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 THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
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|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 |
| | |
| | |
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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." |
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|Hospital |Event Number: 35474 |
+------------------------------------------------------------------------------+
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| 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. |
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