Event Notification Report for June 24, 1999
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/23/1999 - 06/24/1999
Power Reactor
Event Number: 35857
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [] [2] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: ROY GREEN
HQ OPS Officer: BOB STRANSKY
Region: 1 State: NY
Unit: [] [2] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: ROY GREEN
HQ OPS Officer: BOB STRANSKY
Notification Date: 06/24/1999
Notification Time: 17:05 [ET]
Event Date: 06/24/1999
Event Time: 15:41 [EDT]
Last Update Date: 06/24/1999
Notification Time: 17:05 [ET]
Event Date: 06/24/1999
Event Time: 15:41 [EDT]
Last Update Date: 06/24/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(ii) - ESF ACTUATION
10 CFR Section:
50.72(b)(2)(ii) - ESF ACTUATION
Person (Organization):
GLENN MEYER (R1)
GLENN MEYER (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | A/R | Y | 100 | Power Operation | 0 | Hot Shutdown |
AUTOMATIC REACTOR SCRAM WITH PARTIAL LOSS OF OFFSITE POWER
An automatic reactor scram occurred due to low reactor vessel water level. The low level condition was caused by the failure of a feedwater level controller. All control rods inserted following the scram. Offsite power line #5 failed to transfer following the scram, causing the following ESF actuations to occur: reactor building ventilation isolation, standby gas treatment system initiation, Division 1 and 3 emergency diesel generator (EDG) initiation, and control room special filter train initiation. In addition, operators manually closed the main steam isolation valves (MSIVs) in response to decreasing condenser vacuum caused by a loss of power to the offgas system. The unit is currently in Hot Shutdown, with reactor vessel water level being controlled by the reactor core isolation cooling (RCIC) system, and decay heat being removed via the safety/relief valves (SRVs). The licensee plans to take the unit to Cold Shutdown.
The licensee is currently troubleshooting the offsite power line #5 in order to restore power to affected systems.
The NRC resident inspector has been informed of this event.
* * * Update at 2244 on 06/24/99 from Trombley taken by Stransky * * *
Scram recovery activities are continuing. Offsite power line #5 has been restored, and the Division 1 EDG has been secured. The licensee is currently in the process of securing the Division 3 EDG. Operators experienced some problems with the RCIC flow controller and have taken manual control of the system [see related EN 35859]. The NRC Operations Officer notified R1DO (Glenn Meyer).
An automatic reactor scram occurred due to low reactor vessel water level. The low level condition was caused by the failure of a feedwater level controller. All control rods inserted following the scram. Offsite power line #5 failed to transfer following the scram, causing the following ESF actuations to occur: reactor building ventilation isolation, standby gas treatment system initiation, Division 1 and 3 emergency diesel generator (EDG) initiation, and control room special filter train initiation. In addition, operators manually closed the main steam isolation valves (MSIVs) in response to decreasing condenser vacuum caused by a loss of power to the offgas system. The unit is currently in Hot Shutdown, with reactor vessel water level being controlled by the reactor core isolation cooling (RCIC) system, and decay heat being removed via the safety/relief valves (SRVs). The licensee plans to take the unit to Cold Shutdown.
The licensee is currently troubleshooting the offsite power line #5 in order to restore power to affected systems.
The NRC resident inspector has been informed of this event.
* * * Update at 2244 on 06/24/99 from Trombley taken by Stransky * * *
Scram recovery activities are continuing. Offsite power line #5 has been restored, and the Division 1 EDG has been secured. The licensee is currently in the process of securing the Division 3 EDG. Operators experienced some problems with the RCIC flow controller and have taken manual control of the system [see related EN 35859]. The NRC Operations Officer notified R1DO (Glenn Meyer).
Hospital
Event Number: 35858
Rep Org: ALASKA REGIONAL HOSPITAL
Licensee: ALASKA REGIONAL HOSPITAL
Region: 4
City: ANCHORAGE State: AK
County:
License #: 50-18244-01
Agreement: N
Docket:
NRC Notified By: BRADLEY CRUZ
HQ OPS Officer: BOB STRANSKY
Licensee: ALASKA REGIONAL HOSPITAL
Region: 4
City: ANCHORAGE State: AK
County:
License #: 50-18244-01
Agreement: N
Docket:
NRC Notified By: BRADLEY CRUZ
HQ OPS Officer: BOB STRANSKY
Notification Date: 06/24/1999
Notification Time: 19:27 [ET]
Event Date: 06/24/1999
Event Time: 12:00 [YDT]
Last Update Date: 06/24/1999
Notification Time: 19:27 [ET]
Event Date: 06/24/1999
Event Time: 12:00 [YDT]
Last Update Date: 06/24/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
35.33 - MED MISADMINISTRATION
10 CFR Section:
35.33 - MED MISADMINISTRATION
Person (Organization):
JOSEPH TAPIA (R4)
ROBERT PIERSON (NMSS)
JOSEPH TAPIA (R4)
ROBERT PIERSON (NMSS)
MEDICAL MISADMINISTRATIONS CAUSED BY INCORRECT REPLACEMENT PART IN APPLICATOR
The licensee reported that four medical misadministrations occurred due to the installation of an incorrect replacement part into an applicator that is used in conjunction with a brachytherapy device. The affected part is an insert for a "Duiclos mini ovoid" applicator (manufacturer unknown), purchased from the Radiation Products Design catalog. The supplied replacement part looks similar to the original one, but is slightly shorter (the parts are not imprinted with any identification number). Due to the differing dimensions, treatments given using the applicator result in the source being placed at a slightly different axial location than intended, resulting in less than prescribed doses to the treatment area. The misadministrations are characterized as follows: (1) patient prescribed 3000 rads (cGy), received 1874 rads; (2) patient prescribed 3000 rads, received 2035 rads; (3) patient prescribed 2500 rads, received 1822 rads; (4) patient prescribed 3000 rads, received 2004 rads. This condition was discovered when an x-ray indicated that the source was slightly out of position.
The licensee plans to contact the vendor in order to obtain the correct insert for the applicator.
The licensee reported that four medical misadministrations occurred due to the installation of an incorrect replacement part into an applicator that is used in conjunction with a brachytherapy device. The affected part is an insert for a "Duiclos mini ovoid" applicator (manufacturer unknown), purchased from the Radiation Products Design catalog. The supplied replacement part looks similar to the original one, but is slightly shorter (the parts are not imprinted with any identification number). Due to the differing dimensions, treatments given using the applicator result in the source being placed at a slightly different axial location than intended, resulting in less than prescribed doses to the treatment area. The misadministrations are characterized as follows: (1) patient prescribed 3000 rads (cGy), received 1874 rads; (2) patient prescribed 3000 rads, received 2035 rads; (3) patient prescribed 2500 rads, received 1822 rads; (4) patient prescribed 3000 rads, received 2004 rads. This condition was discovered when an x-ray indicated that the source was slightly out of position.
The licensee plans to contact the vendor in order to obtain the correct insert for the applicator.
Power Reactor
Event Number: 35859
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [] [2] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: WALT TROMBLEY
HQ OPS Officer: BOB STRANSKY
Region: 1 State: NY
Unit: [] [2] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: WALT TROMBLEY
HQ OPS Officer: BOB STRANSKY
Notification Date: 06/24/1999
Notification Time: 22:44 [ET]
Event Date: 06/24/1999
Event Time: 22:07 [EDT]
Last Update Date: 06/24/1999
Notification Time: 22:44 [ET]
Event Date: 06/24/1999
Event Time: 22:07 [EDT]
Last Update Date: 06/24/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iii)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(2)(iii)(D) - ACCIDENT MITIGATION
Person (Organization):
GLENN MEYER (R1)
GLENN MEYER (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | N | 0 | Hot Shutdown | 0 | Hot Shutdown |
RCIC SYSTEM DECLARED INOPERABLE
The Unit 2 reactor core isolation cooling (RCIC) system was declared inoperable after operators noticed swings of 200-300 gpm in the system flow rate. The system is currently being used to provide level control to the reactor vessel following a scram [see related EN 35857]. The system flow rate stabilized after operators placed the RCIC flow controller in manual, so the licensee considers the system to be inoperable but functional. The licensee is continuing to cool down Unit 2. The licensee plans to inform the NRC resident inspector of this report.
The Unit 2 reactor core isolation cooling (RCIC) system was declared inoperable after operators noticed swings of 200-300 gpm in the system flow rate. The system is currently being used to provide level control to the reactor vessel following a scram [see related EN 35857]. The system flow rate stabilized after operators placed the RCIC flow controller in manual, so the licensee considers the system to be inoperable but functional. The licensee is continuing to cool down Unit 2. The licensee plans to inform the NRC resident inspector of this report.