Event Notification Report for April 19, 1999

UNIT 2 REACTOR SCRAM FROM CONDITION FIVE

On 4/19/99, at 0438, Unit 2 received an 'A' side half scram signal. Unit 2 was in OPCON 5 (refueling) and Unit 1 was at 100% power in OPCON 1. The scram signal was a result of loss of voltage to 2AY160, the 'A' RPS power supply ('B' RPS was already blocked and a 'B' half scram was in). Due to the loss of 2AY160 several isolations were received on Unit 2 including Reactor Water Cleanup, High Pressure Coolant Injection, Instrument Gas and HVAC Groups (1B, 2A, 2C, 3, 5, 6A, 6B, 6C, 7A and 7B). Unit 1 received groups 6A and 6B Containment Atmosphere Control isolations. An investigation revealed an arcing bus bar on an RPS series output breaker (2AC248). The bus breakers were opened causing the arcing to stop and maintenance is currently being planned. All systems performed their intended function properly.

The licensee notified the NRC resident inspector.

- NEW YORK DEPARTMENT OF ENVIRONMENTAL CONSERVATION NOTIFIED OF 11 GALLON OIL SPILL -

AT 1115 ON 04/19/99, THE LICENSEE NOTIFIED THE NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION THAT APPROXIMATELY 11 GALLONS OF HYDRAULIC OIL HAD SPILLED ON PAVED AND UNPAVED AREAS FROM A RUPTURED FORKLIFT HYDRAULIC LINE. THE LICENSEE CLEANED UP THE OIL AND REMOVED THE AFFECTED SOIL.

THE LICENSEE PLANS TO INFORM THE NRC RESIDENT INSPECTOR.

* * * UPDATE 1431EDT ON 5/18/99 FROM BRIAN WEAVER TO S.SANDIN * * *

The licensee is retracting this report based on the following:

"At 1507 on 4/19/99, a 4-hr non-emergency phone notification was made to the NRC by this facility regarding an 11 gallon hydraulic oil spill on paved and unpaved areas from a rupture on a forklift hydraulic line under the category of 10CFR 50.72(b)(2)(vi), Any event or situation, related to the health and safety of the public or onsite personnel, or protection of the environment, for which a news release is planned or notification to other government agencies has been or will be made.

"Subsequent review of the site reportability procedure and 10CFR 50.72(b)(2)(vi) has determined that this event is not reportable under that statute, specifically that the oil spill was not environmentally significant in that the volume was actually only 2.5 gallons and that the spill was immediately contained and cleaned up such that no oil reached ground or surface water. No news release was made for the incident.

"On this basis, this notification is being retracted."

The licensee notified the NRC Resident Inspector. Notified R1DO(Trapp).

- PLANT SECURITY REPORT -

Unescorted access was inappropriately granted to the plant protected area. Compensatory measures were taken immediately upon discovery. (Contact the NRC Headquarters Operations Officer for additional details.)

The licensee plans to inform the NRC Resident Inspector.

* * * RETRACTED AT 1643 EDT ON 05/05/99 FROM BECKI DOLHANCZYK TO FANGIE JONES * * *

This event is retracted as it did not constitute a Regulatory Unauthorized Access, but a Limerick Generating Station administrative access deficiency. (Contact the NRC Headquarters Operations Officer for additional details.)

The licensee plans to notify the NRC Resident Inspector. The NRC Headquarters Operations Officer notified the R1DO (James Linville).

- NRC BULLETIN 91-01, 4 HOUR REPORT: ABANDONED COLD TRAPS MAY BE COVERED BY AN NCSA -

DURING A WALKDOWN OF NUCLEAR CRITICALITY SAFETY APPROVAL NCSA_PLANT088.A00, "STORAGE of ABANDONED EQUIPMENT" FOR IMPLEMENTATION, IT WAS DETERMINED THAT ABANDONED COLD TRAPS LOCATED IN BUILDINGS X-342 AND X-343 MAY APPLY TO THIS NCSA AND SHOULD HAVE BEEN REPORTED IN JANUARY, 1999 UNDER NRC EVENT REPORT #35275. AT THIS TIME, THERE IS NO PROOF THAT THIS EQUIPMENT BELONGS TO DOE AND WITHOUT THIS DOCUMENTATION, THE MATERIAL FALLS UNDER USEC CONTROL AND SHOULD BE COVERED BY AN NCSA. SINCE THIS EQUIPMENT IS NOT COVERED BY AN NCSA, IT IS REPORTABLE AS A CRITICALITY CONTROL 4 HOUR BULLETIN 91-01 REPORT. THE PLANT FOLLOWED ITS PROCEDURE FOR ANOMALOUS NCSA CONDITIONS. FURTHER EVALUATIONS ARE IN PROGRESS TO DETERMINE IF THIS ABANDONED EQUIPMENT MEETS THE FISSILE MATERIAL LIMITS. THE FISSILE MATERIAL LIMIT OF 15 GRAMS OF U-235 BY PLANT PROCEDURES REQUIRES AN NCSA.

SAFETY SIGNIFICANCE OF EVENTS:
NO COLD TRAP CYLINDERS ARE INSTALLED. PIPING IS LESS THAN OR EQUAL TO 2 INCHES IN DIAMETER WHICH IS A FAVORABLE GEOMETRY. CHEMICAL TRAPS ARE SEALED AND NOT EXPOSED TO ANY WATER OR MODERATOR SOURCE.

POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO[S] OF HOW CRITICALITY COULD OCCUR):
PATHWAY ONLY EXISTS IF MORE THAN 13 POUNDS OF UO2F4 EXISTS IN A SINGLE ITEM AND WATER IS ALLOWED TO OPTIMALLY MODERATE AND REFLECT A SPHERE OF THIS MATERIAL.

CONTROLLED PARAMETERS (MASS, MODERATION. GEOMETRY, CONCENTRATION, ETC.):
NO NCSA HAS BEEN WRITTEN FOR THIS EQUIPMENT. HOWEVER, NCSA_088 ESTABLISHES MASS AND MODERATION CONTROLS FOR THIS EQUIPMENT. PLANT_088 IS NOT IMPLEMENTED AT THIS TIME.

ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS LIMIT AND % WORST CASE CRITICAL MASS):
EXPECTED TO BE LESS THAN 350 GRAMS OF U-235 IN UO2F2 FORM AT 5.0% ENRICHMENT.

NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION OF THE FAILURES OR DEFICIENCIES:
NO NCS CONTROLS ESTABLISHED.

CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEM AND WHEN EACH WAS IMPLEMENTED:
AT 1710, THE AREAS WERE BOUNDARY OFF PER OUR PROCEDURES.

THERE WAS NO LOSS OF HAZARDOUS OR RADIOACTIVE MATERIAL NOR RADIOACTIVE OR RADIOLOGICAL CONTAMINATION EXPOSURE AS A RESULT OF THIS EVENT.

PTS-1 999-029; PR-PTS-99-02208.

THE NRC RESIDENT INSPECTOR HAS BEEN NOTIFIED OF THIS EVENT.

- NRC BULLETIN 91-01, 24 HOUR REPORT: Two exempted parts contained visible quantities of uranium -

At 0910 CDT on 04/19/99, while performing a walk-through of the disassembly area of building C-400, two exempted parts were discovered to contain visible quantities of uranium. The parts were exempted in violation of requirement 3.2.11 of Nuclear Criticality Safety Approval NCSA 400.007.00 which allows NCS exemption of decontaminated parts based on two independent, visual inspections indicating they contain no visible uranium contamination. The purpose of this requirement is to ensure uranium contaminated parts are not exempted from NCS controls prior to proper inspection and verification of no visible uranium contamination. The independent visual inspections were performed in error.

SAFETY SIGNIFICANCE OF EVENTS:
The amount of visible uranium contamination was limited to a small quantity In a crevice of the parts. Although the amount of fissile material present is far below a safe mass, double contingency was not maintained since the Independent visual inspections were performed in error. Both controls relied upon for verification of no visible uranium mass were violated,

POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO[S] OF HOW CRITICALITY COULD OCCUR):
In order for a criticality to be possible, the seal parts would have to contain greater than a safe mass of uranium and form a critical configuration.

CONTROLLED PARAMETERS (MASS, MODERATION. GEOMETRY, CONCENTRATION, ETC.):
Mass

ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS LIMIT AND % WORST CASE CRITICAL MASS):
Less than 80 pounds of uranium; less than 2.0 wt %; UO2F2; (process limit: 2.0 wt %; worst case critical mass: 600 pounds of uranium)

NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION OF THE FAILURES OR DEFICIENCIES:
Double contingency for this scenario is established by implementing two controls on mass.

The first leg of double contingency is based upon inspection results Indicating there is no visible uranium present on seal parts prior to NCS exemption. This is controlled by performing a visual inspection of the seal parts indicating no visible uranium contamination. The documentation for the inspection indicated no visual uranium contamination. The seal parts contained visible quantities of uranium contamination: therefore, this control was violated and the process condition exceeded.

The second leg of double contingency relies upon a second independent, visual inspection verifying there is no visible uranium present on seal parts prior to NCS exemption. This is controlled by performing a second independent visual inspection of the seal parts indicating no visible uranium contamination. The documentation for the second independent inspection also indicated no visual uranium contamination. The seal parts contained visible quantities of uranium contamination: therefore, this control was violated and the process condition exceeded.

Since both controls relied upon for double contingency were violated, double contingency was not maintained.

CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED:
NCSA GEN-01 was immediately implemented upon discovery of the problem to prevent further actions until NCS approved corrective actions can be implemented.

This event is being categorized as a 24-hour event, in accordance with Safety Analysis Report Table 6.9-1, Criteria A.4.a and NRC Bulletin 91-01, Supplement 1 report.

The NRC Senior Resident Inspector has been notified of this event.

PGDP Problem Report No. ATR-99-2212; PGDP Event Report No. PAD-I999-029.

- RADIATION OVERDOSE DURING A BREAST CANCER TREATMENT -

A HOSPITAL TECHNICIAN LEFT A 30 DEGREE WEDGE OUT OF A COBALT TELETHERAPY MACHINE WHICH RESULTED IN A 33% RADIATION OVERDOSE TO A PATIENT DURING A BREAST CANCER TREATMENT. THE OVERDOSE OCCURRED DURING A DAILY TREATMENT FOR FIVE CONSECUTIVE DAYS (04/19-23/99). THERE WAS NO ADVERSE IMPACT TO THE PATIENT. THE PATIENT'S DOSE WILL BE REDUCED OVER THE NEXT 15 TREATMENTS. THE PATIENT'S DOCTOR PLANS TO INFORM THE PATIENT LATER TODAY.

HOSPITAL PERSONNEL PLAN TO SUBMIT A WRITTEN REPORT TO NRC REGION 3 WITHIN 15 DAYS.

PART 21 REPORT - DEVIATION IN A NUCLEAR LOGISTICS INC (NLI) DC POWER SUPPLY.

A DEVIATION HAS BEEN IDENTIFIED IN A NLI DC POWER SUPPLY, P/N NLI-LGS-G-24-OV-R-8018 WHICH HAVE BEEN SUPPLIED AS A CLASS 1E COMPONENT, THAT ALLOWS A PREMATURE OVER VOLTAGE PROTECTION ACTUATION TO OCCUR IN A CIRCUIT SPECIFIC APPLICATION. THIS CONDITION OCCURRED DURING DIESEL GENERATOR STARTUP, SPECIFICALLY DURING DIESEL GENERATOR LOADING. THIS ISSUE WAS DETERMINED TO BE A DEVIATION ON 4/19/99, HOWEVER, TO DATE NLI HAS NOT BEEN ABLE TO DUPLICATE THIS CONDITION DURING LABORATORY TESTING. DATA COLLECTION AND ADDITIONAL TESTING IS BEING PERFORMED TO RESOLVE THE DEVIATION. IT THE PREMATURE OVER VOLTAGE PROTECTION ACTUATION IS DETERMINED TO BE THE RESULT OF THE POWER SUPPLY DESIGN, OTHER NLI-L SERIES POWER SUPPLIES WILL BE TESTED TO DETERMINE THEIR SUSCEPTIBILITY TO SIMILAR CONDITIONS. TESTING AND EVALUATION ACTIVITIES WILL BE COMPLETED ON 7/16/99. THESE COMPONENTS HAVE BEEN SUPPLIED AS SAFETY-RELATED COMPONENTS TO PUBLIC SERVICE ELECTRIC AND GAS COMPANY.

*** UPDATE ON 8/10/99 FROM NLI (FAX) TO POERTNER ***

NLI has been unable to duplicate the condition in laboratory testing. Additional field testing is scheduled for late August. NLI has requested an extension to September 10, 1999 to determine the reportability of the condition.

HOO notified R1DO (GRAY), NRR/PCED Vern Hodge (FAX)