Event Notification Report for March 31, 1999
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
03/30/1999 - 03/31/1999
** EVENT NUMBERS **
35474 35525 35526 35527 35528 35529 35530 35531 35532 35533
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
+------------------------------------------------------------------------------+
|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: 03/30/1999|
| 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. |
| |
| * * * RETRACTION 1002 3/30/1999 FROM JOHN EICHLING TAKEN BY STRANSKY * * * |
| |
| The licensee is retracting this notification. After consultation with NRC |
| Region III (John Jones), the licensee has determined that this event did not |
| constitute a medical misadministration. HOO notified R3DO (Ring). |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 35525 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: BEAVER VALLEY REGION: 1 |NOTIFICATION DATE: 03/29/1999|
| UNIT: [] [2] [] STATE: PA |NOTIFICATION TIME: 20:22[EST]|
| RXTYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 03/29/1999|
+------------------------------------------------+EVENT TIME: 18:01[EST]|
| NRC NOTIFIED BY: TOM COTTER |LAST UPDATE DATE: 03/30/1999|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |KATHLEEN MODES R1 |
|10 CFR SECTION: |STUART RICHARDS NRR |
|AESF 50.72(b)(2)(ii) ESF ACTUATION |FRANK CONGEL IRO |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 N N 0 Cold Shutdown |0 Cold Shutdown |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| PARTIAL LOSS OF POWER DUE TO 4.10KV BUS UNIT STATION SERVICE TRANSFORMER |
| SUPPLY OVERCURRENT TRIP. EMERGENCY DIESEL GENERATOR 2-1 SUPPLYING POWER TO |
| VITAL BUS "AE". |
| |
| At 1801 hours, "4160V Bus Unit Station Service Transformer Supply |
| Overcurrent Trip" alarm was received. This alarm indicates that the supply |
| breaker, 42C, to the normal 4kV bus "2A" opened and deenergized the bus. The |
| "2A" bus supplies train "A" emergency 4kV bus "AE" so it also deenergized. |
| The emergency diesel generator 2-1 started and reenergized the "AE" |
| emergency bus. The "B" train of electrical power and safeguards equipment |
| remained fully operable, the emergency diesel generator is fully operable if |
| needed. Prior to the overcurrent trip, the plant was in mode 5 (cold |
| shutdown) with Reactor Coolant System temperature at 97�F and 280 psig. |
| Their was no interruption to core cooling during the event. Core cooling |
| was being provided by the "B" train of the residual heat removal system and |
| was unaffected. Both trains of residual heat removal remain operable. The |
| site maintenance department is evaluating the cause for the relay protection |
| actuation. The 2-1 emergency diesel generator will continue to supply the |
| emergency bus until this investigation is completed and normal power is |
| restored. The vital buses cannot be cross connected and emergency diesel |
| generator 2-1 has plenty of fuel to keep it operating. Spent fuel pool |
| cooling was not lost. |
| |
| Offsite power is stable, and the other emergency bus "2DF" can supply enough |
| electrical power to safe plant operation while shutdown if electrical power |
| is lost from emergency bus "2AE". |
| |
| The NRC Resident Inspector was notified of this event by the licensee. |
| |
| |
| ***Update on 03/30/99 at 1542 ET from R. Scheib taken by MacKinnon*** |
| |
| Emergency Diesel Generator 2-1 secured after offsite power was restored to |
| Bus 2A at 1148 ET. |
| |
| The licensee checked out relays and breakers before restoring offsite power. |
| The licensee said that DC Charger Bus 5, which supplies "2A" 4kV bus |
| protection relays with power had been oscillating. The licensee found |
| Technical Manual information that indicated that the overcurrent relays are |
| susceptible to ripples. 5% ripples can cause an overcurrent trip. The |
| licensee had regulating problems with the Bus 5 Charger, and they think that |
| the regulating problems caused the overcurrent trip. R1DO (Kathleen Modes) |
| notified. |
| |
| The NRC Resident Inspector was notified of this event update. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 35526 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: US DEPARTMENT OF ENERGY |NOTIFICATION DATE: 03/30/1999|
|LICENSEE: IDAHO NATL ENGINEERING LAB |NOTIFICATION TIME: 11:24[EST]|
| CITY: IDAHO FALLS REGION: 4 |EVENT DATE: 03/30/1999|
| COUNTY: STATE: ID |EVENT TIME: 08:24[MST]|
|LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 03/30/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |LINDA HOWELL R4 |
| |DONALD COOL NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: BOB TUNE | |
| HQ OPS OFFICER: BOB STRANSKY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NINF INFORMATION ONLY | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| SECURITY EVENT INVOLVING THREE MILE ISLAND SHIPMENT |
| |
| A Lockheed-Martin employee left INTEC (Idaho Nuclear Technology |
| Environmental Complex ) building 1774 to retrieve a tool. The individual did |
| not notify security personnel before reentering the area, as required by |
| procedure. The individual was detained and interviewed by security personnel |
| before being released to return to work. The caller stated that this event |
| was reportable because a shipment of TMI material was underway from TAN |
| (Test Area North) to the INTEC. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Other Nuclear Material |Event Number: 35527 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: ALT & WITZIG ENGR. INC. |NOTIFICATION DATE: 03/30/1999|
|LICENSEE: ALT & WITZIG ENGR. INC. |NOTIFICATION TIME: 12:53[EST]|
| CITY: INDIANAPOLIS REGION: 3 |EVENT DATE: 03/30/1999|
| COUNTY: STATE: IN |EVENT TIME: 06:30[CST]|
|LICENSE#: 13-18685-01 AGREEMENT: N |LAST UPDATE DATE: 03/30/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |MARK RING R3 |
| |SCOTT MOORE NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: PHIL DILK | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|BAB1 20.2201(a)(1)(i) LOST/STOLEN LNM>1000X | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| CPN GAUGE STOLEN FROM THE BACK OF A COMPANY PICKUP TRUCK IN FRONT OF A |
| EMPLOYEE'S RESIDENCE. |
| |
| Alt & Witzig Engineering Incorporated located in Indianapolis, Indiana, |
| reported that one of their CPN gauges was reported to them from one of their |
| employees as having been stolen from the back of a company pickup truck. The |
| serial number of the CPN gauge is MD40401995, and the model number of the |
| gauge is MC1. The gauge contained 10 mCi of Cesium-137 and 50 mCi of |
| Americium-241/Beryllium. At approximately 1300 hours on 03/29/99, a company |
| employee arrived at his residence in South Bend in a company owned pickup |
| truck with a CPN gauge triple locked down in the open bed of the pickup |
| truck. This morning around 0630 hours, the person discovered that the CPN |
| gauge was missing from the back of the pickup truck, but the gauge case was |
| still in the back of the truck. The licensee notified the local police, |
| local radio stations, and local television stations that a CPN gauge had |
| been stolen from the back of one of their company pickup trucks. The |
| licensee has already posted fliers with a picture of the stolen CPN gauge. |
| The licensee has also offered a reward for the return of the gauge. |
| |
| The CPN gauge was in a triple lock position with the case being secured to |
| the bed of the truck with a padlock, and a lock was placed on the other half |
| of the case. In addition, the handle was in its locked position. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 35528 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SOUTH TEXAS REGION: 4 |NOTIFICATION DATE: 03/30/1999|
| UNIT: [1] [2] [] STATE: TX |NOTIFICATION TIME: 14:13[EST]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 03/27/1999|
+------------------------------------------------+EVENT TIME: 10:28[CST]|
| NRC NOTIFIED BY: WAYNE HARRISON |LAST UPDATE DATE: 03/30/1999|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |LINDA HOWELL R4 |
|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 N 0 Refueling |0 Refueling |
|2 N Y 100 Power Operation |100 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| BOTH UNIT 1 SOURCE RANGE NUCLEAR INSTRUMENTS (NI-31 & NI-32) WERE DECLARED |
| INOPERABLE AT 1028 ON 03/27/99 BASED ON UNSAT CHECK PERFORMED DURING THE |
| SHUTDOWN OF THE UNIT FOR REFUELING. |
| |
| This event was reported per paragraph 2.G of South Texas Project Operating |
| License |
| |
| During review of source range discriminator bias curve procedures for |
| resolution of the channel check discrepancy, it was discovered that the bias |
| curves in the procedure used to satisfy the Technical Specification |
| surveillance were the same for both channels 31 and 32. Technical |
| Specifications for channel calibration require that the curves be taken and |
| compared with the initial curves. Each channel in each unit should be |
| different and unique which would make four separate curves (N-31 & 32 for |
| Unit 1 and N-31 & 32 for Unit 2). Further investigation showed that the |
| curves for Unit 1 and Unit 2 are not the initial curves as required by the |
| Technical Specification surveillance. |
| |
| Since the same procedures and curves have been used to meet refueling |
| frequency (last refueling for Unit 1 was 3/98 and last refueling for Unit 2 |
| was 10/98) surveillance requirements in the past (since 1995 when the Source |
| Range Channel instruments were replaced), it was determined that those past |
| surveillance tests had not complied with the Technical Specification |
| requirements to compare with the initial curves. Consequently, the past |
| surveillance tests are considered inadequate and to have resulted in a |
| condition prohibited by Technical Specifications. |
| |
| The curves for both Unit 1 source range instruments have been satisfactorily |
| compared to the initial curves in accordance with Technical Specifications. |
| The unsatisfactory channel check has been resolved and the instruments |
| restored to operability. Unit 2 is in Mode 1, and operability of the source |
| range instruments is not required. However, the most recent bias curves for |
| Unit 2 instruments were satisfactorily compared to the initial curves for |
| the instruments, as required by the Technical Specification surveillance. |
| |
| The NRC Resident Inspector was notified of this event by the licensee. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 35529 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SOUTH TEXAS REGION: 4 |NOTIFICATION DATE: 03/30/1999|
| UNIT: [1] [] [] STATE: TX |NOTIFICATION TIME: 14:21[EST]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 03/29/1999|
+------------------------------------------------+EVENT TIME: 21:29[CST]|
| NRC NOTIFIED BY: WAYNE HARRISON |LAST UPDATE DATE: 03/30/1999|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |LINDA HOWELL R4 |
|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 N 0 Refueling |0 Refueling |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| CONTROL ROOM HVAC PLACED IN RECIRCULATION MODE OF OPERATION OF INSTEAD OF |
| BEING PLACED IN FILTERED RECIRCULATION AND MAKE-UP FILTRATION MODE. |
| |
| This event was reported per paragraph 2.G of South Texas Project Operating |
| License. |
| |
| On 03/29/99 at 2129 CST, Unit 1 was in mode 6 (refueling) and the "C" Train |
| battery was removed from service. With the "C" Train battery inoperable, the |
| Control Room HVAC was required to be put in filtered Recirculation and |
| Make-up Filtration Mode within 48 hours per Technical Specification (TS) |
| 3.3.2.10.C, Action 27. Instead, on 03/29/99 at 2129, the Control Room HVAC |
| in the Make-up Filtration Mode resulted in a non-compliance with Technical |
| Specification actions, which is a condition prohibited by TS per 50.73 |
| (a)(2)(i)(B); and a 24 hour notification is required by 2G of the Operating |
| License. The condition was identified and corrected at 0635 on 03/30/99. |
| |
| The NRC Resident Inspector was notified of this event by the licensee. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Other Nuclear Material |Event Number: 35530 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: TENNESSEE DIV. OF RAD. HEALTH |NOTIFICATION DATE: 03/30/1999|
|LICENSEE: MEHTODIST CENTRAL HOSPITAL, |NOTIFICATION TIME: 16:35[EST]|
| CITY: MEMPHIS REGION: 2 |EVENT DATE: 03/29/1999|
| COUNTY: STATE: TN |EVENT TIME: [EST]|
|LICENSE#: TN-99-047 AGREEMENT: Y |LAST UPDATE DATE: 03/30/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |CHARLES OGLE R2 |
| |SCOTT MOORE NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: DEBRA SHULTS | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| A MAN SCHEDULED FOR A THERAPY DOSE TO HIS COLON WAS GIVEN A BRAIN TREATMENT |
| INSTEAD. |
| |
| The text following information is a portion of a facsimile received from the |
| Tennessee Department of Environmental and Conversation Division of |
| Radiological Health: |
| |
| "On 03/30/99, the Radiation Safety Officer at Methodist Central Hospital, |
| Memphis, reported a therapeutic misadministration to the Memphis Field |
| Office Manager. The event occurred on 03/29/99. A man scheduled for a |
| therapy dose to his colon was given a brain treatment instead. The dose to |
| the brain was 200 rad. The man answered to the wrong name when called for |
| treatment. A written report will be submitted to the State of Tennessee |
| Department of Environmental and Conservation Division of Radiological |
| Health within 15 days." |
| |
| The machine used was a linear accelerator. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 35531 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: WASHINGTON NUCLEAR REGION: 4 |NOTIFICATION DATE: 03/30/1999|
| UNIT: [2] [] [] STATE: WA |NOTIFICATION TIME: 17:01[EST]|
| RXTYPE: [2] GE-5 |EVENT DATE: 03/30/1999|
+------------------------------------------------+EVENT TIME: 11:42[PST]|
| NRC NOTIFIED BY: MIKE KELLER |LAST UPDATE DATE: 03/30/1999|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |LINDA HOWELL R4 |
|10 CFR SECTION: | |
|HFIT 26.73 FITNESS FOR DUTY | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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
+------------------------------------------------------------------------------+
| A licensee employee was confirmed positive during a Fitness-For-Duty test. |
| The individual's unescorted access was terminated. (Contact the NRC |
| operations officer for details.) |
| |
| The NRC Resident Inspector will be notified of this event by the licensee. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 35532 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: OYSTER CREEK REGION: 1 |NOTIFICATION DATE: 03/30/1999|
| UNIT: [1] [] [] STATE: NJ |NOTIFICATION TIME: 17:11[EST]|
| RXTYPE: [1] GE-2 |EVENT DATE: 03/30/1999|
+------------------------------------------------+EVENT TIME: 09:10[EST]|
| NRC NOTIFIED BY: D PITRUSKI |LAST UPDATE DATE: 03/30/1999|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |KATHLEEN MODES 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
+------------------------------------------------------------------------------+
| FIRE PROTECTION VALVE FOUND CLOSED |
| |
| At 0910 hours on 03/30/99, Fire Protection Valve, V-9-151 (Supply Valve for |
| Deluge System 4A - Lower Cable Spreading Room) was found closed. This valve |
| being in the closed position was determined to be reportable (24 hour) as a |
| violation of the requirements contained in Section 2.C of the Facility |
| Operating License. |
| |
| This valve being closed would render 1/2 of the cable spreading rooms |
| without fire protection. The licensee thinks that valve V-9-151 was not |
| reopened after the performance of a surveillance test of the Fire Protection |
| system. At the present time, the licensee is looking for the last |
| surveillance test performed on the Fire Protection system which manipulated |
| valve V-9-151 to see if the procedure closed and then reopened the valve. |
| |
| The NRC Resident Inspector was notified of this event by the licensee. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 35533 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: OCONEE REGION: 2 |NOTIFICATION DATE: 03/30/1999|
| UNIT: [1] [2] [3] STATE: SC |NOTIFICATION TIME: 20:50[EST]|
| RXTYPE: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-L|EVENT DATE: 03/30/1999|
+------------------------------------------------+EVENT TIME: 20:15[EST]|
| NRC NOTIFIED BY: ED BURCHFIELD |LAST UPDATE DATE: 03/30/1999|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |CHARLES OGLE R2 |
|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 |
|2 N Y 100 Power Operation |100 Power Operation |
|3 N Y 100 Power Operation |100 Power Operation |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| EMERGENCY OPERATING PROCEDURES (EOP) AND ABNORMAL PROCEDURES (AP) DO NOT |
| PROVIDE SPECIFIC GUIDANCE REGARDING NECESSARY OPERATOR ACTIONS SHOULD LOW |
| PRESSURE INJECTION (LPI) HEADER FLOW INDICATION BE LOST. INTERIM GUIDANCE |
| HAS BEEN PROVIDED TO ON SHIFT OPERATORS TO ADDRESS THIS PROBLEM. |
| |
| During table top review and validation of EOPs, it was discovered that plant |
| procedures did not provide that necessary guidance to ensure adequate |
| operator action will occur during a certain scenario. A review of the EOPs |
| has identified a scenario that is not adequately addressed in the procedure |
| and therefore could place the Oconee Units outside their design basis. |
| Specifically, the EOP requires throttling LPI header flow during a Large |
| Break Loss of Coolant Accident (LOCA) to protect against potential pump |
| runout. If flow cannot be maintained, the EOP directs the operator to |
| Abnormal Procedures (AP) AP/1/A/1700/007, "Loss of LPI System." The EOP |
| (EOP Section 505) and AP do not provide specific guidance regarding the |
| necessary operator actions should LPI header flow indication be lost. This |
| could occur on a subsequent loss of a specific power supply. Failure to |
| take appropriate actions during a LOCA with this specific single failure |
| could result in operators opening the LPI pump header cross connect valves |
| (LP-9 and LP-10) per existing procedures, resulting in the potential loss of |
| both LPI pumps due to runout. |
| |
| Interim guidance to close the valve of the affected Train (Train "A" is |
| LP-17 and Train "B" is LP-18) so runout will not occur has been provided to |
| the operators to address this potential deficiency, and the EOP is currently |
| being revised. |
| |
| The NRC Resident Inspector was notified of this event by the licensee. |
+------------------------------------------------------------------------------+
Page Last Reviewed/Updated Thursday, March 25, 2021