Event Notification Report for March 11, 1999
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
03/10/1999 - 03/11/1999
** EVENT NUMBERS **
35453 35454 35455 35456 35457
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|Power Reactor |Event Number: 35453 |
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| FACILITY: SEABROOK REGION: 1 |NOTIFICATION DATE: 03/10/1999|
| UNIT: [1] [] [] STATE: NH |NOTIFICATION TIME: 09:54[EST]|
| RXTYPE: [1] W-4-LP |EVENT DATE: 03/10/1999|
+------------------------------------------------+EVENT TIME: 09:09[EST]|
| NRC NOTIFIED BY: STRICKLAND |LAST UPDATE DATE: 03/10/1999|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |TOM MOSLAK R1 |
|10 CFR SECTION: | |
|NLTR LICENSEE 24 HR REPORT | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
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EVENT TEXT
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| 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. |
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|Hospital |Event Number: 35454 |
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| REP ORG: ST. JOHNS MERCY MEDICAL CENTER |NOTIFICATION DATE: 03/10/1999|
|LICENSEE: ST. JOHNS MERCY MEDICAL CENTER |NOTIFICATION TIME: 10:06[EST]|
| CITY: ST. LOUIS REGION: 3 |EVENT DATE: 03/09/1999|
| COUNTY: STATE: MO |EVENT TIME: 14:00[CST]|
|LICENSE#: 24-00794-03 AGREEMENT: N |LAST UPDATE DATE: 03/10/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |RONALD GARDNER R3 |
| |LARRY CAMPER NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: TURCO | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| MEDICAL MISADMINISTRATION |
| |
| DURING A REVIEW OF ST. JOHNS MERCY MEDICAL CENTER QUALITY MANAGEMENT |
| PROGRAM, IT WAS DISCOVERED THAT THERE WAS A WRITTEN DIRECTIVE FOR SODIUM |
| IODIDE-131 WHERE THE PRESCRIPTION WAS FOR A 4 MILLICURIE DOSE FOR WHOLE BODY |
| IMAGING. THE PATIENT, HOWEVER, WAS GIVEN 5 MILLICURIES INSTEAD. THIS EVENT |
| OCCURRED ON 02/99 AND THE PATIENT'S PHYSICIAN WILL BE NOTIFIED BY THE |
| MEDICAL CENTER. |
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|Power Reactor |Event Number: 35455 |
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| FACILITY: COOK REGION: 3 |NOTIFICATION DATE: 03/10/1999|
| UNIT: [1] [2] [] STATE: MI |NOTIFICATION TIME: 16:50[EST]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 03/10/1999|
+------------------------------------------------+EVENT TIME: 16:00[EST]|
| NRC NOTIFIED BY: MARY BETH DEPUYDT |LAST UPDATE DATE: 03/10/1999|
| HQ OPS OFFICER: FANGIE JONES +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |RONALD GARDNER R3 |
|10 CFR SECTION: | |
|ADAS 50.72(b)(2)(i) DEG/UNANALYZED COND | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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 |
| | |
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EVENT TEXT
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| 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. |
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|Power Reactor |Event Number: 35456 |
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| FACILITY: PALO VERDE REGION: 4 |NOTIFICATION DATE: 03/10/1999|
| UNIT: [1] [] [] STATE: AZ |NOTIFICATION TIME: 18:45[EST]|
| RXTYPE: [1] CE,[2] CE,[3] CE |EVENT DATE: 03/10/1999|
+------------------------------------------------+EVENT TIME: 13:26[MST]|
| NRC NOTIFIED BY: R. HAZELWOOD |LAST UPDATE DATE: 03/10/1999|
| HQ OPS OFFICER: FANGIE JONES +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |GARY SANBORN R4 |
|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 |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 A/R Y 100 Power Operation |0 Hot Standby |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| 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. |
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|Power Reactor |Event Number: 35457 |
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| FACILITY: THREE MILE ISLAND REGION: 1 |NOTIFICATION DATE: 03/10/1999|
| UNIT: [1] [] [] STATE: PA |NOTIFICATION TIME: 19:50[EST]|
| RXTYPE: [1] B&W-L-LP,[2] B&W-L-LP |EVENT DATE: 03/10/1999|
+------------------------------------------------+EVENT TIME: 19:40[EST]|
| NRC NOTIFIED BY: JOHN SCHORK |LAST UPDATE DATE: 03/10/1999|
| HQ OPS OFFICER: FANGIE JONES +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |TOM MOSLAK 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 |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| 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. |
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