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Event Notification Report for May 13, 1999

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           05/12/1999 - 05/13/1999

                              ** EVENT NUMBERS **

35704  35705  35706  35707  35708  35709  

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   35704       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: WOLF CREEK               REGION:  4  |NOTIFICATION DATE: 05/12/1999|
|    UNIT:  [1] [] []                 STATE:  KS |NOTIFICATION TIME: 03:59[EDT]|
|   RXTYPE: [1] W-4-LP                           |EVENT DATE:        05/12/1999|
+------------------------------------------------+EVENT TIME:        00:38[CDT]|
| NRC NOTIFIED BY:  DAVE DEES                    |LAST UPDATE DATE:  05/12/1999|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |CHARLES CAIN         R4      |
|10 CFR SECTION:                                 |JOSE CALVO           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   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       55       Power Operation  |55       Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| PARTIAL LOSS OF OFFSITE POWER (ONE OF THREE SOURCES) DUE TO A TRANSFORMER    |
| LOCKOUT                                                                      |
|                                                                              |
| At 0038 CDT, the east bus (345 kV) was lost due to a lockout on the #7       |
| transformer.  The loss of the east bus resulted in the loss of normal power  |
| to the 'A' safeguards bus (4.16 kV).  On loss of power to the #7             |
| transformer, a shutdown sequencer actuation occurred due to low power.       |
| This caused the 'A' emergency diesel generator to automatically start and    |
| load the bus.  The following equipment also automatically started:  'A'      |
| centrifugal charging pump, 'A' component cooling water pump, 'A' essential   |
| service water pump, 'A' control room air conditioning unit, 'A' class 1E air |
| conditioning unit, 'A' motor-driven auxiliary feedwater pump,  'A' and 'C'   |
| containment coolers, and the turbine-driven auxiliary feedwater pump.  The   |
| licensee stated that all systems functioned as required and that there was   |
| nothing unusual or not understood.                                           |
|                                                                              |
| At 0058 CDT, the licensee reset the #7 transformer lockout, and the east bus |
| was restored to service at 0059 CDT.  At 0244 CDT, the licensee re-energized |
| the #7 transformer (the normal power feed to the safeguards bus              |
| transformer), and normal offsite power was restored to the 'A' emergency bus |
| at 0256 CDT.                                                                 |
|                                                                              |
| The transformer lockout was initially believed to be caused by a lightening  |
| strike and was later determined to be caused by a raccoon.                   |
|                                                                              |
| The licensee notified the NRC resident inspector.                            |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   35705       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: OCONEE                   REGION:  2  |NOTIFICATION DATE: 05/12/1999|
|    UNIT:  [1] [2] [3]               STATE:  SC |NOTIFICATION TIME: 13:29[EDT]|
|   RXTYPE: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-L|EVENT DATE:        05/12/1999|
+------------------------------------------------+EVENT TIME:        12:58[EDT]|
| NRC NOTIFIED BY:  TODD                         |LAST UPDATE DATE:  05/12/1999|
|  HQ OPS OFFICER:  CHAUNCEY GOULD               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |RUDOLPH BERNHARD     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                                   
+------------------------------------------------------------------------------+
| THE PLANT HAS OPERATED OUTSIDE THE DESIGN BASIS IN THE PAST DURING STARTUP.  |
|                                                                              |
| ON 03/18/99, FRAMATOME (B&W) REQUESTED THE LICENSEE REVIEW A                 |
| PRESSURE-TEMPERATURE LIMIT ANALYSIS FOR OCONEE NUCLEAR STATION               |
| APPLICABILITY.  THE ANALYSIS WAS PERFORMED FOR ANOTHER B&W PLANT AND SHOWED  |
| THAT PRESSURE INCREASES ARE LARGER WITH NITROGEN IN THE PRESSURIZER.  THIS   |
| RESULTED IN A REVISED SET OF LOW-TEMPERATURE OVERPRESSURE PROTECTION ( LTOP) |
| LIMITS FOR STEAM AND NITROGEN OPERATION AT THE OTHER PLANT.  FRAMATOME WAS   |
| NOT AWARE OF NITROGEN PRESENCE BEING CONSIDERED IN THE DETERMINATION OF LTOP |
| LIMITS.                                                                      |
|                                                                              |
| OPERATIONS WAS REQUESTED TO USE A DEDICATED LTOP OPERATOR, AS A CONSERVATIVE |
| MEASURE, IF LTOP APPLICABILITY EXISTED AND NITROGEN PRESSURE WAS IN THE      |
| PRESSURIZER. THIS IS A COMPENSATORY MEASURE REQUIRED BY TECHNICAL            |
| SPECIFICATION 3.4.12, CONDITION 'F.'                                         |
|                                                                              |
| THE LICENSEE HAS COMPLETED AN EVALUATION THAT CONCLUDED THAT NITROGEN        |
| OVERPRESSURE DURING STARTUP COULD RESULT IN LESS THAN 10 MINUTES BEING       |
| AVAILABLE FOR OPERATOR RESPONSE AFTER THE ALARM SETPOINT IS REACHED DURING   |
| AN LTOP EVENT.  SINCE OPERATOR RESPONSE TO AN ALARM IS ONE TRAIN OF THE      |
| OCONEE LTOP SYSTEM, THIS MEANS THAT THIS TRAIN HAS BEEN INOPERABLE DURING    |
| PORTIONS OF PAST STARTUPS.  THE APPLICABLE TIME PERIODS ARE ASSUMED TO HAVE  |
| EXCEEDED THE 4 HOURS ALLOWED BY TECHNICAL SPECIFICATION 3.4.12, CONDITION    |
| 'F,' FOR IMPLEMENTING COMPENSATORY MEASURES.  SINCE THE LTOP MITIGATION      |
| SYSTEM WOULD NOT MEET THE SINGLE FAILURE CRITERION DURING THESE TIME         |
| PERIODS, THIS CONDITION IS BEING REPORTED AS OPERATION OUTSIDE THE DESIGN    |
| BASIS OF THE PLANT.                                                          |
|                                                                              |
| LTOP REQUIREMENTS DO NOT APPLY DURING PLANT OPERATION IN THE RUN MODE, AND   |
| THERE HAVE BEEN NO LTOP EVENTS DURING PLANT OPERATION WITH A NITROGEN        |
| PRESSURE BUBBLE IN THE PRESSURIZER.  THEREFORE, THIS IS NOT CONSIDERED TO    |
| REPRESENT AN ACTUAL CHALLENGE TO THE HEALTH AND SAFETY OF THE PUBLIC.        |
|                                                                              |
| THE RESIDENT INSPECTOR WAS INFORMED.                                         |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   35706       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: NINE MILE POINT          REGION:  1  |NOTIFICATION DATE: 05/12/1999|
|    UNIT:  [] [2] []                 STATE:  NY |NOTIFICATION TIME: 16:12[EDT]|
|   RXTYPE: [1] GE-2,[2] GE-5                    |EVENT DATE:        05/12/1999|
+------------------------------------------------+EVENT TIME:        15:15[EDT]|
| NRC NOTIFIED BY:  GREEN                        |LAST UPDATE DATE:  05/12/1999|
|  HQ OPS OFFICER:  CHAUNCEY GOULD               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |CURTIS COWGILL       R1      |
|10 CFR SECTION:                                 |                             |
|AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION    |                             |
|NLCO                     TECH SPEC LCO A/S      |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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                                   
+------------------------------------------------------------------------------+
| REACTOR CORE ISOLATION COOLING (RCIC) WAS DECLARED INOPERABLE DURING THE     |
| QUARTERLY SURVEILLANCE TEST.                                                 |
|                                                                              |
| DURING THE PERFORMANCE OF THE NORMAL QUARTERLY RCIC SURVEILLANCE TEST, THE   |
| RCIC TURBINE UNEXPECTEDLY TRIPPED WHEN THE  SUCTION PATH WAS SWAPPED FROM    |
| THE SUPPRESSION POOL TO THE CONDENSATE STORAGE TANK.  THE CAUSE OF THE RCIC  |
| TURBINE TRIP IS UNKNOWN AT THIS TIME, AND TROUBLESHOOTING IS CURRENTLY IN    |
| PROGRESS.  THE PLANT IS IN A 14-DAY LIMITING CONDITION FOR OPERATION ACTION  |
| STATEMENT.                                                                   |
|                                                                              |
| THE RESIDENT INSPECTOR WILL BE NOTIFIED.                                     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   35707       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  FLORIDA BUREAU OF RAD CONTROL        |NOTIFICATION DATE: 05/12/1999|
|LICENSEE:  CITRUS MEMORIAL HEALTH FOUNDATION, IN|NOTIFICATION TIME: 17:32[EDT]|
|    CITY:  INVERNESS                REGION:  2  |EVENT DATE:        05/12/1999|
|  COUNTY:                            STATE:  FL |EVENT TIME:             [EDT]|
|LICENSE#:  2067-1                AGREEMENT:  Y  |LAST UPDATE DATE:  05/12/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |RUDOLPH BERNHARD     R2      |
|                                                |JOE HOLONICH         NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  ADAMS                        |                             |
|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| THE FLORIDA BUREAU OF RADIATION CONTROL REPORTED A RADIOLOGICAL INCIDENT,    |
| #FL99-066, WHICH OCCURRED AT THE CITRUS MEMORIAL HEALTH FOUNDATION, INC.,    |
| LOCATED IN INVERNESS, FLORIDA.                                               |
|                                                                              |
| SIX IMPLANTED I-125 SEEDS MEASURING 0.265 mCi EACH WERE REMOVED FROM A       |
| PATIENT AT THE FACILITY.  WHEN THE SEEDS WERE TO BE RETRIEVED FOR SHIPMENT   |
| BACK TO THE MANUFACTURER, ONLY ONE COULD BE FOUND.  A THOROUGH SURVEY OF THE |
| ROOM AND SEWER TRAPS FAILED TO LOCATE THE OTHER FIVE SEEDS.  THE MISSING     |
| MATERIAL WAS PROBABLY LOST IN THE SANITARY SEWER.  A STATE INSPECTOR IS      |
| INVESTIGATING THE INCIDENT.                                                  |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   35708       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  KANSAS DEPT OF HEALTH & ENVIROMENT   |NOTIFICATION DATE: 05/12/1999|
|LICENSEE:  VIA CHRISTI REGIONAL MEDICAL CTR     |NOTIFICATION TIME: 18:11[EDT]|
|    CITY:  WICHITA                  REGION:  4  |EVENT DATE:        05/07/1999|
|  COUNTY:  SEDGWICK                  STATE:  KS |EVENT TIME:        10:00[CDT]|
|LICENSE#:  19-C030-01            AGREEMENT:  Y  |LAST UPDATE DATE:  05/12/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |CHARLES CAIN         R4      |
|                                                |JOE HOLONICH         NMSS    |
+------------------------------------------------+FRANK CONGEL         IRO     |
| NRC NOTIFIED BY:  FRAASS                       |                             |
|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| ON 05/12/99, THE VIA CHRISTI REGIONAL MEDICAL CENTER NOTIFIED THE KANSAS     |
| RADIATION CONTROL PROGRAM THAT A PROBABLE MEDICAL MISADMINISTRATION OCCURRED |
| ON 05/07/99 AT 1000 CDT.                                                     |
|                                                                              |
| A 28-YEAR-OLD FEMALE, WHO IS APPARENTLY 19 WEEKS PREGNANT, WAS GIVEN A       |
| THERAPEUTIC DOSE OF I-131 (11.8 MILLICURIES).  THE CENTER'S RADIATION SAFETY |
| OFFICER CONTACTED REAC/TS, AND THE ONCOLOGIST WHO REQUESTED THE STUDY HAS    |
| ALREADY BEEN CONTACTED BY A PHYSICIAN FROM REAC/TS.  A SECOND CONFERENCE     |
| CALL IS SCHEDULED WITH THE PATIENT'S OB/GYN PHYSICIAN.  THE KANSAS           |
| DEPARTMENT OF HEALTH AND ENVIRONMENT HAS BEGUN AN INVESTIGATION INTO THIS    |
| INCIDENT.                                                                    |
|                                                                              |
| CONTACT THE OPERATIONS CENTER FOR THE STATE CONTACT'S TELEPHONE NUMBER.      |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Fuel Cycle Facility                              |Event Number:   35709       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT      |NOTIFICATION DATE: 05/12/1999|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 22:42[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        05/12/1999|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        02:29[CDT]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  05/12/1999|
|    CITY:  PADUCAH                  REGION:  3  +-----------------------------+
|  COUNTY:  McCRACKEN                 STATE:  KY |PERSON          ORGANIZATION |
|LICENSE#:  GDP-1                 AGREEMENT:  Y  |ROGER LANKSBURY      R3      |
|  DOCKET:  0707001                              |JOE HOLONICH         NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  CAGE                         |                             |
|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|OCBA 76.120(c)(2)(i)     ACCID MT EQUIP FAILS   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| FAILURE OF THE UF6 RELEASE DETECTION SYSTEM - 24-HOUR NOTIFICATION           |
|                                                                              |
| THE FACILITY EXPERIENCED A FAILURE OF THE UF6 RELEASE DETECTION SAFETY       |
| SYSTEM IN C-333, UNIT 5, CELL 3.  THE FAILURE OCCURRED DURING THE            |
| TWICE-PER-SHIFT TECHNICAL SAFETY REQUIREMENT (TSR) SURVEILLANCE WHICH        |
| REQUIRES A TEST FIRING OF THE DETECTOR HEADS.  THE SAFETY SYSTEM WAS         |
| IMMEDIATELY DECLARED INOPERABLE, AND THE TSR-REQUIRED ACTIONS, WHICH INCLUDE |
| PLACING A SMOKE WATCH IN THE AFFECTED AREA, WERE IMPLEMENTED.  IN ADDITION,  |
| THE OPERATING PRESSURE OF THE AFFECTED EQUIPMENT WAS REDUCED TO BELOW        |
| ATMOSPHERIC PRESSURE WHICH PLACED THE EQUIPMENT IN A MODE IN WHICH THE       |
| SAFETY SYSTEM WAS NOT REQUIRED TO BE AVAILABLE AND OPERABLE.                 |
|                                                                              |
| THE NRC RESIDENT INSPECTOR WAS INFORMED.                                     |
+------------------------------------------------------------------------------+