Event Notification Report for March 10, 1999

DEAD SEAL FOUND UPSTREAM OF THE PLANT'S CIRCULATING WATER SCREEN.

THE NATIONAL MARINE FISHERIES SERVICE AND THE EPA WILL BE NOTIFIED OF A DEAD SEAL FOUND UPSTREAM OF THE PLANT'S CIRCULATING WATER SCREEN "1C" (9CW-SR-1C).

THE RESIDENT INSPECTOR WAS NOTIFIED.

RESIDUAL HEAT REMOVAL SYSTEM DETERMINED TO BE OPERABLE BUT DEGRADED

"In mid-February of this year, Condition Reports were written to document that both the Unit 1 and 2 Residual Heat Removal (RHR) systems have a history of flow induced vibration problems dating as far back as 1974. The vibration is high frequency low amplitude, and has resulted in vibration induced fatigue failures.

"Engineering has evaluated this ongoing condition and concluded that the current unacceptable vibration levels may be the result of configuration changes initially established to correct system leaks without due consideration of the impact on system vibration response characteristics. The operation of the system with significant vibration induced fatigue allows operations outside of the limits to which the piping is currently analyzed.

"The significant high frequency low amplitude vibration could impact the integrity of the RHR system pressure boundary. A loss of RHR pressure boundary would impact the operability of the system. Therefore, this is considered to represent an unanalyzed condition that has the potential to significantly compromise plant
safety.

"An Operability Determination has been performed and the RHR system was determined to be operable but degraded. Compensatory measures were implemented after a safety evaluation was performed. Resolution of the vibration problem is being pursued, and fixes evaluated."

The RHR system will be restored to full operable status before plant startup.

The licensee will notify the NRC Resident Inspector.

REACTOR TRIP DUE TO TURBINE CONTROL VALVES CLOSING

"On March 10, 1999, at approximately 1326 MST Palo Verde Unit 1 experienced a reactor trip (RPS actuation) caused by high pressurizer pressure. The apparent cause was the closure of at least two main turbine control valves.

"All of the control rods fully inserted into the core. The steam bypass control system quick opened, per design, directing steam flow to the condenser and atmosphere. Main steam safeties briefly opened and reactor operators also discharged steam briefly via atmospheric dump valves. There was negligible radiological impact. Electrical buses transferred to offsite power as designed. No significant LCOs have been entered as a
result of this event.

"Subsequent to the trip, at approximately 1429 MST, a main steam isolation signal (MSIS) (ESF actuation) occurred due to high steam generator #2 level. As a result of the main steam isolation, operators are presently controlling reactor coolant temperature via the atmospheric dump. The unit is stable at normal operating temperature and pressure in Mode 3. No other ESF actuations occurred and none were required. The event did not result in any challenges to the fission product barrier or result in any releases of radioactive materials. There were no adverse safety consequences or implications as a result of this event. The event did not adversely affect the safe operation of the plant or health and safety of the public. An investigation is in progress to determine the cause of the event."

The licensee notified the NRC Resident Inspector.

CONTROL ROOM PRESSURE CONTROL FAILED TO MAINTAIN POSITIVE PRESSURE

"At 1940 hours on March 10,1999, GPU Nuclear determined that there existed at TMI-1 a condition outside the design basis of the plant in that a positive pressure of 0.10 inches w.g. did not exist in the Main Control Room. The plant was at 100% power at the time of the discovery.

"The TMI-1 FSAR Section 7.4.5.2.1, 'Design Basis' states in part: 'The Main Control Room (CBE Elevation 355'-0") is a leak tight room maintained at a positive pressure of 0.10 inches w.g. by the [Control Building Ventilation System] CBVS in the Emergency Recirculation mode of operation with or without single failure of Outside Air Intake Damper (OAI) AH-D-39, Exhaust Damper AH-D-37 and Damper AH-D-28.'

"Investigation determined that the probable cause of the failure to maintain the positive pressure of 0.10 inches w.g. was a failed closed manual damper immediately upstream of Intake Damper AH-D-39.

"Work is in progress to open the damper and restore the plant to its design basis as specified in 7.4.5.2.1 of the TMI-1 FSAR.

"A 30 day licensee event report will be submitted to the NRC in accordance with 10 CFR 50.73 (a)(2)(ii)."

The licensee will inform the NRC Resident Inspector.

- AGREEMENT STATE REPORT - TWO LOST PORTABLE NUCLEAR SOIL MOISTURE DENSITY GAUGES -

At 1415 on 03/10/99, during a Florida state inspection of J & M Testing, Inc., two portable nuclear soil moisture density gauges were determined to be missing. These are old gauges that were not being used and were last seen during an inventory taken on 12/28/98. The Chipley, FL police department has been notified.

Specifications of the gauges are as follows:
1. Manufacturer: CPN, Model: BRC (1977); Serial No C7304NE147; Isotopes: 8 mCi Cs-137; 50 mCi Am-241/Be
2. Manufacturer: CPN, Model: BRC (1974); Serial No C7404NE50; Isotopes: 8 mCi Cs-137; 50 mCi Am-241/Be

Charles Adams, FL Bureau of Radiation Control, notified NRC Region 2 (FL Radiological Incident No. FL99-07).

******************** UPDATE AT 0745 ON 03/24/99 FROM CHARLES ADAMS TO TROCINE ********************

The State of Florida Bureau of Radiation Control called to correct the FL Radiological Incident No. The number should have been FL99-037.

The NRC operations officer notified the R2DO (Lesser) and NMSS EO (Cool).

AGREEMENT STATE REPORT OF A MEDICAL MISADMINISTRATION AT ANDERSON CANCER CENTER IN HOUSTON TEXAS.

The following text is a portion of a facsimile received from the Texas Department of Health Bureau of Radiation Control:

" Incident 7471 - Broad License L00466, The university of Texas, M.D. Anderson Cancer Center, Houston, Texas"

"Date of Event: March 9, 1999."

"Initial Report: Telephonic report March 10, 1999. (Lost)"

"On the afternoon of March 9, 1999, a patient was loaded with a 51.25 mgRaeq (127.35 millicurie Cesium-137) gynecological implant for a planned treatment time of 44.77 hours. Late that evening the patient was discovered to have removed the implant. The implant was discovered in the bed beside the patient's hand/arm at hip level. Nursing staff removed the loading to the far side of the room, placed a rolling lead shield between the source and the patient, then notified the Gynecological physician on duty and the Brachytherapy Services staff. Estimated treatment time was only about 8.833 hours. This treatment time differed from the prescribed treatment dose by more than 10%. The patient treatment was terminated without additional treatment. The event was reported telephonically on the afternoon of March 10, 1999. This message was never delivered to the proper authorities within the Agency. An initial written report filed by the hospital stated that the facility Radiation Safety Committee did not consider this a misadministration but a refusal of treatment by the patient. The 10% rule was considered by the Agency and a full report was filed by the hospital."