U.S. Nuclear Regulatory Commission Operations Center Event Reports For 04/21/98 - 04/22/98 ** EVENT NUMBERS ** 34007 34035 34107 34110 34111 34112 34113 34114 34115 34116 +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34007 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: CRYSTAL RIVER REGION: 2 |NOTIFICATION DATE: 04/02/98 | |UNIT: [3] [ ] [ ] STATE: FL |NOTIFICATION TIME: 16:49 [ET]| |RX TYPE: [3] B&W-L-LP |EVENT DATE: 04/02/98 | +------------------------------------------------+EVENT TIME: 10:10[EST]| |NRC NOTIFIED BY: RICKY RAWLS |LAST UPDATE DATE: 04/21/98 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |TOM PEEBLES RDO | |APRE 50.72(b)(2)(vi) OFFSITE NOTIFICATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 3 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | OFFSITE NOTIFICATION REGARDING ANOTHER SEA TURTLE AT THE INTAKE STRUCTURE | | (REFER TO EVENT NUMBERS 33979 AND 33988 FOR PAST PROBLEMS WITH TURTLES.) | | | | FLORIDA POWER CORPORATION FOUND A DISTRESSED SEA TURTLE AT THE INTAKE | | STRUCTURE FOR CRYSTAL RIVER UNIT 3. THE TURTLE WAS DETERMINED TO BE A | | KEMP'S RIDLEY SEA TURTLE, WHICH IS AN ENDANGERED SPECIES. AT 1400 ON | | 04/02/98, THE LICENSEE NOTIFIED THE FLORIDA DEPARTMENT OF ENVIRONMENTAL | | PROTECTION (FDEP) AND THE U.S. FISH AND WILDLIFE SERVICE OF THE DISCOVERY | | OF THE TURTLE. THE LICENSEE IS CONTINUING TO WORK WITH THE FDEP AND THE | | U.S. FISH AND WILDLIFE SERVICE TO DETERMINE THE REASON FOR THE INCREASED | | NUMBER OF DEAD AND DISTRESSED SEA TURTLES THAT HAVE BEEN FOUND AT THE | | CRYSTAL RIVER SITE IN THE PAST FEW WEEKS. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED OF THE OFFSITE NOTIFICATION BY THE | | LICENSEE. | | | | ***UPDATE ON 04/02/98 AT 1753 FROM RAWLS TAKEN BY MACKINNON*** | | | | AT 1658 ON 04/02/98, THE LICENSEE FOUND ANOTHER KEMP'S RIDLEY SEA TURTLE IN | | DISTRESS AT THE INTAKE STRUCTURE. THE FDEP WAS NOTIFIED BY THE LICENSEE AT | | 1658. | | | | THE NRC RESIDENT INSPECTOR WILL BE NOTIFIED OF THIS EVENT UPDATE BY THE | | LICENSEE. THE NRC OPERATIONS CENTER NOTIFIED THE R2DO (PEEBLES). | | | | ***UPDATE ON 04/03/98 AT 1132 FROM R. SWEENEY TAKEN BY MACKINNON*** | | | | AT 0634 ON 04/03/98, A DISTRESSED KEMP'S RIDLEY SEA TURTLE WAS FOUND AT THE | | INTAKE STRUCTURE FOR CRYSTAL RIVER UNIT 3. AT 0720, A DECEASED KEMP'S | | RIDLEY SEA TURTLE WAS FOUND IN THE INTAKE STRUCTURE. KEMP'S RIDLEY SEA | | TURTLES ARE ON THE ENDANGERED SPECIES LIST. THE SEA TURTLES HAVE BEEN | | TURNED OVER TO THE CLEARWATER MARINE SCIENCE CENTER PER THE DIRECTION OF | | THE FDEP. THE LICENSEE IS CONTINUING TO WORK WITH THE FDEP, U.S. FISH AND | | WILDLIFE SERVICE, AND NATIONAL MARINE FISHERIES SERVICE TO DETERMINE THE | | REASON FOR THE INCREASED NUMBER OF DEAD AND DISTRESSED SEA TURTLES THAT | | HAVE BEEN FOUND AT THE CRYSTAL RIVER UNIT 3 SITE DURING THE PAST FEW WEEKS. | | THE LICENSEE NOTIFIED THE FDEP OF THE ABOVE EVENT. THE LICENSEE PLANS TO | | ROUTINELY NOTIFY THE FDEP FOR FUTURE CAPTURE OF LIVE TURTLES; HOWEVER, THE | | LICENSEE DOES NOT PLAN TO REPORT TO THE NRC EACH INDIVIDUAL NOTIFICATION OF | | THE FDEP. NOTIFICATION WILL BE MADE TO THE NRC WHEN FDEP IS NOTIFIED OF A | | DECEASED TURTLE. | | | | THE NRC RESIDENT INSPECTOR WILL INFORMED BY THE LICENSEE OF THIS EVENT | | UPDATE. THE NRC OPERATIONS CENTER NOTIFIED THE R2DO (PEEBLES). | | | | ***UPDATE ON 04/03/98 AT 1722 FROM RAWLS TAKEN BY MACKINNON*** | | | | AT 1450 ON 04/03/98, THE LICENSEE NOTIFIED THE FDEP THAT A DECEASED SEA | | TURTLE WAS FOUND IN THE INTAKE STRUCTURE AT 1310. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED OF THIS EVENT NOTIFICATION BY THE | | LICENSEE. THE NRC OPERATIONS CENTER NOTIFIED THE R2DO (PEEBLES). | | | | ***UPDATE ON 04/04/98 AT 1320 FROM RAWLS TAKEN BY MACKINNON*** | | | | AT 0945 ON 04/04/98, THE LICENSEE NOTIFIED THE FDEP THAT ANOTHER DEAD | | KEMP'S RIDLEY SEA TURTLE WAS FOUND IN THE INTAKE STRUCTURE AT 0530. THE | | LICENSEE STATED THAT THE MORTALITY OF ENDANGERED SPECIES IS LIKELY IN PART | | TO BE RELATED TO THE PLANTS OPERATION AND IS, THEREFORE, ALSO REPORTABLE TO | | THE NRC UNDER THE ENVIRONMENTAL PROTECTION PLAN. THE LICENSEE IS STILL | | WORKING WITH THE FDEP, U.S. FISH AND WILDLIFE SERVICES, AND THE NATIONAL | | FISHERIES SERVICE TO DETERMINE THE REASON FOR THE INCREASED NUMBER OF DEAD | | AND DISTRESSED SEA TURTLES THAT HAVE BEEN FOUND AT THE CRYSTAL RIVER SITE | | DURING THE PAST FEW WEEKS. THE LICENSEE PLANS TO ROUTINELY NOTIFY THE FDEP | | FOR FUTURE CAPTURE OF LIVE TURTLES; HOWEVER, THE LICENSEE DOES NOT PLAN TO | | REPORT TO THE NRC EACH INDIVIDUAL NOTIFICATION OF THE FDEP. NOTIFICATION | | WILL BE MADE TO THE NRC WHEN FDEP IS NOTIFIED OF A DECEASED TURTLE. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED OF THIS EVENT NOTIFICATION BY THE | | LICENSEE. THE NRC OPERATIONS CENTER NOTIFIED THE R2DO (PEEBLES). | | | | * * * UPDATE 1815 4/13/1998 FROM BILL BANHAUER TAKEN BY STRANSKY * * * | | | | AT 1600 ON 4/13/1998, ANOTHER DEAD KEMP'S RIDLEY SEA TURTLE WAS FOUND IN | | THE COMMON INTAKE FOR CRYSTAL RIVER UNITS 1, 2, AND 3. THE TURTLE'S DEATH | | DOES NOT APPEAR TO BE DIRECTLY RELATED TO PLANT OPERATION. THE NRC | | RESIDENT INSPECTOR HAS BEEN INFORMED. NOTIFIED R2DO (SKINNER). | | | | * * * UPDATE AT 1732 ON 04/21/98 FROM DICK SWEENEY TO DICK JOLLIFFE * * * | | | | AT 1330 ON 04/21/98, THE LICENSEE FOUND TWO DEAD KEMP'S RIDLEY SEA TURTLES | | UPSTREAM OF THE INTAKE TRASH SCREEN. AT 1531, THE LICENSEE NOTIFIED THE | | FLORIDA DEPARTMENT OF ENVIRONMENTAL PROTECTION OF THE DISCOVERY OF THE | | TURTLES. THE LICENSEE IS CONTINUING TO WORK WITH THE FLORIDA DEPARTMENT | | OF ENVIRONMENTAL PROTECTION AND THE NATIONAL MARINE FISHERIES SERVICES TO | | DETERMINE THE REASON FOR THE INCREASED NUMBER OF DEAD AND DISTRESSED SEA | | TURTLES THAT HAVE BEEN FOUND AT THE CRYSTAL RIVER SITE DURING THE PAST FEW | | WEEKS. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. THE NRC OPERATIONS | | OFFICER NOTIFIED THE R2DO WALTER ROGERS. | +------------------------------------------------------------------------------+ !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34035 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: DUANE ARNOLD REGION: 3 |NOTIFICATION DATE: 04/08/98 | |UNIT: [1] [ ] [ ] STATE: IA |NOTIFICATION TIME: 05:23 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 04/08/98 | +------------------------------------------------+EVENT TIME: 02:06[CDT]| |NRC NOTIFIED BY: STEIMER |LAST UPDATE DATE: 04/21/98 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MARK RING RDO | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 REFUELING | 0 REFUELING | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | A PRESSURE DISCHARGE TO THE SUPPRESSION POOL OCCURRED WHILE TWO | | SURVEILLANCES WERE BEING PERFORMED CONCURRENTLY. | | | | WHILE THE PLANT WAS IN DAY 4 OF REFUEL OUTAGE 15 WITH CORE ALTERATIONS IN | | PROGRESS, LOCAL LEAK RATE TESTING (LLRT) WAS IN PROGRESS ON THE "A" INBOARD | | MAIN STEAM ISOLATION VALVE (MSIV) WITH APPROXIMATELY 40 PSIG OF AIR | | PRESSURE BETWEEN THE "A" INBOARD MSIV AND THE "A" MAIN STEAM LINE PLUG AT | | THE REACTOR VESSEL. SURVEILLANCE TESTING OF THE AUTOMATIC DEPRESSURIZATION | | SYSTEM (ADS) TIMER CALIBRATION AND LOGIC SYSTEM FUNCTIONAL(TEST) WAS BEING | | PERFORMED CONCURRENTLY WITH THE LLRT. THE SURVEILLANCE TEST ACTUATES THE | | PILOT SOLENOIDS TO THE 4 ADS SAFETY RELIEF VALVES (SRVs), WHICH PROVIDES | | THE PNEUMATIC PRESSURE TO OPEN THEM. WHEN THIS OCCURRED, THE PRESSURE THAT | | WAS ESTABLISHED IN THE "A" MAIN STEAM LINE DISCHARGED TO THE SUPPRESSION | | POOL. THE DEPRESSURIZATION WAS CONFIRMED BY PERSONNEL PERFORMING THE LLRT | | AND THE SUPPRESSION POOL LEVEL RECORDERS. THE ADS LOGIC TEST WAS SUSPENDED | | UNTIL THE "A" MAIN STEAM LINE WAS COMPLETELY DEPRESSURIZED. | | | | THE RESIDENT INSPECTOR WAS NOTIFIED. | | | | * * * RETRACTED AT 1145 EDT ON 4/21/98 BY JOHN KUZALA TO FANGIE JONES * * * | | | | AFTER FURTHER INVESTIGATION OF THE EVENT, THE LICENSEE DETERMINED THAT THE | | ACTUATION WAS NOT CAUSED BY PLANT CONDITIONS. THE ACTUATION WAS FROM THE | | AUTOMATIC DEPRESSURIZATION SYSTEM SURVEILLANCE TEST PROCEDURE. THE | | LICENSEE IS RETRACTING THIS NOTIFICATION AFTER DETERMINATION THAT IT WAS | | NOT REPORTABLE. THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. THE | | HEADQUARTERS OPERATIONS OFFICER INFORMED THE R3DO (JIM GAVULA). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34107 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: CALVERT CLIFFS REGION: 1 |NOTIFICATION DATE: 04/20/98 | |UNIT: [1] [2] [ ] STATE: MD |NOTIFICATION TIME: 14:43 [ET]| |RX TYPE: [1] CE,[2] CE |EVENT DATE: 04/20/98 | +------------------------------------------------+EVENT TIME: 09:45[EDT]| |NRC NOTIFIED BY: OSBORNE / HOLLEMAN |LAST UPDATE DATE: 04/21/98 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JOHN ROGGE 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 REFUELING | 0 REFUELING | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - FITNESS FOR DUTY REPORT - | | | | AT 0945 ON 04/20/98, A NON-LICENSED SUPERVISOR TESTED POSITIVE FOR ALCOHOL | | DURING A RANDOM TEST. THE EMPLOYEE'S PLANT ACCESS AUTHORIZATION HAS BEEN | | TERMINATED AND HE HAS BEEN RELIEVED OF HIS NUCLEAR RELATED DUTIES. REFER | | TO THE HOO LOG FOR ADDITIONAL DETAILS. THE LICENSEE INFORMED THE NRC | | RESIDENT INSPECTOR. | | | | * * * UPDATE ON 04/21/98 AT 1059 BY HOLLEMAN TO GOULD * * * | | | | THE NON-LICENSED SUPERVISOR ONLY HAD ACCESS AUTHORIZATION TO THE EOF; | | THEREFORE, ONLY THE EMPLOYEE'S EOF ACCESS AUTHORIZATION WAS TERMINATED. | | | | THE LICENSEE WILL NOTIFY THE NRC RESIDENT INSPECTOR. | | | | THE NRC OPERATIONS OFFICER NOTIFIED THE R1DO (JOHN ROGGE). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34110 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: CLINTON REGION: 3 |NOTIFICATION DATE: 04/21/98 | |UNIT: [1] [ ] [ ] STATE: IL |NOTIFICATION TIME: 10:00 [ET]| |RX TYPE: [1] GE-6 |EVENT DATE: 04/21/98 | +------------------------------------------------+EVENT TIME: 00:00[CDT]| |NRC NOTIFIED BY: FRANTZ |LAST UPDATE DATE: 04/21/98 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JIM GAVULA RDO | |CDEG 21.21(c)(3)(i) DEFECTS/NONCOMPLIANCE | | | |VERN HODGE NRR | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | 10 CFR PART 21 REPORT - LACK OF RCIC CIRCUIT ISOLATION. | | | | THE LICENSEE SUBMITTED A PART 21 REPORT CONCERNING THE POSSIBILITY THAT | | REMOTE SHUTDOWN PANEL OPERATION OF THE REACTOR CORE ISOLATION COOLING | | (RCIC) SYSTEM MAY BE PREVENTED FOLLOWING A MAIN CONTROL ROOM FIRE DUE TO A | | SUPPLIER DESIGN LACKING CIRCUIT ISOLATION. THIS CONDITION IS DUE TO THE | | INSTALLATION OF INTERFACE CONNECTIONS TO THE RCIC SYSTEM TO PROVIDE INPUTS | | FOR THE GE TRANSIENT ANALYSIS RECORDING SYSTEM (GETARS). THIS GE DESIGN | | LACKED ISOLATION FOR CABLE 1RI85C CONNECTED TO THE FLOW CONTROL INPUT AT | | THE SIGNAL CONVERTER, 1E51-N590, AND CABLE 1RI85B CONNECTED TO THE RCIC | | TURBINE EG-M CONTROL BOX, 1E51-N591, SPEED OUTPUT TO THE TURBINE | | TACHOMETERS. | | | | THE CORRECTIVE ACTION WILL BE TO MODIFY THE INTERFACE OF GETARS CABLES | | 1RI85B AND 1RI85C WITH THE REMOTE SHUTDOWN PANEL TO PROVIDE ADEQUATE | | ISOLATION. THE LICENSEE WILL ALSO PERFORM A COMPREHENSIVE REVIEW OF SAFE | | SHUTDOWN REQUIRED CONTROL CIRCUITS TO ENSURE THAT THE POTENTIAL FOR FIRE | | DAMAGE IN THE MAIN CONTROL ROOM IS PROPERLY EVALUATED FOR IMPACT ON SAFE | | SHUTDOWN OPERATION FROM THE REMOTE SHUTDOWN PANEL. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 34111 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: STATE OF TENNESSEE |NOTIFICATION DATE: 04/21/98 | | CITY: REGION: 2 |NOTIFICATION TIME: 15:00 [ET]| | COUNTY: STATE: TN |EVENT DATE: 04/21/98 | |LICENSE#: R-47075 AGREEMENT: Y |EVENT TIME: 12:00[EDT]| | DOCKET: |LAST UPDATE DATE: 04/21/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |WALTER RODGERS RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: DEBRA SHULTS | | |HQ OPS OFFICER: DICK JOLLIFFE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - STATE OF TENNESSEE AGREEMENT STATE EVENT REPORT - | | | | ON 03/04/98, A VETERINARIAN AND A TECHNOLOGIST AT THE UNIVERSITY OF | | TENNESSEE VETERINARIAN TEACHING HOSPITAL WERE TREATING ANIMALS USING A | | PICKER #C-9 TELETHERAPY UNIT. THIS NEUTRON PRODUCTS, INC, MODEL | | #NP1-20-6500W UNIT CONTAINED A SOURCE OF APPROXIMATELY 6400 Ci OF | | COBALT-60. | | | | AFTER TREATING A DOG, THE DOCTOR AND THE TECHNOLOGIST ENTERED THE ROOM AND | | REMOVED THE ANIMAL WITHOUT BEING AWARE THAT THE Co-60 SOURCE WAS STILL IN | | THE EXPOSURE POSITION. TWO OTHER INDIVIDUALS ENTERED THE ROOM MOMENTARILY. | | | | WHEN THE LICENSEE DISCOVERED THAT THE INTERLOCK TO THE DOOR HAD FAILED | | TO RETRACT THE SOURCE, THEY NOTIFIED THE STATE OF TENNESSEE AND SENT THE | | DOSIMETERS TO LANDAUER COMPANY FOR EMERGENCY PROCESSING. THE HIGHEST | | DOSIMETER READINGS WERE 1.2 REM DEEP DOSE EQUIVALENT (DDE) AND 1.74 REM | | SHALLOW DOSE EQUIVALENT (SDE) AND ONE RING DOSIMETER READING WAS 2.99 REM | | SDE. | | | | ON 03/13/98, NEUTRON PRODUCTS, INC, PERFORMED MAINTENANCE ACTIVITIES ON THE | | TELETHERAPY UNIT. | | | | THE STATE OF TENNESSEE, DEPARTMENT OF ENVIRONMENT AND CONSERVATION, | | DIVISION OF RADIOLOGICAL HEALTH SENT A NOTICE OF NON-COMPLIANCE TO THE | | LICENSEE FOR TWO VIOLATIONS OF THEIR LICENSE: OPERATING PROCEDURES WERE | | NOT BEING FOLLOWED AND THE INTERLOCK TO THE TREATMENT DOOR DID NOT PROPERLY | | RETRACT THE SOURCE INTO THE OFF POSITION. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34112 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: NINE MILE POINT REGION: 1 |NOTIFICATION DATE: 04/21/98 | |UNIT: [1] [ ] [ ] STATE: NY |NOTIFICATION TIME: 15:35 [ET]| |RX TYPE: [1] GE-2,[2] GE-5 |EVENT DATE: 04/21/98 | +------------------------------------------------+EVENT TIME: 15:00[EDT]| |NRC NOTIFIED BY: DAVE MORR |LAST UPDATE DATE: 04/21/98 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JOHN ROGGE 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 +------------------------------------------------------------------------------+ | - CONTROL ROOM AIR TREATMENT SYSTEM INOPERABLE DUE TO MISCALIBRATION - | | | | A LICENSEE REVIEW OF CALCULATIONS USED TO DETERMINE THE SET POINT OF THE | | CONTROL ROOM AIR TREATMENT (CRAT) SYSTEM (aka CONTROL ROOM EMERGENCY | | VENTILATION SYSTEM) RADIATION MONITORS AND THE CALCULATION OF THE EXPECTED | | RADIATION LEVELS IN THE EVENT OF A MAIN STEAM LINE BREAK HAS REVEALED | | THAT THE CRAT SYSTEM RADIATION MONITORS WOULD NOT INITIATE THE CRAT | | SYSTEM DURING THIS EVENT. THIS WOULD RESULT IN EXCEEDING THE 10CFR50, | | APPENDIX 'A' AND GENERAL DESIGN CRITERIA #19 EXPOSURE LEVELS IN THE | | CONTROL ROOM. THIS IS BEING CONSIDERED OPERATION OUTSIDE THE DESIGN | | BASIS OF THE PLANT. | | | | THE LICENSEE DECLARED THE CRAT SYSTEM INOPERABLE. TECH SPEC 3.4.5 REQUIRES | | THE LICENSEE TO RESTORE THE CRAT SYSTEM TO OPERABLE STATUS WITHIN 7 DAYS OR | | SHUT THE PLANT DOWN. THE LICENSEE IS INVESTIGATING THIS EVENT AND PLANS TO | | RECALIBRATE THESE INSTRUMENTS. | | | | THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |GENERAL INFORMATION or OTHER | |EVENT NUMBER: 34113 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: WYLE LABORATORIES, INC |NOTIFICATION DATE: 04/21/98 | | CITY: REGION: 0 |NOTIFICATION TIME: 15:36 [ET]| | COUNTY: STATE: |EVENT DATE: 04/21/98 | |LICENSE#: AGREEMENT: |EVENT TIME: 12:00[EDT]| | DOCKET: |LAST UPDATE DATE: 04/21/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |ELMO COLLINS RDO | | | | +------------------------------------------------+VERN HODGE NRR | |NRC NOTIFIED BY: EDWARD W. SMITH | | |HQ OPS OFFICER: DICK JOLLIFFE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |CCCC 21.21 UNSPECIFIED PARAGRAPH | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - POTENTIAL 10CFR PART 21 REPORT - | | | | ON 04/07/98, WYLE LABORATORIES, INC AND SIEMENS CORPORATION PERSONNEL | | INSTALLED AN INTERLOCK KIT TO UPGRADE WYLE/SIEMENS SAFETY RELATED 4 KV, 350 | | MVA, 1200 AMP CIRCUIT BREAKERS AT ARKANSAS UNITS 1 AND 2. THIS UPGRADE WAS | | BEING INSTALLED DUE TO CONDITIONS OBSERVED ON SIMILAR SIEMENS CIRCUIT | | BREAKERS IN NON-SAFETY RELATED APPLICATIONS AT SALEM/HOPE CREEK. | | | | HOWEVER, THE SIEMENS TECHNICIAN DID NOT INSTALL THE KIT INTO THE CIRCUIT | | BREAKER PER THE APPROPRIATE SIEMENS DRAWING. THE IDENTIFIED CIRCUIT | | BREAKER, ALONG WITH NINE ADDITIONAL CIRCUIT BREAKERS WILL BE SHIPPED FROM | | ARKANSAS TO THE SIEMENS MANUFACTURING FACILITY AT WENDELL, NORTH CAROLINA | | WHERE THEY WILL UNDERGO AN APPROVED EVALUATION PROCEDURE. | | | | THIS REPORT IS CLASSIFIED AS A POTENTIAL 10CFR PART 21 REPORT. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |FUEL CYCLE FACILITY | |EVENT NUMBER: 34114 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 04/21/98 | | RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 15:48 [ET]| |COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 04/21/98 | | 6903 ROCKLEDGE DRIVE |EVENT TIME: 09:30[EDT]| | BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 04/21/98 | | CITY: PIKETON REGION: 3 +-----------------------------+ | COUNTY: PIKE STATE: OH |PERSON ORGANIZATION| |LICENSE#: GDP-2 AGREEMENT: N |JIM GAVULA RDO | | DOCKET: 0707002 |MIKE BELL, NMSS EO | +------------------------------------------------+STUART RUBIN, IRD AEOD | |NRC NOTIFIED BY: KEITH VANDERPOOL | | |HQ OPS OFFICER: DICK JOLLIFFE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NBNL RESPONSE-BULLETIN | | |NLTR LICENSEE 24 HR REPORT | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - NRC BULLETIN 91-01, 24 HOUR REPORT - | | | | AT 0930 ON 04/21/98 PORTSMOUTH WASTE OPERATIONS PERSONNEL DISCOVERED THAT A | | NUCLEAR CRITICALITY SAFETY APPROVAL (NCSA) REQUIREMENT WAS NOT BEING | | MAINTAINED WITHIN THE XT-847 WAREHOUSE DURING A DRY ACTIVE WASTE (DAW) | | SORTING EVOLUTION. NCSA-PLANT018.A01 REQUIREMENT #2 REQUIRES THAT DAW WITH | | VISIBLE CONTAMINATION OR SUSPECTED ITEMS SHALL BE COLLECTED IN CONTAINERS | | WITH A DIAMETER OF 5.25 INCHES OR LESS FOR A SAFE MASS LIMIT. A BAG | | CONTAINING THREE DISCARDED TUBES FROM THE X-710 LABORATORY WITH LESS THAN | | THE SAFE MASS LIMIT OF RESIDUAL UF6 FOR ENRICHMENT OF 100% U-235 (350 | | GRAMS) WAS DISCOVERED WITHIN THE DAW CONTAINER. THE FACT THAT VISIBLE | | CONTAMINATION WAS FOUND WITHIN THE CONTAINER VIOLATED REQUIREMENT #2 WHICH | | CONSTITUTES A LOSS OF CONTROL "B" (MASS) IN THE DOUBLE CONTINGENCY MATRIX | | FOR CONTINGENCY EVENT B.4.1. CONTROL "A" (INTERACTION/SPACING) WAS | | MAINTAINED THROUGHOUT THE EVENT. | | | | AT 1237 ON 04/21/98, PLANT PERSONNEL PLACED THE TUBES IN A PROPER CONTAINER | | TO REESTABLISH CONTROL "B". | | | | THERE WAS NO LOSS OF HAZARDOUS OR RADIOACTIVE MATERIALS NOR RADIOACTIVE OR | | RADIOLOGICAL CONTAMINATION EXPOSURE AS A RESULT OF THIS EVENT. | | | | PLANT PERSONNEL NOTIFIED THE NRC RESIDENT INSPECTOR AND THE ONSITE DOE | | REPRESENTATIVE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |FUEL CYCLE FACILITY | |EVENT NUMBER: 34115 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PADUCAH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 04/21/98 | | RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 16:38 [ET]| |COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 04/21/98 | | 6903 ROCKLEDGE DRIVE |EVENT TIME: 14:30[CDT]| | BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 04/21/98 | | CITY: PADUCAH REGION: 3 +-----------------------------+ | COUNTY: McCRACKEN STATE: KY |PERSON ORGANIZATION| |LICENSE#: GDP-1 AGREEMENT: Y |JIM GAVULA RDO | | DOCKET: 0707001 | | +------------------------------------------------+ | |NRC NOTIFIED BY: RODNEY COOK | | |HQ OPS OFFICER: DICK JOLLIFFE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |PAAA 95.57(b) LOSS OF CLASSIFIED INFO | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - LOSS OF CONTROL OF CLASSIFIED DOCUMENTS - | | | | LOSS OF CONTROL OF CLASSIFIED DOCUMENTS. COMPENSATORY MEASURES HAVE BEEN | | TAKEN AND AN INVESTIGATION IS UNDERWAY. PLANT PERSONNEL NOTIFIED THE NRC | | RESIDENT AND WILL NOTIFY THE ONSITE DOE REPRESENTATIVE. REFER TO THE HOO | | LOG FOR ADDITIONAL DETAILS. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 34116 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: QUEENS MEDICAL CENTER, HONOLULU, HI |NOTIFICATION DATE: 04/21/98 | | CITY: HONOLULU REGION: 4 |NOTIFICATION TIME: 17:30 [ET]| | COUNTY: STATE: HI |EVENT DATE: 04/20/98 | |LICENSE#: 53-16533-02 AGREEMENT: N |EVENT TIME: 11:00[AH ]| | DOCKET: |LAST UPDATE DATE: 04/21/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |ELMO COLLINS RDO | | |MIKE BELL, NMSS EO | +------------------------------------------------+STUART RUBIN, IRB AEOD | |NRC NOTIFIED BY: SCOTT DUBE | | |HQ OPS OFFICER: DICK JOLLIFFE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - MEDICAL MISADMINISTRATION REPORT - | | | | AT 1030 AH ON 04/20/98, THE QUEENS MEDICAL CENTER ASSISTANT RADIATION | | SAFETY OFFICER (ARSO) MISREAD A LABEL AND INCORRECTLY CALIBRATED A MEDICAL | | DOSE CALIBRATOR BY A FACTOR OF THREE. | | | | AT 1100 AH ON 04/20/98, A PATIENT WAS GIVEN A DOSE OF 3 MILLICURIES OF | | LIQUID P-32 DURING AN ARTHRITIS TREATMENT INSTEAD OF A PRESCRIBED DOSE | | OF 1 MILLICURIE OF LIQUID P-32. | | | | AT 1200 AH ON 04/20/98, A SECOND PATIENT WAS GIVEN A DOSE OF | | 1.5 MILLICURIES OF LIQUID P-32 DURING AN ARTHRITIS TREATMENT INSTEAD | | OF A PRESCRIBED DOSE OF 0.5 MILLICURIES OF LIQUID P-32. | | | | AT 1700 AH ON 04/20/98, THE ARSO DISCOVERED THIS ERROR AND DETERMINED | | THAT THE INCORRECT DOSES POSED NO ADVERSE HEALTH EFFECTS TO THE PATIENTS. | | HOSPITAL PERSONNEL PLAN TO NOTIFY THE PATIENTS AND THEIR REFERRING | | PHYSICIANS OF THE OVERDOSES. | | | | HOSPITAL PERSONNEL ARE INVESTIGATING THIS EVENT AND PLAN TO SUBMIT A | | WRITTEN REPORT TO NRC REGION 4 WITHIN 15 DAYS. | +------------------------------------------------------------------------------+