Event Notification Report for April 04, 2000

STRONTIUM/YTTRIUM SOURCE LOST TO LANDFILL

A generally licensed strontium/yttrium source, 500 mCi, from an 'In Flight Blade Inspection System' was improperly placed in a dumpster which in turn was dumped at a regular land fill. The U.S. Navy is investigating the incident and trying to determine where and how deep the source is in the land fill.

The U.S. Navy notified NRC Region 2 (M. Fuller) and intends to notify the State of Arizona.

****************** UPDATE AT 0814 ON 04/06/00 FROM GARY HIGGINS TO LEIGH TROCINE ******************

The licensee called to provide the following correction to the original report:

The licensee reported that they were provided with an incorrect activity for the missing source. They were originally informed that the activity was 500 mCi when in fact the actual activity was 500 µCi.

The licensee notified the NRC Region 2 office (Mike Fuller). The NRC operations officer notified the R2DO (Cahill), R4DO (Jones), and NMSS EO (Sturz).

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

NONESSENTIAL SERVICE WATER SYSTEM ISOLATION

At 0724, valves associated with the nonessential portion of the Division I service water system closed unexpectedly. Less than a minute later, three of the four running service water pumps tripped due to low flow. The running pump provides sufficient flow for required safety related loads. Plant operators entered procedures appropriate for nonessential service water system header isolation. Initial walkdowns of the Division I service water piping and electrical systems did not reveal any obvious problems with the system.

The NRC resident inspector has been informed of this event by the licensee.

MANUAL REACTOR TRIP DUE TO LOSS OF MAIN FEEDWATER

While racking out the emergency diesel generator (EDG) 1-1 output breaker, the breaker was inadvertently closed, motorizing the 1-1 EDG and causing a momentary undervoltage condition on emergency busses 1C and 1D. The undervoltage condition caused both EDGs to automatically start, and caused the instrument AC bus to transfer to an alternate source. During the transfer, the cooling tower pumps and heater drain pumps tripped. Loss of the heater drain pumps caused the main feedwater pumps to trip. Reactor coolant pumps remained running throughout the event.

Operators manually tripped the reactor, and all control rods inserted completely. The auxiliary feedwater system automatically started following the trip due to low steam generator water levels. The unit is currently stable in Hot Standby, with decay heat being removed using the steam generator (S/G) atmospheric dump valves, and S/G levels being maintained using the auxiliary feedwater system.

The NRC resident inspector has been informed of this event by the licensee.

LOSS OF RESERVE STATION TRANSFORMER CAUSED LOSS OF REACTOR COOLANT PUMP WHICH REQUIRED A REACTOR TRIP

The 'C' reserve station transformer (RST) deenergized which resulted in a loss of the Unit 2 'C' reactor coolant pump (RCP). The Unit 2 loss of RCP 'C' required a reactor trip, which was initiated manually, all rods fully inserted and the plant is stable in Hot Standby. Unit 2 was on the steam dumps to the condenser and main feedwater at the time of the trip and continue on them.

Unit 1 '1H' emergency bus was lost due to the problem with the 'C' RST and the failure of the '1H' emergency diesel generator (EDG) to start. The loss of the '1H' bus caused the loss of the 'C' RCP and 'A' Residual Heat Removal (RHR) pump, which led to the loss of core cooling circulation, but was restored in less than 2 minutes by starting the 'B' RHR pump.

The 'C' RST and the '1H' EDG problems are being investigated, the cause of the problems are unknown at this time. Unit 2 will remain in Hot Standby until all problems are corrected.

The licensee informed the NRC Resident Inspector.

* * * UPDATE AT 1503 EDT ON 4/5/00 BY JIM CROSSMAN TO FANGIE JONES * * *

The licensee made a correction to the reporting criteria. Removed the original criteria of 10 CFR 50.72(b)(1)(ii) Degraded Condition During Operation, this was for Unit 1 which was shutdown at the time. Added the criteria 10 CFR 50.72(b)(2)(ii) ESF Actuation, due to a real start signal to two of the emergency diesel generators.

The licensee notified the NRC Resident Inspector. Notified R2DO (Steve Cahill).

LICENSEE RECEIVED NOTICE FROM THE NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION OF A VIOLATION OF THE "STATE POLLUTANT DISCHARGE ELIMINATION PERMIT"

The licensee received a fax notification of a violation of their 'State Pollutant Discharge Elimination Permit' from the New York State Department of Environmental Conservation. On 3/27/00, during maintenance on yard drains, a vacuum truck was used to suck water from one drain and discharged to another drain. The 'Permit' requires that the water be treated before discharge to a drain.

The licensee intends to notify the NRC Resident Inspector.

CALIBRATION CONSTANT INACCURACY MAY HAVE CAUSED THE UNIT TO EXCEED LICENSED LIMIT

During calibration of main feedwater flow instruments, the licensee determined that a calibration constant that converts differential pressure to flow was not updated when the unit was re-rated in October 1998. The result of the change not being made may have resulted in a power determination such that actual power exceeded the licensed thermal limit by approximately 3.5 megawatts thermal. An investigation is ongoing to determine the full implications of the inaccurate calibration constant.

The licensee notified the NRC Resident Inspector.

PATIENT DID NOT RECEIVE THERAPEUTIC DOSE OF I-131 AS PRESCRIBED

On 4/4/2000 at 1230 hours a patient undergoing treatment for thyroid cancer did not receive the 100 mCi of I-131 as stated in the written instructions. The Patient Appointment Center misinterpreted the instruction "100mCi I-131 followed by a whole body scan" to mean "I-131 whole body scan." A diagnostic administration of 4.26 mCi I-131 was given for the whole body scan. The whole body scan results were reviewed and the prescribing physician concluded that the therapeutic dose was not required. The patient was informed. The Heath Physicist consultant to the hospital reviewed the incident and advised the hospital that the error was recordable but not reportable. This report is being made following an inspection by NRC Region 4 (J. Cruz).