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Event Notification Report for July 9, 1999

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           07/08/1999 - 07/09/1999

                              ** EVENT NUMBERS **

35871  35902  35903  35904  

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
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|Fuel Cycle Facility                              |Event Number:   35871       |
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| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT   |NOTIFICATION DATE: 06/26/1999|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 19:04[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        06/26/1999|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        05:33[EDT]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  07/08/1999|
|    CITY:  PIKETON                  REGION:  3  +-----------------------------+
|  COUNTY:  PIKE                      STATE:  OH |PERSON          ORGANIZATION |
|LICENSE#:  GDP-2                 AGREEMENT:  N  |MIKE JORDAN          R3      |
|  DOCKET:  0707002                              |ROBERT PIERSON       NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  DALE NOEL                    |                             |
|  HQ OPS OFFICER:  BOB STRANSKY                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|OCBA 76.120(c)(2)(i)     ACCID MT EQUIP FAILS   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| MOTOR STOP BUTTON FAILED TO FUNCTION AS DESIGNED                             |
|                                                                              |
| "ON 6/26/99 AT 0533 HOURS, THE X-333 PROCESS BUILDING AREA CONTROL ROOM      |
| (ACR) #1 MOTOR STOP BUTTON FAILED TO FUNCTION AS DESIGNED WHEN CALLED UPON   |
| TO SHUTDOWN MOTORS ON CELL 33-5-10 (CASCADE OPERATIONAL MODE Ill). THIS      |
| REPRESENTS THE FAILURE OF TECHNICAL SAFETY REQUIREMENT (TSR) SURVEILLANCE    |
| 2.2.3.14.3 FOR CASCADE D.C. CONTROL POWER WHICH STATES: 'UTILIZE THE ACR     |
| MOTOR STOP BUTTON FOR EACH SCHEDULED CELL TRIP. MONITOR EXPECTED CELL BLOCK  |
| VALVE CLOSURE AND ANY RECYCLE VALVE ACTUATION.' OPERATIONS PERSONNEL         |
| IMMEDIATELY UTILIZED AN ALTERNATE MEANS LOCATED AT THE CELLS LOCAL CONTROL   |
| CENTER (LCC) TO TRIP CELL 33-5-10 MOTORS.                                    |
|                                                                              |
| "THIS EVENT IS REPORTABLE DUE TO A SAFETY SYSTEM COMPONENT (SSC) REQUIRED BY |
| THE TSR NOT BEING AVAILABLE OR OPERABLE AND NO REDUNDANT EQUIPMENT WAS       |
| AVAILABLE TO PERFORM THE REQUIRED SAFETY FUNCTION.                           |
|                                                                              |
| "THERE WAS NO LOSS OF HAZARDOUS/RADIOACTIVE MATERIAL OR                      |
| RADIOACTIVE/RADIOLOGICAL CONTAMINATION EXPOSURE AS A RESULT OF THIS EVENT."  |
|                                                                              |
| The NRC resident inspector has been informed of this event by the licensee.  |
|                                                                              |
| * * * UPDATE AT 1820 ON 7/8/99 BY SISLER, RECEIVED BY WEAVER * * *           |
|                                                                              |
| "THIS EVENT RETRACTION IS BEING SUBMITTED BASED ON FURTHER REVIEW OF THE     |
| PROCESS CELL DC CONTROL AND TRIP CIRCUITRY. TSR 2.2.3.14.3  SPECIFIES THAT   |
| DC CONTROL (CELL TRIP) POWER FOR UF6 STAGE MOTORS SHALL BE OPERABLE.   AS    |
| PART OF THE CELL TRIP CIRCUIT THERE ARE FOUR REMOTE LOCATIONS FROM WHICH THE |
| X-333 CELLS COULD BE TRIPPED (i.e., THE ACR, LCC,  X-533 SWITCHYARD AND      |
| X-300).  THE PURPOSE OF THE TSR SURVEILLANCE 2.2.3.14.3, WHICH REQUIRES THE  |
| USE OF THE ACR MOTOR STOP BUTTON DURING SCHEDULED CELL SHUTDOWNS,  IS TO     |
| DEMONSTRATE THE RELIABILITY OF THE ACR CELL TRIP FUNCTION.                   |
|                                                                              |
| "HOWEVER, IN A TRANSIENT CONDITION, ANY OF THE CELL TRIP LOCATIONS MAY BE    |
| USED TO INITIATE CELL SHUTDOWN.   IN THIS EVENT, THE CELL WAS BEING SHUTDOWN |
| DUE TO A TRANSIENT CONDITION (SURGING) AND THE SURVEILLANCE REQUIREMENT DID  |
| NOT APPLY.  THE CELL WAS SUCCESSFULLY SHUTDOWN UTILIZING THE LCC WHICH       |
| DEMONSTRATED THAT THE CELL TRIP CIRCUIT WAS OPERABLE.                        |
|                                                                              |
| "THIS EVENT IS BEING RETRACTED BASED UPON DC CONTROL AND CELL TRIP POWER WAS |
| OPERABLE, LIMITING CONDITIONS FOR OPERATIONS (LCO) WAS MAINTAINED AND A      |
| SAFETY FAILURE DID NOT OCCUR."                                               |
|                                                                              |
| The licensee notified the NRC resident Inspector.  The operations center     |
| notified the R3DO (Vegel).                                                   |
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|Power Reactor                                    |Event Number:   35902       |
+------------------------------------------------------------------------------+
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| FACILITY: BYRON                    REGION:  3  |NOTIFICATION DATE: 07/08/1999|
|    UNIT:  [1] [2] []                STATE:  IL |NOTIFICATION TIME: 13:51[EDT]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        07/08/1999|
+------------------------------------------------+EVENT TIME:        11:55[CDT]|
| NRC NOTIFIED BY:  L. RUPPERT                   |LAST UPDATE DATE:  07/08/1999|
|  HQ OPS OFFICER:  WILLIAM POERTNER             +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |TONY VEGEL           R3      |
|10 CFR SECTION:                                 |                             |
|AENS 50.72(b)(1)(v)      ENS INOPERABLE         |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| LOSS OF EMERGENCY NOTIFICATION SYSTEM (ENS) AND COMMERCIAL TELEPHONE LINES.  |
|                                                                              |
| At 11:55 CDT on 07/08/99, the main communication lines to Byron were cut at  |
| Byron Prairie View Golf Course.  This resulted in the ENS, Nuclear Accident  |
| Reporting System, and normal offsite communication lines being lost.  The    |
| licensee presently has 4 cellular telephones available (1 in the main        |
| control room, 1 in the plant managers office, and 2 in the TSC) and the      |
| company tie lines are available (load dispatcher).                           |
|                                                                              |
| The licensee estimate for repair is 24 hours (Refer to HOO Log for cellular  |
| telephone number).                                                           |
|                                                                              |
| The licensee has notified the NRC resident inspector and the State.          |
|                                                                              |
| ***UPDATE ON 07/08/99 @ 1521 BY ALLEN TO POERTNER ***                        |
|                                                                              |
| ENS and commercial telephone lines have been returned to service.            |
|                                                                              |
| The NRC operations officer notified the R3DO (Tony Vegel).                   |
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+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   35903       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  SW INDIANA RAD ONCOLOGY CENTER       |NOTIFICATION DATE: 07/08/1999|
|LICENSEE:  SW INDIANA RAD ONCOLOGY CENTER       |NOTIFICATION TIME: 16:33[EDT]|
|    CITY:  EVANSVILLE               REGION:  3  |EVENT DATE:        05/18/1999|
|  COUNTY:                            STATE:  IN |EVENT TIME:        12:00[CST]|
|LICENSE#:  13-25945-01           AGREEMENT:  N  |LAST UPDATE DATE:  07/08/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |TONY VEGEL           R3      |
|                                                |                             |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  SAIYID SHAH                  |                             |
|  HQ OPS OFFICER:  DOUG WEAVER                  |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| MEDICAL MISADMINISTRATION - UNDER DOSE                                       |
|                                                                              |
| A patient was prescribed a treatment plan consisting of two doses, 5040 cGy  |
| and 2000 cGy using Co-60 therapy.  The first dose was given as prescribed on |
| 5/18/99,  but the second dose was never given.   The prescribing doctor was  |
| out of town and his substitute did not notice the second half of the         |
| treatment which was written on a second piece of paper.   This error was     |
| discovered when the original doctor returned to work.   The patient was      |
| immediately notified of the mistake and requested to come in to finish the   |
| treatment.  The patient has refused further therapy.                         |
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+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   35904       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SAN ONOFRE               REGION:  4  |NOTIFICATION DATE: 07/09/1999|
|    UNIT:  [] [2] [3]                STATE:  CA |NOTIFICATION TIME: 02:10[EDT]|
|   RXTYPE: [1] W-3-LP,[2] CE,[3] CE             |EVENT DATE:        07/08/1999|
+------------------------------------------------+EVENT TIME:        20:35[PDT]|
| NRC NOTIFIED BY:  MATT THURBERN                |LAST UPDATE DATE:  07/09/1999|
|  HQ OPS OFFICER:  BOB STRANSKY                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |CHARLES MARSCHALL    R4      |
|10 CFR SECTION:                                 |                             |
|AESF 50.72(b)(2)(ii)     ESF ACTUATION          |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|3     N          Y       100      Power Operation  |100      Power Operation  |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| TRAIN 'A' TOXIC GAS ISOLATION SIGNAL  ACTUATION                              |
|                                                                              |
| A train 'A' toxic gas isolation signal (TGIS) occurred, causing the control  |
| room ventilation system to isolate and the train 'A' emergency chill water   |
| system to start. The TGIS was caused when the ammonia channel went into      |
| alarm. The licensee is investigating the cause of the ammonia alarm, but     |
| reported that maintenance workers were venting freon at the time of the      |
| actuation. The NRC resident inspector has been informed of this event by the |
| licensee.                                                                    |
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