Event Notification Report for December 14, 1999

TECHNICAL SPECIFICATION VIOLATION - 24 HOUR REPORT

"This is the report on a violation of Technical Specification 3.2.1. Due to the incorrect connection of the high voltage to the compensated voltage connection of a compensated wide range ion chamber, the Log N Channel required in Table 3.1, Required Safety Channels, was inoperable during the reactor startup on 14 December 1999. Review of the power level indication from the other nuclear instrumentation channels shows that no limiting safety system settings were approached during the reactor startup.

"Indications from the operable nuclear instruments and temperature system indicate that no limiting safety system settings were approached. Determination of the response of the period portion of the Log N system compared to the periods derived from other properly responding nuclear instrument channels indicates that the period circuit was measuring periods of similar magnitude and that the 30-second period for reactor control rod withdrawal inhibit was not challenged."

There were three root causes identified: (1) The Log N circuit and the linear level circuit are both compensated ion chambers. However, the bridge connections are opposite, and the operators used the linear connections to make up the Log N connections. (2) The operators knew or should have known that an abnormal reading of the Log N circuit was possible after maintenance, and (3) the reactor startup procedure specifies that operators are to "Hold" power at 500 kW to perform the checks, but it has become acceptable to slowly move through the 500 kW point and record the reading. Also, the calorimetric procedure specifies that after a 1 MW calorimetric, the Log N channel should indicate 40-100% (it indicated 25%).

The reactor was shut down from full power (2 MW) and will not be restarted for sustained operation until an operational review of this reportable occurrence and other non-reportable events is made and presented to the Safety Review Committee (SRC). An outside review of recent operations is being sought and is hoped to be completed prior to requesting permission from the Director and the SRC for sustained operation.

The following other measures are planned: Labeling of the cable connections for all the nuclear instrument detectors will be reviewed and improved; possible design changes to make the connectors have different configurations. Operational training will be given on procedures, and practical performances will be evaluated.

The licensee notified the NRC Project Manager (Theodore Michaels) and NRC Inspector (Thomas Dragoun).

(Call the NRC operations officer for a contact telephone number.)

MANUAL REACTOR TRIP DUE TO LOSS OF CONDENSATE PUMP

The plant was initially at 100% power. At 0354 EST, a ground fault occurred on the "A" condensate pump resulting in a loss of the "A" condensate pump. This caused a subsequent trip of the "A" condensate booster pump and "A" main feedwater (MFW) pump. The plant automatically ran back to approximately 60% power. Steam generator (SG) levels lowered and approached the automatic trip setpoint so the reactor was manually tripped from approximately 60% at 0355 EST. All rods fully inserted into the core. The auxiliary feedwater (AFW) pumps were manually started to aid SG level control; however, an automatic AFW initiation signal was properly received. All ESF components actuated as required. There were no safety problems encountered after the trip. The plant is stable in Hot Shutdown with main feedwater in service. No power-operated relief valves opened.

The NRC resident inspector was notified of this event by the licensee.

POSSIBLE MEDICAL MISADMINISTRATION

During insertion of iodine-125 (I-125) seeds in a prostate treatment, one of the needles broke during seed planting and remains in the patient about 3 centimeters outside the prostate gland. The needle retained four of the seeds, each containing 0.326 mCi of I-125. The needle has been left in place, as that has been determined to be in the best interest of the patient at this time. The attending physician was present and the patient informed. There will be little impact on the treatment of the prostrate. The licensee is evaluating whether any adverse effect to the patient is expected of this possible misadministration, the seeds located outside the treatment site. The hospital contacted NRC Region 3 inspector (James Cameron).

(Call the NRC operations officer for a contact telephone number.)

STOLEN TROXLER MOISTURE DENSITY GAUGE

The licensee reported a Troxler moisture density gauge (model 3430, serial number 28862) stolen some time last night after 2110 EST from the cargo area of a locked Nissan Pathfinder. The gauge was in a locked box in the vehicle at the technician's home in Cincinnati. The gauge sources contain 8 mCi of Cs-137 and 40 mCi of Am/Be-241. The City of Cincinnati Police responded and are investigating the theft (no report number at this time). The licensee notified the Ohio Bureau of Radiation Safety, part of the Department of Health as part of their license requirement.

(Call the NRC operations officer for a contact telephone number.)


* * * UPDATE ON 3/26/00 @ 1105 BY WIDENER TO GOULD * * *

A civilian notified the licensee, on 3/25/00 @ 2130 EST, that they had discovered the above Troxler gauge at Paddock Rd and I-75 in Cincinnati, OH. The device was not damaged and there was no leakage detected by their survey meter. The licensee took possession of the device on 3/26/00 @ 0830 EST. The Ohio Bureau of Radiation Safety was notified and the Cincinnati Police Department will be notified.

The Reg 3 RDO(Wright) and the NMSS EO(Camper) were notified.

10-CFR-PART-21 REPORT ON 3-INCH DIAPHRAGM VALVES WITH 3250L ACTUATORS

"Recently, Engineered Valves was asked by a customer to perform tests and analysis documenting the maximum shutoff pressure for a diaphragm valve configuration. Based on testing and engineering calculations performed in November and December of 1999, Engineered Valves has discovered that 3" diaphragm valves with 3250L actuators, supplied to the nuclear power industry, may not be capable of bubble tight shutoff at customer specified operating conditions.

"These valves were supplied to the nuclear power industry for design pressures up to 200 psig and were factory tested at or above specified shutoff pressure depending on design specification or ASME Section III requirements. The testing and analysis described above indicate that there is a statistical possibility, depending on the tolerances of each valve and actuator component, that a valve can be built which will shut off bubble tight at no more than 147 psig. Therefore, it is possible that a valve, which has been maintained or repaired with new components or subassemblies might not have sufficient actuator thrust to shut off against the specified pressure."

Purchasers and sites include the following:
Westinghouse Electric Corporation at multiple locations
TVA at Bellefonte
Louisiana Power and Light at Waterford
Toledo Edison at Davis Besse
Iowa Electric at Duane Arnold
Pacific Gas and Electric at Diablo Canyon
Consolidated Edison at Indian Point
Virginia Electric and Power Company at Surry
Florida Power and Light at Turkey Point and St. Lucie
Duke Energy Corp. at Oconee

Due to organizational and name changes, include the following names as possible organizations over the past 31 years: ITT Corporation, ITT Grinnell Corporation, ITT Grinnell Valve Division, ITT Dia Flo, ITT Specialty Valve Group, ITT Fluid Products Corporation, ITT Fluid Technology Corporation, ITT Engineered Valves, and ITT Industries.

Engineered Valves is now finalizing the list of affected purchasers and will notify them by Monday, 12/20/99.

(Call the NRC operations officer for ITT Engineered Valves contact information.)