Event Notification Report for March 2, 1999
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
03/01/1999 - 03/02/1999
** EVENT NUMBERS **
34725 34935 35334 35364 35396 35415 35419 35424 35426 35427
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
+------------------------------------------------------------------------------+
|Hospital |Event Number: 34725 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: GARDEN CITY HOSPITAL |NOTIFICATION DATE: 09/02/1998|
|LICENSEE: GARDEN CITY HOSPITAL |NOTIFICATION TIME: 11:35[EDT]|
| CITY: GARDEN CITY REGION: 3 |EVENT DATE: 09/01/1998|
| COUNTY: WAYNE STATE: MI |EVENT TIME: 23:30[EDT]|
|LICENSE#: 21-04072-01 AGREEMENT: N |LAST UPDATE DATE: 03/01/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |ROGER LANKSBURY RDO |
| |DON COOL EO |
+------------------------------------------------+ |
| NRC NOTIFIED BY: DR. LUTSIC | |
| HQ OPS OFFICER: STEVE SANDIN | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| A PATIENT UNDERGOING TREATMENT FOR STAGE IV CANCER RECEIVED A VARIATION IN |
| EXCESS OF 50% OF THE PRESCRIBED PALLIATIVE DOSE. |
| |
| AT 2330EDT ON 9/1/98 A NURSE DURING ROUNDS DISCOVERED THAT A FEMALE PATIENT |
| UNDERGOING TREATMENT FOR ENDOMETRIAL CANCER HAD REMOVED HER APPLICATOR |
| CONTAINING THREE (3) CESIUM-137 SOURCES; 17.76 mCi, 25.05 mCi AND 25.0 mCi. |
| THE PATIENT RECEIVED ONLY 278 OF THE 580 mGRAM RADIUM EQUIVALENT HOURS |
| DOSE. THE PRESCRIBING PHYSICIAN DOES NOT PLAN ON RESCHEDULING TREATMENT |
| SINCE THE THERAPY WAS PALLIATIVE IN NATURE TO MINIMIZE BLEEDING. THE |
| LICENSEE INFORMED REGION 3(JONES). |
| |
| SEE HOO LOG FOR CONTACT INFORMATION. |
| |
| *** UPDATE ON 3/1/99 @ 1430 BY WEITZ TO GOULD *** EVENT RETRACTION |
| |
| THE LICENSEE IS RETRACTING THIS EVENT BASED ON A RECOMMENDATION FROM REG 3 |
| THAT THE EVENT IS NOT REPORTABLE. |
| |
| REG 3 RDO(JORGENSEN) WAS NOTIFIED ALONG WITH NMSS(BRIAN SMITH). |
+------------------------------------------------------------------------------+
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
+------------------------------------------------------------------------------+
|Hospital |Event Number: 34935 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: WILLIAM BEAUMONT HOSPITAL |NOTIFICATION DATE: 10/19/1998|
|LICENSEE: WILLIAM BEAUMONT HOSPITAL |NOTIFICATION TIME: 18:28[EDT]|
| CITY: ROYAL OAK REGION: 3 |EVENT DATE: 10/19/1998|
| COUNTY: STATE: MI |EVENT TIME: 10:40[EDT]|
|LICENSE#: 21-01333-01 AGREEMENT: N |LAST UPDATE DATE: 03/01/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |MIKE JORDAN RDO |
| |MICHAEL WEBER, MNSS EO |
+------------------------------------------------+ |
| NRC NOTIFIED BY: CHERYL SCHULTZ, RSO | |
| HQ OPS OFFICER: DICK JOLLIFFE | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| - MEDICAL MISADMINISTRATION OF INCORRECT NECK AND CHEST SCAN DOSE - |
| |
| AT 1040 ON 10/19/98, A PATIENT SCHEDULED FOR A NECK AND CHEST SCAN WAS |
| PRESCRIBED AND ADMINISTERED AN ORAL LIQUID DOSE OF 2.0 MILLICURIES OF |
| SODIUM IODIDE (I-131). THE PATIENT LEFT THE HOSPITAL AFTER THE DOSE WAS |
| ADMINISTERED. AFTER THE PATIENT HAD LEFT THE HOSPITAL, THE ADMINISTERING |
| TECHNOLOGIST DISCOVERED THAT THERE WAS STILL 0.9 MILLICURIES OF |
| CONCENTRATED I-131 LEFT IN THE DOSE VIAL. HOSPITAL PERSONNEL CONTACTED |
| THE PATIENT WHO RETURNED TO THE HOSPITAL. |
| |
| AT 1230 ON 10/19/98, THE PATIENT WAS ADMINISTERED A DOSE OF 1.0 MILLICURIES |
| OF I-131 WITH A GENEROUS AMOUNT OF WATER. |
| |
| THERE WAS NO ADVERSE IMPACT TO THE PATIENT. HOSPITAL PERSONNEL NOTIFIED |
| THE PATIENT'S PHYSICIAN AND ARE DETERMINING CORRECTIVE ACTIONS. |
| |
| *** UPDATE ON 3/1/99 @ 1223 BY SCHULTZ TO GOULD *** EVENT RETRACTION |
| |
| THE LICENSEE IS RETRACTING THIS EVENT AFTER A DISCUSSION WITH REG 3 ABOUT |
| THE ERROR BEING FOUND WITHIN 5 MINS AND CORRECTED VERY RAPIDLY. |
| |
| THE REG 3 RDO(JORGENSEN) WAS NOTIFIED. |
| |
| NMSS EO(BRIAN SMITH) WAS NOTIFIED. |
+------------------------------------------------------------------------------+
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 35334 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: BEAVER VALLEY REGION: 1 |NOTIFICATION DATE: 01/29/1999|
| UNIT: [] [2] [] STATE: PA |NOTIFICATION TIME: 18:55[EST]|
| RXTYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 01/29/1999|
+------------------------------------------------+EVENT TIME: 18:00[EST]|
| NRC NOTIFIED BY: COTTER |LAST UPDATE DATE: 03/01/1999|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |DAVID SILK R1 |
|10 CFR SECTION: | |
|AOUT 50.72(b)(1)(ii)(B) OUTSIDE DESIGN BASIS | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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
+------------------------------------------------------------------------------+
| AN ERRONEOUS ASSUMPTION WAS MADE IN THE FIRE PROTECTION SAFE SHUTDOWN |
| REPORT. |
| |
| A REVIEW ASSOCIATED WITH AN ENGINEERING FIRE PROTECTION SELF-ASSESSMENT HAS |
| IDENTIFIED AN ERRONEOUS ASSUMPTION REGARDING AN OPERATOR ACTION CREDITED IN |
| THE FIRE PROTECTION SAFE SHUTDOWN REPORT. POTENTIAL FIRE-INDUCED SPURIOUS |
| OPERATION OF THE REACTOR COOLANT SYSTEM (RCS) LOOP DRAIN VALVES 2RCS-MOV557A |
| , B, OR C, IN CONJUNCTION WITH SPURIOUS OPERATION OF THE DOWNSTREAM VALVES, |
| RCS EXCESS LETDOWN VALVES 2CHS-HCV137 AND 2CHS-MOV201 WAS NOT ADEQUATELY |
| CONSIDERED. THE UNIT 2 FIRE PROTECTION SAFE SHUTDOWN REPORT STATES THAT IN |
| THE EVENT OF A FIRE-INDUCED SPURIOUS OPERATION OF 2RCS-MOV557A, B, OR C, THE |
| OPERATOR COULD MANUALLY CLOSE EITHER 2CHS-MOV201 OR 2CHS-HCV137 TO ISOLATE |
| THE RESULTING EXCESS LETDOWN FLOW. OPERATION OF THESE VALVES FROM THE |
| CONTROL ROOM DOES NOT SATISFY THE REQUIREMENT SINCE THE FIRE MAY HAVE |
| DAMAGED THE CONTROL AND/OR POWER CIRCUITS. LOCAL MANUAL OPERATION OF THESE |
| VALVES WOULD NOT BE FEASIBLE WITHIN THE REQUIREMENTS OF THE SAFE SHUTDOWN |
| ANALYSIS BECAUSE OF INACCESSIBILITY IN CONTAINMENT. |
| |
| AT 1806, POWER WAS REMOVED FROM THE RCS LOOP DRAIN VALVES TO ISOLATE THIS |
| POTENTIAL FLOW PATH AND THUS RESTORE COMPLIANCE WITH THEIR POST-FIRE SAFE |
| SHUTDOWN ANALYSIS. |
| |
| THE NRC RESIDENT INSPECTOR WAS NOTIFIED BY THE LICENSEE. |
| |
| ******************** UPDATE AT 1457 ON 03/01/99 FROM GEORGE STOROLIS TO |
| GOULD ******************** |
| |
| The following text is a portion of a facsimile received from the licensee: |
| |
| "This notification is made to retract a prior NRC non-emergency event |
| notification, made on January 29, 1999, |
| at approximately 1855 hours. The prior notification followed the |
| determination of a design basis event, in |
| accordance with 10CFR50.72(b)(ii)(B), and identified an inappropriate |
| operator action credited in the Fire |
| Protection Safe Shutdown Report (FPSSR). The credited operator action |
| involved local manual operation to |
| close the reactor coolant system (RCS) excess letdown heat exchanger |
| isolation 2CHS*MOV201 or the |
| downstream control valve 2CHS*HCV137 to terminate an unplanned letdown flow |
| event through the RCS |
| excess letdown heat exchanger. This unplanned letdown flow event would |
| result from fire-induced operation |
| (opening) of the RCS loop drain valves 2RCS*MOV557A, or B, or C, in |
| conjunction with the 2CHS*MOV201 |
| and 2CHS*HCV137. During the ongoing FPSSR self-assessment, it was |
| recognized that the location of these |
| valves within containment would preclude access to the valves. Due to the |
| combination of the normal RCS |
| letdown flow and the unplanned RCS excess letdown flow, it was then |
| determined that the plant design basis |
| requirement of achieving approach to cold shutdown conditions within 72 |
| hours could not be assured." |
| |
| "Subsequent Nuclear Engineering Department evaluation following the January |
| 29, 1999, event notification has determined the maximum total time required |
| to achieve cold shutdown with the inability to isolate the letdown flow |
| path, is achievable within the 10 CFR [Part 50,] Appendix R design basis |
| requirement of 72 hours. This shutdown can be accomplished with the |
| existing plant design and current operating procedures. This evaluation |
| included consideration of the maximum expected RCS letdown flow, the |
| capability to achieve cold shutdown boration conditions within 10 hours and |
| meeting the overall requirement of achieving cold shutdown conditions within |
| 72 hours, and the capacity of one charging pump to meet the flow |
| requirements during the shutdown/cooldown sequence, assuming maximum normal |
| letdown flow." |
| |
| "Under the assumed failure conditions, the maximum total letdown flow rate |
| (normal and unplanned, due to the spurious valve openings) would be 202 gpm, |
| consisting of the following: |
| |
| - 37 gpm for the excess flow path due to the fire-induced operation |
| (opening) of the RCS loop drain valves |
| 2RCS*MOV557A, or B, or C, in conjunction with the 2CHS*MOV201 and |
| 2CHS*HCV137 or downstream |
| control valve 2CHS*HCV389, and |
| |
| - 165 gpm for the normal letdown flow path consisting of one 45-gpm orifice |
| and two 60-gpm orifices." |
| |
| "In addition to that described above, the charging pump must supply flow, as |
| indicated, for the following: |
| |
| - 70 gpm for the charging pump recirculation flow (minimum flow of 60 gpm) |
| [and] |
| |
| - 28 gpm seal water supply flow to the Reactor Coolant Pumps." |
| |
| "Comparison of the maximum total required charging pump flow rate (including |
| the flow from the excess letdown flow path created from the fire-induced |
| opening of RCS valves described above) with the specific pump curves, shows |
| adequate capability of a charging pump to provide this flow rate." |
| |
| "The time of 10 hours to borate to cold shutdown concentration described in |
| the FPSSR requires a letdown/boration flow of approximately 12 gpm, based on |
| the most limiting reactivity conditions. This flow requirement is well |
| within the capability of the letdown and charging systems and, therefore, |
| would be achievable." |
| |
| "Based on the subsequent evaluation as described above, a condition did not |
| exist which would have prevented meeting the design requirement to achieve |
| approach to cold shutdown condition within 72 hours. In addition, as a |
| result of this event notification retraction, Licensee Event Reporting |
| regarding this issue is not required nor is planned." |
| |
| "Power will be restored to the RCS loop drain valves." |
| |
| The licensee notified the NRC resident inspector. The NRC operations center |
| notified the R1DO (Modes). |
+------------------------------------------------------------------------------+
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 35364 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: CLINTON REGION: 3 |NOTIFICATION DATE: 02/11/1999|
| UNIT: [1] [] [] STATE: IL |NOTIFICATION TIME: 23:31[EST]|
| RXTYPE: [1] GE-6 |EVENT DATE: 02/11/1999|
+------------------------------------------------+EVENT TIME: 19:45[CST]|
| NRC NOTIFIED BY: ROBERT POWERS |LAST UPDATE DATE: 03/01/1999|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |GARY SHEAR R3 |
|10 CFR SECTION: | |
|AINC 50.72(b)(2)(iii)(C) POT UNCNTRL RAD REL | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N N 0 Cold Shutdown |0 Cold Shutdown |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| TORQUE VALUE USED ON THE MSIVs FOUND TO BE LESS THAN REQUIRED BY SEISMIC |
| ANALYSES |
| |
| "During an evaluation of the torque values for the Main Steam Isolation |
| Valve's (MSIV) actuator cylinder yoke |
| upper flange studs, Clinton Power Station discovered that the torque value |
| for the lower flange bolts as specified |
| by the vendor manual and plant procedure is much smaller [than] that used in |
| the seismic qualification of the MSIV actuators. The Vendor manual specifies |
| 200 ft-lbs while plant procedures specify 200 to 240 ft-lbs. However, the GE |
| seismic qualification document NEDE-30725 uses 620 ft-lbs. |
| |
| "A review of the seismic qualification indicated that the minimum applied |
| torque of 200 ft-lbs is acceptable for |
| mode 4 (cold shutdown), the plant's current mode of operation. |
| |
| " This condition during a seismic event could cause the valve stem to bind |
| which could have prevented MSIV |
| operation. Thus, a notification is being made per 10 CFR 50.72(b)(2)(iii)(c) |
| [because] this condition could have |
| prevented the fulfillment of the safety function of systems that are needed |
| to control the release of radioactive |
| material." |
| |
| The licensee notified the NRC Resident Inspector. |
| |
| *** UPDATE ON 3/1/99 @ 1817 BY POWERS TO GOULD *** EVENT RETRACTION |
| |
| FURTHER EVALUATION OF THIS CONDITION HAS DETERMINED THAT THIS EVENT IS NOT |
| REPORTABLE. THE TORQUE VALUE OF 200 FT-LBS HAS BEEN EVALUATED IN NUCLEAR |
| STATION ENGINEERING DEPT. CALCULATION IP-Q-0438, REVISION 0, AND FOUND TO |
| NOT AFFECT THE SEISMIC QUALIFICATION OF THE MSIV ACTUATORS. HOWEVER, |
| ENGINEERING CHANGE NOTICE 31374 HAS BEEN ISSUED TO CHANGE THE DESIGN |
| SPECIFIED TORQUE VALUE FOR THE AFFECTED FASTENERS TO 400 FT-LBS (+/-10% |
| LUBRICATED). |
| |
| THE RESIDENT INSPECTOR WAS NOTIFIED. REG 3 RDO(JORGENSEN) WAS |
| NOTIFIED. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 35396 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SURRY REGION: 2 |NOTIFICATION DATE: 02/23/1999|
| UNIT: [1] [2] [] STATE: VA |NOTIFICATION TIME: 17:58[EST]|
| RXTYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 02/23/1999|
+------------------------------------------------+EVENT TIME: 14:30[EST]|
| NRC NOTIFIED BY: THOMAS SOWERS |LAST UPDATE DATE: 03/01/1999|
| HQ OPS OFFICER: FANGIE JONES +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |ROBERT HAAG R2 |
|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 Y 100 Power Operation |100 Power Operation |
|2 N Y 100 Power Operation |100 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| FITNESS-FOR-DUTY REPORT |
| |
| A contract supervisor was determined to be in possession of a controlled |
| substance. The employee's access to the plant has been terminated. |
| (Contact the NRC Operations Officer for additional details.) |
| |
| The licensee informed the NRC Resident Inspector. |
| |
| *** UPDATE ON 3/1/99 @ 1446 BY SOWERS TO GOULD *** |
| |
| THE FOR CAUSE DRUG SCREEN RESULTS WERE CONFIRMED POSITIVE. |
| |
| THE RESIDENT INSPECTOR WAS NOTIFIED. |
| |
| THE REG 2 RDO(HAAG) WAS NOTIFIED. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Hospital |Event Number: 35415 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: SAN DIEGO MEDICAL CENTER |NOTIFICATION DATE: 02/26/1999|
|LICENSEE: VA MEDICAL SYSTEM |NOTIFICATION TIME: 17:31[EST]|
| CITY: SAN DIEGO REGION: 4 |EVENT DATE: 02/26/1999|
| COUNTY: STATE: CA |EVENT TIME: 08:10[PST]|
|LICENSE#: 04-15030-01 AGREEMENT: Y |LAST UPDATE DATE: 03/01/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |ELMO COLLINS R4 |
| |JOHN HICKEY NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: MIKE ZORN | |
| HQ OPS OFFICER: BOB STRANSKY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|BAAA 20.1906(d) SURFACE CONTAMINATION E| |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| PACKAGE RECEIVED WITH SURFACE CONTAMINATION ABOVE LIMITS |
| |
| At 0810 PST, a courier delivered a shipment of radiopharmaceuticals from the |
| SYNCOR pharmacy in San Diego, CA. Upon receipt, the licensee performed a |
| routine wipe sample of the external surfaces of the outer container (ammo |
| box), and discovered contamination in excess of the reporting requirements |
| of 10 CFR 20.1906. Initial wipes indicated up to 30,000 CPM of gross |
| activity for a swab that had been run over all surfaces of the container. |
| The package contained two vials of radiopharmaceuticals; 10 mCi of Tc-99m |
| META solution, and 10 mCi of Ga-67 (not NRC regulated). The licensee did |
| not report any damage to the vials, and they were administered to patients. |
| No contamination occurred at the medical center as a result of this |
| shipment. |
| |
| A more detailed survey of the container revealed up to 50,000 cpm/300cm2. |
| The licensee did not determine the isotope of the contaminant. A |
| representative of SYNCOR visited the medical center, and took several wipe |
| samples for isotopic identification. The licensee plans to investigate this |
| event with SYNCOR. |
| |
| |
| *** UPDATE ON 3/1/99 @ 1322 BY ZORN(FAX) TO GOULD *** |
| |
| BASED ON WIPE SURVEYS, THREE SEPARATE LOCATIONS ON THE EXTERIOR SURFACE OF |
| THE SYNCOR PACKAGE BORE RADIOACTIVE CONTAMINATION IN EXCESS OF THE 22 DPM/SQ |
| CM 49 CFR 173.443 LIMIT. THE THREE AREAS MEASURED AS FOLLOWS: |
| |
| PACKAGE WIPE LOCATION CALCULATED DPM/SQ CM |
| |
| BOTTOM THIRD OF FRONT SIDE 89.7 |
| MIDDLE THIRD OF FRONT SIDE |
| 74.8 |
| MOST OF RIGHT SIDE |
| 206.3 |
| (THESE VALUES WERE OBTAINED BY USING A COUNTING EFFICIENCY OF ~89% FOR |
| Tc-99m AND Ga-67) |
| |
| FOR EACH OF THESE THREE AREAS LISTED ABOVE, AN AREA OF 300 SQ CM WAS WIPED |
| WITH AN ALCOHOL SWAB AND ANALYZED IN A SEARLE 1195 GAMMA COUNTER. |
| |
| THE SUMMARY OF THE DETAILS IS AS FOLLOWS: |
| |
| 1. AT 0810, A SYNCOR COURIER PLACED A RADIOACTIVE MATERIAL PACKAGE ON |
| COUNTER IN ROOM 4059. THE PACKAGE CONTAINED ONE UNIT DOSE OF TECHNETIUM-99m |
| AND ONE UNIT DOSE OF GALLIUM-67 (EACH UNIT DOSE HAD AN ACTIVITY OF 10 |
| MILLICURIES). |
| |
| 2. ON RECEIPT OF THE PACKAGE ITS EXTERIOR WAS SWIPED AND PLACED INTO A GAMMA |
| COUNTER. |
| |
| 3. AFTER RECORDING EXPOSURE RATES FROM THE PACKAGE SURFACE AND AT 1 METER, |
| THE WIPE SAMPLE WAS CHECKED AT ~30000 CPM. |
| |
| 4. TWO SUCCESSIVE REWIPES OF THE PACKAGE EXTERIOR YIELDED ~25000 AND ~11000 |
| CPM, RESPECTIVELY. |
| |
| 5. SYNCOR WAS THAN CONTACTED TO INFORM THEM THAT THE PACKAGE WAS |
| CONTAMINATED AND THAT THEY SHOULD CHECK THE DELIVERY DRIVER AND TRUCK FOR |
| CONTAMINATION. |
| |
| 6. THE VASDHS RAD SAFETY OFFICER WAS NOTIFIED. |
| |
| 7. THE ASSISTANT RAD SAFETY OFFICER WAS INSTRUCTED TO MAKE A THROUGH |
| EVALUATION OF THE PACKAGE. |
| |
| 8. THE PACKAGE WAS THEN MOVED FROM ROOM 4509 TO ROOM 6056. |
| |
| 9. FOURTEEN MORE WIPES OF FOURTEEN AREAS OF THE ENTIRE PACKAGE EXTERIOR |
| SURFACE WERE MADE. THE AREA RANGED FROM 75 SQ CM TO 300 SQ CM. |
| |
| 10. THE 14 WIPES WERE ANALYZED IN A GAMMA COUNTER AND IT WAS DETERMINED |
| THAT THREE AREAS BORE CONTAMINATION IN EXCESS OF THE LIMITS. |
| |
| 11. SYNCORE WAS NOTIFIED THAT THE PACKAGE THEY HAD DELIVERED TO VASDHS HAD |
| EXTERIOR CONTAMINATION IN EXCESS OF THE 10 CFR 70.87(i) LIMITS. |
| |
| 12. THE RADIONUCLIDE WAS IDENTIFIED AS Tc-99m. |
| |
| REG 4 RDO(JONES) WAS NOTIFIED. |
| |
| NMSS EO(BRIAN SMITH) WAS NOTIFIED. |
+------------------------------------------------------------------------------+
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 35419 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: FITZPATRICK REGION: 1 |NOTIFICATION DATE: 02/27/1999|
| UNIT: [1] [] [] STATE: NY |NOTIFICATION TIME: 22:39[EST]|
| RXTYPE: [1] GE-4 |EVENT DATE: 02/27/1999|
+------------------------------------------------+EVENT TIME: 21:56[EST]|
| NRC NOTIFIED BY: STEVE CAROLIN |LAST UPDATE DATE: 03/01/1999|
| HQ OPS OFFICER: BOB STRANSKY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |RICHARD BARKLEY R1 |
|10 CFR SECTION: | |
|AINT 50.72(b)(1)(vi) INTERNAL THREAT | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |65 Power Operation |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| FIRE ONSITE LASTING LESS THAN 10 MINUTES |
| |
| At 2156, the 'A' circulating water pump tripped, and the control room |
| received indication of a fire in the pump motor. The onsite fire brigade |
| responded, and the fire was extinguished at 2204. The licensee reported |
| that the pump motor does not appear to be extensively damaged and that no |
| other equipment was involved in the fire. Reactor power was reduced to 65% |
| of rated due to the unavailability of the circulating water pump. No |
| personnel injuries were reported. |
| |
| The licensee will inform the NRC resident inspector of this event. |
| |
| ******************** UPDATE AT 1129 ON 03/01/99 FROM BOB STEIGERWALD TO |
| TROCINE ******************** |
| |
| The following text is a portion of a facsimile received from the licensee: |
| |
| "This notification retracts an earlier report made February 27, 1999, at |
| 2156, per 10CFR50.72(b)(1)(vi), due to a fire in the 'A' circulating water |
| pump motor junction box. The motor was de-energized, and the fire was |
| extinguished within 10 minutes. The emergency plan was not entered. The fire |
| did not affect the ability of plant personnel in the performance of duties |
| required for safe operation of the plant." |
| |
| "The reporting criteria for fires is based on events that endanger the |
| safety of the plant or interfere with personnel in the performance of duties |
| necessary for safe plant operations. This was a small fire in a motor |
| junction box, located in the non-safety-related area of the screenwell, that |
| was extinguished when the motor was de-energized. Safe plant operation was |
| not affected by the event. Therefore, the 10CFR50.72(b)(1)(vi) event |
| notification is being retracted." |
| |
| The licensee notified the NRC resident inspector. The NRC operations |
| officer notified the R1DO (Modes). |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 35424 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: OCONEE REGION: 2 |NOTIFICATION DATE: 03/01/1999|
| UNIT: [] [2] [] STATE: SC |NOTIFICATION TIME: 00:17[EST]|
| RXTYPE: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-L|EVENT DATE: 02/28/1999|
+------------------------------------------------+EVENT TIME: 20:40[EST]|
| NRC NOTIFIED BY: MIKE HILL |LAST UPDATE DATE: 03/01/1999|
| HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |ROBERT HAAG R2 |
|10 CFR SECTION: | |
|ARPS 50.72(b)(2)(ii) RPS ACTUATION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 A/R Y 98 Power Operation |0 Hot Shutdown |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| -AUTO Rx TRIP ON HIGH RCS PRESSURE DUE TO MAIN TURBINE CONTROL VALVES |
| FAILING CLOSED- |
| |
| At 1609 on 02/28/99, the Unit 2 electro-hydraulic control system lost |
| various power supplies. Main steam pressure increased from a normal 900 psig |
| to 942 psig and reactor power increased from 100% to 100.4%. The main |
| turbine control valves had throttled closed for unknown reasons causing the |
| main steam pressure to increase. Main feedwater was throttled to reduce |
| main steam header pressure since the turbine header pressure control station |
| had no effect. Unit 2 was stabilized at 98.5% power with the main steam |
| pressure at 938 psig and the main feedwater master control stations and the |
| reactor control station in manual. |
| |
| At 2040 on 02/28/99, Unit 2 automatically tripped from 98% power due to a |
| reactor protection system actuation (reactor coolant system high pressure |
| trip). All control rods inserted completely. The main steam code safety |
| valves lifted to dump steam to the atmosphere for approximately 10 minutes. |
| Plant operators verified that the valves reseated properly. Steam is being |
| dumped to the main condenser. The main feedwater system remained |
| operational throughout the event. The reactor control station was in |
| automatic at the time of the trip. Unit 2 is stable in hot shutdown mode. |
| |
| The licensee is investigating the cause of the main turbine control valves |
| failing closed and plans to make necessary repairs. |
| |
| Units 1 and 3 remain at 100% power and were unaffected by this event. |
| |
| The licensee notified the NRC Resident Inspector. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 35426 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: HATCH REGION: 2 |NOTIFICATION DATE: 03/01/1999|
| UNIT: [1] [2] [] STATE: GA |NOTIFICATION TIME: 20:18[EST]|
| RXTYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 03/01/1999|
+------------------------------------------------+EVENT TIME: 19:29[EST]|
| NRC NOTIFIED BY: BUTLER |LAST UPDATE DATE: 03/01/1999|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |ROBERT HAAG R2 |
|10 CFR SECTION: | |
|AARC 50.72(b)(1)(v) OTHER ASMT/COMM INOP | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N N 0 Hot Shutdown |0 Hot Shutdown |
|2 N Y 100 Power Operation |100 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| BOTH MAIN AND BACKUP PROMPT NOTIFICATION SYSTEMS WERE OUT OF SERVICE. |
| |
| THE NOAA WEATHER RADIO SIGNALS WERE NOT BEING RECEIVED AT HATCH FOR |
| APPROXIMATELY 6 MINUTES. IT APPEARS THAT DUE TO A LOOSE WIRE ON THE |
| MICROPHONE, NOAA HAD NOT RECORDED ANYTHING ON THE TAPE THAT IS TRANSMITTED |
| TO THE LICENSEE. THE PROBLEM WAS CORRECTED AT 1935. |
| |
| THE RESIDENT INSPECTOR WILL BE NOTIFIED. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 35427 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: VOGTLE REGION: 2 |NOTIFICATION DATE: 03/02/1999|
| UNIT: [] [2] [] STATE: GA |NOTIFICATION TIME: 04:32[EST]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 03/02/1999|
+------------------------------------------------+EVENT TIME: 02:06[EST]|
| NRC NOTIFIED BY: LEE MANSFIELD |LAST UPDATE DATE: 03/02/1999|
| HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |ROBERT HAAG R2 |
|10 CFR SECTION: | |
|ARPS 50.72(b)(2)(ii) RPS ACTUATION | |
|AESF 50.72(b)(2)(ii) ESF ACTUATION | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 M/R Y 100 Power Operation |0 Hot Standby |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| - MANUAL Rx TRIP FROM 100% DUE TO CLOSURE OF LOOP 3 MAIN FEEDWATER ISOLATION |
| VALVE - |
| |
| WHILE IN THE PROCESS OF HANGING AN OUTAGE CLEARANCE TAG ON UNIT 1 EQUIPMENT |
| (SEE EVENT #35421), PLANT TECHNICIANS ERRONEOUSLY PULLED THE FUSES TO THE |
| UNIT 2 LOOP 3 MAIN FEEDWATER ISOLATION VALVE (#2HV-5229) TO #3 STEAM |
| GENERATOR CAUSING THE VALVE TO CLOSE. CONTROL ROOM OPERATORS OBSERVED THE |
| LOW WATER LEVEL IN #3 STEAM GENERATOR AND THE STEAM FLOW/FEED FLOW MISMATCH |
| ANNUNCIATORS. |
| |
| AT 0206 ON 03/02/99, CONTROL ROOM OPERATORS MANUALLY TRIPPED THE REACTOR |
| FROM 100% POWER. ALL CONTROL RODS INSERTED COMPLETELY. THE AUXILIARY |
| FEEDWATER SYSTEM ACTUATED, AS EXPECTED. STEAM IS BEING DUMPED TO THE MAIN |
| CONDENSER. |
| |
| DURING THE TRIP, AN ELECTRO-HYDRAULIC CONTROL (EHC) SYSTEM POWER SUPPLY |
| FAILED CAUSING ERRONEOUS INDICATIONS OF MAIN CONDENSER VACUUM AND EHC |
| PRESSURE. |
| |
| UNIT 2 IS STABLE IN MODE 3 (HOT STANDBY). |
| |
| THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. |
+------------------------------------------------------------------------------+
Page Last Reviewed/Updated Thursday, March 25, 2021