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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 THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!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.                                               |
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