Event Notification Report for April 09, 2005
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/08/2005 - 04/09/2005
EVENT NUMBERS
41582415834159241635
Power Reactor
Event Number: 41582
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: JOHN REINSBURROW
HQ OPS Officer: CHAUNCEY GOULD
Region: 2 State: NC
Unit: [] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: JOHN REINSBURROW
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 04/09/2005
Notification Time: 04:53 [ET]
Event Date: 04/09/2005
Event Time: 00:50 [EST]
Last Update Date: 04/09/2005
Notification Time: 04:53 [ET]
Event Date: 04/09/2005
Event Time: 00:50 [EST]
Last Update Date: 04/09/2005
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):
WALTER ROGERS (R2)
WALTER ROGERS (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | A/R | Y | 61 | Power Operation | 0 | Hot Shutdown |
REACTOR SCRAMMED FROM 61% POWER DUE TO LOW REACTOR WATER LEVEL
"On 04/09/05 at approximately 00:50 an automatic reactor scram occurred on Brunswick Unit 2. The Reactor Protection System (RPS) actuated on low reactor water level (LL1). All control rods inserted from the RPS signal. The LL1 signal also provided a Group 2 (floor and equipment drain isolation valves), 6 (monitoring and sampling isolation valves) and 8 (shutdown cooling isolation valves) isolation signal for the respective containment Isolation valves. Reactor low level 2 (LL2) resulted in a Reactor Core Isolation Cooling (RCIC) system actuation and injection into the reactor. The High Pressure Coolant Injection (HPCI) system actuated but did not inject because reactor water level recovered. The Reactor Water Cleanup system (RWCU) isolated (Group 3 isolation). Secondary Containment isolated and the Standby Gas Treatment (SBGT) system initiated. An Alternate Rod Insertion signal was received and the Reactor Recirculation Pumps tripped as designed. An investigation is in progress to determine the cause of the reactor level transient. Safety systems and isolations functioned as designed."
The NRC Resident Inspector was notified.
"On 04/09/05 at approximately 00:50 an automatic reactor scram occurred on Brunswick Unit 2. The Reactor Protection System (RPS) actuated on low reactor water level (LL1). All control rods inserted from the RPS signal. The LL1 signal also provided a Group 2 (floor and equipment drain isolation valves), 6 (monitoring and sampling isolation valves) and 8 (shutdown cooling isolation valves) isolation signal for the respective containment Isolation valves. Reactor low level 2 (LL2) resulted in a Reactor Core Isolation Cooling (RCIC) system actuation and injection into the reactor. The High Pressure Coolant Injection (HPCI) system actuated but did not inject because reactor water level recovered. The Reactor Water Cleanup system (RWCU) isolated (Group 3 isolation). Secondary Containment isolated and the Standby Gas Treatment (SBGT) system initiated. An Alternate Rod Insertion signal was received and the Reactor Recirculation Pumps tripped as designed. An investigation is in progress to determine the cause of the reactor level transient. Safety systems and isolations functioned as designed."
The NRC Resident Inspector was notified.
Power Reactor
Event Number: 41583
Facility: SEQUOYAH
Region: 2 State: TN
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: CALVIN FIELDS
HQ OPS Officer: WESLEY HELD
Region: 2 State: TN
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: CALVIN FIELDS
HQ OPS Officer: WESLEY HELD
Notification Date: 04/09/2005
Notification Time: 13:20 [ET]
Event Date: 04/09/2005
Event Time: 11:11 [EDT]
Last Update Date: 04/09/2005
Notification Time: 13:20 [ET]
Event Date: 04/09/2005
Event Time: 11:11 [EDT]
Last Update Date: 04/09/2005
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):
WALTER ROGERS (R2)
WALTER ROGERS (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 ON TURBINE TRIP DUE TO LOW AUTO STOP OIL PRESSURE ON PRESSURE SWITCHES
"At 11:11 Unit 1 Turbine Tripped initiating Reactor Trip. Initial Indications are Turbine Trip due to Lo Auto Stop Oil Pressure on 2 pressure switches. Investigating Switch Actuations.
"#2 and #4 S/G [Steam Generator] Atmospheric Relief Valves did not control properly and RxOp [Reactor Operator] closed valves with Control Switch.
"Current Conditions: U1 [Unit 1] Mode 3, Stm Dumps In Service Normal, RCS temp at 547.4F, Pressure 2238 psig. 2 AFW [Auxiliary Feedwater] trains In Service at Normal Operation.
"All Rods Fully Inserted. Yes."
The licensee indicated there was not excessive cooldown or depressurization in the steam generators whose atmospheric relief valves had to be manually closed.
The NRC Resident Inspector has been notified.
* * * UPDATE PROVIDED BY LICENSEE (FIELDS) TO NRC (HELD) ON 4/9/05 ON 1901 * * *
"AFW Actuation - due to FW [Feedwater] Isol[ation] tripping both MFPs [Main Feed Pumps] (trips start AFW)"
AFW includes 2 motor-driven and 1 turbine-driven pump.
R2DO (Rogers) notified.
"At 11:11 Unit 1 Turbine Tripped initiating Reactor Trip. Initial Indications are Turbine Trip due to Lo Auto Stop Oil Pressure on 2 pressure switches. Investigating Switch Actuations.
"#2 and #4 S/G [Steam Generator] Atmospheric Relief Valves did not control properly and RxOp [Reactor Operator] closed valves with Control Switch.
"Current Conditions: U1 [Unit 1] Mode 3, Stm Dumps In Service Normal, RCS temp at 547.4F, Pressure 2238 psig. 2 AFW [Auxiliary Feedwater] trains In Service at Normal Operation.
"All Rods Fully Inserted. Yes."
The licensee indicated there was not excessive cooldown or depressurization in the steam generators whose atmospheric relief valves had to be manually closed.
The NRC Resident Inspector has been notified.
* * * UPDATE PROVIDED BY LICENSEE (FIELDS) TO NRC (HELD) ON 4/9/05 ON 1901 * * *
"AFW Actuation - due to FW [Feedwater] Isol[ation] tripping both MFPs [Main Feed Pumps] (trips start AFW)"
AFW includes 2 motor-driven and 1 turbine-driven pump.
R2DO (Rogers) notified.
Hospital
Event Number: 41592
Rep Org: VA NATIONAL HEALTH PHYSICS PROGRAM
Licensee: VA NATIONAL HEALTH PHYSICS PROGRAM
Region: 4
City: DALLAS State: TX
County:
License #: 03-23856-01VA
Agreement: Y
Docket:
NRC Notified By: EDWIN LEIDHOLDT, PHD
HQ OPS Officer: BILL HUFFMAN
Licensee: VA NATIONAL HEALTH PHYSICS PROGRAM
Region: 4
City: DALLAS State: TX
County:
License #: 03-23856-01VA
Agreement: Y
Docket:
NRC Notified By: EDWIN LEIDHOLDT, PHD
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/12/2005
Notification Time: 16:18 [ET]
Event Date: 04/09/2005
Event Time: 00:00 [CST]
Last Update Date: 04/12/2005
Notification Time: 16:18 [ET]
Event Date: 04/09/2005
Event Time: 00:00 [CST]
Last Update Date: 04/12/2005
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):
JOHN MADERA (R3)
SCOTT FLANDERS (NMSS)
REBECCA NEASE (R4)
JOHN MADERA (R3)
SCOTT FLANDERS (NMSS)
REBECCA NEASE (R4)
POSSIBLE MEDICAL EVENT
The VA National Health Physics Program (master materials licensee) reported a possible medical event at one of its permittees involving a Co-60 teletherapy device. The possible event occurred at the VA North Texas Health Care System, Dallas, Texas, on the dates of April 9 and 10, 2005.
"A patient was treated on Saturday and Sunday, April 9 and 10, 2005, for spinal cord compression. The written directive prescribed a dose of 500 cGy in two equal daily fractions. The intent was to give a total dose of about 2900 cGy, with another directive for the remainder of the fractions to be written on April 11, 2005. The treatment time for the fractions on April 9 and 10, 2005, was miscalculated. 330 cGy were administered instead of the prescribed 500 cGy. To avoid too low a dose, an additional fraction of 200 cGy will be given to the patient. This would not have met the definition of a medical event had a single directive, instead of two, been written for the entire treatment series.
"No adverse effect to the patient from the event is expected. The permittee has notified the referring physician and patient."
The licensee will notify the NRC Region III Project Manager (Kevin Null).
The VA National Health Physics Program (master materials licensee) reported a possible medical event at one of its permittees involving a Co-60 teletherapy device. The possible event occurred at the VA North Texas Health Care System, Dallas, Texas, on the dates of April 9 and 10, 2005.
"A patient was treated on Saturday and Sunday, April 9 and 10, 2005, for spinal cord compression. The written directive prescribed a dose of 500 cGy in two equal daily fractions. The intent was to give a total dose of about 2900 cGy, with another directive for the remainder of the fractions to be written on April 11, 2005. The treatment time for the fractions on April 9 and 10, 2005, was miscalculated. 330 cGy were administered instead of the prescribed 500 cGy. To avoid too low a dose, an additional fraction of 200 cGy will be given to the patient. This would not have met the definition of a medical event had a single directive, instead of two, been written for the entire treatment series.
"No adverse effect to the patient from the event is expected. The permittee has notified the referring physician and patient."
The licensee will notify the NRC Region III Project Manager (Kevin Null).
Power Reactor
Event Number: 41635
Facility: MCGUIRE
Region: 2 State: NC
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: PHIL THOMPSON
HQ OPS Officer: MIKE RIPLEY
Region: 2 State: NC
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: PHIL THOMPSON
HQ OPS Officer: MIKE RIPLEY
Notification Date: 04/25/2005
Notification Time: 15:57 [ET]
Event Date: 04/09/2005
Event Time: 10:39 [EDT]
Last Update Date: 04/25/2005
Notification Time: 15:57 [ET]
Event Date: 04/09/2005
Event Time: 10:39 [EDT]
Last Update Date: 04/25/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
JOEL MUNDAY (R2)
JOEL MUNDAY (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | N | 0 | 0 |
INVALID SPECIFIED SYSTEM ACTUATION
"This report is being made under 10CFR50.73(a)(2)(iv)(A) - Invalid Safety System Actuation.
"At 10:39:06 on April 9, 2005, the steam supply valve to Unit 2 turbine-driven auxiliary feedwater pump, 25A-48ABC, was manually failed open during a maintenance activity causing the pump to start. There was no valid actuation signal. The train of auxiliary feedwater started and functioned successfully. The actuation was complete and lasted for 1 minute and 25 seconds."
The licensee notified the NRC Resident Inspector.
"This report is being made under 10CFR50.73(a)(2)(iv)(A) - Invalid Safety System Actuation.
"At 10:39:06 on April 9, 2005, the steam supply valve to Unit 2 turbine-driven auxiliary feedwater pump, 25A-48ABC, was manually failed open during a maintenance activity causing the pump to start. There was no valid actuation signal. The train of auxiliary feedwater started and functioned successfully. The actuation was complete and lasted for 1 minute and 25 seconds."
The licensee notified the NRC Resident Inspector.