Event Notification Report for April 23, 1999

INFORMATION ON A DEVIATION THAT DOES NOT REACH THE LEVEL OF A PART 21 REPORT

There was an incorrect resistor shipped on log amplifier printed circuit assemblies. The worst case environmental temperature deviation would cause a maximum deviation of 6% (equivalent full-scale) error in the indicating region from 3 X 10-3% to 50% power. This would not compromise the ability to monitor safe shutdown reactor power level adequately during and after a design basis event.

The following text is a portion of a facsimile received from GAMMA-METRICS:

"Our lot control capability allowed us to determine that nineteen of the incorrect resistors were shipped from GAMMA-METRICS to our customers. ... We are recalling all nineteen defective resistors or the printed circuit assemblies. We will replace the resistors with the correct component and re-certify the repair at no charge to any of the listed customers."

The following is a list of the facilities affected:

1. Georgia Power, Vogtle 1 and 2 - 9 assemblies (replaced in March 1999)
2. Duke Energy, Catawba - 1 assembly
3. AEP DC Cook - 2 assemblies (not installed)
4. Ontario Hydro, Pickering - 1 assembly (not installed)
5. Maine Yankee - 4 assemblies (not installed and plant shutdown for decommissioning)
6. Penn State University - 2 assemblies (not installed)

There were letters sent to the affected customers.

(Call the NRC operations officer for a contact telephone number.)

HPCI SYSTEM DECLARED INOPERABLE, AND PLANT ENTERED LCO ACTION STATEMENT.

THE HPCI SYSTEM WAS DECLARED INOPERABLE FROM 0214 CDT TO 0220 CDT DUE TO MOISTURE IN THE TURBINE STEAM INLET LINE. A 14-DAY LCO ACTION STATEMENT WAS ENTERED, AND RCIC WAS VERIFIED OPERABLE. HPCI TURBINE INLET HIGH DRAIN POT LEVEL ANNUNCIATION WAS RECEIVED DUE TO STROKING MO-2036 (TURBINE STEAM SUPPLY VALVE) AS PART OF THE REACTOR SHUTDOWN PROCEDURE AT REACTOR PRESSURE OF 500 PSIG. THE STEAM LINE MANUAL DRAIN VALVE WAS OPENED, AND THE ANNUNCIATOR CLEARED AT 0220 CDT. HPCI WAS DECLARED OPERABLE AND IN STANDBY. THE 14-DAY LCO ACTION STATEMENT WAS ALSO EXITED AT 0220 CDT.

THE NRC RESIDENT INSPECTOR WILL BE NOTIFIED BY THE LICENSEE.

THE PLANT HAD A REACTOR TRIP FROM 35% POWER ON A 2-OUT-OF-4 POWER RANGE HIGH SIGNAL.

THE REACTOR TRIP OCCURRED WHILE THE PLANT WAS COMING OUT OF A REFUELING OUTAGE AND THE I&C TECHNICIANS WERE WORKING ON THE NUCLEAR INSTRUMENTATION RACKS ADJUSTING POWER RANGE TRIP SETPOINTS. CHANNEL 1 HAD JUST BEEN COMPLETED, AND CHANNEL 2 WAS IN PROGRESS WITH BOTH BISTABLES TRIPPED IN THE CHANNEL 2 PROTECTION RACKS. AT THIS POINT, CONTROL ROOM TURNOVER HAD STARTED, AND THE TECHNICIANS HAD STOPPED WORK UNTIL TURNOVER WAS COMPLETE. UPON RESUMING WORK, THE TECHNICIANS INADVERTENTLY WENT TO NIS CHANNEL 3 AND PULLED INSTRUMENT POWER FUSES. THE REACTOR TRIPPED ON 2 OUT OF 4 POWER RANGE HI LEVEL IMMEDIATELY UPON PULLING THE CHANNEL 3 FUSES. ALL RODS FULLY INSERTED, NO ECCS OCCURRED, AND NO SAFETY RELIEF VALVES LIFTED. THE PLANT IS USING THE ATMOSPHERIC RELIEF VALVES AS THE HEAT SINK. THE PLANT IS CURRENTLY IN MODE 3, Tavg IS 547°F, AND RCS PRESSURE AT 2,235 PSIG.

SINCE THE LICENSEE WAS COMING OUT OF A REFUELING OUTAGE, THE MAIN STEAM ISOLATION VALVES WERE CLOSED DUE TO LOW DECAY HEAT, AND THE MAIN STEAM GENERATOR ATMOSPHERIC VALVE ON EACH STEAM GENERATOR WAS USED TO MAINTAIN Tavg.

THE INCIDENT WAS DUE TO PERSONNEL ERROR.

THE NRC RESIDENT INSPECTOR WAS INFORMED BY THE LICENSEE.

AUXILIARY BUILDING DISCOVERED AT POSITIVE PRESSURE TO THE OUTSIDE.

The licensee determined at 1600 on 04/23/99 that this report met the criteria for reporting under 10CFR50.72 as a 1-hour report.

The following text is a portion of a facsimile received from the licensee:

"On 04/13/99 at 2135, the Unit 1 auxiliary building was found to be at a +0.03 inches of water with respect to the outdoors. The Updated Final Safety Analysis Report (UFSAR) states that the auxiliary building is designed to be at a slight negative pressure continuously with respect to the outdoors, to satisfy the criterion for preventing the uncontrolled release of radioactivity. Subsequent investigation found that the #12 auxiliary building exhaust fan was rotating backwards. The fan had been returned to service at 1337 on 04/13/99, the fan was removed from service at 2216. Maintenance inspections had been performed earlier that day that required the motor leads to be disconnected. The apparent cause is incorrect wiring of the motor by the maintenance technician. The fan was reworked and returned to service at 1110 on 04/14/99. Tech Spec 3.7.7.1 was in effect for the duration."

The licensee intends to notify the NRC Resident Inspector.

THERAPEUTIC MEDICAL MISADMINISTRATION AT KAISER PERMANENTE MEDICAL CARE PROGRAM OF SOUTHERN CALIFORNIA.

A PATIENT WAS SCHEDULED FOR THREE THERAPEUTIC TREATMENTS FOR CANCER OF THE CERVIX USING THE HIGH DOSE RATE AFTERLOADER. PRIOR TO THE INITIATION OF THE FIRST TREATMENT ON 04/23/99, THE AUTHORIZED USER MADE A "LAST MINUTE" CHANGE IN THE TREATMENT PLAN WITH RESPECT TO THE SOURCE TRAVEL DISTANCE. AFTER THE CHANGE WAS MADE, THE SETUP CALLED FOR THE SOURCE TO BEGIN AT 989 MILLIMETERS. THE PHYSICIST, HOWEVER, SET UP THE UNIT SO THAT THE SOURCE BEGAN ITS TRAVEL AT 889 MILLIMETERS. PRIOR TO INITIATION OF THE TREATMENT, THE AUTHORIZED USER, PHYSICIST, AND TECHNOLOGIST SIGNED OFF ON THIS TREATMENT PLAN. THE PATIENT WAS THEN TREATED. THE SOURCE TRAVEL DISTANCE WAS 100 MILLIMETERS SHORTER THAN THE TREATMENT PLAN REQUIRED, AND DIFFERENT FROM THAT INTENDED. IT WAS NOT NOTED DURING OR AFTER COMPLETION OF THIS TREATMENT.

THE SECOND TREATMENT OCCURRED ON 04/30/99. A SECOND PHYSICIST, WITHOUT VERIFYING THE ACCURACY OF THE FIRST TREATMENT, SET UP THE SECOND TREATMENT USING THE SAME PARAMETERS, A TRAVEL DISTANCE OF 894 MILLIMETERS. THE AUTHORIZED USER, PHYSICIST, AND TECHNOLOGIST SIGNED OFF ON THE SECOND TREATMENT PLAN. THE TREATMENT WAS ADMINISTERED TO A DIFFERENT LOCATION THAN INTENDED. THE ERROR WAS NOT NOTED PRIOR TO, DURING, OR AFTER THIS TREATMENT.

THE THIRD TREATMENT PERFORMED ON 05/07/99 BY A THIRD PHYSICIST WHO SET UP THE PARAMETERS CORRECTLY, AS PLANNED (TRAVEL DISTANCE OF 994 MILLIMETERS) WAS COMPLETED WITHOUT INCIDENT.

THE THIRD PHYSICIST PERFORMED A CHART REVIEW ON 05/11/99 AND FOUND THE ERROR IN THE 04/23/99 AND 04/30/99 TREATMENTS AND NOTIFIED THE RADIATION THERAPY ADMINISTRATOR AND CHIEF OF SERVICE.

THE REGIONAL RADIATION SAFETY OFFICER (RSO) WAS NOTIFIED ON 05/17/99 BY THE SITE RSO IN VIOLATION OF THE REQUIRED 4 HOUR NOTIFICATION TIME.

THE PATIENT AND HIS REFERRING PHYSICIAN WERE NOTIFIED OF THIS INCIDENT ON 05/18/99.

A COMPLETE INVESTIGATION OF THESE INCIDENTS, INCLUDING A DOSE ASSESSMENT, AND THE DEVELOPMENT OF AN ACTION PLAN TO PREVENT FURTHER OCCURRENCES WILL BE MADE.