ML20113J000

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Report to Congress on Abnormal OCCURRENCES.January-March 1992
ML20113J000
Person / Time
Issue date: 07/31/1992
From:
NRC OFFICE FOR ANALYSIS & EVALUATION OF OPERATIONAL DATA (AEOD)
To:
References
NUREG-0090, NUREG-0090-V15-N01, NUREG-90, NUREG-90-V15-N1, NUDOCS 9208060263
Download: ML20113J000 (30)
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NUREG-0090 Vol.15, No.1 Report to Congress on Abnorma:L Occurrences January - March 1992 U.S. Nuclear Regulatory Commission Olrice for Analysis and Evaluation of Operational Data

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Available from Superintendent of Documen's U.S. Government Printing Offico Post Office Box 37082 Washington, D.C. 20013 7082 A year's subscriptiori consists of 4 issues for this put,lication.

Single copics of this publication are evollable from National Technical Information Service, Springfield, VA 22161 s

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Office for i o alysis and Evaluation of Operational Data U.S. Nuclear Regulator; TJommission Washington, DC 20555

Previous Reports in Series -

NUREO 75/090 January June 1975, NUREG420, Vol 6, Na 4, October-December 1983 pubished October 1975 published May 1984

' NURE04D0-1, July-September 1975, NUREG4DO, Vol 7, Na 1, January March 1984,

. publ6hed March 1976 -

nublished July 1984 NUhE041090-2, October-December 1975, NURE047)0, Vol 7, Na 2 Apnl-June 1984,

- publahed March 1976 published October 19&1 NURE04mtb3, January-March 1976 NUREG420. Vol 7, Na 3 July September 1954, published July 1976 publahed April 19S5 NUREG4004 April-June 1976, NURE04M, Vol 7. Na 4, October-December 1984, pubbshed March 1977 published May 1985 NURE04fAh5, July-September 1976 NURE04XDO, Vol. 8, Na l, January-March 1985, published March 1977 pubhshed August 1985 NURE04WO-6, October-December 1976-NUREG4XWO, Vol 8, Na 2. April-June 19S5, eblish;,d June 1977 published November 1985 NUI U>0, Ja i ry March 1977 NUREG4f>0, Vol 8. No. 3. July-Septem1rr 1985, NI I bh

$^

NU G A1, la October-December 1985, r1 p

NUR E04Y)0-9, July-September 1977 NUl[0 K )

1, 'a 1. January-March 1986, published Nov mber 1%1 NURE041090-10, OctoNr-December 1977, published September 1986 NUREG-0090, Vol 9, Na 2, April-June 1986.

pubished March li-':

NUREOMMO, Vol 1 No.1, January-March 1978, published January 1987 NUREG4XY)0, Vol 9, No. 3. July-September 1986 published June 1978 NURF04m0, Vol 1, Na 2, ApnbJ me 1978, published April 1987 NUREG4WO, Vol 9 Na 4, October-December 1986, aubushed September 1978 NUliEO4XWO, Vol 1, Na 3, July September 1978, published July 1987 published Dwember 1978 NUREG4eXI, Vol 10, No.1. January-March 1987, NURE04.U)0, Vol 1, Na 4, October-December 1973, published October 1987 publisned March 1979 NUREG4010.Vct 10, Na 2, April-June 1987, NURE04XWO, Vol. 2 Na 1, January-Mart.h 1979, published November 1987 published July 1979 NURE0400, Vol 10, Na 3, July-September 1987.

NUREO4WO, Vol 2, Na2, ApribJune 1979, publahed March 1988, pubbshed November 1979 NUREG400, Vol 10, Na 4, October-December 1987, NURE04WO, Vol 2, Na 3, July-September 1979, publahed March 1988 published February 1980 -

NUREG-0090 Vol 11, No.1. JanumpMarch 1968.

NUREG-0090, Vol 2, Na 4 October-December 1979, published July 1988 NUREGM% \\pril 1980 NUREG4Y)0, Vol 11, No. 2, Apnl Jme 1988 published A ot 3, Na 1, January 4f arc',i 1980.

pubbshed December 19SS pubh 3.ed September 1980 NUREO-0090, Vol 11, Na 3, July-September 1988,

'NURUO4010 Vol 3, Na 2. April-June 1980, pubbshed January 1989 pubhshed November 1980 NUR EG4pX), Vol 11, Na 4, October 4xcember 1988,

- NURE04XM, Vol 3, Na 3. July-September 1980, published April 19S9 published February 1981 NUREG4y>0, Vol 12, No 1, Ianuary-March 1989, NUREO4WO, Vol 3,Na 4, October-December 1980, published August 1989

- published May 1981 NUREG-0090, Vol 12, No. 2 ApribJune 1989 NURE04Xyx), Vol 4, Na 1. January-March 1931, published October 1989 NUlfI

~

tXy, L a 2, ApribJune 1981, bb

'J n a 1 NURL 0090, o Na 4, October-Decemta 1989 N

o

, July. September 1981, NUd

, 'ot a 4, oc~ ber-Decenber 1981, NUREG4MO, Vol 13, No.1, January-March 1990, published July 1990 published May 1982 NUREG4Y)0, Vol 5, Noi 1, January March 1982.

NURE047X), Vol 13, No. 2, April-June 1990, published October ~71

-l published August 1982 N19 EO420, Vol 13, a 3. July-Septembec 1990, NURE04eX), Vol 5 Na 2, ApribJune_1982, published December 1982 published January 1991 NUREG-0090, Vol 13, Na 4. October-December 1990, NURE04390. Vol 5, No. 3, July-September 1982, pubbshed January 1983 published March 1991 NUREO400, Vol ",, Na 4, October-Dwemtrr 1982.

NUREG-ClB0, Vol 14, Na 1, January-March 1991, published May 1983 pubbshed June 1991 NUREO 0090, Vol 6, Na 1, January-March 1983, NUREG4M Vol 14, Na 2, Apnbjune 1991, pubished September 1983 published September 1991 NUREG-0090, Vol 6, No. 2, ApribJune 1983, NUREG4m0, Vol 14. No. 3 'uly-September 1991, pubished November 1983 published December 1991 NURE04NO,Vol 6.No 3. July-September 1933 NUR E04MO. Vol 14. Na 4, October-December 1991, publshed April 1984 published March 1992 ii w

Abnormal Occurrences,1st Otr CY92 AllSTRACT Section 208 of the I!nergy Reorganization Act of 1974 Tnree abnormal occurrences involdng medical therapy identifies an abnormal ocrurrence as an unscheduled inci-misadministrations at NRC licensed facilities are dis-dent or event that the Nuclear Regulatory Commission cussed in this report. There were no abnormal occur-determines to be significant from the standpoint of public rences at a nuclear power plant, and none were rer "ted health or safay and requires a quarterly report of such by NRC's Agreement States. The report also contains events to be made to Congress. This report covers the information updating some previously reported ebnormal period from January I through March 31,1992.

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iii NUREG--0090, Vol.15, No.1

,a Abnormal Occurrences,1st Qtr CY92 CONTENTS Page Abstract.....

iii

Preface.............................................................................

vii Introduction.................

vu

't he R e;;ulat ory Syst e m.......,.......................................

vil Reportabic Occurrences............................

vii Agree m e n t S t at e s.................................................................

viii Fore ign I n form a t ion..................................................,.........

viii Report To Congress on Abnormal Occurrences. January-March 1992..

1 N uclear Pow er Pl a n t s.............................................................

1 Fuel Cycic Facilities (Other than Nuclear Power Plants)..........................,......

1 Other NI'.C Licensees (Industrial Radiographers, Medical Institutions, Industrial Users, etc.)....

I 92-1 Medical'Ihcrapy Misadministration at St. John Medical Center in Tu lsa, O klahoma.......................................

1 92-2 Medical'Iherapy Misadministration at Harper Hospital in Detroit, Michigan 2

92-3 Multiple Medical Therapy Misadministrations at G. Anthony Doener. M.D.,

Fa.'ility in Freehold, New J ersey........................................

3 Agreement S tate Lice nsees......................................................

4 R e f er e nce s..............,..............................................

5 Appendix A-Abnormal Occurrence Criteria...............

7 Appendix ll-Update of T eviourly Reported Abnormal Occuirences 13 Fuel Cycle Facilities........................

13 91-6 Potential Criticality Accident at the General Electric Nuclear Fuel and Component Manufacturing Facility in Wilmington, North Carolina..

13 Other NRC Licens es.........

14 91-8 Radiation Exposures of Members of the Public from a Lost Radioactive Source......

14 Appendix C-Other Events of Interest............

15

Nuc! car Power Plants...........................

15 1.

Inoperable Automatic Depressurization System at Peach Bottom Unit 3.

15

' 2.

Degraded Ice Condenser lower Inlet Doors at Sequoyah Units 1 and 2,

16

. Referenect.for Appendices 19 u

v NUREG-0040. Vol.15, No. I

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Abnormal Occurrences,1st Otr CY92 PREFACE liltrOdlieliOI) rules and regulations in Title 10 of the Code of Federa!

Regrdations. 'lhis includes public participation as an ele-The Nuclear Regulatory Commission reports to the Con-ment. To accomplish its objectives, NRC regularly con-gress each quarter under provisions of Section 208 of the ducts liccasing proceedings, inspection and enforcement linergy Heorganization Act of 1974 on any abnormal oc-activitics, evaluation of operating experience, and confir-currences involving facilities and activitics regulated by matory rescarch, whil_e maintaining programs for estab-the NRC, An abnormal occurrence is defined in Section lishing standards and issuing technical reviews and stud.

20S as an unscheduled incident or event that the Commis-ies.

sion determines is significant from the standpoint of pub-lic health or safety.

In licensing and regulating nuclear power plants, the NRC follows the philosophy that the health and safety of Events are cu rently identified as abnormal occurrences the public are best ensured through the establishment of mu tiple levels of protection.These multiple !cvels can be ach{ieved and maintained through regulations spec for this report by the NRC using the criteria and accom, panying examples listed in Appendix A. These were promulgated in an NRC policy statement that was pub.

requirements that will ensure the safe use of nuclear lished in the federal Register on February 24,1977 (Vol.

matenals. }rhc rcgulations include design and quqlity as-42, No. 37, pages 10950-10952).

surance enteria appropriate for the canous activitics h.

censed by the NRC. An inspection and enforcement pro-

.The NRC poney statement was published before licen.

gr m helps ensure compliance with the regulations.

secs were required to report medical misadministrations to the NRC, Few of Ca examples in the policy statement Reportable Occurrenices are applicabic to medical misadm;nistrations. Therefore, during 1984, the NRC developed guidelines for selecting Actual operating ex;3crience is an enential input to the such events for abnormal occurrence reporting. These regulatory process for assunng that licensed activities are guidelines, which have been used by the NRC since the conducted safely. Licensees are required to report certain latter part of 1984, augment the NRC policy statement incidents or events to the NRC. This reportiag helps to examples and are summarized in Table A-1 in Appendix identify deficiencies early and to ensure that corrective A. On January 27,1992, new medical mkadministration actions are taken to prevent recurrence definitions became effective, Therefore, revised guide-

- lines 1or identifying medical misadmmistrations as abnor-For nuclear power plan's, dedicated groups have been formed both by the NRC and by the nuclear power indus-

- mal occurrences are currently being developed The re-try for the detailed review of operating experience to nelp vised guidelines will be pubbshed for comment m the Federal Reg l ster.

Mentify safety concerns early; to improve dissemination of such.nformation; and to feed back the experience into licensing, regulations, and operations. In addition, the -

In order to InovFJe wide dissemination of information to NRC and the nuclear power industry have ongoing efforts the pubb.e, a 1..cacral Ifcgister not.c ts issued on each to improve the operational Cta systems, which include abnot nal occurrenet. lmptes of the notice at e distributed not only the type and quality of reports required to be to the NRC pnblic Document Room and all lecal Public submittad, but aho the methods usco to analyze the data.

Document Roorns. At a minimum, cach notice must con ~

In order to more effectively collect, collate, store, re-tam the date and place of the occurrence and desenbe its trieve, and evaluate operational data, the information is E

nature and probable consequences.

maintained in computer-based data files.

The NRC has determined that only those evems de-Two primary sources of operational data are Licensee scribed in this report meet the criteria for abnot nat oc-Event Reports (LERs) and immediate notifications made currence reporting. This report covers the period from pursuant to 10 CFR 50.72.

January I through March 31,1992. Information reported on cach event includes date and place, nature and prob-Except for records exemp from public disclosure by stat-able consequences, u isc or causes, and actions taken to ute and/or regulation, info nation concerning reportable

' prevent recurrence, occurrences at facilitics :isensed or otherwise regulated

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by the NRC is routinely disseminated by the NRC to the nuclear industry, the public, and other interested groups The Regulatory System

- as theac events occur.

The system of licensing and teguhion by which NRC Dissemination includes special notifications to licensees carries out its responsibitines is implemented through and other affected or interested groups, and public an-vii NUREG-0090, Vol.15, No.1

. Abnormal Occurrences,1st Otr CY92 nouncements. In _ addith,'information on reportable '

programs must be comparable to and compatible with the events is routinely sent tc the NRC's more than 100 h> cal Commission's program for such material.

public doeurnent rooms throughout thc United States nnd

- to the NRC Public Document Room in Washington, D.C.

Presently, information on reportable occurrences.in

'1he Congress is routinely kept informed of reportable Agreement State licensed activities is publicly available at events occurring in licensed facilitics.

the State level. Certain information is also provided to the NRC under exchange of infortnation provisions in the Another primary source of operational data is reports of agreements.

- reliability data submitted by licensees under the Nuclear Plant Reliability Data System (NPRDS).The NPRDS is a In early 1977, the Commission determmed tha araormat

= voluntary, industry-supported system operated by the In, occurrences happening at facilities of Agreement State stitute of Nuclear Power Operations (INPO), a nuclear heensees should be included in the quarterly reports to utility organization. Both engineering and fadure data are Congress. The abnormal occurrence criteria included in submitted by nuclear power plant licensees for speified Appendix A are applied uniformly to events at NRC and plant components and systems The Commission consid-Agreement State licensee facilities Procedures have ers the NPRDS to be a vital adjunct to the 1JiR system for been developed and implemented, and abnormal occ r-the collection, review, and feedback of operational expe.

rences reported by the Agreement States to the NRC are rience; therefore, the Commission periodically rr onitors neluded m these quarterly reports to Congress.

the NPRDS reporting activitics.

Foreign Information

. Agrecrilent States The NRC participates in an exchange of information with various foce!gn governments that have nucicar facilities.

Section 274 of the Atomic Energy Act, as amended.

This foreign information is reviewed and considered in

- authorizes the Commission to enter into agreements with the NRC's assessment of operating experience and in its States wlhereby the Commission relinquishes and the research and regulatory activities, Reference to foreign States assume _ regulatory authority over byproduct, information may occasionally be mad; m these quarterly

- source, and special nuclear materials (in quantities not abnormal occurrenu reports to Congress howeve r, only capable of sustaining a chain reaction). Agreement State domestic abnormal occurrences are reported.

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Abnormal Occurrences,1st Qtr CY92 REPORT TO CONGRESS ON ABNORMAL OCCURRENCES J ANUARY-MARCil 1992 Nuclear Power Plants The NRC_ is reviewing events reported at the nuclear NRC has not determined that any events were abnormal power plants licensed to operate. For this report, the occurrences.

I Fuel Cycle Facilities (Other Than Nuclear Power Plants)

De NRC is reviewing events reported by these licensees.

events were abnormal occurences.

For this report, tbc NRC has not determined that any Other NRC Licensees (Industrial Radiographers, Medical Institutions, Industrial Users, etc.)

%cre are cma.ntly wer 8000 NRC' nuclear material The patient was scheduled to receive ten Teatments of licenses in effect in the United States, principally for use 300 rads each to the right scapula. After the second treat-of radioisotopes in the medical, industrial, and academic ment was performed by the theu pists, the oncologist fields. Incidents were report ed in this catege y f: ;m licen.

reviewed the port film and nm ed that 80 percent of the sees.such as radiographers, medical innmons, and

- intended area had been missed. An investigation by the byproduct material users. The NRC is reviewing events licensee determined that in simulating the treatment to reported by these licensees. For this report, the N RC has be performed on the patient, the oncologist placed a mark l determined that the following events were abnormal oc-on the patient's chest as indicated by the ceiling laser currences using the criteria and guidelines given in Ap-position. During treatment, however, the back pointer on pendix A. As noted in the Preface to this report, the

he teletherapy unit was positioned on this mark. As the guidelines for identifying medical rnisadministrations as back pointer and eciling laser result in difierent angles to abnormal occurrences are currently being revised.

the cobalt-60 radiation beam, the tissue volume treated was medial to the intended treatment site.

92-1 Medice Therapy Misadministration The oncolog..ist amended the original prescription to m.-

L at St. John Medical t nter.in-clude two additional treatment fractions to tne appropri.

e Tulsa, Oklahoma ate area, bringing the total treatment dose to that area to the intended 3000 rads.

The following information pertaining to this event is also being reported concurrently in the rederal Register. Ap.

The patient was notified of the treatment error. the

pendir A (see Event 'I)pe 3 in Table A-1) of this report licensee stated that the misadministration should have no notes that a therapeutic exposure to a part of the body not adverse effect on the patient.

- scheduled to receive radiation can he considered an nb-normal occurrence.

Cause or Causes-There was a breakdown in communi-cation between the oncologist and therapis' during simu-lation. Either proper instruction was not given regarding

. Center; Tulsa, Oklahoma; -14,1992: St. John Medical patient positioning and which mdicator to use, or it was Date and Place-January 13 not carried out correctly.

Nature '~and Probable Consequences-On January 21, Actions Taken to Prevent Recurrence 1992, the licensec notified NRC Region IV that on Janu-

- ary 20,1992, a medicet misadministration was discovered 1.icensee-The licensee has reviewed this incident with

- that involved two therapeutic mdiation doses to a part of a all staff members and communicated by memo to ah patient's body that was not atended to be treated. The prescribing physicians explaining the different kicaliza-tres snents were administered on January 13 and 14 tion methods. In addition, the licensee's Quality Manage 1992, by a cobalt.60 teletherapy unit.

ment Program was amended to require review of pon 1

NUREG-0090, Vol.15, No.1

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Abnormal Occurrences,1st Qtr'CY92 Jilms after the first treatment in a series; this would not continued until the balance of the prescribed 28 treat-

have prevented a misadministration, but might have ments wcs completed.

identified the error prior to the administration of the second treatment.

The treating physician stated that in her judgment the misadministration did not compromise the patient's treat.

NRC-An inspecti o was conducted on February 13-14, ment, either from an underdose to the prescribed site or

_i 1992, to review the circumstances associated with the from the inadvertent dose to the incorrect area.

misadministration. The inspection report was forwarded to the licensee by letter dated April 6,1992 (Ref.1).

Cause or Causes-ne radiation therapy technologists Although no vie!ations of NRC requirements were iden.

stated that the error occurred becaus-they confused a tified, the NRC was concerned that the misadministration leveling tattoo on the left collar bone arwa with the treat-was a result of a verbd miscommunication between the ment tattoo on the right collar bone area. They alvo did onwlogist ar.d the therapist. The licensee was requested not follow the procedures for confirming the accuracy of to describe corrective actions taken to prevent such mis-the treatment site for agreement with the prescribed communications among staff rnembers, treatment site as specified in the licensee's Quality Man-agement Program.

His item is considered closed for the purprus of this report.

In regard to the lateness of reporting the event to the NRC, the misadministration had been promptly reported to hospital management. Ifowever, the person responsi-92 Medical Therapy Misadministra.

ble for reviewing the incident to determine if an NRC tion at Harper llospitalin Detroit, report was requhed used an incorrect draft of the hospi.

tal s pokey manual which contained an error m its defim.

Mich.igan tion of a misadministration. He incident was not deter-mined to be a misadministration and was therefore not The following information pertaining 'o this cien+ ietso reported to the NRC until March 16,1992.

being reported concurrently in the Federal Reester. Ap-penuix A (see Event Type 3 in Table A-1)of this report Actions Taken to Prevent Recurrence notes that a therapeutic exposure to a pan of the body not scheduled to receive radiation can be considered an ab' l.icensee-The remaining treatments in the patient's normal oc urrence.

treatment series were performed by three technologists to assure treatment accuracy. The lisensee is now using Date and Place-February 24, 1992; liarper llospital; different tattoos for the treatment area and for leveling.

Detroit, Michigan.

The licensee had implemented a written Quality Manage-

.Na ure and-Probable Consequences-On March 16, ment Program en January 27,1992. The program requires 1992, the licensee notified N RC Region IH that on Febru-that befen a treatment is administered, the detailmf the ary 24,1992, a patient with cancer had received a thera-treatment must be checked far agreement with the pre.

peutic radiation dose to the incorrect side of the chest scription and plan of treatment and the accuracy of the area. (In accordance with NRC requirements, the thera-treatment site must also be confirmed. Herapists were

- peutic misadministration should have been reported to provided further instruction on appropriate policies and the NRC on February 25,1992,i.e,within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> of the.

procedures.%c incomplete paticy manual has been up-i

' time of discovery on February 24, 1992. However, the dated, and personnel have been trained on NRC licensee did not properly categorize the event as a thera-misadministration reporting requirements.

peutic misadministration until March 16, 1992.)

26-27,1992, to review the circemstances associated with NRC-A special inspection was conducted on March The patient was scheduled to receive 28 daily treatments of 180 rads each to the right collar bone area and 90 rads the misadministration (Ref. 2i On Aprd 22,1992, the each to tangential areas of the right breast. The treat.

NRC issued a Notice of Violation (Ref. 3). Two violations ments began on February 12,1992, and eight treatments of NRC requirements were identified; (1) failure to fol-l:

were delivered as prescrib(1 On February 24,1992, how-low the instructions of the Quality Management Program, ever, the radiation therapists erroneously treated the left and (2) failure to report the mtsadministration no later collar bone area instead of the intended treatment area than the next day following its discovery.

on the right.The therapists discovered the error as they prepared to treat the two tangential areas of the left Unless new, significant information becomes available,

. breast.he therapist repositioned the patient to treat the this item is considered closed for the purposes of this prescribed rignt breast. The treatment plan was then report.

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Abnormal Occurrences,1st Qtr CY92 n

92-3 Mtiltiple Medical Therapy Misad.

Ihe licensee has submitted all required documentation /

rninistrations at G, Anthony Ikener, reports of the misadministrations to the NRC. Ilased on M.D., Facility in Freehold, New Jersey the licens c's review of p ti nt tre (ment charts, two patients have received supplemental treatment. Ihree of

'1he following information pertrinmg to this event is also the p tients are deceased and the licensee reported that

' being reported concurrently in the Federal Register. Ap-the remaining eight patients would not be adversely af-pendix A (see Event I)pe 5 in Table A-1)of ti.is report fccted. According to the hcensee, the patients were notd notes that a therapeutic misadministration affecting two fied of the treatment error by phone and m wnting.

- or more patients at the same facility can be considered an Cause or Causee- 'The pmbable causes arc (1) failure of abnormal occurrence, the authorized user to identify the previous physicist's errer on treatment time charts through independent veri-Date and Place-July 1,1990 to February 28,1992; G.

fication, and (2) failure of the previous physicist to per-Anthony Doener, h1.D., facility; Frechold, New Jersey.

form a secondary check of treatment times for charts Nature and Probable Consequences-On hiarch 18 1992, the current consulting teletherapy physicist for the Actions Taken to Prevent Recurrence

~ licensee informed NRC Region I of numerous therapeu-tic misadministrations that occurred between July 1990 Licensee-Corrected treatment time charts were pro-and February 28,1992. The physicist reported that pa-vided to the licensee by the current teletherapy physicist, tients who had received external beam therapy from a lhese charts are currently being used by the licensee.The Picker Corporation Model 6103 (C-1000) teletherapy current teletherapy physicist will provide treatment time unit may have been underdosed by about 151040% of the charts to the licensee on a bimonthly basis, intended doses.

Treatment times will be independently verified by the The misadministrations appeared to have resulted from current teletherapy physicist on a weekly basis or when an error intmduced by the licensee's previous consulting treatment times for a patient cu rently being treated are teletherapy physicist into tables of treatment times he changed.

generated for various field sizes and treatment depths' Ihe erroncotts treatment times were then used by the The licensee hi,s submitted a Qualit" hianagement Plan to the NRC.Tne plan is being revie' ed.

w licensee in treating patients According to the licensee, approximately 13 patients were involved. One patient was NRC-Inspections were conducted at the licensee's facil-undergomg treatment when the error was identified on ity on h1 arch 19 and April 22,1992. Activities authorized February 28,1992, and this patient's treatment time was by thw licenses were inspected. In addition, actions taken adjusted to correct for the error prior to completion of in response to the CAL were reviewed.

treatment..

The inspector verified by calculation that the treatment i

On March 26,1992, the NRC issued Confirmatory Action time charts contained errors and that the error began on -

Letter (C AL) No.92-004 to confirm the actions taken, or the July 1990 time chart. The average error determined l

- to be taken, by the licensee (Ref. 4)-

by the inspector was 20% The inspector was unable to 4

verify that corrected treatment time charts had been pro-

'the previous teletherapy physicist was contacted by tela--

vided to the licensee for 1991. The licensee learned on phone on hiarch 18,1992 and interviewed by NRC Re-h1 arch 13,1992, that the misadministrations had oc-gion I on April 2,1992. On both occasions, the previous curred but did not report them to NRC Region I until i

teletherapy physicist stated that he tmd discovered in late hfarch 18,1992. Records of misadministrations required l

1990 the error in the treatment time charts he had prt-by 10 CFR Part 35 were properly maintained by the licen-pared for January through December 1991. Ha stated

. see. Corrected treatment time charts provided by the

that he had mailed corrected time charts for 1991 along current teletherapy physicist were checked by the inspec-with a hand written note to the licensee the first week of tor and found to contain accurate treatment times. The January 1991, lie did not recall what the note stated not inspector reviewed treatment charts for patients cur-did he maintain a copy of the nd s lie did not send the rently being treated and found that corrected treatment
charts via certified mail nk did he attempt to contact the times were being used.

- licensee by telephone to inform the licensee of the crror.

lie was not aware that a similar error had occurred in The mspector found that seven of eight commi ments t

charts he provided to the licensee for the period July 1990 listed in the CAL had been completed at the time of the to December 1990. The authorized user and office man-inspection.The action not completed by the licensee was j

ager stated that they had not received corrected time to have the teletherapy physicist independently review all charts for either 1990 or 1991.

patient charts from the date the misadministrations began 3

NURiiG-0090, Vol 15, No. I

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Abnormal Oceterences,1st Otr CY92 through December 1991 to identify all patients subjected licensee to require the te!ctherapy physicist to review

- to a misadministration. A letter from the licensee dated-teletherapy spot check results within 15 days:(5) failure to iMay.1,1992, stated that patient charts from July 1990 perform an adegoate accuracy test of the dose calibrator; through December 1991 have been sent to the mirrent and (6) failure to mathematically correct dose calibrator teietherapy physicist for review. The cal; is ensidered reading for a linearity error exceeding 10 percent. Items 3,

- closed and. authorization was given to the licensee to 4,and 5 above are repeat violations. A Notice of Violation resume patient treatments.

was issued.

'lhe misadministrations did not appear to be the result of

'lhe licensee's Quality Management Plan has been sub-violations of NRC requirements. Ilowever, the inspector mitted to the NRC and is being rev;cwed.

~ identified a number of apparent violations of licensed 1

activiths, including: (1) failure to perform a full calibra-

'The NRC medical consultant is currently reviewing the tion at intervals not to exceed one year; (2) failure to incident.

notify NRC Region I by telephone within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> of a

- therapeutie misadministration;(3)failureof monthlyspot Unicss new significant information becomes available, j

checks to include a deterrnination of timer on+ff error this item is considered closed for the purpose:: of this and timer linearity over the range of use; (4) failure of Ihe report.

Agreement State Licensees Procedures have been developed for the Agreement events to the NRC for inclusion in these quarterly reports

- States to screen unscheduled incidents or events using the to Congress. For this period, the Agreement States re-

- same criteria as the NRC(see Appendix A)and report ti,e ported no events as abnormal occurrences, l

NUREG-0090, Vol.15, No.1 4

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Abnormal Occurrences,1st Qtr CY92 REFERENCES 1.

letter from I..J. Callan,1;irector, Division of Ita-3.

lxtterfrorn A.llett Dasis, Regional Administrator, diation Safety and Safeguards, NRC Region IV, to NRC Region III, to hla A L Peakhus, Executive Geo ge Kendall, Senior Vice President St. sohn Vice President and Chiel Operating Officer, liar-Medical Centet, forwarding NitC Inspection Re.

per llospital, forwarding a Notice of Violation, I.i-port No.

030-11619/92-01, I.icense No.

cense No. 21-04127-06, 90ckc; No. 030-09376, 35-00376-05, Docket No. 030-11619, April 6, April 22,1992.*

1992.'

4.

Confirmatory Action Ixtter No.92-004 from Mal-colm R. Knapp, Direcior, Division of Radiation Safety and Safeguards, NRC Region I, to G. An-2.

Ietter from Charles E. Norelius, Director, Division thony Doener, M.D., License Nos. 29-06760-07 of Radiation Safety and Safcguards, NitC Region and 29-06760-08, Docket Nos. 030-09761 and Ill, to Mark L Penkhus, F.xecutive Vice President 030-12688, March 26,1992."

and Chief Operating Officer,liarper Ilospita' for-b warding NRC Inspection Report No.

. wp aste bri crion m co ing for a rec in the Nac rubut

.1)wun enilu,nm. :t:01,5 tree NW}( mer Irvt!), Washingt,n,1)C 030-09376/92-01, l.icense No. 21-04127-06, Docket No. 030-09376, April 14,1992

  • 20555.

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NUP EG-0090, Vol 15, No.1

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Abnormal Occurrences,1st Qtr CY92 APPENDIX A ABNORMAL OCCURRENCE CRITERIA The following criteria for this report's abnormal occur-5.

Any loss of licensed matedal in such quantities and j

tence (AO) determinations were set forth in au NRC under such circumstances that substantial hazard

policy statement published in the Federa/ Regirtzt on Feb-may reMt to persons in unrestricted arcas, ruary 24,1977 (Vol. 42, No 37, pages 1095010952).

6.

A substantiated case of actual or attempted theft or j

An event will be considered an AO if it involves a major diversion of licensed material or sabotage of a facil.

reduction in the degree u: +otection of the public health "Y-or safety. Such an event wou'd involve a moderate or 1.

An7 substantiated ioss of sI>ecial nuclear rraterial or more severe impact on the public health or safety and any subswitiated inventory discrepancy that is could include but need not be limited to:

Judged to be sigm,ficant relative to normuliy ex-pected performance and that is judged to be caused 1.

' Mod: rate exposure to,or relt ase of, radioactive ma-by theft or diversion or by substaritial break 6own of terial licensed by or otherwise regulated by the the accountability system.

Commission; 8.

Any substantial breakdown of physical security or

. 2.

Major degradation of essential safety-related equip-material control (i.e., access control, containment, ment; or or accountability systems) that significantly weak-ened the protection against theit, diversion, or salw 3.

Major deficiencies in design, construction, use ef, or tage.

management controlsforlicensedfacilitiesormate-rial.

9.

An accidental criticality [10 CFR 70.52(a)).

10. A major deficiency m design, construction, or o;.cra-Examples of the types on events that are evaluated in detail using these criteria are:

tion having safes / smnlications requiring immediate remedial action.

For All 1,icensees it Serious deficiency in management or proc (dural 1.

Nposure of the whole body of any individual to 25 rem or more of radiation; exposure of the skin of the

12. Series of events (where individual es ents are not of whole body of any individual to 150 rem or more of

'mjor importance), recurting incidents. and inci-rafation; or exposure of the icet, ankle, hands or dents with ;mplicat ons for similar facilities (gcactic i

f.. arms of any individual to 375 rem or more of ra-incidents) that create major safety concern.

diation [10 CFR 20.403(a)(1)], or equivalent expo-sures from internal sources.

For Commercial Nuclear Power Plants 1.

Exceeding a safety limit of license technical specifi-2.

' An exposure to an individualin an unt estricted arca such t_ hat the whole body dose received exceeds 0.5 canons [10 CFR 50.36(c)].

rem in one calendar </ car [10 CFR 20.105(a)]~

2.

Major degradation of fuel integrity, pnmary coolant pressure boundary, or primary containment bound-The release of radioactive material - an unre-

- stricted area in' concentrations whica.'if averaged

3. -

over a period of 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />, exceed 500 times the regu*

3.

Im of plant capability to perform essential safety latory lima of Appendix 11, Table II.10 CFR Part 20 furctions such that a potential release of radioactiv.

[ClH 20.403(b)(2)}-

ity la excess of 10 CFR Part 100 guidelines could re-sult from a postulated t ransient or accident (e.g., loss 4.

Radiation or conta' : ttion levels in excess of design of emergency core cooling systein, loss of control rod values on vackage loss of confinement of radio-system).

active material sucw v (a) a radiation dose rate of 1000 mrem per hour three icet from the surface of a 4.

Discovery of a major condition not specificalip.on-packsge containing the radioactive material,' or (b) sidered in the safety analysis report (SAR)or techni-release of radioactive material from a package in cal specifications that requites immediate remedici

amounts greater than the regulatory limit.

action.

7 NUREG-0090, Vol. IS, No.1

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p-IAbnormal Occurrences,Ilst Qtr CY92 g-

- Personnel error or procedural deficiencies that re-cceded and a plant s'mido.vn is required (10 CFR sult in loss of plant _ capability to perform essential So.36(c)].

safety functions such that a potential release of ra-dioactivhy in excess of 10 CIH Part 100 guidelines -

2.

A major condition not specifically considered in the could result from a postulated transient or accident safW ar.alysis report or technical specifications that

- (e.g., Ns of emergency core cooling system, loss of reqires immediate remedial action.

control rod system).

h 3.

A 1 event tha seriously compromised the ability of a

~

For i uel Cycle Licensees -

confinement system to perform its designated func-

.i 1.

A safety limit of license tech nical specifications is ex-tion.

Medical Misadministrations

. As discussed in the Preface to this report, the NRC policy guidelines, which are summarized in Table A-1, augmem statement on AOs was published before li~ mees were the NRC policy statement.

required to report rnedical misadministiations to the As noted in the Preface, revised guidelines are currently-NRC.Therefore, during 1984, t he NRC developed guide-

_being developed because new medical misadministration lines for selecting such events for AO reporting.These definitions became effective on January 27.1992.

l.

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ll LNURE041090; Vol.15, No.1.

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Abnormal Occurrences,1st Qtr CY92 Table A-1 NitC Guidelines for Scleding Medical Misadministration thents for Abnormal Occurrence (AO)lleporting AO itepot ting Threshold Event Type Diagnostic Exposure Therapeutic Ihposure (1) Administering a If the improper administration if the impro[ cr administration radiopharmaceutical results in any past of the body results m any part of the IWy or radia' ion from a receiving unu:heduled radiation, receiving unscheduled indiation, scaled source other an AO 7, port should be an AO repcrt should be pro-than the one intended.

propoved if:

posed for any such evcat.

(a) the actual dose to the If the parts of the body wrong body part is greater eceiving radiation improperly than five times the upper would have received radiation limit of the normal range anyway, had the proper of exposeres prescribed administration been used, an for dtagnostic procedures AO report should be proposed involving that body part, or if:

(b) there are e inical indications (a) the actual dose is of any adverse tealth effects greater than 1.5 times tc Qc wrong bady part.

that intended to the above described body If the parts of the body parts, or, receiving radiation in. properly would have received radiation (b) the actual aoc is less

-r anyway, had he proper admini-th:m 0.5 times that stration been used, an AO report intended to the should be proposed if:

above descobed body parts, or, (a) the actual dose is greater than five times that (c) the above described body intended to the above parts show signs of adverse described body parts, or, health effe,:ts greater than expecterl had the proper (b) the abov ucribed body parts admini.itration been used, show signs of adverse health or effects greater than expected had the proper administration (d) the event (regardless of any been used.

l.,alth effects) affects two or mote patients at Ge same facility.

(2) Adr'inistering; An AC report should be proposed An AO report should be radinpharmaceutical if:

proposed for any suel. event.

or udiation to the wrong patient.

(a) the actual dose to the wrong patient exceeds five times the prescribed dose for the intended patient, or (b) the event results in any adverse health effects.

4 NUlmG-0090, Vol.15, No 1

Abnormal Occurrences,1st Otr CY92 Table A-1 (Continued)

AO Reporting Threshold Event Type Diagnostic Exposure Therapeutic Esposure (3) Administering a radio-Same guidelines as for Same guidelines as for pharmaceutical or livent rype 1.

!! vent Type 1.

radiation by a route of administration other than that intended by the

- prescribing physician.

(4) Administering a diagnostic An AO report should be Not apphcable.

dccc of a radiopharma-proposed if:

ceutical differing from the prescribed dose by more (a) the actual dose is greater

han 50 percent, than five times the prescribed dose, or, (b) the event results in adverse health effects worse than expected for the normal r;inge of exposures prescribed for the diagnostic procedure, (5) Admininering a thera-Not applicable.

An AO report should peutic dose of a radio--

be proposed if:

g pharmaceutical differing from the prescribed (a) tbc actual dose is dose by more than gree.ter than 1.5 10 percent; er administer-times the prese-ibed ing a therapaut; radiation dose, or, dose from a scaled

)

source such that errors (b) the actual dose is in the source calibration, less than 0.5 times time of exposure, and the prescribed dose.or treatm;nt geometry result in a calculated (c) the event results total treatment dooc in adverse health differing from the effects worac than final prescribed total would be expected Dr tr:atment dose by the normal range of more than 10 percent.

exposures presenbed for the therapeutic procedure, or, (d) the event (regardless of any health effects) affects two or more natiems at the same facility.

-(b) Recurnng or series For either diagnostic or the-apeutic exposures, an AO report should b' of events (regardless proposed for recurring events or a series of eveats (in which each individual of the number of patients misadministration is not of major importance.nat create a significant public or facilities involved) health or r.afety concern.

NURl!G-0000, Vol.15, No. I 10 j

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' Abnormal Occurrences,1st Qtt CY92 in

' Table A-1 (Continued)

~-

AO Reporting Threshold'

+

\\

Ctent Type.

-Diagnosde Exposure

. Therapeutic Exposure

-(7)i Generic events.

For either diagnostic ce therapeutic exposures, an AO report should be proposed for misadministrations with generic implications that create a significant public health or safety conce a.

a t

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11 NU REG-0090, Vcl. IS, No.1

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Mnormal Occurrences,1st Otr CY92 APPENDIX B UPDATE OF PREVIOUSIX REPORTED ABNORM AL OCCURRENCES During the January through March 1992 period, NRC provide the in.ial and any subsequent updating informa-a lictasces, Agreement States, Agreement State licensees, tion on the abnormal occurrences discussed. (Ihe updat-and other involved parties, such as reactor vendors and ing provided generally covers events that tr ak place dur.

- architect engineering firms, continued with the imple-ing the report period; some updating, however, may be mentation of actions necessaty to prevent recurrence of more current as indicated by the associated event dates.)

previously reported abnormal occurrences. De refer.

Open items will be discussed in subsequent reports in the enced Congressional abnormal occurrenc^ reporte i Aow series.

Fuel Cycle Fulities 91-6 Potential Criticality Accident at the tions were conducted at the facility from August 19-Si p Gene.al Electric Nuclear Fuel and tember 13,1991, to review the IIT findings for possible i

enforcement acti ns. The inspections identified several Component Manufacturing Facilit7 n apparent violations; the findings were documented m Wilnu.ngion, North Caroh,na NRC Inspection Report No. 70-1113/91-04, which was forwarded to the licensee on December 23,1991 (Ref.

,Du.s abnormal occurrence was originally reported.m 11-1). An enforcement conference was held on February NUREG-0090, Vol.14, No. 2, " Report to Congress on 7,1992, in the NRC Region 11 office to discuss the apnar'-

- Abnormal Occurrences: April-June 1991. It was up' ent violations, their causes, and the licensee's correc'tive glated in Vol.14, No. 3 and Vol.14, No. 4. The event, actions to preclude recurrence (Ref.11-2).

mvolving degraded nuclear criticality safety controls, was investigated by an NRC Incident investgation Team On March 13,1992. the NRC issued a Notice of Violation (llT). As mentioned in the previous reports, the NRC Ifp and Proposed imposition of Civil Penalty in the amount

. formal report was published in August 1991 m NURl!G-1450 (" Potential Criticality Accident at the of $20,000 (Ref.11-3). The action was based on violations

- General Electric Nuclear Fuel and Component Manufac-relawd to inadequate procedures and the failure to follow turing Facility, May 29,1091")flhe abnormal occurrence procedures that collectively recited in ineffective proc-ess and mass limit controls These vmlations were classi-is further updated as follows:

ficd m, the aggregate as a Severity level !! problem, on a

- Periodic NRC inspector prescnce was maintained at the scale in which Severity Levels I through V are the most site during the January through March 1992 time period and least sigmfictmt, respectivdy. In addition, some other violations were identified; these were classified as Sever-ne inspectors reviewed operations 'l progress as the

. licensee operated the solvent extraction process, and re-ity Level IV with no associated civil penalty. The licenre viewed actions being taken by the licensee to improve its has responded to the Notice of Violation and paid the civil performance in the area of nuclear criticality safety.The penahy m full.

licensee's solvent extraction process has been operated in a safe manner since operation was resumed in mid-Octo.

As mentioned in the original report, on Aucust 13.1991, ber of 1991.

the NRC lixecutive Director for Operations issued a memorandum to assign NRC office responsibility for ge-De licenxe continues to evaluate its nuclear criticality neric and plant-specific staff actio..s resulting from the sW ty propamt as areas for improvement are idenHfied.

IIT (Ref.11-4). Numerous actions were identified under they are bemg added to the licensce's Performance im-t he general categories of (1) adequacy of criticality safety provement Program (PIP). Status reports on the PIP have reviews, (2) adequacy of facility operational safety, (3) been submitted monthly by the licensee to the NRC.The adequacy of emergency preparedness, and (4) adequacy NRC will meet with the licensee on a quarterly basis to ei operating esperience review. So ne of the ahort term resicw the beensec's progress in completing the elements actions were resolvc 3 during the latter part of 1991. The specified in the licensee's PIPJlhe first such meeting was remaining items are scheduled for completion in the lat-

- held March 4,1902, with a followup meeting to discuss te parts of 1992,1993, and 1994/I he status of resolution addition!d details held on April li1992.

of each of the statf action items will be included in the Annual Reports issued by the NRC Office for Analysis The char:cr of the IITdid not include assessing violations and livaluation of Operational Data (NUREG-1272 ne.

. of NRO rules and requirements.Derefore, NRC inspec.

ries).

13 NUREG-0090. Vol.15, No.1

Abnormal Occarrences,1st Otr CY92 This item will be updated from time to time in these information becomes available.

quarterly reports to Congress as new, significant Other NRC Licensees 91-8 Itadiation Exposures of Members of the correi %e actions which either have been taken, or the l'ublic from a 1.ost Itadioactive will be taken. 'the company's licensed activitics rernain under NRC iavestigation. liina! P'Rt en orcement action Source is pending.

This abnormal occurrence was originally reported in llecause the company is a licensee of the Agreement NUREG-0090, Vol.14. No. 3, " Report to Congress on State of Texas, as well as of the NRC, the event was also Abnormal Occurrence *: July-September 1991,"and up' (State Agency'y the Texas Bureau of Radiatio:. Control nyestigated b dated m Vcl.14. No. 4. Ihe abt.ormal occurrence is

). In order to avoid duplication of effort, it further updated as follows was mutually agreed that the NRC would concentrate on violations of rules directly related to transport of the As previously mentioned, on December 20,1991, the source, and the State Agency would concentrate on,iola-NRC issued a k*otice of Violation and Proposed imposi-tions of rules pertaining to radiation levels in uritestricted tion of Civil Penalty in the amount of $10,000 to Western areas and human exposures.

Atlas International for violating NRC rcquirements in the loss of Qc radioactive source (Ref.11-5). 'Ihc pro-The State Agency identified three apparent violations of posed civil penalty was based on two violations: (1) failure agency rules: (1) the transport contairier not being prop-to bloc, rmd brace tl e radioactive source container ade-crly secured resul'Ug in less of the radiation source and quately Juting transportation; and (2) failure to ensure subsequent exposure to members of the public,(2) levels that the container's closure device was prsocrlyinstalled, of radiation from an external source in an unrestricted secured, and free of defects. The NRC also cited the area exceeding applicable regulatory limits, and (3) un-licensec for five other violations which were not assc3 sed necessary enosure of an individual while recovering the a ciul penalty.

source Escalated enforcement actions have been initi-i ated a3a:nst the licensee.

J On January 24,1992, the licensee responced to the No-tice of Violation, admitting the violations and describing n ture reports will be made as apprcpriate.

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NUREG-0090, Vol.15, N>,1 la

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Abnormai Occurrences,1st Qtr CY92 '

APPENDIX C OTilER EVENTS OF INTEREST The folloEing items are described because they may pos-tions in the level of protection provided for public health sibly be perceived by the public to be of public health or or safety; therefore, they are not reportable as abnormal safety significance.nc items di not involo major reduc-occurrences.

Nuclear Pouer Plants 1.

Inoperable Automatic Depressurization For the period when both IIPCI and ADS were inoper.

System at Peach Bottom Unit 3 able, the ability of the plant to cope with a small break 1.OCA was degraded. Ilowever, during the operating cy-On February 21,1992, the NRC issued a Notice of Viola.

c!c, no events invoiving elevated primary coolant leakage rates occurred. In addition, tl.cre were no events requir-tion and Proposed Imposition of Civil Penalties in the

- amount of $235,000 to Philadelphia Electric Company, ing manual or automatic operation of any SpVs. The the licensee for Peach llottom Units 2 and 3 (Ref. C-1).

pressure relief function of'he SRVms %gnificantly_

This action was based on two violations associated with affected. For all but a small percen are of the tirne the the automatic d, pressurization system (ADS) installed it.

IIPCI system was available to mitigate an accident, and each unit. Peach llottom Units 2 and 3 are General Elec.

the operation of ADS would not have been needed. Al-tnc-designed bo;1:ng-water reactors located in Yo:k though not engineered safety features, three SRVs and the reactor core isohstion cooling system (RCIC) were County, Pennsylvania.ne circumstances associated with available during those periods when IIPCI was ineper-

' the violations are as followe.

able. The two operable ADS valves, in conjunction with -

the RCIC system and manual opcration of the other Safety relief valves (SRVs) are included on each plant to SRVs, provided accident mitigation capability. llowever, rotect against overpressurizing the reactor coolant sys-the amMon would result m additional challenges to the tem. At Peach llottom there are 11 SRVs on each unit.

plant design and operators.

Fach SRV is equipped with one solenoid operated valve (SOV)and associated cable. Five of the 11 SRVs are als As part of its immediate corrective action, the licensee -

, part of the ADS. In the event of a small break loss of performed a walkdown of the Unit 2 SRVs and concluded coolant accident (LOCA), the high pressure coolant m-that all insulation was properly installed. Subsequently, lection (IIPCI) system is designed to provide an adequat the NRC Resident inspector performed a wa'Sdown and cooling water supply. lf the llPCI system failed to operate identified that one Unit 2 SRV was not propwy insu-during an accident, the ADS acts as a back-up system and lated. later testing of tbc Unit 2 valve demonstrau that automatically operates to reduce reactor pressure, His -

t would have operated.

would allow lower pressure emergency core cooling sys-tems to inject water.

The factors contributing to the Unit 3 problem included

1) inadequate maintenance planning and post-mainte-

~ In September 1991, the licensee removed thtee Unit 3 nance inspection, 2) inatte- ' n to detail in performing

- SRVs for periadic testing.They observed that the SOVs ~

post-nuxlification inspectic

3) poor follow-up to con.

1-

~ and1.ibles showed significant degraJation.De licensee cerns raised by a technicim atmut the condition of the found that the thermal insulat:on on these three valves.

SRV insulation during a Unit 3 mid-cycle outage, and 4) a

- and the remaining eight SRVs, was installed improperly.

lack of understarJing of the critical r.ature of the thermal During plant operation this resulted in local arca tem-insulation.

peratures of about 434 degrees fahrenheit, causmg the ol'scrved degradation. De licensee tested the SOVs un-The Unit 2. deficiency occurred because the insulation

' der normal and worst case accident environmental condi-had been altered by a contractor in 1988 without proper tions. The licensee's testing indicated that only two ADS ~

authorization.The licensee's failure to identify the Unit 2 L

valves, and three non. ADS SRVs were operable. The problem resulted from inadequate licensee planning and

~

i plant's final safety analysis report (FS AR) states tl.at four control of the inspection of the Unit 2 equipment follow-ADS vidves are to be operable.De licensee concluded ing identification of the Unit 3 prob!cm.

that the Unit 3 ADS had been inoperable for most of the 21 month operating cycle. During the same period, the The hcensee implemented a series of corrective actions

. Unit 3 IIPCI system was unavailable for a total oi 510 including 1) repair of all affected SRVs,2) engineering n

l hours. -

reviews of critical insulation applications and in-plant

=

5 NURiiG-0090. Vol.15, N 1

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m I Abnormal Occurrences 1st Qtr CY92 w;alkdowns of high temperature piping to identify any is directed up toward the ice beds, where the melting ice l additional errors,3) revision of maintenance procedures, condenses the steam and cools the air. Discharge from tne

' and 4) plant staff trairang.

ice condenser is made to the upper compartment of the containment wher,: continued cooling is ensured by opt The circumstances associated with the degraded systems, cration of the containment spra) system.

and the licensec}Ihc results of the inspections were is-corrective actions, were reviewed by

'the cmse or the probicm was discovered to be upward NitC inspectors.

rnt.vement of the ice condenser floor wear slabs that form sued to the hcensec on December 24,1991 (Ref. C._).

k layu of the ice condenser floor assembly. Thic On January 17, 1992, the NitC held an linforcement

      • ""'nt regulted in nahanical interfenence with the Conference ~ Mh licensee management to discuss the flashing at tht botto(n of numerous doors, thereby mter.

event and the licensecs follow up actions. As previously fering with the openmg of the doors. lhe upward move-

-mentioned, on February 21, 1992, the NRC issued an ment of the fk>or wear slabs, as well as extensive cracking, escalated criforcement action to the licersee (Ref. C-1).

was attributed to water mtrusion, freezing, and expansion liased on the safety system degradation, the significance within the floor assembly because the floor is mamtamed ot the programmaticweaknesses hit bebw freezing by passing refrigerant through tubing in-had poor past licensee performanI;hlightedbytheevent, e in these areas, tbc stallea in the.thier tissembly.

NitC judged the Unit 3 problem to be a Severity 1.evel11 On March 23,1992, the NRC issued a Confirmation of

- violation, and the Unit 2 problem a Severity I.evel III Action 1.ctter to the licensee (Re f. C-3) documenting the violation (on a scale in which Severity Levels I through V NRC's understanding that prior :o restart of Unit 1, the

_- are the must and least significant,- respectively).The pro-licensee will (a) investigate the event including the root posed civil penaltics for the Severity Levels !! and 111 causc analysis and extent of conditior.of the ice condenser violations werc $160,000 end 5125,000, respectively. On components, (b) perfonn a safety evaluation, (c) submit to March 20,1992, the licensee responded to the etion.

the NRC the licensec's plans for short_ and long term acknowledged the violations, and paid the civd penalties

-_in full.

corrective actions, and (dj meet with the NRC to discuss resolution of the problem. On March 27,1992, the licen-see responded to it em (a), (b), and (c), above (R ef. C-4 2.

Degradet! Ice Condenser Lower Inlet To evaluate the dfects of the inoperable ice condenser Doors at Sequoyah Units I and 2 doors on the Inss of Coolant Accident (LOCA) analysis (which forms the basis for the peak calculatcd contain-

On March 16,1902, during the initial st.rvey of the con-n ent pressure),'lVA petformed an analysis using their

- tahment at thestart of Sequoyah Unit 2 refurling outage, containment / subcmrpartment analysis program. 'the li-thcTennessee Valley Authdrity (the licensee)found that ansee concluded that for Unit _1, all doors would open 27 of thv48 inlet doors to the iec condenser were binding.

,vith no change in the opening times. 'iherefore, there Confirmatory inspection of Sequoyah Unit I on March was no impact on the 1/SAR analysis. I a Unit 2, the 18,1992, which was operating near 100 percent power, licensee concit"Jed that there was an insignificant effect identified a similar problem that affected 11 of the 48 on the peak containment pressure resulting from a inlet doors.The licensee conducted an orderly shutdown _

l.OCA, an acceptable increase in the subcompartment of Unit 1 to resolve tht problem; hot standby was t eached pressttre resulting from a LOCA, and no change in the

im Macch 19,1992. Sequoyah Units 1 and 2 are Westin, peak containment pressure resulting from a main steam ghousM:: signed pressurim!. water reactors, hicated in line break accident. 'Ihc overall conclusions reached by llamilton County, Tennessce, the licensec were that the reduction la margin between the technical specifications requirements and the safety.

The Sequoyah plant containments arc of an ice condenser

!imit was acceptabic, the ice condensers would han per-pressure suppression design. The ice condenser is a pas.

formed their intended safety fcaction, and that the safety sive device containing borated ice that is utilized to absorb analysis remained valid.

L thermal energy that would be released in the event of a The staff has reviewed the information presente ! by the loss-of-coolant accident (LOCA) or high-energy line licenste and determined that the effectmr it. as-found

- break (1IELil), thereby limiting the tmtial peak pressure condition of the ice condenscr doors on the LOCA or high m the containment followmg such an event. Durmg a energy line break accident, and on the containment integ-postulated LOCA or IIELil(which can only occur m the ritv, would not have resulted in the loss of containment

-lower compartment of the contamment), steam emanat'

nt'egrity; therefore, the radiation doses would rernain the tng from the bicak h> cation is directed primarily to the ice same, within the guidelines of 10 CFR Part 100.There--

condcryser section via pressur e-driven flow through the 18 f

niNm is Mnimi lower tec doors, these doors are des:gned to open at a differential pressme of I pound per square foot. After The licensec also iNected the various ice condenser entering the ice condenser, the steam and/or air mixture components and verified their structural integrity, evalu-NUREG-0090, Vol 15, No. I 16

Abnormal Occurcences,1st Qtr CY92 at ed the cracking and areas of distress in the concrete, and trip, a hardware failure of the steam dump controller de' ermined that the impae'.i on the design loadings were caused a cooldown which ruulted in a safety injection (SI) acceptable, determined that the dead weight impact of signal. The Si caused the isolation of the glycol system the water and/or ice within the floor asse mbly was accept-from the ice condenser for approximately two hours. Af-able, determined that the wear slab was capable of per-

'cr this isolation, the fkior monitors showed a gradual forming its inter ded fonction during a seismic event, de-trend up on six of the ice bays.This trend continued until termined that the upward movement effeca on the approximately May 16, 1992, at wnich time indications structural components o the iec condenser were insig-showed that the fkior movement had stopped coin" dent r

nificant, and determined that the functions performed by with a manual reactor trip on the same day. A' the the other ice condenser components (other than the ruanual trip, the licensee inspected the ice condenser doors) wue not affected by the condition of the floor.

floor area and determined it to be acceptable. Unit I was restarted on May 17, 1992, and as of May 21,1992,no llowever, because of the long-term stagnation of water /

adJitional upward movement trend was apparent. The ice around the wear slah, soine of the ice condenser com-licensee continues to monitor the fhior movement for ponents (e.g., wear slab, insulation, column supports)and Unit 1.

steel containment vessel could experience age-related degradation (corrosion, inadequate drainage, reduced in-Repairs were completed to the Umt 2 ice condenser and sulation effectiveness, etc.). 'lhe licensee implemented a the unit restarted from the refueling outage on May 15, monitoring program to detect floor movement, and com-1992. As of May 21,1992, there was no upward trend on mitted to evaluate the condition of the ice condenser the Unit 2 ice condenser floor monitors, structures and components during the next tefueling out-age to determine future activities. 'lhe ice condenser An enforcement contwer.cc was held on May 1,1992, at fhiors were repaired.

the NRC Region II office to discuss an apparent violation of the technical specifications, its causes, and the licen-A meeting was held with the licensee on April 3,1992, to see's corrective actions to preclude recurrence. On May discuss the resolution of the ice condenser lower door 19,1992, a Notice of Violation was issued to the beensee problem. The meeting was the final restart item of the for its failure to maintain all of the ice condenser inlet Confirmatory Action 1.etter issued March 23,1992.

doors operable (Ref. C-5). The violation was classified as Severity I.evel til on a scale in which Severity Levels 1 Unit I restarted on April 17,1992. On April 28, IM, through V range from the most sienificant to least signifi-Unit I tripped.The next day, while in Mode 3 after the cam, respectively, 17 NURl!G-0090, Vol 15, No.1

Abnorrnal Occurrences,1st Qtr CY92 L

REFERENCES FOR APPENDICES 11 - 1 ietter from J. Philip Stohr, Director, Division of forwarding Notice of Violation and Proposed impo-Radiation Safety and Safeguards; NRC Region II, sition of Civil Penalty-$10,000, License No.

to William Ogden, Acting Manager, Nuclear Fuel 42-02964-01, Docket No. 030-06402, December and Components Manufacturing, General Electric '

20,1991.*

Company, forwarding NRC Inspection Report No.

70-1113/91-04, License No. SNM-1097, Docket C-1 lxtter irom Thomas T, Martin, Regional Adminis-No. 70-1113, December 23,1991.*

trator, NRC Region I, to Dickinson M. Smith, Senior Vice President-Nuclear, Philadelphia B-2 letter from J. Philip Stohr, Director, Division of filectric Company, forwarding a Notice of Violation Radiation Safety and Safeguards, NRC Region II, and Proposed imposition of Civil Penal-to D L Silverthorne, Manager, Nuclear Fuels and tics-S285,000, Docket Nos. 50-277.md 50-278, Components Manufacturing, General Electric February 21,1992.*

Company, forwarding " Enforcement Conference Summary," License No. SNM-1097, Docket No.

C-2 Irtter ? rom Charles W. llehl, Director, Division of 70-1113, February 20,1992,*

Reactor Projects, NRC Region I to D.M. S;nith, Senior Vice President-Nuclear, Philadelphia B-3 Letter from Steward D Ebneter, Regional Admin-Electric Company, forwarding Combined Inspec-

- istrator, NRC Region II, to Dallas L Silverthorne, tion Report Nos. 50-277/91-33 and 50-278/91-33, Manager Nuclear Fuel and Components Manufac-Docket Nos. 50-277 and 50-278, December 24, turing, General Electric Company, forwarding 1992.*

" Notice of Violation and Proposed Imposition of Civil Penahy-$20,000," License No. SNM-1097, C-3 Confirmation of Action 1 ctter from Stewart D.

Docket No. 70-1113, March 13,1992,*

Ebacter, Regional Administrator, NRC Region II, to J. R. Ilynum, Vice Presideat, Nuclear Opera-11-4 Memorandum from James M. Taylor, NRC Execu-tions, Tenncace Valley Authority, Docket Nos.

tive Director for Operations, to Edward L Jordan, 50-327 and 50-328, March 23,1992

  • Director, NRC Offica for Analysis and Evaluatian of Operational Data, et al,
  • Staff Actions Resuu-C-4 Ixtter from J. L Wilson, Vice Prerident, Sequoyah ing from the Investigation of the Potential Nuclear Plant, Tenaessee Valley Authority, to

- Criticality Accident at the General Electric Nuclear Docket Control Desk, U.S. Nuclear Regulatory

- Fuct and Component Manuf acturing Facility, May Commission, Docket Nos. 50-327 and 50-328, 29,1991,(NUREG-1450)," August 13,1991,*

March 27,1992.*

i 11-5 Letter from Robert D. Martin, Regional Adminis-C-5 Letter from Stewart D, Ebneter, Regional Admin-l' trator, NRC Region IV, to Bill Rose, Radiation istrator, NRC Region II, to Dr. Mark O. Medford,

- Protection Officer, Western Atlas International, Vice President, Nuclear Assurance. Licensing and fuels, Tennessee Valley Authority, forward ng a WntINnN[l$r t$D rYehel)

E Notice of Violation, Docket Nos. 50-327 and h

n

-20555, 50-328, May 19,1992.*

L i

19 NUREG-0090, Vol 15, No.1

NRO FORM 335 U.S. NUCLEAR REGULATORY COMMISSION

1. REPORT NUMBER (249).

( Assigned by NRC, Aad Vot,

tsacM 1102, Supp, Rev, and Adoendurn Nurn-8

  • 3202 BIBLIOGRAPHIC DATA SHEET
    • '5.

H anya (e instructions on ti.e reverse)

NUREG-0090 Vol.15, No.1 2, Tna mo suuma

^ ' ' " ' " " ' " " * " '

Report to Congress on Abnormal Occurrences:

l January - March - 1992 uONTH vrAR July 1992

4. FIN OR GRAF, NUMBER
6. AU TetVH(b)
6. T YPE OF REPORT Quarterly
7. PEHioO COVERED (inclusive Dates)

January - March 1992 t

6. PERFORMNG ORGAFAIATION - NAME AND ADDRESS Uf t#tC. provide Division. Offee w Region. V S. twear Regulatwy CommJsse, and rnaihng address; it contracty, provide name and rAalung address-)

-Office for Analysis and Evaluation of Operational Data U.S. Nuclear Regulatory Commission Washington, DC 20555 -

9. SPONSOFuNO OHaAralATION - NAME AND ADDDESS Of NRC, type "bama as above"; if contractor, prov de t4RC Division, Office u Region, U.S. Nuclear Regulatory Commission, and marung address.)

r Same as 8., above to SUPf11MLNT A9Y NOTES 11 ADSTRACT (200 words or less)

Section 208 of the Energy Reorganization Act of 1974 identifies *m abnormal occurrence as an unscheduled incident or even; that the Nuclear Regulato.y Commission (letermines to ba significant from the standpoint of public health end safety and requires a quarterly report of such events to be made to Congress. This report covers the period January through March 1992. 'three abnormal occurrences involving medical therapy misadministrations at NRC-licensed facilities are discusscJ in thir report. There were no abnormal occurrences at _a_ nuclear power plant, and none were reported by NRC's Agreement States. The report also contains information updating some previously reported abnormal occurrences.

12. EEY WORDSiOESCRtPf0R$ (List words or phrases that win assist researchers in tecating t*e rerort.)

a AVA W W STAT M NT Unlimited

14. ScCURITY CLASSFiCATION Medical Therapy Mmdministmtions motw)

Inoperable Automatic Depressurization System at Peach Ecttom Unit 3 Unclassified Degraded Ice Condenser 1 ower Intet Doors at Sequoyah Units 1 and 2

- m,,,,g,n Unclassified

15. NUMSLR OF PAGES
16. PHICE

- NRC 7 ORM a35 (2-69)

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i THIS DOCUMENT WAS PRINTED USING RECYCLED PAPER

NUREG-0090, Vol. i5, Na 1

!!EPORh TO CONGDF.SS ON ABNORMAL OCCURRENCES JULY 1992 UNITED STATES NUCLEAR REGULATORY COMMISSION FIRST CLASS Mall POSTAGE AND FEES PAID

-WASHINGTON, D.C. 20555-0001 uSnRc FERMIT NO. G-67 OFFICIAL BUSINESS PENALTY FOR PRIVATE USE, $300 i idN1C01CV1CY1 h0555139531 PUBLICATIONS SVCS ADM g

P0p-NUREG p.211 DC 0555 Wr.SHINGTON

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