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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 THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!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 97F 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.       |
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