Event Notification Report for October 11, 2004
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/10/2004 - 10/11/2004
EVENT NUMBERS
41111411134111441133
Power Reactor
Event Number: 41111
Facility: COOK
Region: 3 State: MI
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: TOD KASPAR
HQ OPS Officer: HOWIE CROUCH
Region: 3 State: MI
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: TOD KASPAR
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/11/2004
Notification Time: 07:16 [ET]
Event Date: 10/11/2004
Event Time: 00:20 [EDT]
Last Update Date: 10/11/2004
Notification Time: 07:16 [ET]
Event Date: 10/11/2004
Event Time: 00:20 [EDT]
Last Update Date: 10/11/2004
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):
BRENT CLAYTON (R3)
BRENT CLAYTON (R3)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | N | 0 | Refueling | 0 | Refueling |
CONTAINMENT VENTILATION ISOLATION SYSTEM INOPERABLE DURING FUEL MOVEMENT
The following information was obtained from the licensee via facsimile:
"In accordance with 10 CFR 50.72(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'], D.C. Cook Unit 2 is making an 8-hour non-emergency report.
"At 00:20 [EDT] on 10-11-2004, it was discovered that neither train of the Containment Ventilation Isolation System would have automatically isolated containment purge on a high radiation signal within the containment. Also, a manual Phase A containment isolation actuation would not have isolated containment purge.
"At all times, containment purge could have been isolated using individual control switches from the Unit 2 Control Room.
"D.C. Cook Unit 2 Technical Specification 3.9.9 requires during core alterations or movement of irradiated fuel within the Containment that the Containment Purge and Exhaust Isolation System be operable. Technical Specification 3.9.4.c requires during core alterations or movement of irradiated fuel within the containment that each containment penetration providing direct access from the containment atmosphere to the outside atmosphere be closed by an isolation valve, blind flange, manual valve, or equivalent, OR be capable of being closed by an operable automatic Containment Purge and Exhaust isolation valve.
"Technical Specification 3.0.4 requires when a Limited Condition of Operation is not met, entry into an operational mode or other specified condition in the applicability shall be made only in specified conditions. Core alterations and movement of irradiated fuel assemblies began at 14:41 on 10-09-2004, approximately 71 minutes after the Containment Ventilation Isolation System had been made inoperable.
"At approximately 13:30 on 10-09-2004, breaker 2-CRID-1-7 (Reactor Protection and Safeguards Actuation Cabinet RPS-A Input Channel I & All RPS A Output) and 2-GRID-4-8 (Reactor Protection & Safeguards Actuation Cabinet RPS-B Input Channel IV & ALL RPS B) were opened and tagged as part of a clearance. This prevented the automatic actuation of both trains of the Containment Ventilation Isolation System and prevented a manual phase A containment isolation from isolating containment purge. Thereafter, at 14:41 on 10-09-04, fuel movement commenced from the reactor vessel to the Spent Fuel Pit.
"At 23:25 on 10-10-2004, breakers 2-CRID-1-7 and 2-CRID-4-8 were re-closed.
"At 0020 on 10-11-2004, it was discovered that during the time from approximately 13:30 on 10-09-2004 to 23:25 on 10-10-2004, the Containment Ventilation isolation system had been inoperable.
"D.C. Cook Unit 2 is currently stable in Mode 6 during the Unit 2 Cycle 15 refueling outage with core offload to the Spent Fuel Pit in progress."
The licensee has notified the NRC Resident Inspector.
The following information was obtained from the licensee via facsimile:
"In accordance with 10 CFR 50.72(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'], D.C. Cook Unit 2 is making an 8-hour non-emergency report.
"At 00:20 [EDT] on 10-11-2004, it was discovered that neither train of the Containment Ventilation Isolation System would have automatically isolated containment purge on a high radiation signal within the containment. Also, a manual Phase A containment isolation actuation would not have isolated containment purge.
"At all times, containment purge could have been isolated using individual control switches from the Unit 2 Control Room.
"D.C. Cook Unit 2 Technical Specification 3.9.9 requires during core alterations or movement of irradiated fuel within the Containment that the Containment Purge and Exhaust Isolation System be operable. Technical Specification 3.9.4.c requires during core alterations or movement of irradiated fuel within the containment that each containment penetration providing direct access from the containment atmosphere to the outside atmosphere be closed by an isolation valve, blind flange, manual valve, or equivalent, OR be capable of being closed by an operable automatic Containment Purge and Exhaust isolation valve.
"Technical Specification 3.0.4 requires when a Limited Condition of Operation is not met, entry into an operational mode or other specified condition in the applicability shall be made only in specified conditions. Core alterations and movement of irradiated fuel assemblies began at 14:41 on 10-09-2004, approximately 71 minutes after the Containment Ventilation Isolation System had been made inoperable.
"At approximately 13:30 on 10-09-2004, breaker 2-CRID-1-7 (Reactor Protection and Safeguards Actuation Cabinet RPS-A Input Channel I & All RPS A Output) and 2-GRID-4-8 (Reactor Protection & Safeguards Actuation Cabinet RPS-B Input Channel IV & ALL RPS B) were opened and tagged as part of a clearance. This prevented the automatic actuation of both trains of the Containment Ventilation Isolation System and prevented a manual phase A containment isolation from isolating containment purge. Thereafter, at 14:41 on 10-09-04, fuel movement commenced from the reactor vessel to the Spent Fuel Pit.
"At 23:25 on 10-10-2004, breakers 2-CRID-1-7 and 2-CRID-4-8 were re-closed.
"At 0020 on 10-11-2004, it was discovered that during the time from approximately 13:30 on 10-09-2004 to 23:25 on 10-10-2004, the Containment Ventilation isolation system had been inoperable.
"D.C. Cook Unit 2 is currently stable in Mode 6 during the Unit 2 Cycle 15 refueling outage with core offload to the Spent Fuel Pit in progress."
The licensee has notified the NRC Resident Inspector.
Power Reactor
Event Number: 41113
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: MARK JENKINS
HQ OPS Officer: STEVE SANDIN
Region: 4 State: KS
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: MARK JENKINS
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/11/2004
Notification Time: 13:35 [ET]
Event Date: 10/11/2004
Event Time: 07:25 [CDT]
Last Update Date: 10/11/2004
Notification Time: 13:35 [ET]
Event Date: 10/11/2004
Event Time: 07:25 [CDT]
Last Update Date: 10/11/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
RUSSELL BYWATER (R4)
CHRISTOPHER GRIMES (NRR)
RUSSELL BYWATER (R4)
CHRISTOPHER GRIMES (NRR)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 98 | Power Operation |
LOSS OF SWITCHYARD WEST BUS
"On 10/11/2004 at 0725 CDT, Wolf Creek Generating Station experienced a loss of the west bus in the switchyard causing a loss of power to the Startup Transformer and the 'B' Train 4.16 Kv ESFAS bus NB02. The 'B' Emergency Diesel Generator started and loaded, as expected, to supply power to the NB02 bus. The shutdown sequencer started the required components. Turbine load was reduced by the control room staff following the expected start of the steam driven auxiliary feedwater pump to maintain reactor thermal power below license limits.
"Following the shutdown sequencer start of the 'B' Essential Service Water (ESW) pump it was noted the 'B' Control Room Air Conditioning unit condenser inlet end bell gasket had started leaking. The Control Room Air Conditioning unit was secured and ESW was isolated to and from the unit. All other equipment operated as required.
"System Operations and Site personnel are investigating the cause of the power loss to the west switchyard bus, no cause has been identified at this time. Turbine load is being reduced to 950 MWe net per System Operations request to ensure grid stability is maintained.
"The Senior Resident has been contacted concerning this issue."
The licensee intends to reduce reactor power to 78-80% while investigating the cause for the loss of the west bus. There is no indication of any malevolent intent involved. The "B" EDG will maintain loads on the NB02 bus.
"On 10/11/2004 at 0725 CDT, Wolf Creek Generating Station experienced a loss of the west bus in the switchyard causing a loss of power to the Startup Transformer and the 'B' Train 4.16 Kv ESFAS bus NB02. The 'B' Emergency Diesel Generator started and loaded, as expected, to supply power to the NB02 bus. The shutdown sequencer started the required components. Turbine load was reduced by the control room staff following the expected start of the steam driven auxiliary feedwater pump to maintain reactor thermal power below license limits.
"Following the shutdown sequencer start of the 'B' Essential Service Water (ESW) pump it was noted the 'B' Control Room Air Conditioning unit condenser inlet end bell gasket had started leaking. The Control Room Air Conditioning unit was secured and ESW was isolated to and from the unit. All other equipment operated as required.
"System Operations and Site personnel are investigating the cause of the power loss to the west switchyard bus, no cause has been identified at this time. Turbine load is being reduced to 950 MWe net per System Operations request to ensure grid stability is maintained.
"The Senior Resident has been contacted concerning this issue."
The licensee intends to reduce reactor power to 78-80% while investigating the cause for the loss of the west bus. There is no indication of any malevolent intent involved. The "B" EDG will maintain loads on the NB02 bus.
Power Reactor
Event Number: 41114
Facility: SUMMER
Region: 2 State: SC
Unit: [1] [] []
RX Type: [1] W-3-LP
NRC Notified By: ROBERT SWEET
HQ OPS Officer: STEVE SANDIN
Region: 2 State: SC
Unit: [1] [] []
RX Type: [1] W-3-LP
NRC Notified By: ROBERT SWEET
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/11/2004
Notification Time: 13:51 [ET]
Event Date: 10/11/2004
Event Time: 10:57 [EDT]
Last Update Date: 10/11/2004
Notification Time: 13:51 [ET]
Event Date: 10/11/2004
Event Time: 10:57 [EDT]
Last Update Date: 10/11/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
CHARLES R. OGLE (R2)
CHARLES R. OGLE (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
LOSS OF EMERGENCY SIREN CAPABILITY FOLLOWING PLANNED SIREN MAINTENANCE
"On October 11, 2004, at 1057 [hrs. EDT] , while performing modification work to support security upgrades, the radio system controller that activates the plant offsite warning system was removed from service during a pre-planned activity. At 1148, the system was rebooted but failed to perform correctly. Approximately 70 % of the sirens were communicating with the system, while plant procedures direct that less than 75 % of the offsite warning system meets the reporting threshold. At 1226, the offsite warning system capability was restored to greater than 75%.
"Since the removal of the offsite notification network from service was a planned evolution, the county, state and the NRC resident inspector were notified prior to the removal from service. Appropriate compensatory measures were taken by the state and local agencies.
"The cause of the event was the new Federal Signal activation frequency not reloading after the outage since it was not hard-coded into the software for the radio system controller. This caused all 27 of the Federal Signal sirens from being activated. Three other sirens had pre-existing conditions which made 30 sirens inoperable out of a total of 106.
"The correct information was loaded into the software via modem and a silent siren test confirmed 93% capability at 1226. The frequency information was hard coded into the software to prevent future occurrences."
The licensee notified state/local agencies and the NRC resident inspector.
"On October 11, 2004, at 1057 [hrs. EDT] , while performing modification work to support security upgrades, the radio system controller that activates the plant offsite warning system was removed from service during a pre-planned activity. At 1148, the system was rebooted but failed to perform correctly. Approximately 70 % of the sirens were communicating with the system, while plant procedures direct that less than 75 % of the offsite warning system meets the reporting threshold. At 1226, the offsite warning system capability was restored to greater than 75%.
"Since the removal of the offsite notification network from service was a planned evolution, the county, state and the NRC resident inspector were notified prior to the removal from service. Appropriate compensatory measures were taken by the state and local agencies.
"The cause of the event was the new Federal Signal activation frequency not reloading after the outage since it was not hard-coded into the software for the radio system controller. This caused all 27 of the Federal Signal sirens from being activated. Three other sirens had pre-existing conditions which made 30 sirens inoperable out of a total of 106.
"The correct information was loaded into the software via modem and a silent siren test confirmed 93% capability at 1226. The frequency information was hard coded into the software to prevent future occurrences."
The licensee notified state/local agencies and the NRC resident inspector.
Hospital
Event Number: 41133
Rep Org: ST. VINCENT HOSPITAL
Licensee: ST. VINCENT HOSPITAL
Region: 3
City: INDIANAPOLIS State: IN
County:
License #: 13-00133-02
Agreement: N
Docket:
NRC Notified By: ED WROBLEWSKI
HQ OPS Officer: STEVE SANDIN
Licensee: ST. VINCENT HOSPITAL
Region: 3
City: INDIANAPOLIS State: IN
County:
License #: 13-00133-02
Agreement: N
Docket:
NRC Notified By: ED WROBLEWSKI
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/19/2004
Notification Time: 12:05 [ET]
Event Date: 10/11/2004
Event Time: 00:00 [CST]
Last Update Date: 10/21/2004
Notification Time: 12:05 [ET]
Event Date: 10/11/2004
Event Time: 00:00 [CST]
Last Update Date: 10/21/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JULIO LARA (R3)
SANDRA WASTLER (NMSS)
JULIO LARA (R3)
SANDRA WASTLER (NMSS)
MEDICAL EVENT INVOLVING FRACTIONATED DOSE DELIVERY LESS THAN PRESCRIBED
On 10/11/04 a 49 year old female patient received the first of two treatments for endometrial cancer. A total dose of 700 centiGray was prescribed to be delivered in two (2) 350 cGy fractions using a 1500 mm length catheter containing a 7.035 curies Ir-192 source (duration 189 seconds). Due to an error on the part of the Health Physicist, the 995 mm length catheter was used. This resulted in a calculated dose of less than 1 cGy to the thigh at a distance of 505 mm from the intended site. There are no expected adverse consequences.
Both the patient and prescribing physician were informed. A new treatment plan has been developed and the patient rescheduled. Corrective actions are to be determined. The licensee informed Region 3 (Mike Lafranzo).
* * * UPDATE ON 10/21/04 @ 1246 BY ED WROBLEWSKI TO CHAUNCEY GOULD * * *
The following text is an updated corrected version of the above initial report which was submitted by the licensee after consulting with Region 3.
On 10/11/04 a 49 year old female patient received what was to be the first of two High Dose Rate (HDR) treatments for endometrial cancer using a remote afterloading unit. The physician planned two fractions of 350 cGy for a total of 700 cGy at 0.5 cm from the GYN cylinder (2.0cm) wall using a 7 Ci Ir-192 source. The GYN cylinder is connected to the HDR unit using a 1500 mm transfer tube. A treatment of 189 seconds with an active length of 5 cm was to be treated with an indexer position of 1500 mm. Due to an error on the part of the medical physicist, an indexer length of 995 was programmed into the treatment unit. This resulted in the source not entering the patient. The source remained positioned in the transfer tube for the treatment duration at an estimated distance of 35-50 cm from the patient's skin. This resulted in a calculated dose between 1.4 - 4.3 R to the patient's skin. There are no expected adverse consequences.
Notified Reg 3 RDO (Julio Lara) and NMSS EO (Sandra Wastler)
On 10/11/04 a 49 year old female patient received the first of two treatments for endometrial cancer. A total dose of 700 centiGray was prescribed to be delivered in two (2) 350 cGy fractions using a 1500 mm length catheter containing a 7.035 curies Ir-192 source (duration 189 seconds). Due to an error on the part of the Health Physicist, the 995 mm length catheter was used. This resulted in a calculated dose of less than 1 cGy to the thigh at a distance of 505 mm from the intended site. There are no expected adverse consequences.
Both the patient and prescribing physician were informed. A new treatment plan has been developed and the patient rescheduled. Corrective actions are to be determined. The licensee informed Region 3 (Mike Lafranzo).
* * * UPDATE ON 10/21/04 @ 1246 BY ED WROBLEWSKI TO CHAUNCEY GOULD * * *
The following text is an updated corrected version of the above initial report which was submitted by the licensee after consulting with Region 3.
On 10/11/04 a 49 year old female patient received what was to be the first of two High Dose Rate (HDR) treatments for endometrial cancer using a remote afterloading unit. The physician planned two fractions of 350 cGy for a total of 700 cGy at 0.5 cm from the GYN cylinder (2.0cm) wall using a 7 Ci Ir-192 source. The GYN cylinder is connected to the HDR unit using a 1500 mm transfer tube. A treatment of 189 seconds with an active length of 5 cm was to be treated with an indexer position of 1500 mm. Due to an error on the part of the medical physicist, an indexer length of 995 was programmed into the treatment unit. This resulted in the source not entering the patient. The source remained positioned in the transfer tube for the treatment duration at an estimated distance of 35-50 cm from the patient's skin. This resulted in a calculated dose between 1.4 - 4.3 R to the patient's skin. There are no expected adverse consequences.
Notified Reg 3 RDO (Julio Lara) and NMSS EO (Sandra Wastler)