Event Notification Report for September 14, 2000
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
09/13/2000 - 09/14/2000
** EVENT NUMBERS **
37312 37313 37314 37315 37316 37317 37318
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|Power Reactor |Event Number: 37312 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: MILLSTONE REGION: 1 |NOTIFICATION DATE: 09/13/2000|
| UNIT: [] [] [3] STATE: CT |NOTIFICATION TIME: 07:35[EDT]|
| RXTYPE: [1] GE-3,[2] CE,[3] W-4-LP |EVENT DATE: 09/12/2000|
+------------------------------------------------+EVENT TIME: 07:40[EDT]|
| NRC NOTIFIED BY: WILLIAM HOFFNER |LAST UPDATE DATE: 09/13/2000|
| HQ OPS OFFICER: FANGIE JONES +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |JAMES TRAPP R1 |
|10 CFR SECTION: | |
|HFIT 26.73 FITNESS FOR DUTY | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
| | |
|3 N Y 100 Power Operation |100 Power Operation |
+------------------------------------------------------------------------------+
EVENT TEXT
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| 24 HOUR FITNESS FOR DUTY REPORT |
| |
| A licensed operator was administered a for-cause breathalyzer test after |
| observation by operating staff that the individual's breath smelled of |
| alcohol. The operator was oncoming and was not allowed to take the watch. |
| Operations management personnel directed that the individual be taken home |
| pending management review of the situation. Corrective action for |
| consideration of resumption of licensed duties will follow management's |
| review. |
| |
| The licensee notified the NRC Resident Inspector and will notify the State |
| of Connecticut. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 37313 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: NINE MILE POINT REGION: 1 |NOTIFICATION DATE: 09/13/2000|
| UNIT: [] [2] [] STATE: NY |NOTIFICATION TIME: 07:58[EDT]|
| RXTYPE: [1] GE-2,[2] GE-5 |EVENT DATE: 09/13/2000|
+------------------------------------------------+EVENT TIME: 04:33[EDT]|
| NRC NOTIFIED BY: MATT WALDECKER |LAST UPDATE DATE: 09/13/2000|
| HQ OPS OFFICER: FANGIE JONES +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |JAMES TRAPP R1 |
|10 CFR SECTION: | |
|AESF 50.72(b)(2)(ii) ESF ACTUATION | |
|AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 N N 0 Cold Shutdown |0 Cold Shutdown |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| AUTOMATIC START OF THE HIGH PRESSURE CORE SPRAY PUMP |
| |
| The licensee reported that the high pressure core spray (HPCS) pump |
| automatically started when the pump control switch was taken out of the |
| "pull-to-lock" position. The HPCS system was out of service for maintenance |
| at the time of the event and had been declared inoperable on 09/12/00 at |
| 0520 EDT. The HPCS spray injection valve did not open, as it was |
| deenergized closed. The divisional diesel generator did not start as it was |
| configured in the maintenance mode. |
| |
| There was no impact on the plant. The plant is in cold shutdown with the |
| mode switch in the refuel position. The cause of the actuation is unknown |
| and an investigation is in progress. |
| |
| The licensee intends to notify the NRC Resident Inspector. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 37314 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: LASALLE REGION: 3 |NOTIFICATION DATE: 09/13/2000|
| UNIT: [] [2] [] STATE: IL |NOTIFICATION TIME: 13:15[EDT]|
| RXTYPE: [1] GE-5,[2] GE-5 |EVENT DATE: 09/13/2000|
+------------------------------------------------+EVENT TIME: 09:54[CDT]|
| NRC NOTIFIED BY: OKOPNY |LAST UPDATE DATE: 09/13/2000|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |MARK RING R3 |
|10 CFR SECTION: | |
|AESF 50.72(b)(2)(ii) ESF ACTUATION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 N Y 100 Power Operation |100 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| THE "2A" DIESEL GENERATOR WAS INADVERTENTLY STARTED BY THE UNIT OPERATOR |
| |
| Unit 2 was operating at 100% power. A Division 2 Residual Heat Removal |
| (RHR) Surveillance was in progress, which required the "2A" Diesel Generator |
| Cooling Water Pump to be started. The Unit Operator inadvertently placed the |
| Control Switch for the "2A" Diesel Generator to START. The Unit Operator |
| recognized the error and the Diesel Generator Control Switch was immediately |
| placed in STOP. The "2A" Diesel Generator and |
| Diesel Generator Cooling Water Pump switches are side by side on the panel. |
| The Diesel Generator reached at Least 150 RPM as indicated by the Auto Start |
| of the "2A" Diesel Generator Cooling Water Pump. The Diesel Generator was |
| returned to a Standby Operable condition. |
| |
| The NRC Resident Inspector was notified. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 37315 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: WNP-2 REGION: 4 |NOTIFICATION DATE: 09/13/2000|
| UNIT: [2] [] [] STATE: WA |NOTIFICATION TIME: 14:38[EDT]|
| RXTYPE: [2] GE-5 |EVENT DATE: 09/13/2000|
+------------------------------------------------+EVENT TIME: 11:19[PDT]|
| NRC NOTIFIED BY: ARBUCKLE |LAST UPDATE DATE: 09/13/2000|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |GARY SANBORN R4 |
|10 CFR SECTION: | |
|AOUT 50.72(b)(1)(ii)(B) OUTSIDE DESIGN BASIS | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|2 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| PLANT OUTSIDE DESIGN BASIS FOR CONTROL ROOM EMERGENCY FILTRATION SYSTEM |
| UNFILTERED INLEAKAGE BASED UPON TRACER GAS TESTING - IMPACT ON CONTROL ROOM |
| DOSE CONSIDERATIONS |
| |
| "During September 8 through 11, 2000, a series of special tests, using a |
| tracer gas decay methodology, were performed to determine the total |
| inleakage into the control room and the associated impact on control room |
| dose. These tests were performed in support of a proposed Technical |
| Specification amendment request that is in the process of being developed |
| for removal of main steam leakage control system test requirements and |
| resolution of a long-standing issue pertaining to secondary |
| containment/standby gas treatment system performance, using alternative |
| source term methodology. The testing was also performed in response to |
| NRC-industry initiative efforts to resolve the generic issue of the validity |
| of control room unfiltered air infiltration rate assumed by licensees in |
| control room habitability assessments. |
| |
| "On September 13, 2000, test results were evaluated and a preliminary |
| assessment shows the highest train measured unfiltered inleakage for the |
| control room emergency filtration system, as determined by the tracer gas |
| testing, to be 83 � 37 cfm. This is in excess of the current licensing and |
| design basis limit of 10.55 cfm. The impact of this unfiltered inleakage |
| increase on control room dose was evaluated and it was determined that the |
| design basis thyroid dose of 30 rem to the control room operators would be |
| exceeded during post-accident conditions. |
| |
| "A Follow-Up Assessment of Operability (similar to a Justification for |
| Continued Operation) was prepared to allow continued plant operation in this |
| condition. The operability determination, which was based upon an |
| evaluation of control room dose for several accident scenarios, concluded |
| that the as-found inleakage did not render the control room emergency |
| filtration system inoperable (based upon 10CFR50, Appendix A, GDC 19). In |
| addition, a follow-up interim compensatory measure to reduce the calculated |
| control room thyroid dose below the 30 rem limit includes administration of |
| potassium iodide in accordance with requirements contained in abnormal |
| operating procedures. Final resolution of this issue will be addressed by |
| implementation of alternative source term methodology at WNP-2 and as part |
| of the proposed Technical Specification amendment request. A feasibility |
| study, using alternative source term methodology, has shown that inleakage |
| rates well in excess of 83 � 37 cfm (approximately 300 cfm) would result in |
| control room doses below the regulatory limit. This is a design basis |
| analysis issue and no plant hardware changes are required in the resolution |
| of the problem. We are continuing to follow the NRC-industry initiative |
| efforts to resolve generic issues related to control room habitability." |
| |
| The NRC Resident Inspector was notified. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Hospital |Event Number: 37316 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: UNIVERSITY OF VIRGINIA HOSPITAL |NOTIFICATION DATE: 09/13/2000|
|LICENSEE: UNIVERSITY OF VIRGINIA HOSPITAL |NOTIFICATION TIME: 16:39[EDT]|
| CITY: CHARLOTTESVILLE REGION: 2 |EVENT DATE: 09/07/2000|
| COUNTY: STATE: VA |EVENT TIME: [EDT]|
|LICENSE#: AGREEMENT: N |LAST UPDATE DATE: 09/13/2000|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |STEPHEN CAHILL R2 |
| |LARRY CAMPER NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: PICCOLO | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| THE UNIVERSITY OF VIRGINIA HOSPITAL REPORTED A MEDICAL MISADMINISTRATION |
| DURING BRACHYTHERAPY. |
| |
| A patient being treated for cervical cancer was given a higher dose (8 gray) |
| instead of the prescribed dose (5 gray) due to human error resulting in the |
| wrong dwell times being used. It appears there will be no adverse affects |
| to the patient. The patient and the referring physician will be notified. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 37317 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: VERMONT YANKEE REGION: 1 |NOTIFICATION DATE: 09/13/2000|
| UNIT: [1] [] [] STATE: VT |NOTIFICATION TIME: 17:51[EDT]|
| RXTYPE: [1] GE-4 |EVENT DATE: 09/13/2000|
+------------------------------------------------+EVENT TIME: 16:36[EDT]|
| NRC NOTIFIED BY: MAY |LAST UPDATE DATE: 09/13/2000|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |JAMES TRAPP R1 |
|10 CFR SECTION: | |
|ARPS 50.72(b)(2)(ii) RPS ACTUATION | |
|AESF 50.72(b)(2)(ii) ESF ACTUATION | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 M/R Y 100 Power Operation |0 Hot Shutdown |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| MANUAL REACTOR SCRAM FROM 77% POWER FOLLOWING LOSS OF CONDENSER VACUUM |
| |
| This occurred when the plant lost condenser vacuum after the steam jet air |
| ejector valves closed. This valve closure was the result of a blown valve |
| indication light bulb being changed. The reactor was manually scrammed |
| from 77% power when the vacuum reached 6.5" Hg and decreasing. After the |
| reactor scram the reactor vessel water level dipped below 127"(as low as |
| 121") initiating groups 2, 3, 4 and 5 isolations and start of the standby |
| gas treatment system. All rods fully inserted, no ECCS injection occurred |
| and no relief valves lifted. |
| |
| The NRC Resident Inspector will be informed |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 37318 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: ARIZONA RADIATION REGULATORY AGENCY |NOTIFICATION DATE: 09/13/2000|
|LICENSEE: UNIVERSITY OF ARIZONA |NOTIFICATION TIME: 18:40[EDT]|
| CITY: TUCSON REGION: 4 |EVENT DATE: 07/22/2000|
| COUNTY: STATE: AZ |EVENT TIME: [MST]|
|LICENSE#: 10-024 AGREEMENT: Y |LAST UPDATE DATE: 09/13/2000|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |GARY SANBORN R4 |
| |LARRY CAMPER NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: GODWIN (VIA FAX) | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| TRITIUM RELEASE FROM THE UNIVERSITY OF ARIZONA |
| |
| At approximately 10:30 AM, September 6, 2000, the Agency was advised by the |
| Radiation Safety Officer of the University that a laboratory had reported |
| approximately 100 microcuries of tritium had been picked up by the custodial |
| staff. The University Radiation Control office commenced an investigation of |
| the problem and on September 7, 2000 reported that approximately 31 |
| millicuries of tritium may have been lost out of a fume hood stack. This |
| release was confirmed on September 11, 2000. The release occurred around |
| July 22 - 30, 2000. |
| |
| The University and the Agency continue to investigate this event. |
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