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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       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| 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.                         |
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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                                   
+------------------------------------------------------------------------------+
| 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                                   
+------------------------------------------------------------------------------+
| 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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