Event Notification Report for June 25, 1999

MISSING SHIPMENT OF SULFUR-35

The licensee reported that 7 millicuries (mCi) of S-35 was missing from a shipment that arrived from ICN radiochemicals of California on the morning of 6/25/1999. Upon receipt, an individual inspected the package and reported that the shipment was present; however, during the investigation, he admitted that he may not have properly checked it. The loss was discovered when the package was opened in the laboratory, and the researcher discovered that the package contained only dry ice.

The licensee has contacted the vendor, who indicated that the package went through a quality assurance inspection before shipment. The licensee's investigation is continuing.

NRC BULLETIN 91-01 REPORT

"ON 6/25/99 PLANT PERSONNEL PERFORMING A WALKDOWN OF X-744L (STOREROOM) TO ENSURE COMPLIANCE WITH NCSA-PLANT046 'CONTAMINATED METAL' DISCOVERED PALLETS OF VACUUM PUMPS (3-4 pumps) STACKED FOUR TO A PALLET ON STORAGE RACKS WITHIN A CONTAMINATION STORAGE AREA. THE PUMPS ARE CONTAMINATED BUT THERE IS NO DOCUMENTATION IMMEDIATELY AVAILABLE IDENTIFYING THE URANIUM CONCENTRATION IN THESE PUMPS. THIS BUILDING HAS PREVIOUSLY BEEN SCANNED BY THE APPLIED NUCLEAR TECHNOLOGY GROUP FOR NDT ANALYSIS OF THE MATERIAL. WITHOUT THIS DOCUMENTATION READILY AVAILABLE THE NCSA REQUIRES THE MATERIAL TO BE SPACED AT A MINIMUM TWO FOOT EDGE-TO-EDGE SPACING. THIS IS A VIOLATION OF ONE CONTROL (SPACING) OF THE DOUBLE CONTINGENCY MATRIX. THE OTHER CONTROL VOLUME WAS MAINTAINED."

The NRC resident inspector has been informed of this event by the licensee.

- CONTROL ROOM VENTILATION SYSTEM INOPERABLE DUE TO A BROKEN DOOR LATCH MECHANISM -

AT 1023 CDT ON 06/25/99, WITH BOTH UNITS AT 100% POWER, THE LICENSEE DISCOVERED THAT PERSONNEL ENTRY DOOR #158 TO CONTROL ROOM CHILLER ROOM #122 HAD A BROKEN LATCH MECHANISM ON IT. THIS CONSTITUTES A BREACH OF THE CONTROL ROOM SPECIAL VENTILATION SYSTEM AND THUS, BOTH TRAINS OF THE CONTROL ROOM SPECIAL VENTILATION SYSTEM ARE INOPERABLE (TECH SPEC 3.13.A.1).

AT 1121 CDT ON 06/25/99, PLANT TECHNICIANS REPAIRED THE BROKEN DOOR LATCH MECHANISM AND DECLARED THE VENTILATION SYSTEM OPERABLE.

THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR.

UNUSUAL EVENT DECLARED DUE TO LOSS OF TELEPHONE SERVICE

"At 1430, Fermi 2 determined that the Emergency Notification System (ENS) phones were not available. The local telephone company notified Fermi 2 that an offsite fiber optic cable was cut. Additionally, local phone service to Monroe County, including the Monroe County Sheriffs Department is unavailable. Security radio communication to the Monroe County Sheriff is available and has been verified. RERP phone service to locations outside Monroe County is available.

"This report is being made in accordance with 10CFR50.72(b)(1)(v), as an event that results in a major loss of emergency response assessment capability, or communications capability.

"At 1508, an Unusual Event was declared due to notification that the Emergency Call Out System (ECOS) may also be impaired, due to the loss of local phones."

The NRC resident inspector has been informed of this notification.

* * * UPDATE 1844 6/25/99 FROM MAREK TAKEN BY STRANSKY * * *

The Unusual Event was terminated at 1838 after the ENS and offsite telephone service were restored. The licensee will inform the NRC resident inspector of this update. Notified R3DO(Jordan), NRR EO (Hannon), FEMA (Sullivan).

10CFR PART 21 REPORT REGARDING ABB COMBUSTION ENGINEERING 4KV VACUUM BREAKERS

The following text is excerpted from a facsimile received in the NRC Operations Center:

"The defect concerns ABB 1200A 4KV Vacuum Breakers delivered to Baltimore Gas and Electric Company's (BG&E's) Calvert Cliffs Nuclear Power Plant (CCNPP). Specifically, the defect concerns the breaker performing a trip free operation when a close signal is received by the breaker. This defect results in the breaker failing to remain in the closed position. The defect could lead to non-conservative failure of not starting certain plant equipment upon demand such as an Emergency Core Cooling Pump."

* * * UPDATE AT 1613 ON 06/30/99 BY VIRGIL PAGGEN TO JOLLIFFE * * *

The above 10CFR Part 21 Report was submitted to the NRC via ABB Combustion Engineering Letter #LD-99-035, dated 06/25/99. The following is an update to the above 10CFR Part 21 Report via ABB Combustion Engineering Letter #LD-99-039, dated 06/30/99, Same Subject.

The activity for which this report is being filed is the use of ABB 1200A 4KV Vacuum Breakers in an application where the breaker is normally open and must close on demand. This defect applies only to BG&E's CCNPP.

The defect identified is associated with the use of the ABB 1200A 4KV Vacuum Breaker only in applications where the breaker must close on demand. The defect was detected during site testing of the breaker during installation into CCNPP. During this test, a close signal was applied to the breaker and the breaker tripped free (i.e., failed to remain in the closed position).

These breakers are intended for both normally open and normally closed operation. In some applications, the breaker must close upon demand. This may be for electrical distribution applications or component control applications (e.g., start an Emergency Core Cooling pump). Demands can be automated (e.g., by ESFAS) or based on manual operator demands. If the breaker does not remain closed when demanded (i.e., trips free), the safety function cannot be performed. This breaker is intended for use in multiple redundant safety divisions. Multiple redundant divisions could be affected by this defect.

The defect applies only to ABB 1200A 4KV Vacuum Breakers delivered to CCNPP. Thirty-seven (37) of these breakers were delivered to CCNPP. ABB Combustion Engineering understands that several of these breakers have been installed at CCNPP, however, none are installed in any application that requires a close on demand function.

The NRC Operations Officer notified the R1DO Larry Doerflein and NRR Vern Hodge (via fax).

* * * UPDATE AT 1740 ON 7/20/00, BY PAGGEN VIA FAX RECEIVED BY WEAVER * * *
An additional defect has been discovered.

The defect concerns ABB 1200A 4KV Vacuum Breakers delivered to the Calvert Cliffs Nuclear Power Plant. Specifically, the defect reported herein concerns the potential for breaker stalling due to interference between an adjustment nut on the auxiliary switch extension rod and the mechanism top cover plate. Such interference could result in failure of the auxiliary switch contacts to fully change state, which could prevent the breaker from being remotely opened on demand and could lead to failure of certain plant equipment to start on demand. This defect could also potentially provide incorrect information to operators regarding the status of the breaker.

The Operations Center notified the R1DO (Cranston) and NRR (Hodge) via fax.

PERSONNEL OVEREXPOSURE

A worker received internal contamination resulting in an estimated total effective dose equivalent (TEDE) of 14.5 rem (145 mSv). The individual had been involved in decontamination activities on the 1974' elevation of the auxiliary building, in the valve gallery of the Boron Thermal Regeneration System room. Upon exiting the area, significant contamination was detected on the individual's face (up to 80,000 dpm on the right side of the face). The individual was decontaminated and a whole body count was performed. The whole body count indicated the presence of cobalt-58 contamination in the individual's gastrointestinal tract. Whole body counts were given to other individuals who had been working in the same area, but no additional internal contamination was discovered.

The licensee has issued a stop work order for all work areas with contamination levels in excess of 50,000 dpm, except those with specific approval from the Radiation Protection Manager. The licensee is also forming an Incident Investigation Team to determine the root cause of this event. The NRC resident inspector has been informed of this event by the licensee.


* * * UPDATE AT 0920 ON 6/26/99, BY HUBBARD TAKEN BY WEAVER * * *
The licensee has notified the State of this event and also issued a press release. HOO notified R4DO (Tapia).

* * * COMMISSIONERS ASSISTANTS BRIEFING 2000 6/26/99 * * *

A Commissioners Assistants briefing was held regarding this event. Participants: NRR (Donahue, Richards, Zwolinski), Region IV (Brockman, Brush, Hackney, Good, Ricketson, Henderson, Graves-briefer), NMSS (Cool), OCA (Madden), OPA (Gilliland), OSP (Sollenberger), EDO (Knapp, Lange), IRO (Giitter), Chm Jackson (Johnson), Comm Merrifield (McCabe), Comm Dicus (Lubenau), Comm McGaffigan (Crockett), Comm Diaz (Castleman).

* * * RETRACTED AT 1751 EDT ON 6/27/99 BY RICK HUBBARD TO FANGIE JONES * * *

Further reviews of this event identified a significant error in the original dose calculations which were the basis of the report. The error was in the use of a software generated activity rather than actual activity, a matter of using the wrong column's information in the calculations. Using the correct value, the internal exposure is estimated to be 2 mRem. The external exposure received by the individual on that work activity was 5 mRem. The assigned total effective dose equivalent (TEDE) is a combination of the internal and external exposures. Therefore, when corrected, the TEDE is estimated to be approximately 7 mRem versus the 14.5 Rem reported on June 25, 1999.

The exposure of the individual involved in the June 25 decontamination evolution was well below regulatory limits and, therefore, does not meet the reporting requirements. Therefore, Event Notification # 35863 is being
retracted.

The licensee notified the NRC Resident Inspector for the Wolf Creek Generating Station and will also notify the State of Kansas and the media. The Headquarters Operations Officer notified the R4DO (Joseph Tapia).

FAILURE OF LICENSEE TO SUBMIT CHANGES TO LICENSING BASIS FOR NRC REVIEW

On 6/25/99, the NRC notified the licensee that the use of equipment failure probabilities (TORMIS) in the assessment of tornado and missile effects on the emergency feedwater (EFW) system constitutes a change to the licensing and design bases of the system. Such changes to the licensing and design bases constitute an Unreviewed Safety Question (USQ) and require formal NRC review and approval in accordance with 10 CFR 50.90. The licensee has decided not to contest the conclusion by the NRC.

An engineering evaluation had previously been performed to postulate the effects of tornado winds and missiles on the EFW pump turbine steam supply piping and steam exhaust stack. The evaluation concluded that the results were acceptable, based on criteria provided in NRC Regulatory Guide 1.117. Based upon this evaluation, the licensee has concluded that the EFW system is operable with respect to its design basis functions, including the effects of tornado winds and missiles.

The licensee plans to submit a formal license amendment request in accordance with 10 CFR 50.90 to incorporate the use of TORMIS. The NRC resident inspector has been informed of this notification by the licensee.

HPCI SYSTEM DECLARED INOPERABLE

The licensee declared the high pressure coolant injection (HPCI) system inoperable after the manual/automatic flow controller (E41-R614) was found to be indicating full downscale. The cause of the problem is currently under investigation. The licensee entered Technical Specification 3.5.1.c, and verified that all other emergency core cooling systems are operable. Although the HPCI flow controller would be unable to automatically control system flow, the licensee believes that operators would be able to control system flow manually, if needed.

The NRC resident inspector has been informed of this event by the licensee.

EMERGENCY DIESEL GENERATOR DECLARED INOPERABLE

"The Diesel Generator Fuel Oil System is designed to provide the required amount of diesel fuel to operate the EDGs on each unit for a minimum of seven days at the full load capacity of the generators. Two fuel oil transfer pumps are provided for each EDG to transfer diesel fuel from the storage tank to the fuel oil day tank. From each day tank, the fuel oil flows by gravity into the suction of the engine-driven fuel pump. The pump provides nine gpm at 35 psig and discharges through a duplex fuel oil filter into the two fuel oil supply manifolds.

"Some of the fuel oil which flows from the supply manifold into the injection pump is not delivered to the spray nozzle. This excess fuel oil circulates through the injection pump, cooling the injection pump, and providing lubrication for the fuel oil side of the pump. The fuel oil then flows to the return manifold. To maintain a fixed pressure in the supply manifold, a relief valve at the end of each supply manifold (SV-200 set at 25 psig) bypasses fuel oil to the return manifold.

"On 6/25/99, during routine inspection of the fuel oil lines, it was discovered that SV-200 on one of the Unit 1 EDGs was installed backwards, effectively blocking the safety valve from relieving excess pressure on the supply manifold. This configuration may have existed since initial construction. The EDG has been operated successfully many times with this condition, but uncertainty about the ability to operate for 7 days, especially at low loads, has caused the EDG to be declared inoperable and prompted this 4 hour NRC notification. The EDG remains available and will be repaired at the earliest opportunity."

The licensee will inform the NRC resident inspector of this notification.