U.S. Nuclear Regulatory Commission Operations Center Event Reports For 10/21/98 - 10/22/98 ** EVENT NUMBERS ** 34937 34938 34939 34940 34941 34942 34943 34944 +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34937 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SEABROOK REGION: 1 |NOTIFICATION DATE: 10/21/98 | |UNIT: [1] [ ] [ ] STATE: NH |NOTIFICATION TIME: 07:44 [ET]| |RX TYPE: [1] W-4-LP |EVENT DATE: 10/20/98 | +------------------------------------------------+EVENT TIME: 08:58[EDT]| |NRC NOTIFIED BY: MESSINA |LAST UPDATE DATE: 10/21/98 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |LAURIE PELUSO RDO | |HFIT 26.73 FITNESS FOR DUTY | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | NON-LICENSED SYSTEM OPERATOR TESTED POSITIVE FOR ALCOHOL. | | | | A NON-LICENSED OPERATOR WAS OBSERVED TO HAVE ALCOHOL ON HIS BREATH. THE | | NON-LICENSED SYSTEM OPERATOR FAILED THE FITNESS FOR DUTY FOR CAUSE ALCOHOL | | SCREEN TEST ON 10/20/98. THE EMPLOYEE WAS SUSPENDED FROM DUTY FOR 14 DAYS | | AND HIS VITAL ACCESS WAS WITHDRAWN. ALL WORK PERFORMED BY THE EMPLOYEE HAS | | BEEN REVIEWED. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED OF THIS EVENT BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34938 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: CATAWBA REGION: 2 |NOTIFICATION DATE: 10/21/98 | |UNIT: [ ] [2] [ ] STATE: SC |NOTIFICATION TIME: 11:32 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 10/21/98 | +------------------------------------------------+EVENT TIME: 09:48[EDT]| |NRC NOTIFIED BY: ROBERT WHITE |LAST UPDATE DATE: 10/21/98 | |HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |PIERCE SKINNER RDO | |ARPS 50.72(b)(2)(ii) RPS ACTUATION | | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | M/R N 0 STARTUP | 0 HOT STANDBY | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MANUAL REACTOR TRIP DURING STARTUP DUE TO ROD CONTROL SYSTEM FAILURE | | | | DURING A REACTOR STARTUP, WITH THE UNIT SUBCRITICAL, THE ROD CONTROL SYSTEM | | FAILED, PREVENTING THE SYSTEM FROM INSERTING OR WITHDRAWING CONTROL RODS. | | OPERATORS WERE WITHDRAWING CONTROL BANK "A" AT THE TIME OF THE FAILURE. | | OPERATORS MANUALLY TRIPPED THE UNIT IN ORDER TO INSERT ALL CONTROL AND | | SHUTDOWN BANKS TO THE FULL-IN POSITION. AN AUTOMATIC FEEDWATER ISOLATION | | OCCURRED DUE TO THE OPENING OF THE REACTOR TRIP BREAKERS CONCURRENT WITH | | Tave BELOW 564øF. THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR OF | | THIS EVENT. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34939 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BROWNS FERRY REGION: 2 |NOTIFICATION DATE: 10/21/98 | |UNIT: [1] [2] [3] STATE: AL |NOTIFICATION TIME: 13:16 [ET]| |RX TYPE: [1] GE-4,[2] GE-4,[3] GE-4 |EVENT DATE: 10/21/98 | +------------------------------------------------+EVENT TIME: 10:40[CDT]| |NRC NOTIFIED BY: TERRY KNUETTEL |LAST UPDATE DATE: 10/21/98 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |PIERCE SKINNER 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 | | 3 | N Y 90 POWER OPERATION | 90 POWER OPERATION | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | A CONTRACTOR SUPERVISOR'S PLANT ACCESS AUTHORIZATION WAS TERMINATED AFTER | | HE ADULTERATED HIS URINE SAMPLE DURING A ROUTINE DRUG TEST. REFER TO THE | | HOO LOG FOR DETAILS. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 34940 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: HOSPITAL OF THE GOOD SAMARITAN |NOTIFICATION DATE: 10/21/98 | | CITY: REGION: 4 |NOTIFICATION TIME: 15:00 [ET]| | COUNTY: STATE: CA |EVENT DATE: 10/15/98 | |LICENSE#: 0280-19 AGREEMENT: Y |EVENT TIME: 12:00[PDT]| | DOCKET: |LAST UPDATE DATE: 10/21/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |BLAINE MURRAY RDO | | |DON COOL, NMSS EO | +------------------------------------------------+FRANK CONGEL IRD | |NRC NOTIFIED BY: DON BUNN, CA DHS | | |HQ OPS OFFICER: DICK JOLLIFFE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | -THERAPEUTIC TREATMENT ADMINISTERED TO THE WRONG SIDE OF A PATIENT'S BRAIN- | | | | AT 1500 PDT ON 10/20/98, A REPRESENTATIVE OF THE HOSPITAL OF THE GOOD | | SAMARITAN NOTIFIED THE CALIFORNIA DEPARTMENT OF HEALTH SERVICES (DHS), | | LOS ANGELES RADIATION MANAGEMENT OFFICE, OF THE FOLLOWING THERAPEUTIC | | MEDICAL MISADMINISTRATION EVENT. DON BUNN, CA DHS, SACRAMENTO, CA, | | IN TURN, NOTIFIED THE NRC OF THIS EVENT. | | | | ON 10/15/98, A PATIENT AT THE HOSPITAL OF THE GOOD SAMARITAN WAS | | PRESCRIBED A TREATMENT OF 90 GRAY (9000 RAD) TO THE LEFT TRIGEMINAL | | NERVE (FIFTH CRANIAL NERVE) OF HIS BRAIN USING A GAMMA KNIFE. | | | | HOWEVER, THE TREATMENT WAS ACTUALLY ADMINISTERED TO THE RIGHT SIDE | | OF THE PATIENT'S BRAIN. | | | | THE MEDICAL PHYSICIST HAD SET UP THE TREATMENT INCORRECTLY. THE | | NEUROSURGEON WAS SUPPOSED TO REVIEW THE TREATMENT PLAN BUT HE DID NOT, | | AND THE ONCOLOGIST SIGNED THE TREATMENT PLAN WITHOUT REVIEWING IT. | | | | A COMPLETE REPORT WILL BE FILED BY THE HOSPITAL. | | | | THE STATE OF CALIFORNIA WILL FILE AN ABNORMAL OCCURRENCE REPORT | | AS SOON AS ALL THE FACTS ARE KNOWN. | | | | AS OF 10/21/98, THE HOSPITAL OF THE GOOD SAMARITAN CONTINUES TO TREAT | | PATIENTS WITH THEIR GAMMA KNIFE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34941 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: RIVER BEND REGION: 4 |NOTIFICATION DATE: 10/21/98 | |UNIT: [1] [ ] [ ] STATE: LA |NOTIFICATION TIME: 15:22 [ET]| |RX TYPE: [1] GE-6 |EVENT DATE: 10/21/98 | +------------------------------------------------+EVENT TIME: 13:30[CDT]| |NRC NOTIFIED BY: ANGELA ORGERON |LAST UPDATE DATE: 10/21/98 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BLAINE MURRAY RDO | |DDDD 73.71 UNSPECIFIED PARAGRAPH | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | -PLANT SECURITY EVENT - FAILURE TO DISCLOSE PERSONAL BACKGROUND INFORMATION | | | | DISCOVERY OF A POSSIBLE CRIMINAL ACT INVOLVING A CONTRACTOR GRANTED ACCESS | | TO THE SITE. IMMEDIATE COMPENSATORY MEASURES WERE TAKEN UPON DISCOVERY. | | REFER TO THE HOO LOG FOR ADDITIONAL DETAILS. THE LICENSEE INFORMED THE NRC | | RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34942 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: FT CALHOUN REGION: 4 |NOTIFICATION DATE: 10/21/98 | |UNIT: [1] [ ] [ ] STATE: NE |NOTIFICATION TIME: 15:48 [ET]| |RX TYPE: [1] CE |EVENT DATE: 10/21/98 | +------------------------------------------------+EVENT TIME: 14:35[CDT]| |NRC NOTIFIED BY: ERICK MATZKE |LAST UPDATE DATE: 10/21/98 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BLAINE MURRAY RDO | |AUNA 50.72(b)(1)(ii)(A) UNANALYZED COND OP | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | -EMERGENCY TEMPORARY PLANT MODIFICATION PLACED THE PLANT IN AN UNANALYZED | | CONDITION- | | | | AT 0200 CDT ON 10/20/98, A VENTILATION DUCT FROM ROOM #81 (THE ROOM | | IMMEDIATELY OUTSIDE CONTAINMENT THROUGH WHICH THE MAIN STEAM LINES PASS) | | TO THE SWITCHGEAR ROOMS HAD TWO FIRE DAMPERS AND A DROP DOWN DAMPER | | DEFEATED IN A NON-CONSERVATIVE DIRECTION. THESE DAMPERS ARE TAKEN CREDIT | | FOR IN A MAIN STEAM LINE BREAK ACCIDENT ANALYSIS. | | | | AN EMERGENCY TEMPORARY PLANT MODIFICATION (ETPM) HAD BEEN INSTALLED TO | | TAPE THE DROP DOWN DOOR SHUT AND BLOCK THE FIRE DAMPERS OPEN. THIS WAS | | DONE TO PROVIDE ADDITIONAL OUTSIDE COOLING DURING MAINTENANCE ACTIVITIES | | ON THE AIR CONDITIONING UNITS FOR THE ELECTRICAL SWITCHGEAR ROOMS. THE | | ETPM HAD BEEN REVIEWED FROM A FIRE SAFE SHUTDOWN PERSPECTIVE BUT NOT | | FROM A MAIN STEAM LINE BREAK ACCIDENT PERSPECTIVE. | | | | LATER IN THE DAY, DURING A REVIEW OF THE ETPM, THE LICENSEE IDENTIFIED | | THE IMPORTANCE OF THE ORIGINAL CONFIGURATION. | | | | AT 1330 CDT, THE LICENSEE RETURNED THE PLANT TO ITS ORIGINAL ANALYZED | | CONDITION. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34943 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: FARLEY REGION: 2 |NOTIFICATION DATE: 10/21/98 | |UNIT: [1] [ ] [ ] STATE: AL |NOTIFICATION TIME: 18:51 [ET]| |RX TYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 10/21/98 | +------------------------------------------------+EVENT TIME: 15:06[CDT]| |NRC NOTIFIED BY: VAUDY HOLLEY |LAST UPDATE DATE: 10/21/98 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |PIERCE SKINNER 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 +------------------------------------------------------------------------------+ | - FUEL TRANSFER CANAL WATER TRANSFER CAUSED RADIOACTIVITY TO GO AIRBORNE - | | | | UNIT 1 IS IN MODE 6 IN A REFUELING OUTAGE. | | | | AT 1506 CDT ON 10/21/98, DURING THE TRANSFER OF RECYCLE HOLDUP TANK MAKEUP | | WATER TO THE UNIT 1 FUEL TRANSFER CANAL, THE PENETRATION ROOM FILTRATION | | SYSTEM RECEIVED A VALID AUTOMATIC START SIGNAL ON A HIGH RADIATION ALARM | | FROM THE RAD MONITOR IN THE SPENT FUEL POOL (SFP) VENTILATION SYSTEM, | | #R-25B. WHEN THIS MAKEUP WATER ENTERED THE FUEL TRANSFER CANAL AREA, | | THE LOOSE RADIOACTIVE MATERIAL WENT AIRBORNE. BOTH TRAINS OF THE | | PENETRATION ROOM FILTRATION SYSTEM AUTO STARTED AND SUCKED THE AIRBORNE | | RADIOACTIVE MATERIAL OUT OF THE ROOM. | | | | AT 1510 CDT, ALL SYSTEMS RETURNED TO THEIR NORMAL CONDITION. | | | | NO PERSONNEL WERE CONTAMINATED. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34944 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SOUTH TEXAS REGION: 4 |NOTIFICATION DATE: 10/21/98 | |UNIT: [1] [ ] [ ] STATE: TX |NOTIFICATION TIME: 19:01 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 10/21/98 | +------------------------------------------------+EVENT TIME: 13:14[CDT]| |NRC NOTIFIED BY: WAYNE HARRISON |LAST UPDATE DATE: 10/21/98 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |BLAINE MURRAY RDO | |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 +------------------------------------------------------------------------------+ | - TECH SPEC 3.0.3 ENTERED TO REPLACE A FAILED MOTOR IAW A NOED - | | | | AT 1314 CDT ON 10/21/98, THE LICENSEE ENTERED TECH SPEC 3.0.3 WHEN ALL | | THREE FUEL HANDLING BUILDING (FHB) EXHAUST BOOSTER FANS (EBFs) WERE MADE | | INOPERABLE TO FACILITATE THE REPLACEMENT OF A FAILED MOTOR FOR EBF #11A. | | THE LICENSEE ENTERED TECH SPEC 3.0.3 WHEN THEY PLACED THE EBFs IN THE | | PULL-TO-LOCK POSITION WHICH RENDERS THEIR ASSOCIATED AUTOMATIC ACTUATION | | INOPERABLE. IN ADDITION, PERSONNEL ENTRY INTO THE COMMON PLENUM SERVING | | THE EBFs CAUSES ALL THE REQUIRED TRAINS OF THE FHB EXHAUST VENTILATION | | SYSTEM TO BE INOPERABLE. | | | | THE LICENSEE TOOK THIS ACTION IN ACCORDANCE WITH A NOTICE OF ENFORCEMENT | | DISCRETION (NOED) APPROVED BY NRC NRR EARLIER IN THE DAY WHICH ALSO ALLOWS | | THE LICENSEE TO INSTALL A TEMPORARY PLANT MODIFICATION TO ISOLATE THE | | EXHAUST DUCT CONTAINING THE FAILED EBF MOTOR SO THAT THE MOTOR CAN BE | | REMOVED. THE LICENSEE INSTALLED THE TEMPORARY PLANT MODIFICATION AND | | REMOVED THE MOTOR AND EXITED TECH SPEC 3.0.3 AT 1532 CDT ON 10/21/98. | | | | THE NOED ALSO ALLOWS THE LICENSEE TO REENTER TECH SPEC 3.0.3 AFTER | | THE MOTOR IS REPLACED TO RESTORE THE SYSTEM TO NORMAL CONFIGURATION. | | CONSEQUENTLY, THE LICENSEE ANTICIPATES REENTERING TECH SPEC 3.0.3 | | AGAIN ON 10/25/98 TO REPLACE THE MOTOR AND REMOVE THE TEMPORARY PLANT | | MODIFICATION. | | | | THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR. | | | | NOTE: THE CONDITIONS FOR THIS EVENT ARE NEARLY IDENTICAL TO THOSE FOR | | EVENT #34170 ON 05/02/98 FOR EXHAUST BOOSTER FAN/MOTOR #11B. | +------------------------------------------------------------------------------+