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 THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!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 THIS EVENT HAS BEEN RETRACTED.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
Page Last Reviewed/Updated Thursday, March 25, 2021