Event Notification Report for May 27, 1999
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
05/26/1999 - 05/27/1999
** EVENT NUMBERS **
35697 35709 35768 35769 35770
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
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|Power Reactor |Event Number: 35697 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: NINE MILE POINT REGION: 1 |NOTIFICATION DATE: 05/10/1999|
| UNIT: [1] [] [] STATE: NY |NOTIFICATION TIME: 15:18[EDT]|
| RXTYPE: [1] GE-2,[2] GE-5 |EVENT DATE: 05/10/1999|
+------------------------------------------------+EVENT TIME: 13:00[EDT]|
| NRC NOTIFIED BY: BELDEN |LAST UPDATE DATE: 05/26/1999|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |CURTIS COWGILL R1 |
|10 CFR SECTION: | |
|ADAS 50.72(b)(2)(i) DEG/UNANALYZED COND | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N N 0 Cold Shutdown |0 Cold Shutdown |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| UNIT 1 VALVES FAILED THEIR LOCAL LEAK RATE TEST. |
| |
| UNDER THE APPENDIX J PROGRAM PLAN (#NMP1-APPJ-001) SECTION III/1.8 OUTAGE |
| TESTING REQUIREMENTS INCLUDE MAINTAINING A COMBINED TOTAL TYPE 'B' AND 'C' |
| AS-FOUND MINIMUM PATHWAY LEAKAGE. IN ACCORDANCE WITH TECH SPEC 6.16.4, THE |
| COMBINED LOCAL LEAK RATE TEST (TYPE 'B' & 'C' TESTS INCLUDING AIRLOCKS) |
| ACCEPTANCE CRITERIA IS LESS THAN 0.6 La, CALCULATED IN THE MINIMUM PATHWAY |
| BASIS, AT ALL TIMES WHEN CONTAINMENT INTEGRITY IS REQUIRED. THE VALUE OF |
| 0.6 La FOR UNIT 1 WAS CALCULATED TO BE 388.44 SCFH. THE RESULTS OF THE TEST |
| MEASURED 388.756 SCFH, WHICH EXCEED THE CALCULATED VALUE FOR THE COMBINED |
| AS-FOUND TYPE 'B' AND 'C' LOCAL LEAK RATE TESTS. THIS CONDITION WOULD HAVE |
| BEEN A TECH SPEC VIOLATION IF IDENTIFIED DURING POWER OPERATION. |
| |
| THIS CONDITION WILL BE CORRECTED PRIOR TO PLANT RESTART. |
| |
| THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. |
| |
| * * * UPDATE 1000EDT ON 5/26/99 FROM KEN BELDEN TO S.SANDIN * * * |
| |
| THE LICENSEE IS RETRACTING THIS REPORT BASED ON THE FOLLOWING: |
| |
| "IT HAS SINCE BEEN DETERMINED THAT ACTUAL LEAKAGE RESULTS FROM THESE TESTS |
| DOES NOT EXCEED 0.6La (388.44 SCFH). ACTUAL LEAKAGE HAS BEEN CALCULATED TO |
| BE 345.086 SCFH. |
| |
| "THE ORIGINAL DETERMINATION ON 5/10/99 WAS BASED ON A PROJECTION OF FINAL |
| TYPE B AND C RESULTS PRIOR TO ACTUAL COMPLETION. RESULTS FROM APPROXIMATELY |
| 15 LEAK RATE TESTS WHICH WERE NOT COMPLETE AT THE TIME OF THE ORIGINAL |
| NOTIFICATION, WERE MUCH BETTER THAN EXPECTED, WHICH CAUSED A CHANGE FROM |
| THIS CONDITION BEING REPORTABLE TO NOT REPORTABLE. [THE] ORIGINAL |
| NOTIFICATION [IS] RESCINDED." |
| |
| THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. NOTIFIED R1DO( CONTE ). |
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!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
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|Fuel Cycle Facility |Event Number: 35709 |
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| 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: 05/26/1999|
| 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
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| 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. |
| |
| * * * UPDATE 0900EDT ON 5/26/99 FROM TOM WHITE TO S.SANDIN * * * |
| |
| THIS REPORT IS BEING RETRACTED BASED ON THE FOLLOWING INFORMATION: |
| |
| "On May 19, 1999, NRA provided the Plant Shift Superintendent (PSS) with |
| guidance related to the reportability of PGLD surveillance testing failures. |
| Subsequent to the subject notification, the reportability of process leak |
| detection (PGLD) TSR testing failures has been reviewed. This concluded that |
| the twice per shift test causes the PGLD alarm system to be out of service |
| until the system is reset and that the TSR Limiting Conditions of Operation |
| (LCO) action time begins at the point the test is initiated. Thus, failures |
| that occur during testing occur when the system is out of service and under |
| active LCO. Failures occurring while equipment is out of service are not |
| reportable under 10CFR76.120 (c) (2) unless there is firm evidence that the |
| inoperability existed prior to the test. Therefore, this notification is |
| being retracted. This has been discussed with the PGDP Senior NRC Resident. |
| |
| "PGDP Problem Report No. ATR-99/2737; PGDP Event Report No. PAD-1999-037. |
| NRC Event Notification Worksheet No. 35709." |
| |
| Notified R3DO(Vegel) and NMSS(Combs). |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Fuel Cycle Facility |Event Number: 35768 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 05/26/1999|
| RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 04:29[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 05/25/1999|
| 6903 ROCKLEDGE DRIVE |EVENT TIME: 21:05[EDT]|
| BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 05/26/1999|
| CITY: PIKETON REGION: 3 +-----------------------------+
| COUNTY: PIKE STATE: OH |PERSON ORGANIZATION |
|LICENSE#: GDP-2 AGREEMENT: N |TONY VEGEL R3 |
| DOCKET: 0707002 |FRED COMBS NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: RON CRABTREE | |
| HQ OPS OFFICER: STEVE SANDIN | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NBNL RESPONSE-BULLETIN | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| 24-HOUR NRC BULLETIN 91-01 REPORT INVOLVING THE LOSS OF ONE OF THE TWO |
| DOUBLE CONTINGENCY CONTROLS |
| |
| "On 5/25/99 at 2105 hours, while processing waste water solution through |
| X-705 microfiltration filter press 'A', approximately 5 gallons of solution |
| leaked from between the second and third filter plates, spilling onto the |
| floor. At the time of this spill, Operations personnel were processing a |
| 2072 liter 'batch' of waste water which contained 29.44 grams of U-235 at an |
| enrichment of 1.4 wt % U-235. Plant Nuclear Criticality Safety Personnel |
| determined the leak to be a loss of a single control (physical integrity of |
| the system) such that only one of the double contingency controls (geometry) |
| remained in place. |
| |
| "This event is reportable under NRC Bulletin 91-01, 24-hour criticality |
| control. |
| |
| "There was no radioactive / radiological exposure as a result of this |
| event. |
| |
| "SAFETY SIGNIFICANCE OF EVENTS: |
| On May 25, 1999, approximately 5-gallons of concentrate leaked from filter |
| press A in the microfiltration system. The leak occurred between the second |
| and third filter press plates, most likely the result of a failed 0-ring. |
| NCSA.0705_076 covers the use of inadvertent containers in X-705, given the |
| concern of leaks/spills from the various solution bearing systems. |
| NCSA.0705_076 considers the leak/spill of more than 4.8-liters from any |
| system to be an unlikely event, given the design and physical integrity of |
| the systems (i.e., the systems are designed and built to contain the |
| solution). While this leak resulted in greater than 4.8-liters spilling from |
| the system in question, the second contingency was not violated in that the |
| solution did not accumulate in an unsafe geometry (it spilled to the floor |
| and spread out into a safe slab geometry). |
| |
| "Based on sampling and batching calculations performed on the concentrate |
| storage tank (i.e., T.103A) the total mass of material to be fed to the |
| filter press is known prior to introducing concentrate into the filler |
| press. NCSA-0705_015 limits the mass of U-235 to be processed (i.e., in a |
| single batch) to a maximum of 350 grams. Per the filter press batch sheet |
| for batch 103A-511, the batch being fed when this leak occurred contained |
| 29.44 grams U-235. This amount of material is well below the safe mass of |
| material, even at 100 wt% enrichment (ref. GAT-225). The actual enrichment |
| of the material being processed was 1.4% U-235, per the filter press batch |
| sheet for batch 103A-511. Therefore, while one of the contingencies was |
| lost, the safety significance for this occurrence was low given the |
| prerequisite for limiting the mass in the batch to 350 grams U-235. |
| |
| "POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO[S] OF HOW |
| CRITICALITY COULD OCCUR): |
| A significant amount of uranium-bearing solution would have to leak from a |
| system and accumulate in an unsafe geometry in order for a criticality to |
| occur. |
| |
| "CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.): |
| The parameters being controlled for this event were volume of a leak in a |
| system in X-705. NCSA-0705_076 considers it unlikely that a leak of more |
| than 4.8-liters would occur given the physical integrity of systems in |
| X-705. In addition, the mass of U-235 in the batch being processed was |
| limited to a maximum of 350 grams. |
| |
| "ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS |
| LIMIT AND % WORST CASE OF CRITICAL MASS): |
| Based on PR-PST-99-02948 and filter press batch sheet for batch 103A-511 |
| the volume of solution which leaked was approximately 5-gallons. The maximum |
| amount of U-235 in the concentrate was 29.44 grams and the maximum |
| enrichment of material was 1.4 wt% U-235. It should be noted that the actual |
| mass of U-235 which was in the leaked solution would be less than 29.44 |
| grams, since the total amount of solution being processed was 2072 liters. |
| |
| "NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION |
| OF THE FAILURES OR DEFICIENCIES: |
| NCSA-0705_075 considers it unlikely that more than 4.8-liters of solution |
| would leak from a system given the physical integrity of the systems used in |
| X-705. The leak in question resulted in approximately 5-gallons of solution |
| leaking from the filter press. This amount of solution exceeded the |
| considered limit for the unlikely event and resulted in the loss of double |
| contingency for this leak. |
| |
| "CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEM AND WHEN EACH WAS |
| IMPLEMENTED:" |
| |
| Operations informed the NRC resident inspector and will inform the DOE site |
| representative. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 35769 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: MARYLAND DEPT OF ENVIRO. |NOTIFICATION DATE: 05/26/1999|
|LICENSEE: CARROLL COUNTY GENERAL HOSPITAL |NOTIFICATION TIME: 14:40[EDT]|
| CITY: REGION: 1 |EVENT DATE: 05/14/1999|
| COUNTY: CARROLL STATE: MD |EVENT TIME: 00:00[EDT]|
|LICENSE#: MD-13-001-02 AGREEMENT: Y |LAST UPDATE DATE: 05/26/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |RICHARD CONTE R1 |
| |FRED COMBS NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: LEON RACHUBA | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| "On May 26, 1999. I conducted an investigation of the Iodine-125 |
| brachytherapy seeds which were reported as leaking in a letter dated May 14, |
| 1999 from the licensee's radiation safety officer, Richard Haar, M.D. The |
| letter was faxed to this office on May 18, 1999 along with an analysis |
| report from Krueger-Gilbert Health Physics, Inc., dated May 14. 1999. Copies |
| of the letter and the report are attached. |
| |
| "The investigation was conducted with Ms. Gina Sebald, Assistant |
| Administrative Director, Radiology and nuclear medicine technicians Messrs. |
| Michael Robertson and Joseph Shaw. Mr. Robertson informed the inspector that |
| following an Iodine-125 prostate seed implant on May 10, 1999, an unused |
| pre-loaded cartridge of I-125 seeds obtained from Amersham was unloaded |
| according to the licensee's protocol in the Nuclear Medicine Hot Lab. The |
| cartridge contained ten seeds which were all removed and placed in a lead |
| pig for storage. The cartridge was then surveyed with a sodium iodide |
| detector to confirm that all of the seeds had been removed and the readings |
| obtained were above background. Mr. Robertson then visually inspected the |
| seeds and saw that one of the seeds was damaged. A wipe sample taken from |
| the seeds also showed a count rate higher than expected. Spectral analysis |
| showed a discernable photopeak in the range of 23 to 41 keV. The radiation |
| safety officer. Dr. Richard Haar, was immediately notified and |
| Krueger-Gilbert was asked to help quantify the licensee's data. |
| Krueger-Gilbert's testing was done on May 14, 1999 and showed removable |
| activity of 0.007 microcuries. |
| |
| "The ten seeds in question were subsequently returned to Amersham on May 25, |
| 1999. Three other seeds from a different cartridge of ten seeds used in the |
| same implant were unused and were placed in a lead pig to be held for decay |
| prior to disposal by the licensee. The lead pig is kept in the hot lab |
| behind an L-block shield. A copy of the report covering the disposition of |
| the seeds is attached. |
| |
| "Mr. Robertson said he was told by Krueger-Gilbert that Bio-assays were not |
| necessary due to the low activity involved. |
| |
| "The weekly wipe survey of the hot lab conducted by the licensee on May 15, |
| 1999 showed no contamination of the area. |
| |
| "Independent measurements were taken by the inspector with an Eberline Pulse |
| Ratemeter PRM--6, s/n 1239, calibrated on September 1, 1998, using an LEG |
| probe. No contamination was found." |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 35770 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: NINE MILE POINT REGION: 1 |NOTIFICATION DATE: 05/26/1999|
| UNIT: [] [2] [] STATE: NY |NOTIFICATION TIME: 20:27[EDT]|
| RXTYPE: [1] GE-2,[2] GE-5 |EVENT DATE: 05/26/1999|
+------------------------------------------------+EVENT TIME: 16:35[EDT]|
| NRC NOTIFIED BY: BRIAN WEAVER |LAST UPDATE DATE: 05/26/1999|
| HQ OPS OFFICER: DOUG WEAVER +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |RICHARD CONTE R1 |
|10 CFR SECTION: | |
|AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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
+------------------------------------------------------------------------------+
| FAILURE TO PERFORM REQUIRED IN SERVICE TESTING |
| |
| While performing a review of the pressure testing program, Nine Mile Point |
| Unit 2 Engineering discovered that the High Pressure Core Spray System (CSH) |
| suction line from the Condensate Storage Tanks (CST) check valve 2CSH*V59 |
| has not been tested since November 1997. Testing of this valve was stopped |
| when available licensing and design basis information incorrectly determined |
| testing was not required under the second 10-Year IST Program Plan. |
| |
| NMP2 Engineering initial review revealed that valve 2CSH*V59 is the |
| redundant barrier to prevent uncontrolled suppression pool level loss in the |
| event of the active failure of the CST motor operated Suction valve 2CSH*MOV |
| 101 to close during a coincident Safe Shutdown Earthquake (SSE) and DBA Loss |
| Of Coolant Accident (LOCA). |
| |
| As the required testing on 2CSH*V59 has not been performed, 2CSH*MOV 101 has |
| been de-energized shut as a compensatory action to isolate this line. High |
| Pressure Core Spray has been declared inoperable and actions per Tech Spec |
| 3.5.1 initiated. CSH remains available with suction lined up to the |
| suppression pool. |
| |
| This notification is being made as required per 10CFR50.72.b.2.(iii).(D) for |
| unplanned inoperability of a single train ECCS system. |
| |
| The licensee informed the NRC Resident Inspector. |
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