U.S. Nuclear Regulatory Commission Operations Center Event Reports For 07/21/98 - 07/22/98 ** EVENT NUMBERS ** 34433 34514 34542 34545 34547 34548 34549 34550 34551 34552 34553 34554 34555 34556 34557 34558 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34433 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: CATAWBA REGION: 2 |NOTIFICATION DATE: 06/24/98 | |UNIT: [1] [2] [ ] STATE: SC |NOTIFICATION TIME: 15:35 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 06/24/98 | +------------------------------------------------+EVENT TIME: 13:30[EDT]| |NRC NOTIFIED BY: JACK VRISSON |LAST UPDATE DATE: 07/21/98 | |HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |CHARLES OGLE 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 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | INOPERABLE CONTROL ROOM AREA VENTILATION SYSTEM | | | | ON 06/22/98, CONTROL ROOM AREA VENTILATION SYSTEM TRAIN 'B' WAS INOPERABLE | | AS PART OF PRE-PLANNED MAINTENANCE ACTIVITY. AT APPROXIMATELY 2300 HOURS, | | AN OIL LEAK WAS FOUND ON AN INSTRUMENTATION LINE ON THE 'A' TRAIN CONTROL | | ROOM AREA VENTILATION SYSTEM CHILLER. THE LEAK WAS ON THE DISCHARGE OIL | | PRESSURE SENSING LINE. THIS LINE IS AN OIL-FILLED COPPER TUBE AND IS USED | | TO SENSE DISCHARGE OIL PRESSURE AS AN INPUT TO THE OIL REGULATION AND | | CONTROL INSTRUMENTATION (OIL PRESSURE AND OIL PRESSURE SAFETY SWITCH). THE | | LINE IS STATIC AND DOES NOT NORMALLY HAVE OIL FLOWING THROUGH IT. | | INITIALLY, IT WAS DETERMINED THAT THE LEAK WAS NOT LARGE ENOUGH TO CAUSE | | INOPERABILITY OF THE SYSTEM BECAUSE THE OIL LEVEL COULD BE PERIODICALLY | | MONITORED AND BECAUSE THE SUPPLY COULD BE PERIODICALLY REPLENISHED. ON | | 06/23/98, A TEMPORARY PATCH WAS INSTALLED WHICH HAS STOPPED THE LEAKAGE. | | | | UPON FURTHER REVIEW, IT WAS DETERMINED THAT THE AREA WOULD BE INACCESSIBLE | | DURING POST-LOSS OF COOLANT ACCIDENT (LOCA) CONDITIONS, PREVENTING | | REPLENISHMENT OF THE OIL SUPPLY. BECAUSE THIS SYSTEM IS REQUIRED TO | | FUNCTION POST-LOCA, THIS CONDITION RENDERED THE TRAIN INOPERABLE. THE | | TRAIN WAS INOPERABLE BETWEEN THE TIME THE LEAK OCCURRED UNTIL INSTALLATION | | OF THE PATCH. THIS CONDITION WAS DETERMINED TO BE A SINGLE CAUSE OR | | CONDITION THAT ALONE COULD HAVE PREVENTED THE FULFILLMENT OF THE SAFETY | | FUNCTION OF STRUCTURES THAT ARE NEEDED TO MITIGATE THE CONSEQUENCES OF AN | | ACCIDENT. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED OF THIS EVENT BY THE LICENSEE. | | | | *** UPDATE ON 07/21/98 @ 1712 FROM HAMILTON TO GOULD *** RETRACTION | | | | THE LICENSEE IS RETRACTING THIS EVENT NOTIFICATION SINCE FURTHER REVIEW HAS | | INDICATED THAT THE CHILLER WAS AVAILABLE TO PERFORM ITS INTENDED FUNCTION | | BOTH DURING NORMAL OPERATION AND UNDER POSTULATED ACCIDENT CONDITIONS; | | THEREFORE, IT WAS OPERABLE AT ALL TIMES. SINCE THE CHILLER WAS OPERABLE, | | THIS EVENT IS NOT REPORTABLE. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED BY THE LICENSEE. THE R2DO (LESSER) | | WAS NOTIFIED BY THE NRC OPERATIONS OFFICER. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34514 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: CATAWBA REGION: 2 |NOTIFICATION DATE: 07/15/98 | |UNIT: [1] [2] [ ] STATE: SC |NOTIFICATION TIME: 13:23 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 07/15/98 | +------------------------------------------------+EVENT TIME: 00:00[EDT]| |NRC NOTIFIED BY: KELLER |LAST UPDATE DATE: 07/21/98 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |THOMAS DECKER 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 | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AN EMPLOYEE ASSIGNED TO PERFORM DUTIES WITHIN THE SCOPE OF 10 CFR PART 26 | | ADMITTED TO INVOLVEMENT WITH A CONTROLLED SUBSTANCE. THE INDIVIDUAL'S SITE | | ACCESS HAS BEEN SUSPENDED. | | | | (REFER TO THE HOO LOG FOR SITE CONTACT INFORMATION AND ADDITIONAL EVENT | | DETAILS.) | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED BY THE LICENSEE. | | | | ***UPDATE AT 1115 EDT ON 07/21/98 FROM R. ERBY TO BAILEY*** | | | | THE RESULTS OF TESTS CONFIRMED THE USE OF A CONTROLLED SUBSTANCE BY THE | | EMPLOYEE. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. THE NRC OPERATIONS | | OFFICER INFORMED THE R2DO (TOM DECKER). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34542 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: THREE MILE ISLAND REGION: 1 |NOTIFICATION DATE: 07/20/98 | |UNIT: [1] [ ] [ ] STATE: PA |NOTIFICATION TIME: 16:52 [ET]| |RX TYPE: [1] B&W-L-LP,[2] B&W-L-LP |EVENT DATE: 07/20/98 | +------------------------------------------------+EVENT TIME: 14:56[EDT]| |NRC NOTIFIED BY: BOYER |LAST UPDATE DATE: 07/21/98 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |KATHLEEN MODES 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 +------------------------------------------------------------------------------+ | THE PLANT DISCOVERED THAT TWO OUT OF EIGHT CHECK VALVES WERE MISSING FROM | | THE FLOOR DRAINS IN THE INTAKE PUMP SCREEN HOUSE. | | | | THE FLOOR DRAINS IN THE INTAKE PUMP SCREEN HOUSE WERE INSPECTED IN THE 'A' | | AND 'B' PUMP ROOMS PER FINAL SAFETY ANALYSIS REPORT SECTION 2.6.A. THESE | | FLOOR DRAINS SHOULD HAVE CHECK VALVES FOR FLOOD PROTECTION, BUT TWO OF THE | | EIGHT CHECK VALVES WERE DISCOVERED TO BE MISSING. IT HAS NOT BEEN | | DETERMINED IF THE CHECK VALVES WERE REMOVED, AND AN INVESTIGATION IS IN | | PROGRESS. AS AN INTERIM FIX, A TEMPORARY CHANGE WILL BE MADE TO THE FLOOD | | PROCEDURE SO THAT CREDIT CAN BE TAKEN FOR OPERATOR ACTION. | | | | THE NRC RESIDENT INSPECTOR WILL BE NOTIFIED BY THE LICENSEE. | | | | ***UPDATE ON 07/21/98 @ 1726 FROM SCHORK TO GOULD *** | | | | THE LICENSEE CHANGED THE EVENT REPORTING CLASSIFICATION FROM A 4-HOUR | | SAFE-SHUTDOWN-CAPABILITY REPORT TO A 1-HOUR OUTSIDE-DESIGN-BASIS REPORT. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED BY THE LICENSEE. THE R1DO (MODES) | | WAS INFORMED BY THE NRC OPERATIONS OFFICER. | +------------------------------------------------------------------------------+ !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34545 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: HADDAM NECK REGION: 1 |NOTIFICATION DATE: 07/20/98 | |UNIT: [1] [ ] [ ] STATE: CT |NOTIFICATION TIME: 18:56 [ET]| |RX TYPE: [1] W-4-LP |EVENT DATE: 07/20/98 | +------------------------------------------------+EVENT TIME: 18:33[EDT]| |NRC NOTIFIED BY: MORGAN |LAST UPDATE DATE: 07/21/98 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |KATHLEEN MODES RDO | |ADAS 50.72(b)(2)(i) DEG/UNANALYZED COND | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N N 0 DECOMMISSIONED | 0 DECOMMISSIONED | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE LICENSEE HAS DETERMINED THAT AN ISSUED LICENSE AMENDMENT IS NO LONGER | | ACCURATE. | | | | NRC LICENSE AMENDMENT 193 WAS ISSUED BY THE NRC BASED UPON INFORMATION THAT | | "IF OFFSITE POWER CANNOT BE REESTABLISHED WITHIN APPROXIMATELY 2 HOURS | | AFTER A LOSS OF NORMAL POWER, LIMITED MAKEUP WATER TO THE FUEL POOL COULD | | BE PROVIDED BY GRAVITY FEED FROM A TANK..." THIS INFORMATION IS NO LONGER | | ACCURATE SINCE THE TANK HAS BEEN ABANDONED. THIS CONDITION MAY PLACE THE | | PLANT IN A CONDITION OUTSIDE THE DESIGN BASIS. CORRECTIVE MEASURES WILL BE | | DETERMINED. | | | | THE NRC RESIDENT INSPECTOR AND APPLICABLE STATE AND LOCAL AGENCIES WERE | | NOTIFIED BY THE LICENSEE. | | | | *** UPDATE ON 07/21/98 @ 1949 FROM CALDWELL TO GOULD *** RETRACTION | | | | UPON FURTHER EVALUATION, IT HAS BEEN DETERMINED THAT THE DESIGN BASIS OF | | THE PLANT CONTINUES TO BE MAINTAINED. MULTIPLE FUEL POOL MAKEUP | | CAPABILITIES ARE PROVIDED TO REPLACE EVAPORATIVE LOSSES DURING A LOSS OF | | OFFSITE POWER EVENT AND ARE NOT DEPENDENT ON GRAVITY FEED CAPABILITY. | | MAKEUP WATER TO THE POOL IS AVAILABLE FROM THE DEMINERALIZED WATER STORAGE | | TANK USING HOSES AND A PORTABLE GASOLINE-DRIVEN PUMP, AND THE BACKUP SUPPLY | | USING THE RIVER WATER VIA THE FIRE WATER SYSTEM. THEREFORE, THE LICENSEE | | IS RETRACTING THE EVENT NOTIFICATION. | | | | THE NRC RESIDENT INSPECTOR WILL BE NOTIFIED BY THE LICENSEE. THE R1DO | | (MODES) WAS NOTIFIED BY THE NRC OPERATIONS OFFICER. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |GENERAL INFORMATION or OTHER | |EVENT NUMBER: 34547 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: EARTH CONSULTANTS, INC. |NOTIFICATION DATE: 07/21/98 | | CITY: BELLEVUE REGION: 4 |NOTIFICATION TIME: 09:36 [ET]| | COUNTY: STATE: WA |EVENT DATE: 07/16/98 | |LICENSE#: WN-L061-1 AGREEMENT: Y |EVENT TIME: 08:30[PDT]| | DOCKET: |LAST UPDATE DATE: 07/21/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |TOM STETKA RDO | | |FRED COMBS, NMSS EO | +------------------------------------------------+ | |NRC NOTIFIED BY: TERRY FRAZEE, WA DOH | | |HQ OPS OFFICER: DICK JOLLIFFE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - DAMAGED TROXLER MOISTURE DENSITY GAUGE (SOURCE NOT DAMAGED) - | | | | TERRY FRAZEE, STATE OF WASHINGTON, DEPARTMENT OF HEALTH, DIVISION OF | | RADIATION PROTECTION, REPORTED TO THE NRC THAT A TROXLER MOISTURE DENSITY | | GAUGE (MODEL #3430, SERIAL #28458, OWNED BY EARTH CONSULTANTS, INC., OF | | BELLEVUE, WASHINGTON) WAS HIT BY BULLDOZER AT A TEMPORARY JOB SITE NEAR | | FEDERAL WAY, WASHINGTON. | | | | AT 0830 PDT ON 07/16/98, THE BLADE OF THE BULLDOZER HIT THE GAUGE WHICH | | WAS NOT IN USE AT THE TIME. THE BLADE SKIMMED OVER THE GAUGE BENDING THE | | HANDLE AND THE SOURCE ROD (WHICH WAS IN THE SAFE/UP POSITION) AND CRUSHING | | THE ELECTRONICS. THE LICENSEE REPRESENTATIVE CLOSED THE OPEN SHUTTER OF | | THE GAUGE, MOVED THE GAUGE TO THE LICENSEE'S OFFICE, ISOLATED THE IMMEDIATE | | AREA, AND NOTIFIED THE LICENSEE RADIATION SAFETY OFFICER AND THE WASHINGTON | | STATE DIVISION OF RADIATION PROTECTION. | | | | ON 07/17/98, WASHINGTON STATE DIVISION OF RADIATION PROTECTION STAFF | | MEMBERS EXAMINED THE GAUGE AND DETERMINED BY WIPE TESTS THAT NO LEAKAGE HAD | | OCCURRED AND THAT THE GAUGE COULD BE SAFELY RETURNED TO THE MANUFACTURER | | FOR REPAIR. | | | | THE GAUGE CONTAINED 8 MILLICURIES OF Cs-137 AND 40 MILLICURIES OF | | Am-241/Be. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34548 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: CLINTON REGION: 3 |NOTIFICATION DATE: 07/21/98 | |UNIT: [1] [ ] [ ] STATE: IL |NOTIFICATION TIME: 09:19 [ET]| |RX TYPE: [1] GE-6 |EVENT DATE: 07/20/98 | +------------------------------------------------+EVENT TIME: 00:00[CDT]| |NRC NOTIFIED BY: RON FRANTZ |LAST UPDATE DATE: 07/21/98 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |GEOFFREY WRIGHT RDO | |CCCC 21.21 UNSPECIFIED PARAGRAPH | | | |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 - SHRINKAGE AND CRACKING OF MEDIUM AND HIGH DENSITY | | SILICONE PENETRATION SEALS DUE TO COEFFICIENT OF THERMAL EXPANSION | | | | ON 02/20/98, WHILE PERFORMING A WALKDOWN TO QUALIFY PENETRATION SEALS IN | | ACCORDANCE WITH NUREG 1552, "FIRE PENETRATION SEALS IN NUCLEAR POWER | | PLANTS," ILLINOIS POWER (IP) IDENTIFIED CRACKS IN PENETRATION SEAL | | DG-762-01-5003. THE CRACKS EXTENDED COMPLETELY THROUGH THE SEAL IN THE | | M-BOARD SEPARATOR MATERIAL AT THE INTERFACE BETWEEN THE M-BOARD AND THE | | SF-60 SEALANT AND BETWEEN THE SF-60 SEALANT AND A PIPE PASSING THROUGH THE | | SEAL. THE M-BOARD IS A REFRACTORY FIBER BOARD MADE PREDOMINANTLY OF | | ALUMINA SILICA USED WITHIN THE PENETRATION SEAL TO DIVIDE A PENETRATION | | INTO SECTIONS FOR WHICH A TESTED DESIGN CONFIGURATION CAN BE APPLIED. THE | | SEAL WAS DESIGNED AND INSTALLED BY BISCO, A SUBSIDIARY OF THE BRAND | | COMPANIES, IN PARK RIDGE, ILLINOIS. (THE BISCO ORGANIZATION NO LONGER | | EXISTS.) THE BISCO SF-60 SEALANT MATERIAL WAS MANUFACTURED BY DOW CORNING | | AS SYLGARD 170 (BISCO SF-60 AND BISCO SF-150NH) MATERIAL. | | | | INSPECTIONS OF OTHER SIMILAR PENETRATION SEAL CONFIGURATIONS REVEALED THAT | | THE SHRINKAGE ISSUE IS A GENERIC CONCERN FOR MEDIUM AND HIGH DENSITY | | PENETRATION SEALS THAT HAVE CONFIGURATIONS WITH DIMENSIONS GREATER THAN 12 | | INCHES. THE CRACKS ARE ATTRIBUTED TO SHRINKAGE DUE TO THE VOLUME | | COEFFICIENT OF THERMAL EXPANSION OF THE CURED MATERIAL (APPROXIMATELY 8% | | FOR EACH 100øC OF TEMPERATURE DIFFERENTIAL). CLINTON POWER STATION HAS | | APPROXIMATELY 800 SEALS THAT MAY BE SUSCEPTIBLE TO THIS SHRINKAGE. AS OF | | 07/10/98, IP HAD INSPECTED 157 OF THE SUSPECTED PENETRATION SEALS AND FOUND | | UNACCEPTABLE CRACKS/GAPS IN 32 PENETRATIONS. | | | | IP PLANS TO INSPECT AND REWORK/REPAIR THE SUSPECTED PENETRATION SEALS AS | | NECESSARY. RESOLUTION OF THIS ISSUE IS CURRENTLY SCHEDULED TO BE COMPLETED | | BY MAY 1999. | | | | THE LICENSEE HAS NOTIFIED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34549 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: LASALLE REGION: 3 |NOTIFICATION DATE: 07/21/98 | |UNIT: [1] [ ] [ ] STATE: IL |NOTIFICATION TIME: 09:05 [ET]| |RX TYPE: [1] GE-5,[2] GE-5 |EVENT DATE: 07/21/98 | +------------------------------------------------+EVENT TIME: 05:50[CDT]| |NRC NOTIFIED BY: JIM SPIELER |LAST UPDATE DATE: 07/21/98 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |GEOFFREY WRIGHT 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 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | -UNANTICIPATED AUTOMATIC START OF THE UNIT 1 DIVISION 3 EDG DURING TESTING- | | | | AT 0550 CDT ON 07/21/98, THE LICENSEE DEENERGIZED THE UNIT 1 SYSTEM | | AUXILIARY TRANSFORMER FOR PLANNED REPAIRS. PLANT OPERATORS DID NOT | | FOLLOW THE PROPER PROCEDURE FOR THIS EVOLUTION. | | | | THIS RESULTED IN THE UNANTICIPATED AUTOMATIC START OF THE UNIT 1 DIVISION 3 | | EMERGENCY DIESEL GENERATOR (EDG) WHICH SUPPLIES POWER TO THE HIGH PRESSURE | | CORE SPRAY (HPCS) SYSTEM. THE HPCS SYSTEM WAS IN THE "PULL-TO-LOCK" MODE | | TO PREVENT ACTUATION DURING SCRAM TIME TESTING WHICH WAS IN PROGRESS AT THE | | TIME (BUT IS CURRENTLY SUSPENDED). | | | | THE LICENSEE IS IN THE PROCESS OF SECURING THE EDG. | | | | UNIT 2 IS UNAFFECTED BY THIS EVENT. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34550 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BROWNS FERRY REGION: 2 |NOTIFICATION DATE: 07/21/98 | |UNIT: [ ] [2] [3] STATE: AL |NOTIFICATION TIME: 15:49 [ET]| |RX TYPE: [1] GE-4,[2] GE-4,[3] GE-4 |EVENT DATE: 07/21/98 | +------------------------------------------------+EVENT TIME: 13:15[CDT]| |NRC NOTIFIED BY: MORROW |LAST UPDATE DATE: 07/21/98 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MARK LESSER RDO | |APRE 50.72(b)(2)(vi) OFFSITE NOTIFICATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | 3 | N Y 100 POWER OPERATION | 100 POWER OPERATION | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE LICENSEE NOTIFIED THE STATE OF ALABAMA THAT THE PLANT HAD EXCEEDED THE | | NATIONAL POLLUTION DISCHARGE ELIMINATION SYSTEM (NPDES) REQUIREMENTS. | | | | ENVIRONMENTAL MONITORS HAD INDICATED THAT THE TENNESSEE RIVER DOWN-STREAM | | PLANT TEMPERATURE HAD EXCEEDED THE NPDES REQUIREMENT THAT PLANT INDUCED | | 24-HOUR AVERAGE RESERVOIR WATER TEMPERATURE NOT EXCEED 90øF. THIS NPDES | | VIOLATION REQUIRES DOCUMENTATION IN A MONTHLY REPORT TO THE ALABAMA | | DEPARTMENT OF ENVIRONMENTAL MANAGEMENT (ADEM). AN ADVANCE COURTESY | | NOTIFICATION WAS MADE BY PHONE TO ADEM. RIVER TEMPERATURE PEAKED AT 90.1øF | | AT 2200 ON 07/20/98, BUT IT WAS RESTORED TO WITHIN LIMITS BY 0200 ON | | 07/21/98 BY OPERATION OF COOLING TOWERS IN "HELPER" MODE. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34551 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PALISADES REGION: 3 |NOTIFICATION DATE: 07/21/98 | |UNIT: [1] [ ] [ ] STATE: MI |NOTIFICATION TIME: 16:27 [ET]| |RX TYPE: [1] CE |EVENT DATE: 07/21/98 | +------------------------------------------------+EVENT TIME: 14:52[EDT]| |NRC NOTIFIED BY: KOZUP |LAST UPDATE DATE: 07/21/98 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |GEOFFREY WRIGHT 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | M/R Y 99 POWER OPERATION | 0 HOT SHUTDOWN | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MANUAL REACTOR TRIP FROM 99.6% POWER FOLLOWING A FEEDWATER PUMP TRIP FOR | | UNKNOWN REASONS | | | | THE PLANT RECEIVED A LUBE OIL TROUBLE ALARM ON THE 'A' MAIN FEEDWATER PUMP, | | AND IMMEDIATELY THE FEEDWATER PUMP TRIPPED. (THE CAUSE IS UNKNOWN AND IS | | BEING INVESTIGATED.) THE CONTROL ROOM SUPERVISOR ORDERED A MANUAL REACTOR | | TRIP AS REQUIRED BY THE OFF-NORMAL PROCEDURE FOR A LOSS OF FEEDWATER. THE | | AUXILIARY FEEDWATER SYSTEM ACTUATED AS DESIGNED FOLLOWING LOW STEAM | | GENERATOR LEVEL SIGNAL. ALL RODS FULLY INSERTED, AND THERE WERE NO | | EMERGENCY CORE COOLING SYSTEM ACTUATIONS. NONE OF THE SAFETY RELIEF VALVES | | LIFTED, BUT SOME SECONDARY RELIEF VALVES LIFTED ALONG WITH THEIR | | ATMOSPHERIC STEAM DUMPS. THE CONDENSER IS BEING USED AS THE HEAT SINK. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED BY THE LICENSEE. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |TRANSPORTATION EVENT | |EVENT NUMBER: 34552 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: MEDI-PHYSICS, INC. |NOTIFICATION DATE: 07/21/98 | | CITY: CINCINNATI REGION: 3 |NOTIFICATION TIME: 16:46 [ET]| | COUNTY: STATE: OH |EVENT DATE: 07/21/98 | |LICENSE#: 34-26239-01MD AGREEMENT: N |EVENT TIME: 07:00[EDT]| | DOCKET: |LAST UPDATE DATE: 07/21/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |GEOFFREY WRIGHT RDO | | |MIKE BELL/NMSS EO | +------------------------------------------------+RUTHERFORD (VIA NRC) DOT | |NRC NOTIFIED BY: DOTSON |RICHARD BARRETT/AEOD IRD | |HQ OPS OFFICER: CHAUNCEY GOULD |MIKE WYATT DOE | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NTRA TRANSPORTATION EVENT | | |IBBE 30.50(b)(2)(i) ACCID MIT EQUIP FAILS | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MEDI-PHYSICS, INC., A NUCLEAR PHARMACY, REPORTED THAT ONE OF ITS DELIVERY | | TRUCKS WAS INVOLVED IN AN ACCIDENT. | | | | THIS ACCIDENT OCCURRED ON U.S. ROUTE 50, ONE MILE EAST OF FAYETTE, OHIO. | | THE VAN WAS CARRYING RADIOPHARMACEUTICALS (15.7 MILLICURIES OF TECHNICIUM | | 99M AND 3.8 MILLICURIES OF THALLIUM 201). THE VAN FLIPPED SEVERAL TIMES, | | AND THE DRIVER WAS EJECTED. THE VEHICLE IS DESIGNED TO KEEP THE AMMO | | BOXES, IN WHICH THE RADIOPHARMACEUTICALS ARE TRANSPORTED, IN A BOX IN THE | | REAR OF THE VEHICLE; BUT IT WAS BREECHED IN THE ACCIDENT. THE AMMO BOXES | | CAME OUT OF THE REAR CONTAINER, AND ONE OF THEM CAME OUT OF THE VAN. | | ANOTHER ONE ENDED UP IN THE PASSENGER COMPARTMENT OF THE VAN. THE LID CAME | | OFF OF THIS AMMO BOX, A SYRINGE HOLDER CAME APART, AND A SYRINGE CAME OUT | | OF THE HOLDER. THIS IS AN EQUIPMENT FAILURE IN THAT THE BOX IN THE REAR OF | | THE VEHICLE FAILED TO KEEP ALL OF THE AMMO BOXES INTACT IN THE VAN THUS | | FAILING TO PREVENT A POSSIBLE CONTAMINATION IN AN ACCIDENT. A FULL SURVEY | | WAS MADE AT THE SITE, AND THERE WAS NO CONTAMINATION INSIDE OR OUTSIDE OF | | THE VAN. THE DRIVER WAS TAKEN TO THE HOSPITAL AND WAS NOT CONTAMINATED. | | THE ROAD HAS BEEN CLEARED OF THE ACCIDENT. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 34553 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: VETERANS ADMINISTRATION HOSPITAL |NOTIFICATION DATE: 07/21/98 | | CITY: TUCSON REGION: 4 |NOTIFICATION TIME: 17:37 [ET]| | COUNTY: STATE: AZ |EVENT DATE: 07/21/98 | |LICENSE#: 0206186-01 AGREEMENT: Y |EVENT TIME: 13:37[MDT]| | DOCKET: |LAST UPDATE DATE: 07/21/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |JOSEPH TAPIA RDO | | |MIKE BELL, NMSS EO | +------------------------------------------------+ | |NRC NOTIFIED BY: WILLIAMS | | |HQ OPS OFFICER: CHAUNCEY GOULD | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE TUCSON VETERANS ADMINISTRATION HOSPITAL REPORTED A MEDICAL | | MISADMINISTRATION. | | | | A PATIENT WAS TO RECEIVE 20 MILLICURIES OF TECHNICIUM 99M MPD FOR A BONE | | SCAN, BUT INSTEAD, THE PATIENT RECEIVED 20 MILLICURIES OF TECHNICIUM 99M | | DTPA, WHICH IS USED FOR KIDNEY SCANS. THE MIX UP OCCURRED BECAUSE THE TWO | | RADIOPHARMACEUTICAL KITS HAVE GREEN LABELS. THE PRESCRIBING PHYSICIAN HAS | | NOT YET BEEN NOTIFIED, BUT THE PATIENT HAS BEEN NOTIFIED. NO ADVERSE | | HEALTH AFFECTS ARE EXPECTED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |TRANSPORTATION EVENT | |EVENT NUMBER: 34554 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: SEQUOYAH |NOTIFICATION DATE: 07/21/98 | | CITY: SODDY-DAISY REGION: 2 |NOTIFICATION TIME: 17:59 [ET]| | COUNTY: HAMILTON STATE: TN |EVENT DATE: 07/21/98 | |LICENSE#: AGREEMENT: Y |EVENT TIME: 16:00[EDT]| | DOCKET: |LAST UPDATE DATE: 07/21/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |MARK LESSER RDO | | | | +------------------------------------------------+RICHARD BARRETT/AEOD IRD | |NRC NOTIFIED BY: RUTHERFORD(NATL RESP CTR) |MIKE WYATT DOE | |HQ OPS OFFICER: CHAUNCEY GOULD |FEMA, DOE, USDA, HHS FAX | +------------------------------------------------+EPA, DOT (VIA NRC) FAX | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NTRA TRANSPORTATION EVENT | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE NATIONAL RESPONSE CENTER REPORTED THE RECEIPT OF A NOTIFICATION FROM | | THE SEQUOYAH NUCLEAR PLANT THAT A PICKUP TRUCK SLIPPED OUT OF GEAR ON THE | | ACCESS ROAD AND ROLLED INTO A NEARBY POND. THIS CAUSED AN UNKNOWN AMOUNT | | OF GASOLINE AND OIL TO LEAK INTO THE POND. THE LICENSEE HAS APPLIED | | ABSORBENT BOOMS AND PADS TO THE AFFECTED AREA. | | | | | | HOO NOTE: SEE EVENT #34555. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34555 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SEQUOYAH REGION: 2 |NOTIFICATION DATE: 07/21/98 | |UNIT: [1] [2] [ ] STATE: TN |NOTIFICATION TIME: 18:33 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 07/21/98 | +------------------------------------------------+EVENT TIME: 17:45[EDT]| |NRC NOTIFIED BY: HARRIS |LAST UPDATE DATE: 07/21/98 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MARK LESSER RDO | |APRE 50.72(b)(2)(vi) OFFSITE NOTIFICATION | | | |FEMA, DOE, USDA, HHS FAX | | |EPA, DOT (VIA NRC) FAX | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | THE LICENSEE NOTIFIED THE NATIONAL RESPONSE CENTER OF A SPILL INTO THE | | PLANT'S DIFFUSER POND. | | | | DUE TO A TRUCK SLIPPING OUT OF GEAR AND RUNNING INTO THE PLANT'S DIFFUSER | | POND (LOCATED AT TENNESSEE RIVER MILE 483.6) AT APPROXIMATELY 1600, A | | GASOLINE AND OIL LEAK OCCURRED INTO THE BODY OF WATER. THE AMOUNT OF | | LEAKAGE IS UNKNOWN, BUT THE TRUCK CONTAINED APPROXIMATELY 10 GALLONS OF | | GASOLINE AND 5 QUARTS OF OIL. CLEANUP WILL CONTINUE UNTIL THE TRUCK IS | | REMOVED FROM THE POND AND NO SHEEN REMAINS. | | | | THE NRC RESIDENT INSPECTOR ALONG WITH STATE, LOCAL, AND OTHER AGENCIES WERE | | NOTIFIED. | | | | HOO NOTE: SEE EVENT #34554. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |FUEL CYCLE FACILITY | |EVENT NUMBER: 34556 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PADUCAH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 07/21/98 | | RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 18:12 [ET]| |COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 07/21/98 | | 6903 ROCKLEDGE DRIVE |EVENT TIME: 16:15[CDT]| | BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 07/21/98 | | CITY: PADUCAH REGION: 3 +-----------------------------+ | COUNTY: McCRACKEN STATE: KY |PERSON ORGANIZATION| |LICENSE#: GDP-1 AGREEMENT: Y |GEOFFREY WRIGHT RDO | | DOCKET: 0707001 |MIKE BELL, NMSS EO | +------------------------------------------------+ | |NRC NOTIFIED BY: MAURER | | |HQ OPS OFFICER: CHAUNCEY GOULD | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |PAAA 95.57(b) LOSS OF CLASSIFIED INFO | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | 1-HOUR INCIDENT REPORT | | | | IT WAS DISCOVERED THAT RECORDS WITHIN THE RECORDS MANAGEMENT DATABASE | | MARKED AS UNCLASSIFIED CONTAINED CLASSIFIED INFORMATION. TITLES OF SOME | | RECORDS CONTAINED CLASSIFIED INFORMATION. THE SUBJECT INFORMATION WAS | | ENTERED INTO THE DATABASE DURING 01/96. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED BY PADUCAH PERSONNEL. | | | | HOO NOTE: SEE EVENT #34557. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |FUEL CYCLE FACILITY | |EVENT NUMBER: 34557 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 07/21/98 | | RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 18:40 [ET]| |COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 07/21/98 | | 6903 ROCKLEDGE DRIVE |EVENT TIME: 17:50[EDT]| | BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 07/21/98 | | CITY: PIKETON REGION: 3 +-----------------------------+ | COUNTY: PIKE STATE: OH |PERSON ORGANIZATION| |LICENSE#: GDP-2 AGREEMENT: N |GEOFFREY WRIGHT RDO | | DOCKET: 0707002 |MIKE BELL, NMSS EO | +------------------------------------------------+ | |NRC NOTIFIED BY: SISLER | | |HQ OPS OFFICER: CHAUNCEY GOULD | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |PAAA 95.57(b) LOSS OF CLASSIFIED INFO | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | 1-HOUR INCIDENT REPORT | | | | THE SITE WAS NOTIFIED BY PADUCAH THAT RECORDS WITHIN THE RECORDS MANAGEMENT | | DATABASE MARKED AS UNCLASSIFIED CONTAINED CLASSIFIED INFORMATION. TITLES | | OF SOME RECORDS CONTAINED CLASSIFIED INFORMATION. THE SUBJECT INFORMATION | | WAS ENTERED INTO THE DATABASE DURING 01/96. THIS SAME DATABASE IS USED AT | | THE PORTSMOUTH GASEOUS DIFFUSION PLANT. | | | | THE NRC RESIDENT INSPECTOR AND DEPARTMENT OF ENERGY SITE REPRESENTATIVE | | WERE NOTIFIED BY PORTSMOUTH PERSONNEL. | | | | HOO NOTE: SEE EVENT #34556. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34558 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: POINT BEACH REGION: 3 |NOTIFICATION DATE: 07/21/98 | |UNIT: [1] [2] [ ] STATE: WI |NOTIFICATION TIME: 19:24 [ET]| |RX TYPE: [1] W-2-LP,[2] W-2-LP |EVENT DATE: 07/21/98 | +------------------------------------------------+EVENT TIME: 15:26[CDT]| |NRC NOTIFIED BY: VANA |LAST UPDATE DATE: 07/21/98 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |GEOFFREY WRIGHT 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 +------------------------------------------------------------------------------+ | UNANTICIPATED START OF THE 'G01' EMERGENCY DIESEL GENERATOR | | | | THE UNANTICIPATED START OF THE 'G01' EMERGENCY DIESEL GENERATOR (EDG) | | OCCURRED DURING POST-MAINTENANCE TESTING. THE 'G01' EDG WAS TAKEN OUT OF | | SERVICE ON 07/20/98 FOR SCHEDULED MAINTENANCE, AND ITS COUNTERPART WAS | | ALIGNED FOR THE '1A05' AND '2A05' BUSES IN ACCORDANCE WITH THE OPERATING | | INSTRUCTIONS. INSTRUMENTATION AND CONTROL TECHNICIANS INSTALLED A TEST | | JUMPER IN ACCORDANCE WITH WORK ORDER 97-040 AND UNEXPECTEDLY ACTUATED FAST | | START RELAYS '1' AND '2' CAUSING THE 'G01' EDG TO START. THE START OF THE | | 'G01' EDG WAS NEITHER ANTICIPATED NOR PROCEDURALLY ADDRESSED. | | | | THE LICENSEE THEN INITIATED A STOP SIGNAL FROM THE CONTROL ROOM, BUT THE | | DIESEL DID NOT STOP AS EXPECTED. AN INVESTIGATION REVEALED THAT A WIRE HAD | | SEPARATED FROM TERMINAL BLOCK 'TB25K-30' (RESET COIL FOR THE FAILURE TO | | START RELAY). TEMPORARY CHANGES WERE INITIATED TO THE OPERATING PROCEDURES | | TO SECURE THE DIESEL. THE DIESEL WAS FINALLY SECURED AT 1806 CDT. | | | | IT WAS REPORTED THAT THE CAUSE OF THE AUTOMATIC START OF THE DIESEL WAS AN | | INADEQUATE PROCEDURE REVIEW. | | | | THE NRC RESIDENT INSPECTOR WAS NOTIFIED BY THE LICENSEE. | +------------------------------------------------------------------------------+