Event Notification Report for March 16, 1999
U.S. Nuclear Regulatory Commission Operations Center Event Reports For 03/15/1999 - 03/16/1999 ** EVENT NUMBERS ** 35421 35471 35472 35473 35474 35475 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 35421 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: VOGTLE REGION: 2 |NOTIFICATION DATE: 02/28/1999| | UNIT: [1] [] [] STATE: GA |NOTIFICATION TIME: 03:14[EST]| | RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 02/27/1999| +------------------------------------------------+EVENT TIME: 23:40[EST]| | NRC NOTIFIED BY: CHUCK MEYER |LAST UPDATE DATE: 03/15/1999| | 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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ |1 M/R Y 18 Power Operation |0 Hot Standby | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | -MAN Rx TRIP FROM 18% DUE TO NUCLEAR INSTRUMENTS ANOMALY DURING PLANT | | SHUTDOWN- | | | | WHILE SHUTTING UNIT 1 DOWN FOR A PLANNED REFUELING OUTAGE, CONTROL ROOM | | OPERATORS MANUALLY TRIPPED UNIT 1 FROM 18% POWER DUE TO A CONCERN THAT THE | | NUCLEAR INSTRUMENTS INTERMEDIATE RANGE FLUX TRIP WOULD NOT RESET BEFORE THE | | POWER RANGE (P-10) AUTO UNBLOCK OCCURRED. ALL CONTROL RODS INSERTED | | COMPLETELY. NO SAFETY OR RELIEF VALVES LIFTED. CONTROL ROOM OPERATORS | | MANUALLY ACTUATED THE AUXILIARY FEEDWATER SYSTEM TO MAINTAIN STEAM | | GENERATORS AT THEIR NORMAL WATER LEVELS. UNIT 1 IS STABLE IN MODE 3 (HOT | | STANDBY). THE LICENSEE PLANS TO INVESTIGATE THE CAUSE OF THE NUCLEAR | | INSTRUMENTS ANOMALY AND PROCEED WITH THE PLANNED REFUELING OUTAGE. | | | | THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. | | | | * * * RETRACTION AT 1455 ON 03/15/1999 FROM BILL DUNN TAKEN BY STRANSKY | | | | "Although the normal method of entry into a refueling outage involves | | gradually driving control rods to 0% power, operators performed a manual | | reactor trip from 18% power, as allowed by plant procedures. At the end of | | the current fuel cycle, neutron flux distribution flattened compared to the | | beginning of cycle flux shape. Plant operators had been advised that, during | | shutdown, an intermediate range (IR) neutron flux trip setpoint may not | | reset prior to unblocking the IR trip signal at the P-10 reset setpoint. | | Operators had been reminded that procedures allow a manual trip of the unit | | if this condition occurred. When the predicted IR neutron flux reset did not | | occur as power was reduced to 18%, a manual reactor trip was performed." | | | | "Because the manual trip that occurred was anticipated, pre-job briefings | | were held and because it was addressed in the procedure involved, it does | | not meet the criteria for reporting per 10 CFR 50.72 or 10 CFR 50.73. The | | trip was part of a pre-planned activity, and therefore, the previous | | notification is hereby retracted." | | | | The NRC resident inspector has been informed of this retraction by the | | licensee. The NRC operations officer notified the R2DO (McAlpine). | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 35471 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: CLINTON REGION: 3 |NOTIFICATION DATE: 03/15/1999| | UNIT: [1] [] [] STATE: IL |NOTIFICATION TIME: 03:57[EST]| | RXTYPE: [1] GE-6 |EVENT DATE: 03/15/1999| +------------------------------------------------+EVENT TIME: 01:05[CST]| | NRC NOTIFIED BY: TIM HOLLAND |LAST UPDATE DATE: 03/15/1999| | HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: N/A |RONALD GARDNER R3 | |10 CFR SECTION: | | |AESF 50.72(b)(2)(ii) ESF ACTUATION | | | | | | | | | | | +-----+----------+-------+--------+-----------------+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | UNANTICIPATED REACTOR CORE ISOLATION COOLING (RCIC) SUCTION VALVE ISOLATION | | DURING PERFORMANCE OF A REVISED TEST PROCEDURE | | | | The following text is a portion of a facsimile received from the licensee: | | | | "During the performance of CPS No. 9054.04 (RCIC Automatic Suction Shift | | Test), the RCIC suction valve from the suppression pool (1E51-F031) | | automatically isolated on a valid low steam line pressure signal. This | | isolation was not intended to occur during the performance of this | | procedure." | | | | "The isolation occurred following the removal of a simulated RCIC steam line | | pressure signal of > 60 psig. When the current steam line pressure of 0 | | psig was picked up by the logic, the 1E51-F031 isolated as designed." Upon | | receipt of the valid low steam line pressure signal, all systems functioned | | as required. There was nothing unusual or not understood. | | | | The licensee stated that the test procedure was newly revised and that some | | of the steps had been swapped. The steps should have requested opening of | | the other suction source, closure of this suction source, and then removal | | the simulator. | | | | The licensee notified the NRC resident inspector. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 35472 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: MILLSTONE REGION: 1 |NOTIFICATION DATE: 03/15/1999| | UNIT: [1] [] [] STATE: CT |NOTIFICATION TIME: 13:46[EST]| | RXTYPE: [1] GE-3,[2] CE,[3] W-4-LP |EVENT DATE: 03/15/1999| +------------------------------------------------+EVENT TIME: 13:12[EST]| | NRC NOTIFIED BY: DAVID DVORAK |LAST UPDATE DATE: 03/15/1999| | HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: N/A |JACK MCFADDEN R1 | |10 CFR SECTION: |FEMA, DOE, DOA, HHS FAX | |APRE 50.72(b)(2)(vi) OFFSITE NOTIFICATION |EPA, DOT (VIA NRC) FAX | | | | | | | | | | +-----+----------+-------+--------+-----------------+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ |1 N N 0 Refueling |0 Refueling | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | OFFSITE NOTIFICATION DUE TO OIL SPILL ONSITE | | | | The licensee notified the Connecticut Department of Environmental Protection | | regarding a small release of oil into the Long Island Sound. A vehicle fire | | outside of the protected area (near the training facility) resulted in the | | spillage of approximately 30 gallons of a gasoline/oil mixture onto the | | ground. Attempts were made to contain the spill, but less than one gallon | | of the gasoline/oil mixture entered the storm drains and was released to the | | Long Island Sound. The licensee is currently working to clean up the spill. | | The NRC resident inspector has been informed of this event by the licensee. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |General Information or Other |Event Number: 35473 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | REP ORG: FOXBORO COMPANY |NOTIFICATION DATE: 03/15/1999| |LICENSEE: FOXBORO COMPANY |NOTIFICATION TIME: 16:10[EST]| | CITY: FOXBORO REGION: 1 |EVENT DATE: 03/15/1999| | COUNTY: STATE: MA |EVENT TIME: [EST]| |LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 03/15/1999| | DOCKET: |+----------------------------+ | |PERSON ORGANIZATION | | |VERN HODGE (via fax) NRR | | | | +------------------------------------------------+ | | NRC NOTIFIED BY: GEORGE JOHNSON | | | HQ OPS OFFICER: BOB STRANSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: N/A | | |10 CFR SECTION: | | |CCCC 21.21 UNSPECIFIED PARAGRAPH | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | 10 CFR PART 21 REPORT REGARDING INSPECTION DOCUMENTATION FOR SPARE PARTS | | | | The following facsimile was submitted to the NRC Operations Center: | | | | "In accordance with 10 CFR [Part] 21, this letter is to inform you that | | Foxboro Co. can not provide detail documentation of the inspection criteria | | to support the inspection process for spare parts that may have been | | released to customers in support of Foxboro Nuclear Qualified products. The | | time period affected is from March 31, 1998, to March 12, 1999." | | | | "There is no evidence of any failures or defects in these parts. Foxboro is | | taking immediate corrective action to rectify the situation and will notify | | all utilities affected. Foxboro Co. will be notifying those nuclear | | utilities that have purchased commercial spare parts since April 1998. A | | review for corrective action is still under investigation." | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Hospital |Event Number: 35474 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | REP ORG: WASHINGTON UNIV MEDICAL CTR |NOTIFICATION DATE: 03/15/1999| |LICENSEE: WASHINGTON UNIV MEDICAL CTR |NOTIFICATION TIME: 16:30[EST]| | CITY: ST. LOUIS REGION: 3 |EVENT DATE: 03/15/1999| | COUNTY: STATE: MO |EVENT TIME: 10:30[CST]| |LICENSE#: 24-00167-11 AGREEMENT: N |LAST UPDATE DATE: 03/15/1999| | DOCKET: |+----------------------------+ | |PERSON ORGANIZATION | | |GEOFFREY WRIGHT R3 | | |JOE HOLONICH NMSS | +------------------------------------------------+ | | NRC NOTIFIED BY: GILBERT NUSBAUM | | | HQ OPS OFFICER: BOB STRANSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: N/A | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MEDICAL MISADMINISTRATION | | | | A female patient was prescribed a dose of 3,000 cGy (rads) for gynecological | | treatment to be delivered in six fractions via a high dose rate (HDR) | | afterloader device. The dose was to be administered over a 30-mm linear | | distance, beginning at a distance of 960 mm from the HDR device head. The | | first five fractions were delivered as prescribed. The sixth fraction was | | delivered using the same spacing and dwell times as the other fractions; | | however, the treatment was started at a distance of 988 mm from the HDR | | device head. Thus, dose was administered to unintended tissue adjacent to | | the prescribed treatment site. | | | | The referring physician has been notified, and the hospital plans to contact | | the patient. The licensee has contacted the NRC Region III office regarding | | this event. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 35475 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: ROBINSON REGION: 2 |NOTIFICATION DATE: 03/16/1999| | UNIT: [2] [] [] STATE: SC |NOTIFICATION TIME: 01:20[EST]| | RXTYPE: [2] W-3-LP |EVENT DATE: 03/15/1999| +------------------------------------------------+EVENT TIME: 22:12[EST]| | NRC NOTIFIED BY: DAVID COOK |LAST UPDATE DATE: 03/16/1999| | HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: N/A |EDWARD MCALPINE R2 | |10 CFR SECTION: | | |NINF INFORMATION ONLY | | | | | | | | | | | +-----+----------+-------+--------+-----------------+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | COURTESY NOTIFICATION REGARDING A FATALITY WITHIN THE OWNER CONTROLLED AREA | | OUTSIDE THE 1,400-FOOT BARRIER | | | | The following text is a portion of a facsimile received from the licensee: | | | | "At approximately 2212 on 03/15/99, Robinson Security [personnel] notified | | the Control Room of an automobile with a fatality on the West Entrance Road | | access to the plant outside the site boundary. The cause of the fatality is | | unknown, and this occurrence is being investigated by local law enforcement | | agencies and the State Law Enforcement Division. Due to the fatality | | occurring off-site, but on CP&L property adjacent to the site boundary, and | | [due to] the interaction of several off-site agencies responding to the | | scene, the NRC Operations Center is being notified as a courtesy. This call | | is for informational purposes only and does not fall within the reporting | | criteria of 10 CFR 50.72." | | | | The licensee notified the NRC resident inspector. The licensee does not | | plan to issue a press release. | +------------------------------------------------------------------------------+
Page Last Reviewed/Updated Wednesday, March 24, 2021
Page Last Reviewed/Updated Wednesday, March 24, 2021