U.S. Nuclear Regulatory Commission Operations Center Event Reports For 07/31/98 - 08/03/98 ** EVENT NUMBERS ** 34458 34589 34591 34592 34593 34594 34595 34596 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34458 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: FITZPATRICK REGION: 1 |NOTIFICATION DATE: 06/30/98 | |UNIT: [1] [ ] [ ] STATE: NY |NOTIFICATION TIME: 17:12 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 06/30/98 | +------------------------------------------------+EVENT TIME: 17:00[EDT]| |NRC NOTIFIED BY: DON TORBITT |LAST UPDATE DATE: 07/31/98 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JOHN KINNEMAN 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 VENTILATION SYSTEM DESIGN IS OUTSIDE THE PLANT DESIGN BASIS- | | | | DURING A RECENT LICENSEE ENGINEERING REVIEW OF THE VULNERABILITY OF A | | SINGLE FAILURE OF THE CONTROL ROOM VENTILATION (CRV) SYSTEM, THE LICENSEE | | IDENTIFIED THAT A DESIGN CHANGE IMPLEMENTED IN 1994 RESULTED IN A SINGLE | | POWER SUPPLY FOR THE CRV SYSTEM INLET AND OUTLET MOTOR OPERATED VALVES | | (MOVs). FOLLOWING THE DESIGN CHANGE IMPLEMENTATION, THE CRV SYSTEM HAD | | NOT BEEN ADEQUATELY TESTED IN A CONFIGURATION WHERE BOTH MOVs COULD FAIL | | OPEN AS A RESULT OF THE FAILURE OF THE SINGLE POWER SUPPLY. SUBSEQUENT | | TESTING HAS CONFIRMED THAT THE CONTROL ROOM PRESSURE BOUNDARY DESIGN | | REQUIREMENTS WOULD NOT HAVE BEEN MET WITH BOTH MOVs FAILED OPEN. | | | | THE LICENSEE DETERMINED THAT THIS CONDITION IS OUTSIDE THE DESIGN BASIS | | OF THE PLANT. | | | | AT THE TIME THE LICENSEE IDENTIFIED THIS CONDITION, THE CRV SYSTEM WAS | | OPERATING IN THE ISOLATE MODE. THE CRV SYSTEM IS OPERABLE IN THE ISOLATE | | MODE AND INOPERABLE (BUT FUNCTIONAL) IN THE NORMAL AND RECIRC MODES. | | | | THE LICENSEE IS DETERMINING ACTIONS TO CORRECT THIS CONDITION. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | | | | *** UPDATE ON 7/31/98 @ 1028 BY ZAREMBA TO GOULD *** RETRACTION | | | | ENGINEERING CALCULATIONS HAVE BEEN MADE AND IT HAS BEEN DEMONSTRATED THAT | | THE DESIGN REQUIREMENT WAS MET. THEREFORE THE EVENT WAS NOT REQUIRED TO BE | | REPORTED, SO THE LICENSEE IS RETRACTING THE EVENT. | | | | THE RESIDENT INSPECTOR WAS NOTIFIED. | | | | THE REG 1 RDO(MODES) WAS NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34589 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: SALEM REGION: 1 |NOTIFICATION DATE: 07/30/98 | |UNIT: [ ] [2] [ ] STATE: NJ |NOTIFICATION TIME: 12:32 [ET]| |RX TYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 07/30/98 | +------------------------------------------------+EVENT TIME: 11:30[EDT]| |NRC NOTIFIED BY: M. D. GWIRTZ |LAST UPDATE DATE: 07/31/98 | |HQ OPS OFFICER: FANGIE JONES +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MICHAEL MODES RDO | |ADAS 50.72(b)(2)(i) DEG/UNANALYZED COND | | |NLCO TECH SPEC LCO A/S | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | EVIDENCE OF A PINHOLE LEAK FOUND ON A REACTOR COOLANT INSTRUMENT LINE | | | | DURING A CONTAINMENT WALKDOWN, THE LICENSEE DISCOVERED A SMALL PATCH OF | | BORON CRYSTALS ON A REACTOR COOLANT INSTRUMENT LINE. THE LEAK IS BETWEEN | | ISOLATION VALVE 22RC12 AND LOOP #3 FLOW TRANSMITTER 2FT426. TESTING HAS | | DETERMINED A PROBABLE THRU-WALL LEAK AND THE LINE HAS BEEN ISOLATED WITH | | ENTRY INTO TECHNICAL SPECIFICATION ACTION STATEMENT 3.4.11.1.B FOR ASME | | CODE CLASS 2 LEAK. THE LINE WILL BE REPAIRED OR REPLACED PRIOR TO PLANT | | STARTUP. FURTHER INSPECTIONS ON SIMILAR LINES HAVE BEEN CONDUCTED WITH NO | | SIGNS OF LEAKAGE OBSERVED. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR AND LOCAL TOWNSHIP. | | | | * * * UPDATE AT 1706 EDT ON 7/31/98 BY STEVE SAUER TO FANGIE JONES * * * | | | | FURTHER WALKDOWNS OF REACTOR COOLANT SYSTEM INSTRUMENT TUBING HAS | | IDENTIFIED AN ADDITIONAL 6 LEAKS. THERE ARE 5 ON FLOW INSTRUMENT LINES OF | | THE 21 AND 22 LOOPS AND 1 ON A REACTOR COOLANT SYSTEM SAMPLING LINE. | | SAMPLES WILL BE SENT OFFSITE FOR ANALYSIS TO DETERMINE THE PROBABLE METHOD | | OF FORMATION FOR THE LEAKS. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34591 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: FITZPATRICK REGION: 1 |NOTIFICATION DATE: 07/31/98 | |UNIT: [1] [ ] [ ] STATE: NY |NOTIFICATION TIME: 09:58 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 07/31/98 | +------------------------------------------------+EVENT TIME: 07:20[EDT]| |NRC NOTIFIED BY: ZAREMBA |LAST UPDATE DATE: 07/31/98 | |HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MICHAEL MODES RDO | |AINB 50.72(b)(2)(iii)(B) POT RHR INOP | | |AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION | | |NLCO TECH SPEC LCO A/S | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 70 POWER OPERATION | 70 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE PLANT DECLARED THE HIGH PRESSURE COOLANT INJECTION(HPCI) INOPERABLE. | | | | THE HPCI SYSTEM WAS DECLARED INOPERABLE DUE TO A GROUND ON THE POWER SUPPLY | | FOR '23P150'(HPCI AUX OIL PUMP) BREAKER. THE GROUND DEVELOPED DUE TO WATER | | INTRUSION OF THE BREAKER CUBICLE. THE SOURCE OF THE WATER WAS DRAINAGE | | FROM THE SERVICE WATER LINE BEING DRAINED FOR CHECK VALVE REPAIR. SERVICE | | WATER WAS BEING DRAINED INTO A BARREL, WHICH OVERFLOWED, RESULTING IN THE | | WATER INTRUSION INTO THE BREAKER CUBICLE. THE DRAINAGE HAS BEEN REDIRECTED | | TO A FLOOR DRAIN INSTEAD OF THE BARREL. THEY ARE IN A 7 DAY LCO FOR HPCI | | SYSTEM BEING INOPERABLE UNTIL THEY CLEANUP THE MOISTURE AND WATER IN THE | | CUBICLE. | | | | THE RESIDENT INSPECTOR WAS NOTIFIED. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 34592 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: RADIOLOGY GROUP OF NEW BRUNSWICK |NOTIFICATION DATE: 07/31/98 | | CITY: NEW BRUNSWICK REGION: 1 |NOTIFICATION TIME: 10:32 [ET]| | COUNTY: STATE: NJ |EVENT DATE: 07/29/98 | |LICENSE#: 291747501 AGREEMENT: N |EVENT TIME: 14:00[EDT]| | DOCKET: |LAST UPDATE DATE: 07/31/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |MICHAEL MODES RDO | | |PICCONE EO | +------------------------------------------------+ | |NRC NOTIFIED BY: TOKARZ | | |HQ OPS OFFICER: CHAUNCEY GOULD | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MEDICAL MISADMINISTRATION INVOLVING ADMINISTRATION OF LESS THAN PRESCRIBED | | DOSAGE | | | | A PATIENT WAS BEING TREATED FOR THYROID DISEASE AT THE RADIOLOGY GROUP OF | | NEW BRUNSWICK. THE PRESCRIBED DOSAGE WAS 125 MILLICURIES OF I-131 AS | | SODIUM IODIDE. THE DOSAGE WAS IN FOUR CAPSULES, THREE OF WHICH WERE IN ONE | | VIAL AND OTHER IN A SECOND VIAL. WHEN THE DOSAGE WAS GIVEN TO THE PATIENT, | | ONLY THE THREE CAPSULES IN THE FIRST VIAL WERE ADMINISTERED. THIS RESULTED | | IN THE PATIENT ONLY RECEIVING 82.5 MILLICURIES OF I-131. THE PATIENT WAS | | RELEASED PRIOR TO THIS DISCOVERY. THE ATTENDING PHYSICIAN WAS NOTIFIED AND | | HE NOTIFIED THE PRESCRIBING PHYSICIAN. IT IS NOT KNOWN IF THE PATIENT WAS | | NOTIFIED. THEY HAVE DETERMINED THAT THE DOSAGE GIVEN WAS SUFFICIENT FOR | | THE THYROID TREATMENT. THERE SHOULD BE NO ADVERSE AFFECTS TO THE PATIENT. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34593 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: POINT BEACH REGION: 3 |NOTIFICATION DATE: 07/31/98 | |UNIT: [1] [2] [ ] STATE: WI |NOTIFICATION TIME: 14:32 [ET]| |RX TYPE: [1] W-2-LP,[2] W-2-LP |EVENT DATE: 07/31/98 | +------------------------------------------------+EVENT TIME: 13:00[CDT]| |NRC NOTIFIED BY: CHARLES KRAUSE |LAST UPDATE DATE: 07/31/98 | |HQ OPS OFFICER: FANGIE JONES +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MELVYN LEACH 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 | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | CONDITION DISCOVERED THAT WOULD PREVENT MAINTAINING POSITIVE PRESSURE IN | | THE CONTROL ROOM DURING AN EMERGENCY | | | | THE LICENSEE, WHILE REVIEWING A CONDITION REPORT, DETERMINED THAT OPERATION | | OF THE CONTROL ROOM SMOKE EXHAUST FAN (W-13C) DURING CONTROL ROOM | | VENTILATION OPERATION IN AN EMERGENCY MODE WOULD PREVENT MAINTAINING A | | POSITIVE PRESSURE IN THE CONTROL ROOM. THIS IS OUTSIDE THE DESIGN BASIS OF | | THE PLANT. THE SYSTEM IS SUPPOSED TO MAINTAIN A POSITIVE PRESSURE FOR | | HABITABILITY REQUIREMENTS FOLLOWING A DESIGN BASIS ACCIDENT. THE CONTROL | | ROOM SMOKE EXHAUST FAN HAS ONLY MANUAL CONTROL AND WOULD NOT AUTOMATICALLY | | SECURE. THE FAN HAS BEEN TAGGED TO ENSURE OPERATION ONLY IN ITS DESIGN FOR | | SMOKE REMOVAL. THE LICENSEE IS PURSUING MORE PERMANENT ADMINISTRATIVE | | CONTROLS ON OPERATION WHILE POSSIBLE MODIFICATIONS TO THE FAN CONTROLS TO | | AUTOMATICALLY SECURE THE FAN IN THE EVENT OF ACTUATION OF THE CONTROL ROOM | | VENTILATION IN AN EMERGENCY MODE ARE CONSIDERED. | | | | THE LICENSEE PLANS TO INFORM THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |GENERAL INFORMATION or OTHER | |EVENT NUMBER: 34594 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: TERRACON CONSULTANTS |NOTIFICATION DATE: 07/31/98 | | CITY: TUCSON REGION: 4 |NOTIFICATION TIME: 19:20 [ET]| | COUNTY: STATE: AZ |EVENT DATE: 07/31/98 | |LICENSE#: 10-130 (AZ) AGREEMENT: Y |EVENT TIME: 16:00[MDT]| | DOCKET: |LAST UPDATE DATE: 07/31/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |CHARLES CAIN RDO | | |LARRY CAMPER EO | +------------------------------------------------+FRANK CONGEL IRD | |NRC NOTIFIED BY: JOHN M. LUTTON | | |HQ OPS OFFICER: FANGIE JONES | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | AGREEMENT STATE REPORT INVOLVING STOLEN TROXLER MOISTURE-DENSITY GAUGE | | | | THE FOLLOWING IS A PORTION OF A FACSIMILE RECEIVED: | | | | "THE LICENSEE REPORTED THAT A TRUCK HAVING ON BOARD A TROXLER | | MOISTURE-DENSITY GAUGE, MODEL NUMBER 3430, SERIAL NUMBER 22924, WAS STOLEN | | FROM A MOBILE HOME PARK AT 1552 NORTH MIRACLE MILE, TUCSON, SOMETIME DURING | | THE NIGHT/EARLY MORNING OF JULY 30/31, 1998. THE GAUGE WAS LOCKED IN A | | STEEL BOX BOLTED TO THE TRUCK BED. THE TRUCK IS A 1995 ISUZU, ARIZONA | | LICENSE PLATE 5BH-379. THE GAUGE CONTAINS A 10 MILLICURIE CESIUM 137 | | SOURCE AND A 50 MILLICURIE AMERICIUM 241/BERYLLIUM SOURCE. THE TUCSON | | POLICE DEPARTMENT WAS NOTIFIED AND IS INVESTIGATING. THE LICENSEE HAS | | POSTED A $250 REWARD AND IS MAKING A PRESS RELEASE." | | | | "THE U.S. NRC, MEXICO, COLORADO, NEVADA, UTAH, NEW MEXICO AND CALIFORNIA | | ARE BEING INFORMED OF THIS INCIDENT." | | | | SEE HOO LOG FOR CONTACT INFORMATION. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |OTHER NUCLEAR MATERIAL | |EVENT NUMBER: 34595 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: BAXTER HEALTH CARE |NOTIFICATION DATE: 08/01/98 | | CITY: ABONITA REGION: 2 |NOTIFICATION TIME: 00:25 [ET]| | COUNTY: STATE: PR |EVENT DATE: 07/31/98 | |LICENSE#: 52-21175-01 AGREEMENT: N |EVENT TIME: 19:30[AT ]| | DOCKET: |LAST UPDATE DATE: 08/01/98 | | +-----------------------------+ | |PERSON ORGANIZATION| | |THOMAS PEEBLES RDO | | |LARRY CAMPER EO | +------------------------------------------------+FRANK CONGEL IRD | |NRC NOTIFIED BY: EDWIN BETANCOURT | | |HQ OPS OFFICER: STEVE SANDIN | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |NINF INFORMATION ONLY | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | FATALITY DUE TO AN INDUSTRIAL ACCIDENT AT AN IRRADIATOR FACILITY (BAXTER | | HEALTH CARE) IN ABONITA, PUERTO RICO. | | | | AT 1846EDT, THE SOURCE WAS DOWN FOLLOWING A FAILURE ON THE SYSTEM. THE | | SECOND SHIFT SUPERVISOR WAS TROUBLESHOOTING THE CONVEYOR WHEN HE WAS | | TRAPPED AND CRUSHED BETWEEN CARRIERS RECEIVING A FATAL INJURY SOMETIME | | BETWEEN 1836 AND 1930EDT. THIS WAS AN INDUSTRIAL ACCIDENT AND DID NOT | | INVOLVE EXPOSURE TO A RADIOACTIVE SOURCE. LOCAL POLICE AND THE | | INDIVIDUAL'S FAMILY WERE NOTIFIED. THE LICENSEE INFORMED CORPORATE | | HEADQUARTERS WHO ARE PREPARING A PRESS RELEASE ALTHOUGH THERE IS NO PRESS | | INTEREST AT THIS TIME. | | | | SEE HOO LOG FOR CONTACTS. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 34596 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: DRESDEN REGION: 3 |NOTIFICATION DATE: 08/02/98 | |UNIT: [ ] [2] [ ] STATE: IL |NOTIFICATION TIME: 17:14 [ET]| |RX TYPE: [1] GE-1,[2] GE-3,[3] GE-3 |EVENT DATE: 08/02/98 | +------------------------------------------------+EVENT TIME: 14:46[CDT]| |NRC NOTIFIED BY: RICH GADBOIS |LAST UPDATE DATE: 08/02/98 | |HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |MELVYN LEACH RDO | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | - RECIRC SAMPLE LINE VALVE CLOSED (ESF ACTUATION) DUE TO A BLOWN FUSE - | | | | WHILE CHANGING A LIGHT BULB ON THE #2D INBOARD MAIN STEAM ISOLATION VALVE | | (MSIV) LIGHT INDICATION IN THE MAIN CONTROL ROOM, ELECTRICAL FUSE #595-709A | | BLEW. THIS FUSE SUPPLIES PART OF THE INBOARD MSIV GROUP I (MAIN STEAM | | ISOLATION) ISOLATION LOGIC. THIS RESULTED IN THE RECIRC SAMPLE LINE VALVE | | #2-220-44 (GROUP I ISOLATION VALVE) GOING CLOSED. | | | | THE MSIVs REMAINED OPEN, AS EXPECTED, SINCE A COMPLETE LOSS OF POWER AND A | | FULL GROUP I ISOLATION WAS NOT RECEIVED FOR THESE VALVES. | | | | THE LICENSEE REPLACED THE FUSE AND REOPENED THE RECIRC SAMPLE LINE VALVE. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+