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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 THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!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 ).   |
+------------------------------------------------------------------------------+

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
+------------------------------------------------------------------------------+
|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:  05/26/1999|
|    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                                   
+------------------------------------------------------------------------------+
| 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                                   
+------------------------------------------------------------------------------+
| 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                                   
+------------------------------------------------------------------------------+
| "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.                            |
+------------------------------------------------------------------------------+