United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated With Events > Event Notification Reports > 1999

Event Notification Report for February 18, 1999

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           02/17/1999 - 02/18/1999

                              ** EVENT NUMBERS **

35361  35373  35374  35375  35376  35377  35378  35379  35380  35381  

+------------------------------------------------------------------------------+
|Fuel Cycle Facility                              |Event Number:   35361       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT   |NOTIFICATION DATE: 02/10/1999|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 11:19[EST]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        02/10/1999|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        07:00[EST]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  02/17/1999|
|    CITY:  PIKETON                  REGION:  3  +-----------------------------+
|  COUNTY:  PIKE                      STATE:  OH |PERSON          ORGANIZATION |
|LICENSE#:  GDP-2                 AGREEMENT:  N  |GARY SHEAR           R3      |
|  DOCKET:  0707002                              |SCOTT MOORE          NMSS    |
+------------------------------------------------+FRANK CONGEL         IRO     |
| NRC NOTIFIED BY:  ERIC SPAETH                  |BOB PIERSON          NMSS    |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NBNL                     RESPONSE-BULLETIN      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| NRC BULLETIN 91-01, 4-HOUR NOTIFICATION INVOLVING INCORRECT RAFFINATE MASS   |
| AND CONCENTRATION CALCULATION                                                |
|                                                                              |
| On 02/10/99, X-705 building personnel discovered that a Nuclear Criticality  |
| Safety Approval (NCSA) requirement had not been maintained in the X-705      |
| Decontamination Facility.  Uranium recovery waste stream solutions are       |
| sampled to determine the U-235 concentration, mass, and enrichment as        |
| spelled out in NCSA-0705_027, Heavy Metals Precipitation.  These sample      |
| results are used to calculate U-235 concentration and U-235 mass prior to    |
| transferring and processing the waste solutions as identified in the         |
| administrative requirements of the NCSA.                                     |
|                                                                              |
| Sample results for raffinate solutions (recovery waste streams) were         |
| recorded incorrectly on the raffinate transfer sheet and the heavy metals    |
| batch sheets. The double contingency principle was violated as result of:    |
| 1) failure of the operator to correctly determine the U-235 concentration    |
| prior to transfer (control "A") and 2) failure of supervision to find the    |
| error while verifying the data and calculations (control "B"). This error    |
| resulted in solution being transferred and processed to a geometrically      |
| unfavorable sludge collection tub without the correct U-235 concentration    |
| and U-235 mass being recorded.                                               |
|                                                                              |
| There was no loss of hazardous/radioactive material or radioactive           |
| radiological contamination exposure as a result of this event.               |
|                                                                              |
| SAFETY SIGNIFICANCE OF EVENTS:  The safety significance of this event is     |
| low.  This is because when this material was sampled for enrichment, the     |
| enrichment was found to be 3.95% U-235.  Also, due to the reduction of HEU   |
| material on site, material now being processed through the heavy metals      |
| systems routinely has an enrichment less than 10% U-235.                     |
|                                                                              |
| POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO[S] OF HOW            |
| CRITICALITY COULD OCCUR):  For a criticality to occur, both calculations of  |
| how much material is in the system must be wrong and the total mass of       |
| material must exceed 760 grams U-235.  The minimum critical mass for 100%    |
| enriched material is approximately 760 grams U-235.  Even if the enrichment  |
| had been 100%, the total mass in the system as a result of this event would  |
| have been 245 grams.                                                         |
|                                                                              |
| Also, a second path would be the processing material and collecting material |
| with greater than the minimum critical mass in the heavy metals collection   |
| drums.                                                                       |
|                                                                              |
| CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY. CONCENTRATION, ETC.):     |
| The controlled parameter in this case was mass.  (Both of the mass controls  |
| were lost because the calculations were in error.)                           |
|                                                                              |
| ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS     |
| LIMIT AND % WORST CASE OF CRITICAL MASS):  The total amount of material in   |
| the system was 245 grams U-235 assuming an enrichment of 100%.  The          |
| enrichment was measured after the event and found to be 3.95% U-235.  The    |
| material was uranium solution.  The minimum critical mass at 100% enrichment |
| is approximately 760 grams U-235, and using the 100% enriched values, the    |
| percent worst case critical mass is 32.2%.                                   |
|                                                                              |
| NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION   |
| OF THE FAILURES OR DEFICIENCIES:  NCSA-0705_027 requires that material to be |
| processed through the heavy metals recovery system is sampled and the total  |
| amount of uranium in the material calculated and recorded by an operator on  |
| a transfer sheet and verified by another operator or supervisor on the same  |
| sheet.  If the enrichment of the sample is not known, an enrichment of 100%  |
| is assumed for the calculation.  The total amount of U-235 allowed to be     |
| processed at any time is limited to 200 grams.  The calculations done by     |
| both the operator and the verifier used a concentration value ten times less |
| than the actual enrichment, which was only 3.95%.                            |
|                                                                              |
| CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEM AND WHEN EACH WAS IMPLEMENTED:   |
| The heavy metals precipitation was shutdown and isolated.  Similar           |
| operations (microfiltration filter press and oil and grease removal unit )   |
| were also shut down and isolated.  An investigation has been initiated to    |
| determine if similar anomalous conditions exists in those operations.        |
|                                                                              |
| The NRC resident inspector has been informed of this event by the Portsmouth |
| personnel.                                                                   |
|                                                                              |
| *************** UPDATE AT 1825 ON 02/17/99 FROM JOE HALCOMB RECEIVED BY      |
| TROCINE ***************                                                      |
|                                                                              |
| On 02/10/99, the error in the mass values for the sludge collection drum was |
| corrected.   This changed the total  U-235 mass in the drum from 43.02 grams |
| to 139.78 grams.  This value is below the NCSA limit of 200 grams.           |
|                                                                              |
| Portsmouth personnel notified the NRC resident inspector.  The NRC           |
| operations officer notified the R3DO (Jordan), NMSS EO (Haughney), and IRO   |
| (Hogan).                                                                     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   35373       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SALEM                    REGION:  1  |NOTIFICATION DATE: 02/17/1999|
|    UNIT:  [] [2] []                 STATE:  NJ |NOTIFICATION TIME: 02:16[EST]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        02/17/1999|
+------------------------------------------------+EVENT TIME:        02:02[EST]|
| NRC NOTIFIED BY:  STEVE SAUER                  |LAST UPDATE DATE:  02/17/1999|
|  HQ OPS OFFICER:  DICK JOLLIFFE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |JIM TRAPP            R1      |
|10 CFR SECTION:                                 |                             |
|ASHU 50.72(b)(1)(i)(A)   PLANT S/D REQD BY TS   |                             |
|NLCO                     TECH SPEC LCO A/S      |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     N          Y       100      Power Operation  |98       Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| - TECH SPEC REQUIRED PLANT SHUTDOWN DUE TO A 28 VOLT DC BATTERY CELL TESTING |
| LOW -                                                                        |
|                                                                              |
| AT 0202 ON 02/17/99, DURING THE PERFORMANCE OF A QUARTERLY SURVEILLANCE      |
| TEST, THE VOLTAGE OF ONE OF THE 28 VOLT DC BATTERY CELLS TESTED AT 2.11 VDC. |
| THE TECH SPEC MINIMUM LIMIT IS 2.13 VDC.  TECH SPEC LCO A/S 3.8.2.5 REQUIRES |
| THE LICENSEE TO REPLACE THE AFFECTED CELL IN TWO HOURS OR PLACE UNIT 2 IN    |
| THE HOT STANDBY MODE WITHIN SIX HOURS.  THE LICENSEE PLANS TO REPLACE THE    |
| AFFECTED CELL WITHIN TWO HOURS.                                              |
|                                                                              |
| THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR.                            |
|                                                                              |
| * * * UPDATE AT 0354 ON 02/17/99 FROM STEVE SAUER TO JOLLIFFE * * *          |
|                                                                              |
| AT 0351 ON 02/17/99, THE LICENSEE REPLACED THE AFFECTED BATTERY CELL AND     |
| EXITED TECH SPEC LCO A/S 3.8.2.5.                                            |
|                                                                              |
| THE LICENSEE PLANS TO  INFORM THE NRC RESIDENT INSPECTOR.  THE NRC           |
| OPERATIONS OFFICER NOTIFIED THE R1DO JIM TRAPP.                              |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   35374       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: LIMERICK                 REGION:  1  |NOTIFICATION DATE: 02/17/1999|
|    UNIT:  [1] [2] []                STATE:  PA |NOTIFICATION TIME: 03:50[EST]|
|   RXTYPE: [1] GE-4,[2] GE-4                    |EVENT DATE:        02/17/1999|
+------------------------------------------------+EVENT TIME:        02:50[EST]|
| NRC NOTIFIED BY:  CARL RICH                    |LAST UPDATE DATE:  02/17/1999|
|  HQ OPS OFFICER:  DICK JOLLIFFE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |JIM TRAPP            R1      |
|10 CFR SECTION:                                 |                             |
|DDDD 73.71               UNSPECIFIED PARAGRAPH  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| - PLANT SECURITY REPORT -                                                    |
|                                                                              |
| A COMPROMISE OF PLANT SECURITY DOCUMENT WAS DISCOVERED.  COMPENSATORY        |
| MEASURES WERE IMMEDIATELY TAKEN UPON DISCOVERY.  CONTACT THE NRC OPERATIONS  |
| OFFICER FOR ADDITIONAL DETAILS.                                              |
|                                                                              |
| THE LICENSEE PLANS TO INFORM THE NRC RESIDENT INSPECTOR.                     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   35375       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: QUAD CITIES              REGION:  3  |NOTIFICATION DATE: 02/17/1999|
|    UNIT:  [] [2] []                 STATE:  IL |NOTIFICATION TIME: 05:16[EST]|
|   RXTYPE: [1] GE-3,[2] GE-3                    |EVENT DATE:        02/17/1999|
+------------------------------------------------+EVENT TIME:        00:20[CST]|
| NRC NOTIFIED BY:  DARYL NOHR                   |LAST UPDATE DATE:  02/17/1999|
|  HQ OPS OFFICER:  DICK JOLLIFFE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |MIKE JORDAN          R3      |
|10 CFR SECTION:                                 |                             |
|AESF 50.72(b)(2)(ii)     ESF ACTUATION          |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| - UNIT 2 RECEIVED ESF ACTUATIONS DUE TO A FAILED VOLTAGE REGULATOR. -        |
|                                                                              |
| AT 0020 CST ON 02/17/99, UNIT 2 (100% POWER) UNEXPECTEDLY RECEIVED THE       |
| FOLLOWING ENGINEERED SAFETY FEATURE (ESF) ACTUATIONS:  HALF SCRAM SIGNAL,    |
| HALF PRIMARY CONTAINMENT ISOLATION SYSTEM (PCIS) GROUP 1 ISOLATION SIGNAL    |
| (MAIN STEAM LINE VALVES), HALF PCIS GROUP 2 ISOLATION SIGNAL (VENT AND       |
| SAMPLE VALVES INSIDE THE DRYWELL), AND REACTOR WATER CLEANUP ISOLATION       |
| SIGNAL.  AS PART OF THE PARTIAL PCIS GROUP 2 ESF ACTUATION, SEVERAL PRIMARY  |
| CONTAINMENT ISOLATION VALVES CLOSED.                                         |
|                                                                              |
| AT THE TIME OF THE ESF ACTUATION, THE #2A REACTOR PROTECTION SYSTEM (RPS)    |
| WAS BEING SUPPLIED FROM ITS RESERVE FEED, AND THE LICENSEE DETERMINED IT TO  |
| BE TRIPPED DUE TO A FAILED VOLTAGE REGULATOR.  THE LICENSEE REENERGIZED THE  |
| #2A RPS FROM ITS NORMAL FEED AND RESTORED THE PLANT LINEUP TO NORMAL EXCEPT  |
| THE #2A MAIN STEAM LINE RADIATION MONITOR DOWNSCALE WOULD NOT RESET.  THE    |
| LICENSEE INSERTED A HALF SCRAM SIGNAL AND A HALF PCIS GROUP 1 ISOLATION      |
| SIGNAL IN ACCORDANCE WITH TECH SPEC REQUIREMENTS WHILE REPAIRS ARE IN        |
| PROGRESS.                                                                    |
|                                                                              |
| THE LICENSEE PLANS TO INFORM THE NRC RESIDENT INSPECTOR.                     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   35376       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: COOK                     REGION:  3  |NOTIFICATION DATE: 02/17/1999|
|    UNIT:  [1] [2] []                STATE:  MI |NOTIFICATION TIME: 08:23[EST]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        02/16/1999|
+------------------------------------------------+EVENT TIME:        13:56[EST]|
| NRC NOTIFIED BY:  MARY B. GREENDONNER          |LAST UPDATE DATE:  02/17/1999|
|  HQ OPS OFFICER:  DICK JOLLIFFE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |MIKE JORDAN          R3      |
|10 CFR SECTION:                                 |                             |
|HFIT 26.73               FITNESS FOR DUTY       |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          N       0        Cold Shutdown    |0        Cold Shutdown    |
|2     N          N       0        Cold Shutdown    |0        Cold Shutdown    |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| - FITNESS-FOR-DUTY REPORT -                                                  |
|                                                                              |
| AT 1356 ON 02/16/99, A  LICENSEE SUPERVISOR WAS DETERMINED TO BE UNDER THE   |
| INFLUENCE OF ALCOHOL DURING A FOR-CAUSE FITNESS-FOR-DUTY TEST.  THE          |
| INDIVIDUAL'S PLANT ACCESS AUTHORIZATION WAS TERMINATED.  THE INDIVIDUAL HAS  |
| BEEN REFERRED TO THE LICENSEE FITNESS-FOR-DUTY PROGRAM.  CONTACT THE NRC     |
| OPERATIONS OFFICER FOR ADDITIONAL DETAILS.                                   |
|                                                                              |
| THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR.                            |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Fuel Cycle Facility                              |Event Number:   35377       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT      |NOTIFICATION DATE: 02/17/1999|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 11:22[EST]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        02/17/1999|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        09:52[CST]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  02/17/1999|
|    CITY:  PADUCAH                  REGION:  3  +-----------------------------+
|  COUNTY:  McCRACKEN                 STATE:  KY |PERSON          ORGANIZATION |
|LICENSE#:  GDP-1                 AGREEMENT:  Y  |MIKE JORDAN          R3      |
|  DOCKET:  0707001                              |SCOTT MOORE, NMSS    EO      |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  BILL HALICKS                 |                             |
|  HQ OPS OFFICER:  DICK JOLLIFFE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|BAAA 20.1906(d)          SURFACE CONTAMINATION E|                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| - UF6 CYLINDER RECEIVED WITH REMOVABLE RADIOACTIVE SURFACE CONTAMINATION -   |
|                                                                              |
| AT 0952 CST ON 02/17/99, PADUCAH RECEIVED AN EMPTY UF6 CYLINDER ON THE BACK  |
| OF A FLAT BED TRUCK FROM STARMET CMI, BARNWELL, SC.  THE CARRIER WAS RSB     |
| LOGISTICS, ST LOUIS, MO.  THE SURFACE OF THE CYLINDER WAS SURVEYED UPON      |
| RECEIPT AND CONTAMINATION LEVELS WERE 2,379 DPM PER 100 SQUARE CM BETA/GAMMA |
| REMOVABLE RADIOACTIVE SURFACE CONTAMINATION.  (THE MAXIMUM ACCEPTABLE LIMIT  |
| OF 10CFR71.87(i) IS 2,200.)  THE SURVEY RESULTS OF THE TRUCK WERE LESS THAN  |
| THE MINIMUM DETECTABLE ACTIVITY.  THE LICENSEE PLACED THE CYLINDER IN A      |
| RADIOLOGICALLY CONTROLLED AREA AND PLANS TO DECONTAMINATE IT.                |
|                                                                              |
| PADUCAH PERSONNEL NOTIFIED THE NRC REGION 3 IN ACCORDANCE WITH THE           |
| REQUIREMENTS OF 10CFR20.1906(d)(1) AS A 1-HOUR EVENT NOTIFICATION REPORT.    |
| PADUCAH PERSONNEL ALSO NOTIFIED THE NRC RESIDENT INSPECTOR..                 |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   35378       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: HARRIS                   REGION:  2  |NOTIFICATION DATE: 02/17/1999|
|    UNIT:  [1] [] []                 STATE:  NC |NOTIFICATION TIME: 13:05[EST]|
|   RXTYPE: [1] W-3-LP                           |EVENT DATE:        02/17/1999|
+------------------------------------------------+EVENT TIME:        12:19[EST]|
| NRC NOTIFIED BY:  MARK PALMER                  |LAST UPDATE DATE:  02/17/1999|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |ANN BOLAND           R2      |
|10 CFR SECTION:                                 |                             |
|ASHU 50.72(b)(1)(i)(A)   PLANT S/D REQD BY TS   |                             |
|NLCO                     TECH SPEC LCO A/S      |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |70       Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| TECHNICAL SPECIFICATION REQUIRED PLANT SHUTDOWN DUE TO FAILURE OF THE 'A'    |
| REACTOR TRIP BREAKER TO CLOSE RELIABLY DURING TESTING                        |
|                                                                              |
| The following text is a portion of a facsimile received from the licensee:   |
|                                                                              |
| "During [technical specification] surveillance testing [with the unit] at    |
| 100% power, a testing failure occurred on the train 'A' reactor trip         |
| breaker.  The test in progress was MST-I001, Train 'A' Solid State           |
| Protection System Actuation Logic and Master Relay Test.  During this test,  |
| the 'A' reactor trip breaker failed to close with the test pushbutton.  The  |
| following timeline occurred:"                                                |
|                                                                              |
| "0821- [The] train 'A' reactor trip bypass breaker [was racked in and        |
| closed].  This began a 2-hour time                                           |
| limit allowed for surveillance testing.                                      |
| 0916 - Reactor trip breaker 'A' failed to close with the test pushbutton.    |
| At this point, the 2-hour limit for                                          |
| surveillance testing ended, and [Technical Specification] 3.3.1, action 8,   |
| was entered.  This action                                                    |
| required the plant to be in Mode 3 within 6 hours.  The time to enter Mode 3 |
| is 1516.                                                                     |
| 1026 - NRC Region II representative, George MacDonald, [was] notified of     |
| [limiting condition for operation]                                           |
| and necessity to be in Mode 3 by 1516.  Mr. MacDonald was notified because   |
| [the] Harris resident                                                        |
| inspectors are out of town.                                                  |
| 1219 - [A generator] load reduction for plant shutdown [was commenced].      |
| Maintenance and engineering                                                  |
| personnel are investigating the problem."                                    |
|                                                                              |
| The licensee emphasized that the train 'A' reactor trip breaker did not fail |
| to open, which is its safety function.  The breaker only failed to re-close. |
| It has since been opened and re-closed several times during ongoing          |
| troubleshooting activities.  The licensee currently believes that the        |
| failure of the breaker to re-close reliably may be the result of a possible  |
| problem with the test circuitry allowing the test signal to stay in.         |
|                                                                              |
| Although all of the emergency diesel generators and emergency core cooling   |
| systems are operable and available if needed, the licensee stated that the   |
| emergency response date system is not available due to a Y2K problem.  (The  |
| Y2K problem is not related to the breaker problem.)                          |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   35379       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: CALVERT CLIFFS           REGION:  1  |NOTIFICATION DATE: 02/17/1999|
|    UNIT:  [1] [] []                 STATE:  MD |NOTIFICATION TIME: 15:55[EST]|
|   RXTYPE: [1] CE,[2] CE                        |EVENT DATE:        02/17/1999|
+------------------------------------------------+EVENT TIME:        14:30[EST]|
| NRC NOTIFIED BY:  ERIC MEERBACH                |LAST UPDATE DATE:  02/17/1999|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |JIM TRAPP            R1      |
|10 CFR SECTION:                                 |                             |
|APRE 50.72(b)(2)(vi)     OFFSITE NOTIFICATION   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| OFFSITE NOTIFICATION OF HIGH COLIFORM IN THE DRINKING WATER AT THE VISITOR'S |
| CENTER                                                                       |
|                                                                              |
| A positive coliform result was received for the drinking water at the site's |
| visitor's center.  Accordingly, Chemistry personnel were notified, and an    |
| Issue Report was generated.  The licensee also notified the Maryland         |
| Department of the Environment and the NRC resident inspector.                |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   35380       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  LOWER BUCKS HOSPITAL                 |NOTIFICATION DATE: 02/17/1999|
|LICENSEE:  LOWER BUCKS HOSPITAL                 |NOTIFICATION TIME: 16:24[EST]|
|    CITY:  BRISTOL                  REGION:  1  |EVENT DATE:        02/17/1999|
|  COUNTY:  BUCKS                     STATE:  PA |EVENT TIME:        12:00[EST]|
|LICENSE#:  SNM-1800              AGREEMENT:  N  |LAST UPDATE DATE:  02/17/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |JIM TRAPP            R1      |
|                                                |CHARLEY HAUGHNEY     NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  DR. MARK ANSLEY              |                             |
|  HQ OPS OFFICER:  LEIGH TROCINE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NCAR                     CARDIAC PACEMAKER      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| DEATH OF A PATIENT WITH AN IMPLANTED NUCLEAR-POWERED CARDIAC PACEMAKER       |
| (24-hour report)                                                             |
|                                                                              |
| A representative from Lower Bucks Hospital located in Bristol, PA, reported  |
| the death of a patient with an implanted nuclear-powered cardiac pacemaker.  |
| The patient expired today (02/17/99) at Einstein Hospital located in         |
| Philadelphia, PA.  The pacemaker was manufactured by Coratomic (model        |
| #C-101, serial #1054), and it contained 4 grams of Plutonium-238.            |
|                                                                              |
| The pacemaker is currently implanted in the patient, and the licensee plans  |
| to have Einstein Hospital remove it.  Once the pacemaker is retrieved, it    |
| will be shipped to the manufacturer for proper disposal.  When notification  |
| of receipt is received by the licensee, the licensee plans to submit a       |
| written report to the NRC.  The licensee also plans to notify the NRC Region |
| I Office.                                                                    |
|                                                                              |
| (Contact the NRC operations officer for a site contact telephone number.)    |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   35381       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: NINE MILE POINT          REGION:  1  |NOTIFICATION DATE: 02/17/1999|
|    UNIT:  [1] [] []                 STATE:  NY |NOTIFICATION TIME: 18:47[EST]|
|   RXTYPE: [1] GE-2,[2] GE-5                    |EVENT DATE:        02/17/1999|
+------------------------------------------------+EVENT TIME:        18:40[EST]|
| NRC NOTIFIED BY:  JIM KRONENBITTER             |LAST UPDATE DATE:  02/17/1999|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |JIM TRAPP            R1      |
|10 CFR SECTION:                                 |                             |
|ASHU 50.72(b)(1)(i)(A)   PLANT S/D REQD BY TS   |                             |
|NLCO                     TECH SPEC LCO A/S      |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |98       Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| TECHNICAL SPECIFICATION REQUIRED PLANT SHUTDOWN DUE TO FAILURE TO PERFORM    |
| SURVEILLANCE TESTING IN ACCORDANCE WITH ASME SECTION XI REQUIREMENTS         |
| FOLLOWING REPLACEMENT OF EMERGENCY (ISO) CONDENSER TUBE BUNDLES LAST FALL    |
|                                                                              |
| The following text is a portion of a facsimile received from the licensee:   |
|                                                                              |
| "In accordance with Technical Specification 3.2.6(a)1, Quality Group A, B,   |
| and C components shall satisfy the requirements contained in Section XI of   |
| the ASME Boiler and Pressure Vessel Code and applicable addenda for          |
| continued service of ASME Code Class 1, 2, and 3 components to be considered |
| operable.  The pre-service inspection (radiographs) for emergency condensers |
| 111, 112, 121, and 122 was performed prior to the construction hydrostatic   |
| test for emergency condensers 111, 112, 121, and 122.  This sequence of      |
| testing is contrary to the requirements of the ASME code.  Emergency         |
| condensers 111, 112, 121, and 122 are inoperable.  Technical Specification   |
| 3.1.3(e) requires [that] a normal orderly shutdown shall be initiated within |
| [1-]hour and [that] the reactor shall be in the Cold Shutdown condition      |
| within [10] hours with no emergency cooling system operable."                |
|                                                                              |
| The licensee stated that all of the Unit 1 emergency condensers were         |
| declared inoperable at approximately 1750, and a unit shutdown was commenced |
| at 1840.                                                                     |
|                                                                              |
| The licensee notified the NRC resident inspector.                            |
|                                                                              |
| HOO NOTE:  At approximately 1900 on 02/17/99, the licensee requested a       |
| Notice of Enforcement Discretion to                                          |
| allow 48 hours to perform the required testing.  A Notice of Enforcement     |
| Discretion was granted by                                                    |
| the NRC Region 1 Office at 2026.                                             |
+------------------------------------------------------------------------------+