10/08/98 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: ALERT +-----------------------------+ |10 CFR SECTION: |THOMAS KOZAK RDO | |AAEC 50.72(a)(1)(i) EMERGENCY DECLARED |JACK STROSNIDER EO | | |BERNICE CARR FEMA | | |STUART RUBIN IRD | | |TIM MARTIN AEOD | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 2 | N N 0 REFUELING | 0 REFUELING | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | ALERT DECLARED DUE TO FIRE IN EMERGENCY DIESEL GENERATOR CONTROL PANEL | | | | AT 0230 EDT ON 10/8/98, THE LICENSEE DECLARED AN ALERT IN ACCORDANCE WITH | | EMERGENCY ACTION LEVEL HA-2, "FIRE OR EXPLOSION AFFECTING OPERABILITY OF | | PLANT SAFETY SYSTEMS REQUIRED TO ESTABLISH OR MAINTAIN SAFE SHUTDOWN. | | DURING A 24-HOUR POST-MAINTENANCE RUN OF EMERGENCY DIESEL GENERATOR EDG-12, | | AN OPERATOR NOTICED HEAVY SMOKE COMING FROM THE EDG CONTROL PANEL. THE | | OPERATOR TRIPPED THE ENGINE, OPENED THE OUTPUT BREAKER AND EXITED THE | | BUILDING. THE OPERATOR REPORTED THE CONDITION TO THE MAIN CONTROL ROOM. | | SUBSEQUENTLY, A FIRE ALARM WAS RECEIVED IN THE MAIN CONTROL ROOM. PERSONNEL | | REENTERED THE BUILDING USING SELF-CONTAINED BREATHING APPARATUSES, AND | | OBSERVED THAT THE FIRE WAS EXTINGUISHED. NO AUTOMATIC FIRE SUPPRESSION | | SYSTEMS WERE ACTUATED. THE CONTROL PANEL WAS DEENERGIZED AS A PRECAUTION. | | | | THE PLANT IS CURRENTLY IN DAY 33 OF A REFUELING OUTAGE. THE NRC RESIDENT | | INSPECTOR HAS BEEN INFORMED OF THIS EVENT BY THE LICENSEE. | | | | * * * UPDATE 0423 FROM WITTSCHEN TAKEN BY STRANSKY * * * | | | | THE ALERT WAS TERMINATED AT 0350 EDT. BASED UPON VISUAL INSPECTION, DAMAGE | | APPEARS TO BE LIMITED TO THE LOCAL CONTROL PANEL. THE LICENSEE PLANS TO | | ASSESS THE AREA FOR ADDITIONAL DAMAGE. THE NRC SENIOR RESIDENT IS ONSITE | | AND HAS BEEN INFORMED BY THE LICENSEE. NOTIFIED R3DO (KOZAK), NRR EO | | (STROSNIDER), IRD (RUBIN), AEOD (MARTIN), OPA (BEECHER), OIP (UPSHAW), FEMA | | (CARR), DOE (TANNER), HHS (GRAY), EPA/NRC (TURMAN), USDA (BICKERTON), | | CANADA (PERAULT, JAMES). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34890 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: QUAD CITIES REGION: 3 |NOTIFICATION DATE: 10/08/98 | |UNIT: [1] [2] [ ] STATE: IL |NOTIFICATION TIME: 06:47 [ET]| |RX TYPE: [1] GE-3,[2] GE-3 |EVENT DATE: 10/08/98 | +------------------------------------------------+EVENT TIME: 02:00[CDT]| |NRC NOTIFIED BY: NOHR |LAST UPDATE DATE: 10/08/98 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |THOMAS KOZAK RDO | |AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | 2 | N Y 74 POWER OPERATION | 74 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE LICENSEE DISCOVERED THE CONTROL ROOM AIR FILTRATION DIFFERENTIAL | | PRESSURE WAS GREATER THAN TECHNICAL SPECIFICATION REQUIREMENTS. | | | | DURING THE PERFORMANCE OF QCOS 5750-11 "CONTROL ROOM EMERGENCY FILTRATION | | SYSTEM 18 MONTH TEST", THE CONTROL ROOM AIR FILTRATION UNIT DIFFERENTIAL | | PRESSURE MEASURED AT 6.7 INCHES WATER GAUGE. THE TECH SPEC REQUIREMENT IS | | LESS THAN 6.0 INCHES WATER GAUGE. IN ADDITION, THE SURVEILLANCE FAILED TO | | MAINTAIN ALL AREAS ADJACENT TO THE CONTROL ROOM AT THE TECH SPEC REQUIRED | | POSITIVE PRESSURE OF GREATER THAN OR EQUAL TO 1/8 INCH WATER GAUGE. THIS | | SURVEILLANCE WAS BEING PERFORMED FOLLOWING PLANNED MAINTENANCE ON THE AIR | | FILTRATION UNIT. AN INVESTIGATION IS IN PROGRESS TO DETERMINE IF THE | | MAINTENANCE WORK WAS THE CAUSE OF THE DISCREPANCIES. | | | | THE RESIDENT INSPECTOR WAS NOTIFIED OF THE EVENT. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34891 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: KEWAUNEE REGION: 3 |NOTIFICATION DATE: 10/08/98 | |UNIT: [1] [ ] [ ] STATE: WI |NOTIFICATION TIME: 11:07 [ET]| |RX TYPE: [1] W-2-LP |EVENT DATE: 10/08/98 | +------------------------------------------------+EVENT TIME: 09:15[CDT]| |NRC NOTIFIED BY: ROY SCOTT |LAST UPDATE DATE: 10/08/98 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |THOMAS KOZAK 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 96 POWER OPERATION | 96 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | BOTH TRAINS OF COMPONENT COOLING WATER DECLARED INOPERABLE DURING TEST | | | | DURING PERFORMANCE OF A SPECIAL TEST TO VERIFY OPERABILITY OF AUTO-INHIBIT | | RELAYS IN THE EMERGENCY DIESEL GENERATOR (EDG) LOADING LOGIC, THE LICENSEE | | DECLARED BOTH TRAINS OF THE COMPONENT COOLING WATER (CCW) SYSTEM INOPERABLE | | FOR APPROXIMATELY FIVE MINUTES. THIS CONDITION PLACED THE UNIT OUTSIDE OF | | ITS DESIGN BASIS. | | | | THE TEST PROCEDURE REQUIRED THAT THE AUTOMATIC START SWITCH FOR EDG "B" BE | | PLACED IN "MANUAL". IN THIS CONFIGURATION, THE KEWAUNEE TECHNICAL | | SPECIFICATIONS STATE THAT COMPONENTS POWERED BY TRAIN "B" ARE CONSIDERED TO | | BE OPERABLE AS LONG AS THE NORMAL POWER SUPPLY IS AVAILABLE AND THE | | RESPECTIVE COMPONENTS ON THE OTHER TRAIN ARE OPERABLE. HOWEVER, CONTRARY TO | | THIS REQUIREMENT, THE DISCHARGE VALVE FOR THE "A" CCW PUMP WAS CLOSED IN | | ACCORDANCE WITH THE NORMAL PLANT PROCEDURE FOR PUMP SHUTDOWN, THEREBY | | REMOVING THE "A" CCW PUMP FROM SERVICE. THIS ACTION RESULTED IN BOTH TRAINS | | OF CCW BEING DECLARED INOPERABLE, EVEN THOUGH THE "B" CCW PUMP WAS RUNNING | | THROUGHOUT THE EVENT. | | | | THE LICENSEE HAS NOTIFIED THE NRC RESIDENT INSPECTOR OF THIS EVENT. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34892 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SEABROOK REGION: 1 |NOTIFICATION DATE: 10/08/98 | |UNIT: [1] [ ] [ ] STATE: NH |NOTIFICATION TIME: 12:25 [ET]| |RX TYPE: [1] W-4-LP |EVENT DATE: 10/08/98 | +------------------------------------------------+EVENT TIME: 12:17[EDT]| |NRC NOTIFIED BY: FRITZ/STRICKLAND |LAST UPDATE DATE: 10/08/98 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JIM LINVILLE RDO | |APRE 50.72(b)(2)(vi) OFFSITE NOTIFICATION | | |NLTR LICENSEE 24 HR REPORT | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | OFFSITE NOTIFICATION MADE TO THE UNITED STATES ENVIRONMENTAL PROTECTION | | AGENCY AND THE NATIONAL MARINE FISHERS AGENCY IN ACCORDANCE WITH THE | | FACILITY OPERATING LICENSE SECTION 2.G AND APPENDIX 'B' THAT TWO DEAD SEALS | | WERE FOUND IN THEIR CIRCULATING WATER FOREBAY. | | | | THE NRC RESIDENT WAS NOTIFIED OF THIS EVENT BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34893 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: WOLF CREEK REGION: 4 |NOTIFICATION DATE: 10/08/98 | |UNIT: [1] [ ] [ ] STATE: KS |NOTIFICATION TIME: 18:45 [ET]| |RX TYPE: [1] W-4-LP |EVENT DATE: 10/08/98 | +------------------------------------------------+EVENT TIME: 16:20[CDT]| |NRC NOTIFIED BY: RICK HUBBARD |LAST UPDATE DATE: 10/08/98 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |TOM STETKA RDO | |AINA 50.72(b)(2)(iii)(A) POT UNABLE TO SAFE SD | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | -VCT OUTLET VALVE COULD FAIL DURING A CONTROL ROOM FIRE DUE TO A BLOWN FUSE | | | | FOLLOWING THE NOTIFICATION OF A PROBLEM AT THE CALLAWAY PLANT, A LICENSEE | | REVIEW OF THE CONTROL POWER CIRCUITRY FOR THE 'B' TRAIN VOLUME CONTROL TANK | | (VCT) OUTLET VALVE (#BG-HCV-112C) REVEALED A SIMILAR CONCERN. | | | | THE #112C VALVE CONTROL POWER CIRCUITRY LACKS A REDUNDANT ELECTRICAL | | FUSE INSTALLED IN A CIRCUIT THAT IS IN PARALLEL WITH AN EXISTING FUSE. | | THE EXISTING FUSE COULD BLOW AND RENDER THE VALVE INCAPABLE OF CLOSING | | WHEN DEMANDED BY THE OPERATOR AT THE LOCAL HANDSWITCH AT THE AUXILIARY | | SHUTDOWN PANEL DURING A POSTULATED FIRE IN THE CONTROL ROOM. | | | | DURING A FIRE IN THE CONTROL ROOM, THE 'A' TRAIN EMERGENCY CORE COOLING | | (ECC) SUBSYSTEMS ARE ASSUMED LOST. WITH THE FAILURE OF THE #112C VALVE TO | | CLOSE, THE SUCTION TO THE 'B' CENTRIFUGAL CHARGING (CC) PUMP IS COMPROMISED | | AND COULD CAUSE GAS ENTRAINMENT FROM THE VCT TO THE 'B' CC PUMP SUCTION | | RESULTING IN THE FAILURE OF THE 'B' CC PUMP AND THE SUBSEQUENT LOSS OF THE | | SAFETY FUNCTION OF THE ECC SYSTEMS. | | | | CONTROL ROOM OPERATOR ACTIONS FOR THIS EVENT ARE GOVERNED BY OPERATIONS | | OFF-NORMAL PROCEDURE #OFN-RP-017, "CONTROL ROOM EVACUATION". | | | | THE LICENSEE PLANS TO REVISE THE PROCEDURE TO REQUIRE CONTROL ROOM | | OPERATORS TO VERIFY THAT THE #112C VALVE IS CLOSED IN THE EVENT OF A FIRE | | IN THE CONTROL ROOM AS AN IMMEDIATE CORRECTIVE ACTION AND IS DETERMINING | | LONG TERM CORRECTIVE ACTIONS. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |GENERAL INFORMATION or OTHER | |EVENT NUMBER: 34894 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: DEACONESS MEDICAL CENTER |NOTIFICATION DATE: 10/08/98 | | CITY: SPOKANE REGION: 4 |NOTIFICATION TIME: 20:59 [ET]| | COUNTY: STATE: WA |EVENT DATE: 09/18/98 | |LICENSE#: WN-M005-1 AGREEMENT: Y |EVENT TIME: 00:00[PDT]| | DOCKET: |LAST UPDATE DATE: 10/08/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |TOM STETKA RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: TERRY FRAZEE | | |HQ OPS OFFICER: BOB STRANSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AGREEMENT STATE REPORT | | | | THE FOLLOWING REPORT (WA-98-038) WA RECEIVED IN THE NRC OPERATIONS CENTER | | VIA EMAIL FROM THE STATE OF WASHINGTON AT 0010 ON 10/9/98: | | | | ABSTRACT: An authorized user of an Omnitron/Varian "Varisource" HDR unit | | noted that the movement of the dummy source wire was not very smooth in a | | test run before a planned patient treatment. The authorized user decided | | to lubricate an extra dummy wire and use that wire to lubricate the HDR | | catheter so that the installed dummy wire would move smoothly. When he | | consulted with the onsite medical physicist, he was advised against this | | course of action. However, he did it anyway, using something described as | | "hurricane spray" (composition unknown). This was not in accordance with | | the manufacturer's specified maintenance procedure. | | | | This appeared to work initially, since the dummy wire then ran smoothly | | and the patient treatment was completed successfully. However, when the | | patient returned on September 25 for another treatment, it was noted that | | the dummy wire would not advance completely to the required 130 cm line | | (stopping at the 118 cm line). This caused the HDR unit to retract the | | dummy wire and automatically precluded further use of the unit. The unit | | alarmed due to this malfunction. This alarm cannot be reset by the user | | and the manufacturer had to be notified. After questioning the licensee, | | Varian provided the temporary code to shut off the alarm. The HDR unit | | was taken out of service. | | | | Varian personnel arrived on September 28 and determined that the unit was | | full of a foreign substance which had caused the machine to malfunction. | | They removed the actual source and essentially rebuilt the unit with new | | parts from England. A source reload is planned for October 8. | | | | The licensee will be cited for failure to follow proper maintenance | | procedure. | | | | OVEREXPOSURES: None, no patients or personnel received any exposure of | | any kind from this incident. | | | | UNIT/SS: This was an Omnitron/Varian "Varisource" HDR unit, serial number | | 048, installed at the licensee's facility in October 1997. The Iridium-192 | | source was an Omnitron Model SLV-777, at roughly 9.5 Ci when installed on | | 17 August 1998. | +------------------------------------------------------------------------------+