Event Notification Report for March 10, 2003
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/09/2003 - 03/10/2003
EVENT NUMBERS
396573965839659396513965239653
Power Reactor
Event Number: 39657
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JEFF KINSLEY
HQ OPS Officer: JOHN MacKINNON
Region: 4 State: CA
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JEFF KINSLEY
HQ OPS Officer: JOHN MacKINNON
Notification Date: 03/10/2003
Notification Time: 17:32 [ET]
Event Date: 03/10/2003
Event Time: 07:31 [PST]
Last Update Date: 03/10/2003
Notification Time: 17:32 [ET]
Event Date: 03/10/2003
Event Time: 07:31 [PST]
Last Update Date: 03/10/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MARK SHAFFER (R4)
MARK SHAFFER (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | N | 0 | Cold Shutdown | 0 | Cold Shutdown |
REACTOR COOLANT SYSTEM LOW TEMPERATURE OVERPRESSURE PROTECTION (LTOP) NOT ENABLED
During the eleventh refueling outage on Unit 2 (2R11) the reactor coolant system low temperature overpressure (LTOP) protection was inoperable due to the individual power operated relief valves (PORV's) control switches being selected to the "closed" position. LTOP was unable to perform its required automatic function from 0829 PT on 03/09/03 until the discovery time of 0731 PT on 03/10/03. This discrepancy was discovered by the operator during the beginning of shift board walkdown, at which time the PORV selector switches were returned to "auto" and LTOP protection was enabled. At no time were any of the LTOP setpoints challenged. Residual Heat Removal (RHR) pump suction relief valves (setpoint is 450 psi) were also available during this time frame to provide overpressure protection. Reactor Coolant temperature was 109 degrees F. LTOP setpoint was for 435 psi. The LTOP PORV's control switches were closed during the vacuum degas procedure. Licensee is still investigating this event.
The NRC Resident Inspector was notified of this event by the licensee.
During the eleventh refueling outage on Unit 2 (2R11) the reactor coolant system low temperature overpressure (LTOP) protection was inoperable due to the individual power operated relief valves (PORV's) control switches being selected to the "closed" position. LTOP was unable to perform its required automatic function from 0829 PT on 03/09/03 until the discovery time of 0731 PT on 03/10/03. This discrepancy was discovered by the operator during the beginning of shift board walkdown, at which time the PORV selector switches were returned to "auto" and LTOP protection was enabled. At no time were any of the LTOP setpoints challenged. Residual Heat Removal (RHR) pump suction relief valves (setpoint is 450 psi) were also available during this time frame to provide overpressure protection. Reactor Coolant temperature was 109 degrees F. LTOP setpoint was for 435 psi. The LTOP PORV's control switches were closed during the vacuum degas procedure. Licensee is still investigating this event.
The NRC Resident Inspector was notified of this event by the licensee.
Power Reactor
Event Number: 39658
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: SAM BELCHER
HQ OPS Officer: JOHN MacKINNON
Region: 4 State: LA
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: SAM BELCHER
HQ OPS Officer: JOHN MacKINNON
Notification Date: 03/10/2003
Notification Time: 18:24 [ET]
Event Date: 03/10/2003
Event Time: 11:37 [CST]
Last Update Date: 03/10/2003
Notification Time: 18:24 [ET]
Event Date: 03/10/2003
Event Time: 11:37 [CST]
Last Update Date: 03/10/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
MARK SHAFFER (R4)
MARK SHAFFER (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 87 | Power Operation | 87 | Power Operation |
PRIMARY CONTAINMENT AIRLOCK SEALS DEFLATED.
At 1137 CST on 03/10/03, with the plant at 87% power, the Main Control Room team received indications that the seals were deflated on both doors of primary containment airlock JRB-DRA1. Personnel were exiting containment through the airlock at this time. Personnel were dispatched and airlock integrity was restored at 1208 CST. The cause of the condition appears to be related to the mechanical interlock. This interlock did not function as required to prevent deflation of the seals on both doors concurrently. This condition is being evaluated.
This condition could have resulted in a loss of function of the Primary Containment to confine a postulated release of radioactive material to within limits.
The Senior Resident Inspector was notified of this event by the licensee.
At 1137 CST on 03/10/03, with the plant at 87% power, the Main Control Room team received indications that the seals were deflated on both doors of primary containment airlock JRB-DRA1. Personnel were exiting containment through the airlock at this time. Personnel were dispatched and airlock integrity was restored at 1208 CST. The cause of the condition appears to be related to the mechanical interlock. This interlock did not function as required to prevent deflation of the seals on both doors concurrently. This condition is being evaluated.
This condition could have resulted in a loss of function of the Primary Containment to confine a postulated release of radioactive material to within limits.
The Senior Resident Inspector was notified of this event by the licensee.
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 39659
Facility: COOPER
Region: 4 State: NE
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: ANDREW OHRABLO
HQ OPS Officer: STEVE SANDIN
Region: 4 State: NE
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: ANDREW OHRABLO
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/11/2003
Notification Time: 05:23 [ET]
Event Date: 03/10/2003
Event Time: 22:38 [CST]
Last Update Date: 04/28/2003
Notification Time: 05:23 [ET]
Event Date: 03/10/2003
Event Time: 22:38 [CST]
Last Update Date: 04/28/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MARK SHAFFER (R4)
MARK SHAFFER (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Refueling | 0 | Refueling |
POTENTIAL RAD GROUND RELEASE PATH DISCOVERED DUE TO LOSS OF SECONDARY CONTAINMENT
"This notification is being made pursuant to NRC regulation 10CFR50.72(b)(3)(v)(D), any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.
"On March 10, 2003 at 22:38, it was determined that the secondary containment was inoperable due to a leak in the Z sump manway gasket. The plant was in Mode 5, shutdown, performing fuel shuffle when secondary containment was declared inoperable. LCO 3.6.4.1 was entered. The fuel shuffle was secured at 22:40 after the completion of the fuel move that was in progress. No additional Core Alterations or OPDRVs [Operations Potentially Draining the Reactor Vessel] were in progress. Upon investigation into the secondary containment operability, it was determined that a non-Tech Spec surveillance performed on dayshift also rendered secondary containment inoperable due to additional leakage pathway via the Z sump. A principal safety function of Secondary Containment is to limit the ground level release to the environs of airborne radioactive materials resulting from a fuel handling accident.
"As a result of the alignment of the Z sump the potential existed that if a radioactive release were to occur due to a fuel handling accident, part of the filtered release via Standby Gas Treatment System could be a ground level release vice a release through the Elevated Release Point. The surveillance has been completed and the additional leakage paths that were opened due to the surveillance have been sealed. The leaking manway gasket was determined to be due to not adequately torquing the gasket bolts. The bolts have been retorqued. Secondary containment was reestablished, and was declared OPERABLE at 02:55, 3-11-03.
"The NRC Senior Resident has been notified."
* * * RETRACTION TAKEN ON 04/28/03 AT 1123 EDT FROM JIM SUMPTER TO GERRY WAIG * * *
"THIS IS A RETRACTION OF EVENT #39659.
"On 3/10/2003 at 2238 CST, Cooper Nuclear Station made an 8 hour 50.72 non-emergency notification to the NRC per 50.72 (b)(3)(v)(D). It was determined that the secondary containment was inoperable due to a leak in the Z sump manway gasket. The plant was performing fuel shuffle at the time. LCO 3.6.4.1 was entered. The fuel shuffle was secured at 22:40 after completion of the fuel move that was in progress. Investigation determined that a non-Tech Spec surveillance performed on dayshift also rendered secondary containment inoperable due to an additional leakage pathway via the Z sump. As a result of the alignment of the Z sump, the potential existed that if a radioactive release were to occur due to a filet handling accident, part of the filtered release via the Standby Gas Treatment System could be a ground level release. This would potentially result in unacceptable dose levels since DBA calculations assulne an elevated release point for this accident. Thus, the secondary containment would be unable to fulfill its accident mitigation safety function to limit the release to the environs of radioactive materials from postulated design basis accidents (DBA) to control room occupants and off-site.
"Further evaluation demonstrated that if a fuel handing accident had occurred at the time of discovery of the condition, the thyroid doses to control room personnel (which are the limiting doses for this accident) would have been less than DBA values. Other doses would remain a small fraction of 10CFR100 and General Design Criteria 19 limits. This is because the plant had been shutdown for 14 days reducing considerably the fuel handling accident source term. In addition, the estimated ground level release flow rate was a small percentage of the elevated release point flow rate. Finally, most of the radiation dose from this accident occurs in the first 90 seconds of the event via the unfiltered Reactor Building exhaust. Therefore, the secondary containment, which includes the Standby Gas Treatment system and the elevated release point, would have performed its accident mitigation safety function and was operable."
The licensee will notifiy the NRC Resident Inspector
NRC R4DO (Greg Pick) was notified.
"This notification is being made pursuant to NRC regulation 10CFR50.72(b)(3)(v)(D), any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.
"On March 10, 2003 at 22:38, it was determined that the secondary containment was inoperable due to a leak in the Z sump manway gasket. The plant was in Mode 5, shutdown, performing fuel shuffle when secondary containment was declared inoperable. LCO 3.6.4.1 was entered. The fuel shuffle was secured at 22:40 after the completion of the fuel move that was in progress. No additional Core Alterations or OPDRVs [Operations Potentially Draining the Reactor Vessel] were in progress. Upon investigation into the secondary containment operability, it was determined that a non-Tech Spec surveillance performed on dayshift also rendered secondary containment inoperable due to additional leakage pathway via the Z sump. A principal safety function of Secondary Containment is to limit the ground level release to the environs of airborne radioactive materials resulting from a fuel handling accident.
"As a result of the alignment of the Z sump the potential existed that if a radioactive release were to occur due to a fuel handling accident, part of the filtered release via Standby Gas Treatment System could be a ground level release vice a release through the Elevated Release Point. The surveillance has been completed and the additional leakage paths that were opened due to the surveillance have been sealed. The leaking manway gasket was determined to be due to not adequately torquing the gasket bolts. The bolts have been retorqued. Secondary containment was reestablished, and was declared OPERABLE at 02:55, 3-11-03.
"The NRC Senior Resident has been notified."
* * * RETRACTION TAKEN ON 04/28/03 AT 1123 EDT FROM JIM SUMPTER TO GERRY WAIG * * *
"THIS IS A RETRACTION OF EVENT #39659.
"On 3/10/2003 at 2238 CST, Cooper Nuclear Station made an 8 hour 50.72 non-emergency notification to the NRC per 50.72 (b)(3)(v)(D). It was determined that the secondary containment was inoperable due to a leak in the Z sump manway gasket. The plant was performing fuel shuffle at the time. LCO 3.6.4.1 was entered. The fuel shuffle was secured at 22:40 after completion of the fuel move that was in progress. Investigation determined that a non-Tech Spec surveillance performed on dayshift also rendered secondary containment inoperable due to an additional leakage pathway via the Z sump. As a result of the alignment of the Z sump, the potential existed that if a radioactive release were to occur due to a filet handling accident, part of the filtered release via the Standby Gas Treatment System could be a ground level release. This would potentially result in unacceptable dose levels since DBA calculations assulne an elevated release point for this accident. Thus, the secondary containment would be unable to fulfill its accident mitigation safety function to limit the release to the environs of radioactive materials from postulated design basis accidents (DBA) to control room occupants and off-site.
"Further evaluation demonstrated that if a fuel handing accident had occurred at the time of discovery of the condition, the thyroid doses to control room personnel (which are the limiting doses for this accident) would have been less than DBA values. Other doses would remain a small fraction of 10CFR100 and General Design Criteria 19 limits. This is because the plant had been shutdown for 14 days reducing considerably the fuel handling accident source term. In addition, the estimated ground level release flow rate was a small percentage of the elevated release point flow rate. Finally, most of the radiation dose from this accident occurs in the first 90 seconds of the event via the unfiltered Reactor Building exhaust. Therefore, the secondary containment, which includes the Standby Gas Treatment system and the elevated release point, would have performed its accident mitigation safety function and was operable."
The licensee will notifiy the NRC Resident Inspector
NRC R4DO (Greg Pick) was notified.
Power Reactor
Event Number: 39651
Facility: WATTS BAR
Region: 2 State: TN
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN RODEN
HQ OPS Officer: ARLON COSTA
Region: 2 State: TN
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN RODEN
HQ OPS Officer: ARLON COSTA
Notification Date: 03/10/2003
Notification Time: 03:45 [ET]
Event Date: 03/10/2003
Event Time: 00:12 [EST]
Last Update Date: 03/10/2003
Notification Time: 03:45 [ET]
Event Date: 03/10/2003
Event Time: 00:12 [EST]
Last Update Date: 03/10/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
STEPHEN CAHILL (R2)
CAROLYN EVANS (R2)
STEPHEN CAHILL (R2)
CAROLYN EVANS (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | A/R | Y | 100 | Power Operation | 0 | Hot Standby |
AUTOMATIC REACTOR TRIP DUE TO TURBINE TRIP ON GENERATOR DIFFERENTIAL RELAY ACTUATION
"At 0012 EST on March 10, 2003, with Watts Bar Unit 1 in Mode 1 at 100% power, the reactor tripped due to an automatic signal. All plant safety systems were in service at the time to the trip, except for the 2B-B diesel generator which was out of service for scheduled maintenance, and all [safety systems] responded as designed. All control rods inserted as required and the Auxiliary Feedwater System [AFW] initiated as expected.
"The reactor trip resulted from a turbine trip signal that was generated as a result of a main generator/transformer differential electrical relay actuation. The plant is currently stable in Mode 3 and will remain in this Mode until completion of the investigation."
AFW was removed from operation and the main feed pumps have resumed normal feed to the Steam Generators. The Licensee notified the NRC Resident Inspector.
"At 0012 EST on March 10, 2003, with Watts Bar Unit 1 in Mode 1 at 100% power, the reactor tripped due to an automatic signal. All plant safety systems were in service at the time to the trip, except for the 2B-B diesel generator which was out of service for scheduled maintenance, and all [safety systems] responded as designed. All control rods inserted as required and the Auxiliary Feedwater System [AFW] initiated as expected.
"The reactor trip resulted from a turbine trip signal that was generated as a result of a main generator/transformer differential electrical relay actuation. The plant is currently stable in Mode 3 and will remain in this Mode until completion of the investigation."
AFW was removed from operation and the main feed pumps have resumed normal feed to the Steam Generators. The Licensee notified the NRC Resident Inspector.
Hospital
Event Number: 39652
Rep Org: OAKWOOD HOSPITAL
Licensee: OAKWOOD HOSPITAL
Region: 3
City: DEARBORN State: MI
County: WAYNE
License #: 21-04515-01
Agreement: N
Docket:
NRC Notified By: TALJIT SANDHER
HQ OPS Officer: JOHN MacKINNON
Licensee: OAKWOOD HOSPITAL
Region: 3
City: DEARBORN State: MI
County: WAYNE
License #: 21-04515-01
Agreement: N
Docket:
NRC Notified By: TALJIT SANDHER
HQ OPS Officer: JOHN MacKINNON
Notification Date: 03/10/2003
Notification Time: 11:43 [ET]
Event Date: 03/10/2003
Event Time: 10:00 [EST]
Last Update Date: 03/10/2003
Notification Time: 11:43 [ET]
Event Date: 03/10/2003
Event Time: 10:00 [EST]
Last Update Date: 03/10/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
KEN O'BRIEN (R3)
KEVIN HSUEH (NMSS)
KEN O'BRIEN (R3)
KEVIN HSUEH (NMSS)
MEDICAL EVENT TO AN UNINTENDED SITE
At 1000 EST on 03/10/03 it was discovered that a patient at Oakwood Hospital located in Dearborn, MI had implanted 42 Iodine-125 seeds into his bulb of urethra instead of his prostrate. The urologist had misinterpreted the ultrasound scan. The total activity of the Iodine-125 seeds was 14.2 millicuries, each seed was 0.338 millicuries. The patient and his Medical Doctor have been notified of the error. No side affects to the patient.
At 1000 EST on 03/10/03 it was discovered that a patient at Oakwood Hospital located in Dearborn, MI had implanted 42 Iodine-125 seeds into his bulb of urethra instead of his prostrate. The urologist had misinterpreted the ultrasound scan. The total activity of the Iodine-125 seeds was 14.2 millicuries, each seed was 0.338 millicuries. The patient and his Medical Doctor have been notified of the error. No side affects to the patient.
Power Reactor
Event Number: 39653
Facility: SEQUOYAH
Region: 2 State: TN
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: CALVIN FIELDS
HQ OPS Officer: JOHN MacKINNON
Region: 2 State: TN
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: CALVIN FIELDS
HQ OPS Officer: JOHN MacKINNON
Notification Date: 03/10/2003
Notification Time: 12:12 [ET]
Event Date: 03/10/2003
Event Time: 09:18 [EST]
Last Update Date: 03/10/2003
Notification Time: 12:12 [ET]
Event Date: 03/10/2003
Event Time: 09:18 [EST]
Last Update Date: 03/10/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
CAROLYN EVANS (R2)
CAROLYN EVANS (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | M/R | Y | 100 | Power Operation | 0 | Hot Standby |
MANUAL REACTOR TRIP
Unit 2 Manual Reactor Trip at 0918 ET on 03/10/03 due to the following sequence events:
At 0903 Hotwell Pump "B" tripped on neutral overcurrent.
At 0911 Both # 7 Heater Drain Tank Pumps tripped.
Per AOP-S.04 started decreasing unit power.
At 0918 Main Feedwater Pump "A" tripped initiating Unit Runback Balance of Plant (BOP).
At 0918 Manual Reactor Trip.
Due to both Main Feedwater Pump's rupture discs blown plant is using Steam Generator Atmospheric Relief Valves to cool the plant and maintain a Hot Standby condition. No leaking steam generator tubes. The electrical grid is stable and the emergency diesel generators are fully operable if needed. Sequoyah Unit 1 is in coastdown.
The NRC Resident Inspector was notified of this event by the licensee.
Unit 2 Manual Reactor Trip at 0918 ET on 03/10/03 due to the following sequence events:
At 0903 Hotwell Pump "B" tripped on neutral overcurrent.
At 0911 Both # 7 Heater Drain Tank Pumps tripped.
Per AOP-S.04 started decreasing unit power.
At 0918 Main Feedwater Pump "A" tripped initiating Unit Runback Balance of Plant (BOP).
At 0918 Manual Reactor Trip.
Due to both Main Feedwater Pump's rupture discs blown plant is using Steam Generator Atmospheric Relief Valves to cool the plant and maintain a Hot Standby condition. No leaking steam generator tubes. The electrical grid is stable and the emergency diesel generators are fully operable if needed. Sequoyah Unit 1 is in coastdown.
The NRC Resident Inspector was notified of this event by the licensee.