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 +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 35453 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | 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 | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | 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. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Hospital |Event Number: 35454 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | 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 | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | 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. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 35455 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | 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 | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | 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. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 35456 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | 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 +------------------------------------------------------------------------------+ | 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. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 35457 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | 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 +------------------------------------------------------------------------------+ | 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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Page Last Reviewed/Updated Thursday, March 25, 2021