ML20247N158
| ML20247N158 | |
| Person / Time | |
|---|---|
| Issue date: | 08/31/1989 |
| From: | NRC OFFICE FOR ANALYSIS & EVALUATION OF OPERATIONAL DATA (AEOD) |
| To: | |
| References | |
| NUREG-0090, NUREG-0090-V12-N01, NUREG-90, NUREG-90-V12-N1, NUDOCS 8909260159 | |
| Download: ML20247N158 (29) | |
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Available from Superintendent of Documents U.S. Government Printing Office Post Office Box 37082 Washington, D.C. 20013-7082 A year's subscription consists of 4 issues for this publication.
[h gle copies of this publication are available from National Technical Information Service, Springfield, VA 22161 4
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NUREA-0090 Vol.12, No.1 Report to Congress on Abnormal Occurrences January. March 1989 Date Published: August 1989 Office for Analysis and Evaluation of Operational Data U.S. Nuclear Regulatory Comrnission Washingtoni DC 20555 f"*g, h.....
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Previous Reports in Series NUREG 75/090, January-June 1975, NUREG-0090, Vol.6, No.l. January-March 1983, published October 1975 published Septeucer 1983 NUREG-0090-1, July-September 1975, hUREG-0090, Vol.6, No.2, April-June 1983, published March 1976 published November 1983 NUREG-0090-2, October-December 1975, NUREG-0090, Vol.6, No.3, July-September 1983, published ". orch 1976 published April 1984 NUREG-0090 J. January-March 1976, NUREG-0090, Vo'.6, No.4, October-December 1983, publishec July 1976 published May 1984 NUREG-0090-4 April-June 1976, NUREG-0090, Vol.7, No.1, January-March 1984, published March 1977 published July 1984 NUREG-0090-5, July-September 1976, NUREG-0090, Vol.7, No.2. April-June 1984, published March 1977 published October 1934 NUREG-0090-6, October-Pecember 1976 NUREG-0090, Vol 7, No.3, July-September 1984, published June 1977 published April 1985 NUREG-0090-7, January-March 1977, NUREG-0090, Vol.7, No.4, October-December 1984, published June 1977 published May 1985 NUREGiOO90-8, April-June 1977, NUREG-0090,' Vol.8, No.1, January-March 1985, published September 1977 published August 1985 NUREG-0090-9, July-September 1977,,
NUREG-0090, Vol.8, No.2, April-June 1985, published November 1977 published November 1985 NUREG-0090-10, October-December 1977, NUREG-0090, Vol.8, No.3, July-September 1985, published March 1978 published February 1986 NUREG-0090, Vol.1, No.1, January-March 1978, NUREG-0090 Vol.8, No.4, October-December 1985, published June 1978 published May 1986 NUREG-0090, Vol.1, No.2 April-June 1978, NUREG-0090, Vol.9, No.1, January-March 1986, published September 1978 published September 1986 NUREG-0090, Vol.1, No.3, July-September 1978 NUREG-0090, Vol.9, Nn.2, April-June 1986, published De: ember 1978 published January 1987 NUREG-0090, Vol.1, No.4, October-December 1978, NUREG-0090, Vol.9, No.3, July-September 1986, published March 1979 published April 1987 NUREG-0090, Vol.,2, No.1, January-March 1979, NUREG-0090, Vol.9, No.4, October-December 1986, published July 1979 published July 1987 NUREG-0090, Vol.2, No.2, April-June 1979, NUREG-0090, Vol.10, No.1, January-March 1987, published November 1979 published October 1987 NUREG-0090, Vol.2, No.3, July-September 1979, NUREG-0090, Vol.10, No.2, April-June 1987, published February 1980 published November 1987 NUREG-0090, Vol.2, No.4, October-December 1979, NUREG-0090, Vol.10, No.3, July-September 1987, published April 1980 published March 1988 NUREG-0090, Vol.3, No.1, January-March 1980, NUREG-0090, Vol.10, No.4, October-December 1987, published September 1980 published March 1988 NUREG-0090, Vol.3, No.2, April-Jane 1980, NUREG-0090, Vol.11, No.1, January-March 1988, published November 1980 published July 1988 NUREG-0090, Vol.3, No.3, July-September 1980, NUREG-0090, Vol.11, No.2 April-June 1988, published February 1981 published December 1988 NUREG-009J, Vol.3, Nc.4, October-December 1980, NUREG-0090, Vol.11, No.3, July-September 1988 published May 1981 published January 1989 NUREG-0090, Vol.4, No.1, January-March 1981, NUREG-0900, Vol.11, No.4, October-December 1988, published July 1981 published April 1989 NUREG-0090, Vol.4, No.2, April-June 1901, published October 1981 NUREG-0090, Vol.4, No.3, July-September 1981, published January 1982 NUREG-0090, Vol.4, No.4, October-December 1981, publid ed May 1982 NUREG-OJ90, Vol.5, No.1, January-March 1982, published August 1982 NtMG-0090, 701.5, No.2, April-June 1982, published December 1982 NUREG-0090, Vol.5, No.3, July-September 1982, published January 1983 NUREG-0090 Vol.5, No.4, October-December 1982, published May 1983
1 ABSTRACT Section 208 of the Energy Reorganization Act of 1974 identifies an abnormal occurrence as an unscheduled incident or event which the Nuclear Regulatory Commission determines to be significant from the standpoint of public health or safety and requires a quarterly report of such events to be made to Congress.
This report covers the period from January 1 to March 31, 1989.
For this reporting period, there were two abnormal occurrences at nuclear power plants licensed to operate.
The first had generic implications and involved a plug failure resulting in a steam generator tube leak at North Anna Unit 1.
The second involved a steam generator tube rupture at McGuire Unit 1.
There were three abnormal occurrences under other NRC-issued licenses.
Two involved medi-cal therapy misadministration and one involved a medical diagnostic misadmin-istration. There were no abnormal occurrences reported by the Agreement States.
The report also contains information updating some previously reported abnormal occurrences.
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CONTENTS Page ABSTRACT...............................................................
iii PREFACE...............................................................
vii INTRODUCTION.....................................................
vii THE REGULATORY SYSTEM............................................
vii REPORTABLE OCCURRENCES...........................................
vii AGREEMENT STATES.................................................
viii FOREIGN INFORMATION..............................................
ix REPORT TO CONGRESS ON ABNORMAL OCCURRENCES, JANUARY-MARCH 1989........
1 NUCLEAR POWER PLANTS.............................................
1 89-1 Plug Failure Resul:'ng in Steam Generator Tube Leak at North Anna Unit 1...................................
1 89-2 Steam Generator Tube Rupture at McGuire Unit 1.........
3 FUEL CYCLE FACILITIES (Other than Nuclear Power Plants)..........
4 OTHER NRC LICENSEES (Industrial Radiographer, Medical Institutions, Industrial Users, etc.)............................
4 89-3 Medical Therapy Misadministration......................
S 89-4 Medical Therapy Misadministration......................
6 89-5 Medical Diagnostic Misadministration...................
7 AGREEMENT STATE LICENSEES........................................
8 REFERENCES............................................................
9 APPENDIX A - ABNORMAL OCCURRENCE CRITERIA.............................
11 APPENDIX B - UPDATE OF PREVIOUSLY REPORTED ABNORMAL OCCURRENCES.......
13 NUCLEAR POWER PLANTS.............................................
13 79-3 Nuclear Accident at Three Mile Island..................
13 85-14 Management Deficiencies at Tennessee Valley Authority..
14 APPENDIX C - OTHER EVENTS OF INTEREST.........................
17 1.
Flammable / Explosive Mixtures of Hydrogen in Plant Systems at Robinson Unit 2 and Byron Unit 2.
17 REFERENCES (FOR APPENDICES)...........................................
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I PREFACE INTRODUCTION The Nuclear Regulatory Commission reports to the Congress each quarter under provisions of Section 208 of the Energy Reorganization Act of 1974 on any abnormal occurrences. involving fac'ilities and activities regulated by the NRC.
An abnormal occurrence is defined in Section 208 as an unscheduled incident or event'that the Commission determines is significant from the standpoint of public health or safety.
Events are currently identified as abnormal occurrences for this report by the NRC using the criteria listed in Appendix A.
These criteria were promulgated in an NRC policy statement that w3s published in the Federal Register on February 24, 1977 (Vol. 42, No. 37, pages 10950-10952).
In order to provide wide dissemination of information to the public, a Federal Register notice is issued on each abnormal occurrence.
Copies of the notice are distributed to the NRC Public Document Room and all Local Public Document Rooms.
At a minimum, each nutice must contain the date and place of the occurrence and describe its nature and probable consequences.
The NRC has determined that only those events, including those submitted by the Agreement States, described in this report meet the criteria for abnormal occur-rence reporting.
This report covers the period from January 1 to March 31, 1989.
Information reported on each event includes date and place, nature and probable consequences, cause or causes, and actions taken to prevent recurrence.
THE REGULATORY SYSTEM The system of licensing and regulation by which NRC carries cut its responsibil-ities is implemented through rules and regulations in Title 10 of the Code of Federal Regulations.
This includes public participation as an element.
To accomplish its objectives, NRC regularly conducts licensing proceedir.gs, inspec-tion and en(orcement activities, evaluation of operating experience, and confir-matory research, while maintaining programs for establishing standards and issuing technical reviews and studies.
In licensing and regulating nuclear power plants, the NRC follows the philosophy that the health and safety of the public are best assured through the establish-ment of multiple levels of protection. These multiple levels can be achieved and maintained through regulations specifying requirements that will assure the safe use of nuclear materials.
The regulations include design and quality assurance criteria appropriate for the various activities licensed by NRC.
An inspection and enforcement program helps assure compliance with the regulations.
REPORTABLE OCCUkktNCES Actual operating experience is an essential input to the regulatory process for assuring that licensed activities are conducted safely.
Licensees are required to report certain incidents or events to the NRC.
This reporting helps to l
identify deficiencies early and to assure that corrective actions are taken to prevent recurrences.
i vii
For nuclear power plants, dedicated groups have been formed both by the NRC and by the nuclear power industry for the detailed review of operating experience to help identify safety concerns early; to improve dissemination of such infor-mation; and to feed back the experience into licensing, regulations, and opera-tions.
In addition, the NRC and the nuclear power industry have ongoing efforts to improve the operational data systems, which include not only the type and quality of reports required to be submitted, but also the methods used to ana-lyze the data.
In order to more effectively collect, collate, store, retrieve, and evaluate operational data, the information is maintained in computer-based data files.
Two primary sources of operational data are Licensee Event Reports (LERs) and immediate notifications made pursuant to 10 CFR S 50.72.
Except for records exempt from public disclosure by statute and/or regulation, information concerning reportable occurrences at facilities licensed or other-wise regulated by the NRC is routinely disseminated by the NRC to the nuclear 1
industry, the public, and other interested groups as these events occur.
Dissemination includes special notifications to licensees and other affected or interested groups, and public announcements.
In addition, information on reportable events is routinely sent to the NRC's more than 100 local public document rooms throughout the United States and to the NRC Public Document Room in Washington, D.C.
The Congress is routinely kept informed of reportable events occurring in licensed facilities.
i Another primary source of operational data is reports of reliability data submitted by licensees under the Nuclear Plant Reliability Data System (NPRDS).
The NPRDS is a voluntary, industry-supported system operated by the Institute of Nuclear Power Operations (INP0), a nuclear utility organization.
Both engineering and failure data are submitted by nuclear power plant licensees for specified plant components and systems.
The Commission considers the NPRDS to be a vital adjunct to the LER system for the collection, review, and feedback of operational experience; therefore, the Commission periodically monitors the NPRDS reporting activities.
AGREEMENT STATES Section 274 of the Atomic Energy Act, as amended, authorizes the Commission to enter into agreements with States whereby the Commission relinquishes and the States assume regulatory authority over byproduct, source, and special nuclear materials (in quantities not capable of sustaining a chain reaction).
Agreement State programs must be comparable to and compatible with the Commission's program for such material.
Presently, information on reportable occurrences ir. Agreement State licensed activities is publicly available at the State level.
Certain information is also provided to the NRC under exchange of information provisions in the agreements.
In early 1977, the Commission determined that abnormal occurrences happening at facilities of Agreement State licensees should be included in the quarterly reports to Congress.
The abnormal occurrence criteria included in Appendix A 1
viii 4
are applied uniformly to events at NRC and Agreement State l'censee facilities.
i Procedures have been developed and implemented, and abnormal occurrences reported by the Agreement States to the NRC are included in these quarterly reports to -
' Congress.
FOREIGN INFORMATION The NRC participates in an exchange of information with various foreign govern-ments that have nuclear facilities..This foreign information is reviewed and considered'in the NRC's assessment of operating experience and in its research and. regulatory activities.
Reference to foreign information may occasionally be made in these quarterly abnormal occurrence reports to Congress; however, only domestic abnormal occurrences are reported.
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y REPORT TO CONGRESS ON ABNORMAL OCCURRENCES JANUARY-MARCH 1989
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NUCLEAR POWER PLANTS y
T" NRC is reviewing events reported at the nuclear power plants licensed to operate.
For this report, the NRC has determined that the following events were abnormal occurrences.
89-1 Plug Failure Resulting in Steam Generator Tube Leak at North Anna Unit 1 The following information pertaining to the event is also being reported con-currently in the Federal Register.
Appendix A (see the second general criterion) of this report notes that major degradation of essential safety-related equip-ment can be considered an abnormal occurrence.
Also, Example 10 of "For All Licensees" of Appendix A notes that a major deficiency in design, construction, or operation having safety implications requiring immediate remedial action can i
be. considered an abnormal occurrence.
In addition, Example 12 of "For All Li-censees" of Appendix A notes that an incident with implications for similar facilities (generic incidents) which create major safety concern can be consid-ered an abnormal occurrence.
Date and Place - February 25, 1989; North Anna Unit 1, a Westinghouse-designed pressurized water reactor (PWR), operated by Virginia Electric and Power Company, and located in Louisa County, Virginia.
Nature and Probable Consequences - At 2:07 p.m., Unit 1 automatically trip' ped from 76 percent power.
The initiating signal for the reactor trip was "C steam generator (S/G) steam flow greater than feedwater flow coincident with a low S/G water level; this was later determined to be caused by the "C" main feedwater regulating valve closing due to a problem in the instrument air supply line.
During recovery operations, operators noted that primary system makeup was 50-60 gpm greater than letdown and that the condenser air ejector monitor indicated increased radiation. The licensee identified a primary-to-secondary leak of about 74 gpm in the "C" S/G and declared a Station Alert at 3:25 p.m.
The li-censee continued cooldown and depressurization.
The plant entered cold shut-down at 10:12 p.m. and the Station Alert was terminated at 10:20 p.m.
At the time of the event, Unit 2 was in a refueling shutdown.
Investigation showed that the leak was in tube R3C60 (Row 3 Column 60), about 4 inches-above the seventh support plate.
The tube had been plugged by Westing-house in 1985. The leak was due to a hot leg mechanical plug failure.
The top portion of the plug was severed from the body of the plug, was propelled up the.
inner diameter of the tube by the primary system pressure, and punctured the tube 1
just above the U-bend transition.
The puncture was approximately 2-1/4 inches long and 3/4 inches wide.
The plug dented an adjacent tube, R4C60.
A small radioactive release occurred, resulting in dose rates less than approximately l
l 3 percent of technical specification limits.
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Failure of the plug was attributed to primary water stress corrosion cracking of heat treated plug material (Inconel 600) due to low mill anneal temperatures which rendered the material highly susceptible to stress corrosion cracking.
The primary-to-secondary leak was well within the normal primary system makeup capability; in addition, the radiological releases were well below technical specification limits.
However,- the event identified major safety concerns because:
(a) this was an unexpected failure mechanism for S/G tubes; (b) it was a potential common mode failure mechanism with the possibility of multiple
.S/G tubes failing; and (c) there were generic implications for other plants using such. susceptible tube plugs.
Previously, North Anna Unit 1 experienced an S/G tube rupture on July 15, 1987.
This leak was also in the "C" steam generator, also near the seventh support plate.
The 1987 event was not caused by plug failure, but occurred because of fatigue failure due to fluid elastic excitation.
The tube had failed over 360 degrees of the circumference, and the fractured ends were displaced in the axial direction approximately one-half inch.
The leak rate was estimated to be between 550 to 637 gpm.
This event was reported as abnormal occurrence 87-15 in NUREG-0090, Vol. 10, No. 3.
Cause or Causes - As discussed above, the cause of the plug failure was attrib-E uted to primary water stress corrosion cracking of the heat treated Inconel 600
)
plug material.
Actions Taken to Prevent Recurrence Licensee - The licensee's recovery plan was to investigate (with Westinghouse) the cause of the failure, determine corrective actions, and place Unit 1 into a refueling / maintenance outage so that S/G repairs could be done simultaneously.
~
The susceptible plugs were identified in the S/Gs for both Unit 1 and Unit 2.
Repairs consisted either of removing susceptible plugs and replacing them, or inserting a different type of plug into susceptible plugs.
Repairs were com-pleted for the S/Gs of both Units and the NRC agreed that the plants could be restarted. sUnit 2 returned to power operation by the end of April 1989.
Unit 1 restarted in July 1989.
NRC - The NRC continues to investigate the potential generic implications of heat treated mechanical plugs used by Westinghouse, Combustion Engineering, and Babcock and Wilcox designed plants.
On March 23, 1989, the NRC issued Informa-tion Notice No. 89-33 (" Potential Failure of Westinghouse Steam Generator Tube Mechanical Plugs") to all holders of operating licenses or construction permits for PWRs to alert licensees to the potential for plug failures (Ref. 1).
On May 15, 1989, the NRC issued Bulletin No. 89-01 (" Failure of Westinghouse Steam Generator Tube Mechanical Plugs") to all holders of operating licenses or construction permits for PWRs (Ref. 2).
The bulletin requested the addressees to determine whether certain mechanical plugs supplied by Westinghouse are installed in their steam generators and, if so, that an action plan be imple-mented to ensure that these plugs will continue to provide adequate assurance of reactor coolant system pressure boundary integrity under normal operating, transient, and postulated accident conditions.
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Unless new, significant information becomes available, this item is considered t
closed for the purposes of this report.
- aaaa 89-2 Steam Generator Tube Rupture at McGuire Unit 1 The following information pertaining to this event is also being reported con-currently in the Federal Register.
Appendix A (see the second general criterion) of this report notes that major degradation of essential safety-related equip-ment can be considered an abnormal occurrence.
Also, Example 2 of "For Commer-cial Nuclear Power Plants" of Appendix A notes that major degradation of the primary coolant pressure boundary can be considered an abnormal occurrence.
Date and Place - March 7, 1989; McGuire Unit 1, a Westinghouse-designed pres-surized water reactor (PWR) operated by Duke Power Company, and located in Mecklenburg County, North Carolina.
Nature and Probable Consequences - At 11:40 p.m., Unit 1, while at 100% power, received a "B" main steam line radiation monitor alarm which could not be reset.
A substantial and continual decrease in pressurizer level and steam generator (S/G) "B" feedwater flow were noted in the control room.
The control room opera-tors suspected an S/G tube leak. The licensee immediately took action to reduce plant load.
At 11:45 p.m., the licensee declared a Station Alert.
At 11:46 p.m.,
the reactor was manually tripped (which caused a turbine trip), and the licensee continued procedures for plant cooldown to equalize reactor coolant and S/G pressure to reduce the leak rate.
The licensee terminated the Station Alert at 6:15 p.m. on March 8, 1989.
The maximum tube leak rate was estimated to be between 540 and 600 gpm.
This leak rate considerably exceeds the normal primary system makeup capability [i.e.,
with the centrifugal charging pumps (CCPs) operating as part of the chemical and volume control system].
In order to keep up with the leak, the licensee switched the pumps to their safety injection lineup - the pumps taking suction on the fueling water storage tank and injecting into all four cold legs of the reactor vessel.
In this mode, each CCP can pump from about 150 gpm at normal operating pressure to over 300 gpm at reduced pressure.
Steam generator tube rupture is one of the design basis accidents considered in the NRC safety review of nuclear pown plants.
Significant S/G tube ruptures, where the leak rate considerably exceeds the normal primary system makeup capability, occasionally occur, as it did at McGuire Unit 1, and previously at Ginna and North Anna Unit 1.
The event at Ginna occurred on January 25, 1982 with an estimated maximum leak rate of about 760 gpm; the event was reported as abnormal occurrence 82-4 in NUREG-0090, Vol. 5, No. 1.
The event at North Anna Unit 1 occurred on July 15, 1987 with an estimated maximum leak rate between 550 to 637 gpm; the event was reported as abnormal occurrence 87-15 in NUREG-0090, Vol. 10, No. 3.
An Augmented Inspection Team (AIT) was sent by the NRC to investigate the McGuire Unit 1 event.
The team concluded that the operating crew performed competently, but weaknesses in both normal and emergency operating procedures were identified.
The tube failure did not result in a radiological release to the environment that exceeded regulatory limits.
The event did not result in exceeding a technical 3
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specification (TS) safety limit.
The whole body and thyroid doses from this event were a small fraction of the TS limits.
All notifications to the NRC and offsite agencies were made in a timely manner.
The AIT report, documented in Inspection Report Nos. 50-369/89-06 and 50-370/89-06, was issued to the licensee on April 10, 1989 (Ref. 3).
Cause or Causes - Investigation by the licensee determined that the leak was due to a crack in tube R18C25 on the cold leg side (preheater section) about 3-3/4 inches long, and about one foot above the top of the tube sheet.
The licensee i'
concluded that the cause of the tube rupture was intergranular stress corrosion cracking; the rupture was contained within a long, shallow, axial groove on the outside tube surface.
Actions Taken to Prevent Recurrence Licensee - The-licensee's recovery actions included inspection of all tubes in all four S/Gs, metallurgical analysis of the ruptured tube, removal or plugging of tubes as necessary, and revision of the procedures which the AIT identified i
as needing upgrading.
The licensee committed to a 100% inspection of the inser-vice S/G tubes of all S/Gs at both McGuire Units 1 and 2 at their next refueling outages.
NRC - The NRC staff concurred with the corrective actions taken, and the commit-ments made by the licensee.
Permission to restart Unit 1 was given on May 5, 1989. The plant attained criticality on May 9, 1989, and reached full power operation on May 13, 1989.
This item is considered closed for the purposes of this report.
FUEL CYCLE FACILITIES
- xs***nn (Other Than Nuclear Power Plants)
The NRC is reviewing events reported by these licensees.
For this report, the NRC has not determined that any events were abnormal occurrences.
OTHER NRC LICENSEES (Industrial Radiographer, Medical Institutions, Industrial Users, etc.)
l There are currently about 9,000 NRC nuclear material licenses in effect in the i
United States, principally for use of radioisotopes in the medical, industrial,
)
and academic fields.
Incidents were reported in this category from licensees l
such as radiographer, medical institutions, and byproduct material users.
The NRC is reviewing events reported by these licensees.
For this report, the NRC has determined that the following events were abnormal occurrences:
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89-3 Medical Therapy Misadministration The following information pertaining to this event is also being reported concurrently in the Federal Register.
Appendix A (see the general criterion) of this report notes that an event involving a moderate or more severe impact on public health or safety can be considered an abnormal occurrence.
Date and Place - January 23, 1989; Abbott Northwestern Hospital; Minneapolis, Ennesota.
Nature and Probable Consequences - A patient suffering from a malignant tumor on his right femur (thigh) received a 250 rad radiation dose to the left femur by mistake.
The patient was scheduled for 12 treatments of 250 rads each to the right thigh using a cobalt-60 teletherapy device. The procedure was for the patient to be brought to the teletherapy simulator to begin preparation for the actual treat-ment. The simulator is used to chart or map the exact area on the patient's body to be exposed to the cobalt-60.
Once this area is determined, it is outlined with indelible ink by the simulator technologist.
The patient is then transferred to the cobalt-60 teletherapy room for treatment.
On January 23, 1989, the patient was placed on the simulator table.
Due to machine restrictions, however, the table had to be turned 180 degrees, placing the patient's left thigh closest to the technician and the thigh to be treated furthest away. With the patient's position reversed, the technician mistakenly marked the wrong thigh.
Once the marking was completed, the therapy physician reviewed and approved the incorrect setup.
The patient was then taken to the treatment room where the left femur was exposed to 250 rads of radiation.
The therapy technologist discovered the error within minutes of the exposure when she received a copy of the simulator check list.
The check list specified that the right femur was the area to be treated.
Treatment was subsequently performed on the correct femur and the treatment schedule continued.
The patient's referring physician and the NRC's Region III Office were informed of the misadministration on January 23, 1989.
The licensee determined that the misadministration could possibly cause the patient increased fatigue and possible bone marrow suppression in the left femur.
Cause or Causes - Several ; ersonnel errors occurred in this misadministration.
The simulator technologist, in turning the table, apparently disoriented herself, and marked the wrong thigh.
The therapy physician checked and approved the incor-rect thigh marking and treatment.
The therapy technologist should have waited until the patient's simulator check list was available in the teletherapy unit before commencing treatment.
Actions Taken To Prevent Recurrence t
Licensee - As documented in an NRC Region III Confirmatory Action Letter dated January 25, 1989 (Ref. 4), the licensee committed to:
(1) provide additional guidance to the simulator and operator technologists and the therapy physician on procedures governing teletherapy administration; (2) inform the operator technologist that the completed simulation check list describing the treatment 5
must be on hand and reviewed prior to setup; (3) provide NRC Region III within 30 days a comprehensive quality assurance / quality control (QA/QC) program which will incorporate Item 2; and (4) assure that the QA/QC procedure also will cover dosimetry, treatment planning and implementation, and radiation safety practices.
On February 16, 1989, the licensee notified NRC Region III that it had completed all items listed in the Confirmatory Action Letter.
The licensee's QA/QC program includes dosimetry checks by three independent reviewers, chart checks by two
. independent reviewers, and treatment prescription by a physician.
The hospital had a QA/QC policy prior to the misadministration that included some of the above procedures.
NRC - An NRC inspection was conducted on February 14-15, 1989, to review the circumstances associated with the event (Ref. 5).
Four minor violations of NRC require ~ nts were identified-none relating to the misadministration.
An NRC consuh.;c.g physician reviewed the patient misadministration and determined that the misadministration would not likely have any significant or deleterious effect on the patient.
The licensee's revised policy, and its implementation, will be reviewed by the NRC at the next routine inspection at the hospital.
This item is considered closed for the purposes of this report.
89-4 Medical Therapy Misadministration The following information pertaining to this event is also being reported concurrently in the Federal Register.
Appendix A (see the general criterion) of this report notes that an event involving a moderate or more severe impact on public health or safety can be considered an abnormal occurrence.
Date and Place - March 9, 1989; Kennebec Valley Medical Center; Augusta, Maine.
Nature and Probable Consequences - A radiotherapy physician had prescribed therapeutic treatments in fractionated doses to two clderly patients from a Veteran's Administration facility.
One patient was to be treated for a brain tumor, while the second patient was to be treated for a lesion near the lower palate.
Both patients were brought to the hospital at the same time.
Because of an identification error, the second (lower palate) patient was brought into the treatment room and the procedure for the brain tumor treatment was begun.
When the error was discovered, the procedure was stopped.
A total of 100 rads had been delivered to the brain of the patient. The patient had correctly received 2400 rads to the lower palate from previous treatments.
The licensee has advised the NRC that no adverse effects are anticipated as a result of the misadministration.
Cause or Causes - The misadministration was caused by human error on the part of the staff of the radiotherapy department at the medical center.
The names, physical appearances, and treatment planning pictures of both patients were similar.
6
Actions Taken to Prevent Recurrence Licensee'- The. licensee's planned corrective actions include a strengthening of its patient identification policies along with second person confirmation
'of' patient, identity and treatment parameters.
NRC - NRC Region I will conduct an inspection to review the circumstances associated with this misadministration.
Unless new, significant information becomes available, this item is considered I,
closed for the purposes of this report.
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89-5 Medical Diagnostic Misadministration l
The following information pertaining to this event is also being reported concurrently in the Federal Register.
Appendix A (see the general criterion)
I of this report notes that an event involving a moderate or more severe impact on public health or safety can be considered an abnormal occurrence.
Date and Place - March 14, 1989; New England Medical Center Hospitals; Boston, Massachusetts, Nature and Probable Consequences - A patient was intended to receive an iodine-123 uptake and diagnostic scan. This would result in an exposure to the thyroid of about 7 rads.
However, a staff endocrinologist mistakenly requested an iodine-131 uptake and scan.
A floor administrator, transcribing the request to a computer, selected an iodine-131 whole body scan as the intended request. The dosage for this incorrect procedure was prepared and administered to the patient by nuclear medicine department personnel, resulting in the patient receiving five millicuries of iodine-131.
This misadministration resulted in a therapeutic dose to the thyroid of approximately 4,000 to 5,000 rads, with a possible range be-tween 1,200 and 9,000 rads.
This dosage could affect the function of the thyroid.
The licensee stated that the patient, a cardiac patient under the care of an endocrinologist, might later have been administered a similar dosage of iodine-131 for thyroid ablation as treatment for his cardiac condition.
However, this is no basis for the misadministration; the incident should not have occurred if proper controls had been in place and followed.
Cause or Causes - The licensee stated that the misadministration was caused by human error on the part of the staff endocrinologist and lack of training cf involved personnel.
The root cause was due to inadequate supervision of activities.
Actions Taken to Prevent Recurrence Licensee - The licensee stated that:
(1) the Chief of Nuclear Medicine will review all requests for iodine-131 whole body scans, and (2) there will be weekly interdepartmental meetings of the Nuclear Medicine Department and the Department of Endocrinology.
7
NRC - NRC Region I conducted a special inspection or June 5, 1989, to review the circumstances associated with the event, and ths appropriateness of the licensee's corrective actions.
The results of the inspection are under review.
Region I requested an NRC medical consultant to r -vir.w the incident.
Future reports will be made as appropriate.
- a AGREEMENT STATE LICENSEES Procedures have been developed for the Agreement States to screen unscheduled incidents or events using the same criteria as the NRC (see Appendix A) and report the events to the NRC for inclusion in this report.
For this report, the Agreement States reported no abnormal occurrences te the NRC.
l l
l l
l l
l i
l 8
r REFERENCES
{
l 1.
U.S. Nuclear Regulatory Commission, NRC Information Notice No. 89-33,
" Potential Failure of Westinghouse Steam Generator Tube Mechanical Plugs,". March 23, 1989.*
2.
U.S. Nuclear Regulatory Commission, NRC Bulletin No. 89-01, " Failure of Westinghouse Steam Generator Tuba Mechanical Plugs," May 15, 1989.*
3.
Letter from Stewart D. Ebneter, Regional Administrator, NRC Region II, to H.B. Tucker, Vice President, Nuclear Production Department, Duke Power Company, forwarding Augmented Inspection Team Report Nos. 50-369/89-06 and 50-370/89-06, Docket Nos. 50-369 and 50-370, April 10, 1989.*
l 4.
Confirmatory Action Letter (CAL)-RIII-89-003, from A. Bert Davis, Regional Administrator, NRC Region III, to J. Thomas Payne, Ph.D., Radiation Therapy Department, Abbott Northwestern Hospital, Docket No.30-297, License No. 22-04588-02, January 25, 1989.*
5.
Letter from D.J. Sreniawski, Chief, Nuclear Materials Safety, Section 2, NRC Region III, to Donald Brumm, Senior Administrator, Abbott Northwestern Hospital, Docket No.30-297, License No. 22-04588-02, March 17, 1989.*
I
- Available in NRC Public Document Room, 2120 L Street, NW, (Lower Level)
Washington, D.C., for public inspection and/or copying.
9 l
APPENDIX A ABNORMAL OCCURRENCE CRITERIA The following criteria for this report's abnormal occurrence determinations were set forth in an NRC policy statement published in the Federal Register on February 24, 1977 (Vol. 42, No. 37, pages 10950-10952).
An event will be considered an abnormal occurrence if it involves a major reduction in the degree of protection of the public health or safety.
Such an event would involve a moderate or more severe impact on the public health or j
safety and could include but need not be limited to:
1 1
1.
Moderate exposure to, or release of, radioactive material licensed by or j
otherwise regulated by the Commission; i
)
2.
Major degradation of essential safety-related equipment; or 3.
Major deficiencies in design, construction, use of, or management controls for licensed facilities or material.
Examples of the types of events that are evaluated in detail using these cri-teria are:
l 1
For All Licensees 1.
Exposure of the whole body of any individual to 25 rems or more of radia-tion; exposure of the skin of the whole body of any individual to 150 rems or more of radiation; or exposure of the feet, ankles, hands or forearms of any individual to 375 rems or more of radiation [10 CFR 920.403(a)(1)],
or equivalent exposures from internal sources.
2.
An exposure to an individual in an unrestricted area such that the whole body dose received exceeds 0.5 ram in one calendar year [10 CFR 920.105(a)].
3.
The release of radioactive material to an unrestricted area in concentra-tions which, if averaged 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 regulatory limit of Appendix B, Table II, 10 CFR Part 20 [10 CFR 920.403(b)].
4.
Radiation or contamination levels in excess of design values on packages, or loss of confinement of radioactive material such as (a) a radiation dose rate of 1,000 mrem per hour three feet from the surface of a package containing the radioactive material, or (b) release of radioactive mate-rial from a package in amounts greater than the regulatory limit.
l I
5.
Any loss of licensed material in such quantities and under such circum-stances that substantial hazard may result to persons in unrestricted areas.
6.
A substantiated case of actual or attempted theft or diversion of licensed material or sabotage of a facility.
11
I 7.
Any substantiated loss of special nuclear material or any substantiated inventory discrepancy that is judged to be significant relative to nor-mally expected performance and that is judged to be caused by theft or diversion or by substantial breakdown of the accountability system.
8.
Any Substantial breakdown of physical security or material control (i.e.,
access control, containment, or accountability systems) that significantly weakened the protection against theft, diversion, or sabotage.
9.
An accidental criticality [10 CFR 670.52(a)].
10.
A major deficiency in design, construction, or operation having safety implications requiring immediate remedial action.
11.
Serious deficiency in management or procedural controls in major areas.
12.
Series of events (where individual events are not of major importance),
recurring incidents, and incidents with implications for similar facilities (generic incidents) which create major safety concern.
For Commercial Nuclear Power Plants 1.
Exceeding a safety limit of license technical specifications [10 CFR 550.36(c)].
2.
Major degradation of fuel integrity, primary coolant pressure boundary, or primary containment boundary.
3.
Loss of plant capability to perform essential safety functions such that a potential release of radioactivity in excess of 10 CFR Part 100 guidelines could result from a postulated transient or accident (e.g., loss of emer-gency core cooling system, loss of control rod system).
4.
Discovery of a major condition not specifica'ly considered in the safety analysis report (SAR) or technical specifications that requires immediate remedial action.
4 5.
Personnel error or procedural deficiencies that result in ioss of plant capability to perform essential safety functions such that a potential release of radioactivity in excess of 10 CFR Part 100 guidelines could result from a postulated transient or accident (e.g., loss of emergency core cooling system, loss of control rod system).
i For Fuel Cycle Licensees 1.
A safety limit of license technical specifications is exceeded and a plant shutdown is required [10 CFR S50.36(c)].
2.
A major condition not specifically considered in the safety analysis re-port or technical specifications that requires immediate remedial action.
3.
An event that seriously compromised the ability of a confinement system to perform its designated function.
12
I l
\\
l APPENDIX B UPDATE OF PREVIOUSLY REPORTED ABNORMAL OCCURRENCES During the January through March 1989 period, NRC licensees, Agreement States, Agreement State licensees, and other involved parties, such as reactor vendors and architect-engineering firms, continued with the implementation of actions necessary to prevent recurrence of previously reported abnormal occurrences.
The referenced Congressional abnormal occurrence reports below provide the initial and any subsequent updating information on the abnormal occurrences dis-cussed.
The updating provided generally covers events that took place during the report period; some updating, however, is more current as indicated by the associated event dates.
Open items will be discussed in subsequent reports in the series.
NUCLEAR POWER PLANTS 79-3 Nuclear Accident at Three Mile Island This abnormal occurrence was originally reported in NUREG-0090, Vol. 2, No.1,
" Report to Congress on Abnormal Occurrences:
January-March 1979," and updated in each subsequent report in this series (NUREG-0090, Vol. 2, No. 2 through Vol. 11, No. 4).
It is planned to continue these updates until defueling activities at the site are completed. The update of activities for this report period is as follows:
Reactor Vessel and Ex-Vessel Defueling Operatings During the January through March 1989 period, approximately 19,300 pounds of fuel and debris were removed from the reactor vessel.
The total mass loaded into canisters to date is approximately 227,300 pounds (about 76 percent out of a total of approximately 300,000 pounds of core debris and other materials).
The total mass to be removed includes the mass of the core; structural and absorber materials; mass added by oxidation of core and structural material; and portions of the baffle plates, formers, and other components that will become commingled with core debris during cutting operations. The original core area ha: been defueled; principal remaining areas are the outer periphery of the lower core support assembly (LCSA), lower head, and the area between the core baffle plates and the core barrel.
LCSA disassembly and defueling have proceeded using the core drilling rig and a plasma arc cutting torch.
The LCSA consists of five layers (plates):
the lower grid rib section (LGRS), the flow distributor plate (FDP), the grid forg-ing, the guide tube support plite (GTSP), and the elliptical flow distriteutor (EFD).
The central portions of these five plates have been cut away to provide access to the lower head.
The cut portions of the top four plates have been removed and placed underwater in a modified core flood tank for shielding.
The next steps in the defueling include removing the cut pieces of the EFD and removing the core baffle plates.
Decontamination and Dose Reduction Activities l
i Since early December 1988, the licensee has focused its efforts on the completion of defueling and the support of that activity.
Decontamination (other than 13
l reactor building) and system flushing activities are currently suspended, e % c limited efforts to maintain access to, and the operability of, plant systems.
Fuel Cask Shipments During the period, one additional shipment cantaining 13,600 pounds of core debris was made from TMI-2 to the Idaho National Engineering Laboratory (INEL).
The total amount shipped is 210,900 pounds, about 70 percent of the total to be shipped.
Post-Defueling Monitored Storage As mentioned in previous reports, on April 27, 1988, the NRC staff issued Draft Supplement 3 to the Programmatic Environmental Impact Statement (PEIS) related to the decontamination and disposal of radioactive waste resulting from the March 29, 1979, accident at TMI-2 (Ref. B-1).
This Supplement evaluates the impacts of the licensee's proposal to place the facility in a state of Post-Defueling Monitored Storage (PDMS) until Unit 1 is ready for decommissioning.
The staff received final comments on the draft supplement from the Advisory Panel for the Decontamination of Three Mile Island Unit 2 in October 1988.
The NRC staff is evaluating the comments and preparing the Final Supplement 3 to the PEIS.
Proposal to Dispose of Accident-Generated Water The public hearing on evaporation of accident generated water (AGW) at Three Mile Island Unit 2 by the NRC Atomic Safety and Licensing Board Panel (ASLBP) concluded on November 15, 1988.
Contentions litigated were the analysis of the "no action alternative," characterization of the AGW, evaluations of poten-tial release of microorganisms, and the health effects of tritium.
The ASLBP ruled in favor of the licensee on February 3,1989.
The joint interveners requested a stay of the license amendment authorization and filed an intent to appeal the decision to the Atomic Safety and Licensing Appeal Panel (ASLAP) on February 21, 1989.
TMI-2 Advisory Panel Meetings The Advisory Panel for the Decontamination of Three Mile Island Unit 2 (Panel) met on February 15, 1989.
The Panel was briefed on the status of NRC actions and the status of the cleanup.
The licensee provided the Panel with a descrip-tion of the evaporator with which the licensee plans to dispose of the AGW.
The Panel members also questioned the licensee about scheduling and funding for the remainder of the cleanup.
The Panel will continue to follow issues related to fuel removal, PDMS, and the evaporation of AGW.
Future reports will be made as appropriate.
- * *
- n
- t. nn l
85-la Management Deficiencies at Tennessee Valley Authority This abnormal occurrence was originally reported in NUREG-0090, Vol. 8, No. 3,
" Report to Congress on Abnormal Occurrences:
July-September 1985," and updated in Vol. 9, No. 1; Vol. 9, No. 2; Vol. 9, No. 3; Vol. 10, No. 2; Vol. 10, No. 4; 14
Vol. 11, No. 1; Vol. 11, No. 2; Vol. 11, No. 3; and, Vol. 11, No. 4.
It is further updated for this report as follows:
Sequoyah Since the shutdown of both Sequoyah units in August 1985, the Tennessee Valley Authority (TVA) and the NRC have worked to resolve the issues to be addressed before the restart of the units.
On the basis of the staff review of the TVA program to resolve these issues and corrective actions taken by TVA, the NRC authorized TVA in 1988 to restart both units.
TVA was authorized to restart Unit 2 on March 30, 1988, and achieved criticality on May 13, 1988; TVA was authorized to restart Unit 1 on November 5, 1988, and achieved criticality on l
November 6, 1988.
On January 19, 1989, after a site record of 209 days of con-tinuous operation, Unit 2 was shutdown for a scheduled refueling outage.
Browns Ferry Browns Ferry Units 1, 2, and 3 have been shutdown and defueled since 1985.
Since that time, TVA has implemented various corrective action programs to address the problems which led to the shutdowns.
As a result of this progress and subsequent NRC audits and inspections condteted to assure that personnel, procedures, and training necessery to support a safe refueling and transition to a fueled shutdown mode were completed, TVA was allowed to reload fuel at Unit 2.
Currently, TVA is evaluating the restart schedule of Unit 2.
Prior to granting permission for restart, the NRC will conduct a thorough technical review, audit and inspection program to ensure that the deficiencies previously identified are corrected and that plant systems, procedures, and personnel are adequate to operate the unit safely.
Future reports will be made as appropriate.
15
APPENDIX C l
OTHER EVENTS OF INTEREST l
The following item is described because it may possibly be perceived by the pub-lic to be of public health or safety significance.
The item did not involve a major reduction in the level of protection provided for public health or safety; therefore, it is not reportable as an abnormal occurrence.
1.
Flammable / Explosive Mixtures of Hydrogen in Plant Systems at Robinson Unit 2 and Byron Unit 2 Hydrogen is used in pressurized water reactor (PWR) plants for (1) providing a cover gas in the volume control tank, and (2) for cooling the main turbine generator.
At boiling water reactor (BWR) plants, hydrogen is also used for cooling the main turbine generator and for injection into the feed system for plants which have implemented hydrogen water chemistry.
Because hydrogen becomes flammable and/or explosive at certain concentrations, controls must be taken to prevent hydrogen leaks.
Exposure of hydrogen to an ignition source is not only hazardous to personnel, but could result in damage to equipment required to mitigate the consequences of a design-basis accident.
Recent events during January 1989 are examples of hydrogen intruding into plant systems and igniting after being exposed to ignition sources.
The first event occurred on January 7, 1989, at Carolina Power and Light Company's Robinson Unit 2, a Westinghouse-designed PWR located in Darlington County, South Carolina.
The second event occurred on January 16, 1989, at Commonwealth Edison Company's Byron Unit 2, a Westinghouse-designed PWR located in Ogle County, Illinois.
During a refueling outage at Robinson Unit 2, while attempting to perform a post-maintenance air test on the turbine generator, a breakdown in administra-tive controls resulted in a maintenance technician cross-connecting the plant air systems (i.e., the instrument and station air systems) with the higher pressure hydrogen gas system.
This resulted in an intrusion of hydrogen irto various bran.ches of the plant air systems.
After about an hour into the air test, a small fire on the turbine deck was noted in a box containing several air lines for the moisture separator reheaters.
The fire was extinguished; at the time, the cause of the fire was attributed to welding slag.
About two hours later, a worker from the turbine deck reported flames coming out of his air operated grinder.
The control room shift foreman was informed; he investigated and concluded that hydrogen must have been introduced into the plant air systems.
The air line was isolated, all work was stopped that could cause a spark, and use of air systems was suspended.
The air systems in the reactor, auxiliary, turbine, and containment buildings were sampled.
Flammable concentrations of hydrogen up to about 8 percent were measured.
No hydrogen was detected in the open spaces of the buildings.
The licensee declared an Unusual Event.
The air systems were vented and purged until no hydrogen was detected in the plant air systems.
The Unusual Event was then terminated.
17
Investigation by the licensee indicated that multiple failures of administrative controls were the root causes of the event.
These were:
(1) failure to have procedures to control certain types of activities associated with the turbine generator; (2) failure to take out a clearance as required by the associated turbine generator work order; and (3) failure of operations to assume responsibility for oversight of turbine work during outages.
The licensee is formulating corrective actions to address these areas.
The NRC Resident Inspector followed up on this event and verified that the scope of the problem was being appropriately addressed, and that actions were in progress to mitigate the risk associated with the event.
On April 6, 1989, the NRC issued a Notice of Violation (NOV) to the licensee, partly because of the introduction of hydrogen into the air systems event (Ref. C-1).
The NOV cited the lack of a detailed maintenance procedure that probably could have prevented the occurrence, and also noted a lack of administrative control, inadequate communication, and poor work practices.
In regard to the Byron Unit 2 event, there was a hydrogen detonation in a safety injection accumulator while the plant was in a refueling outage.
Prior to the event, the "2A" accumulator had been drained to allow repair of a leaking manway.
After draindown of the accumulator was completed, the drain valve to the reactor coolant drains collection tank (RCDT) was left open per procedure.
At the time the containment was open to the auxiliary building.
Prior to the event the licensee observed an increase in airborne activity inside containment.
This activity consisted primarily of xenon, but at the time the activity's source had not been identified as the open vent path between the RCDT and the open accumulator manway.
The licensee believes that hydrogen entered the accumulator from the RCDT either from coolant out gassing or from the waste gas collection system which exhausts into the gas space in the RCDT.
A grab sample (taken before the event but analyzed after it) indicated that initially there was a hydrogen concentra-tion of 7.6 percent and an oxygen concentration of 9.6 percent.
On January 16, 1989, a radiation protection technician (RPT) lowered a motor driven air sampler into the open "2A" accumulator.
Sparking from the motor ignited the gaseous contents of the accumulator.
A small cloud of smoke and a rush of warm gas were expelled from the accumulator manway, accompanied by considerable noise and vibration.
The RPT's outer layer of clothing (a rain suit) was shredded; how-ever, he was not contaminated and the only apparent adverse physical effect was a ringing in the ears for several hours.
There was no damage to plant equipment.
The root cause of the event was attributed to procedural inadequacies because personnel had not been informed of hazardous conditions involving hydrogen and oxygen concentrations within the reactor coolant and associated systems.
Pro-cedures regarding the draining of the safety injection accumulator, and regarding sampling (by portable air sampling units) of enclosed spaces connected to the j
reactor coolant system, are being reviewed and appropriate cautionary notes and steps will be included to preclude similar events.
aaaa****
18
,q REFERENCES (FOR APPENDICES)
B-1 U.S. Nuclear. Regulatory Commission, " Programmatic Environmental Impact Statement.(PEIS) Related to Decontamination and Disposal of Radioactive Wastes Resulting from March 28, 1979 Accident at Three Mile Island Nuclear Station, Unit 2, Draft Supplement 3 Dealing with Post-Defueling Monitored Storage and Subsequent Cleanup," NUREG-0683, Draft Supplement No. 3,
' April 1988.*'
C-1 Letter from Stewart D. Ebneter, Regional Administrator, NRC Region II, to L.W. Eury, Executive Vice President, Power Supply and Engineering and Construction, Carolina Power and Light Company, forwarding a Notice of Violation, Docket No. 50-261, April 6, 1989.*
- Available in NRC Public Document Room, 2120 L Street, NW, (Lower Level),
Washington, D.C., for public inspection and/or copying.
i 19
i I
U.S. NUCLEAR REGULATORY COMMISSION 1.
P RT NgE gRy0CM 335 E"aE BIBLIOGRAPHIC DATA SHEET 9
tsee imeructsom on tse reme)
- 3. TITLE AND SUBTITLE R9 port to Congress on Abnormal Occurrences:
January - March 1989 3.
DATE REPORT FJBLISHED
)
MONIH Vi Art August 1989
- b. AUTHOR (S)
- 6. TYPE OF REPORT Quarterly
- 7. PE R toD COV E R E D isoctuure Oerest January - March 1989 B.PERF RMING ANIZ ATION ~ N AM E AND ADDRESS tro NRc. orova orvwon. ortwe er Revon. v.s Nucwor Reputarory Lemmannon. eno mearne ecores ; tr eontractor. orove Office for Analysis and Evaluation of Operational Data O.S. Nuclear Regulatory Commission Washington, DC 20555
- 9. SPONSOR lNG ORGANIZATION - N AM E AND ADDR ESS (19 NRC. troe "Some es ecove";it contractor.orovnw NRC Dovmon. Ortwo or Revon. U.t Nocker A*euterorv comnnwon.
ent anising soaveu)
Same as 8., above
- 10. SUPPLEMENTARY NOTES
- 11. ABST R ACT (200 =orm er *=>
Section 208 of the Energy Reorganization Act of 1974 identifies an abnormal occurrence as an unscheduled incident or event which the Nuclear Regulatory Commission determines to be significant from the standpoint of public health and safety and requires a
- Quarterly report of such events to be made to Congress. This report covers the period January 1 to March 31, 1989. For this reporting period, there were two abnormal occur-rences at nuclear power plants licensed to operate. The first had generic implication.s and involved a plug failure resulting in a steam generator tube leak at North Anna l
Unit 1.
The second involved a steam generator tube rupture at McGuire Unit 1.
There were three abnormal occurrences under other NRC-issued licenses. Two involved medical therapy misadministration and one involved a medical diagnostic misadmini-stration. There were no abnormal occurrences reported by the Agreement States. The report also contains information updating some previously reported abnormal occurrences.
11 AV AILAtsitii v 61 Al t MEN 1
- 12. KE Y WORDS/DESCRtP T ORS ttar words or ohrases ther w#s essist iesearceers m sorereng rne twoorr.J Unlimited Steam Generator Tube Plug Failure; Steam Generator Tube Rupture; iu. cue u ssoc nun Medical Therapy Misadministration; Medical Diagnostic Misadmini-
,,,,,,e,,,
stration; Flammable / Explosive Hydrogen Mixtures in Plant Systems.
Unclassified (Tha Birport)
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