Event Notification Report for July 12, 1999
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
07/09/1999 - 07/12/1999
** EVENT NUMBERS **
35839 35903 35904 35905 35906 35907 35908 35909 35910 35911 35912
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
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|Power Reactor |Event Number: 35839 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PILGRIM REGION: 1 |NOTIFICATION DATE: 06/17/1999|
| UNIT: [1] [] [] STATE: MA |NOTIFICATION TIME: 18:16[EDT]|
| RXTYPE: [1] GE-3 |EVENT DATE: 06/17/1999|
+------------------------------------------------+EVENT TIME: 16:30[EDT]|
| NRC NOTIFIED BY: G FIEDLER |LAST UPDATE DATE: 07/09/1999|
| HQ OPS OFFICER: WILLIAM POERTNER +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |JIMI YEROKUN 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 |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N N 0 Refueling |0 Refueling |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| THREE OF FOUR MAIN STEAM RELIEF VALVES (MSRV) CONEX CONNECTORS INSTALLED |
| BACKWARDS. |
| |
| While shutdown the licensee determined that 3 of 4 MSRV's had the conex |
| connectors installed backwards. The connectors provide the environmental |
| qualification seal to the pilot solenoid valve. ADS may not have functioned |
| under elevated drywell temperature conditions. |
| |
| The licensee plans to notify the NRC resident inspector. |
| |
| *** RETRACTION OF EVENT AT 1120 ON 7/9/99 RECEIVED BY POERTNER *** |
| |
| Further engineering review has determined that the valves would have |
| operated as designed. |
| |
| The licensee will notify the NRC resident inspector. |
| |
| Notified R1DO (J. TRAPP). |
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!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
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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: 07/09/1999|
| 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
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| 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. |
| |
| * * * UPDATE AT 1229 ON 7/9/99 BY SHAH, RECEIVED BY POERTNER * * * |
| The licensee has requested this event be retracted. The licensee consulted |
| with NRC's Region III office and concluded that this event did not |
| constitute a medical misadministration. The Operations center notified R3DO |
| (vegel). |
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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. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 35905 |
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| REP ORG: FLORIDA DIVISION OF RAD CONTROL |NOTIFICATION DATE: 07/09/1999|
|LICENSEE: FLORIDA DEPT OF TRANSPORTATION |NOTIFICATION TIME: 08:49[EDT]|
| CITY: AVENTURA REGION: 2 |EVENT DATE: 07/09/1999|
| COUNTY: STATE: FL |EVENT TIME: [EDT]|
|LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 07/09/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |MARK LESSER R2 |
| |DON COOL NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: JERRY EAKINS | |
| HQ OPS OFFICER: BOB STRANSKY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| TWO TROXLER MOISTURE/DENSITY GAUGES STOLEN FROM WORK SITE |
| |
| Two Troxler moisture/density gauges, one model 3411B (ser #15740) and one |
| model 3440 (ser #20750), were stolen from a Florida DOT work site. Local |
| police have been contacted and are currently at the scene. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 35906 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: FOXBORO COMPANY |NOTIFICATION DATE: 07/09/1999|
|LICENSEE: FOXBORO COMPANY |NOTIFICATION TIME: 10:35[EDT]|
| CITY: FOXBORO REGION: 1 |EVENT DATE: 07/09/1999|
| COUNTY: STATE: MA |EVENT TIME: [EDT]|
|LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 07/09/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |VERN HODGE NRR |
| | |
+------------------------------------------------+ |
| NRC NOTIFIED BY: G. ROBERT JOHNSON | |
| HQ OPS OFFICER: BOB STRANSKY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|CCCC 21.21 UNSPECIFIED PARAGRAPH | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| DEFECTIVE RELAYS PROVIDED TO FOXBORO BY VENDOR |
| |
| "Foxboro Co. has identified a potential defect with N-2A0-L2C-R or |
| N-2A0-L2C-R with ECEP 10273, Contact Output Isolator cards that may contain |
| specific NO152CK or CO147SS relays. These relays, supplied by Potter & |
| Brumfield, were manufactured utilizing pure tin plated contact support arms. |
| As a result, in low voltage, low current applications, the growth of tin |
| whiskers between adjacent metallic surfaces of the contact support arms can |
| lead to the establishment of a resistive shunt path. This shunt path would |
| prevent the relay from functioning as designed. This potential defect is |
| limited to only those relays supplied by Potter & Brumfield manufactured |
| from 1 December 1981 to 31 December 1993. |
| |
| "Foxboro is taking immediate corrective action to rectify the situation and |
| will notify all Nuclear Utilities that have purchased this product from |
| Foxboro during the time period affected and provide replacement relays." |
| |
| The representative reported that two failed relays were identified after |
| being returned by a foreign reactor facility. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Other Nuclear Material |Event Number: 35907 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: U.S. AIR FORCE |NOTIFICATION DATE: 07/09/1999|
|LICENSEE: U.S. AIR FORCE |NOTIFICATION TIME: 10:40[EDT]|
| CITY: CANNON AFB REGION: 4 |EVENT DATE: 07/08/1999|
| COUNTY: CURRY STATE: NM |EVENT TIME: [MDT]|
|LICENSE#: 42-23539-01AF AGREEMENT: Y |LAST UPDATE DATE: 07/09/1999|
| DOCKET: 03028641 |+----------------------------+
| |PERSON ORGANIZATION |
| |CHARLES MARSCHALL R4 |
| |DON COOL NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: KRISTIN SWENSON | |
| HQ OPS OFFICER: BOB STRANSKY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|BAB2 20.2201(a)(1)(ii) LOST/STOLEN LNM>10X | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| MISSING TRITIUM EXIT SIGN |
| |
| While performing an inventory on 7/8/99, personnel at the Cannon AFB in New |
| Mexico discovered that one exit sign, containing 20 Ci of tritium (in 1997), |
| was missing. The sign was installed in a dormitory building. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Other Nuclear Material |Event Number: 35908 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: U.S. ARMY |NOTIFICATION DATE: 07/09/1999|
|LICENSEE: U.S. ARMY |NOTIFICATION TIME: 11:32[EDT]|
| CITY: ROCK ISLAND REGION: 3 |EVENT DATE: 07/09/1999|
| COUNTY: STATE: IL |EVENT TIME: 10:32[CDT]|
|LICENSE#: 12-00722-06 AGREEMENT: Y |LAST UPDATE DATE: 07/09/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |TONY VEGEL R3 |
| |JOSIE PICCONE NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: G. Zeigler | |
| HQ OPS OFFICER: WILLIAM POERTNER | |
+------------------------------------------------+ |
|EMERGENCY CLASS: | |
|10 CFR SECTION: | |
|IBBF 30.50(b)(2)(ii) EQUIP DISABLED/FAILS | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| CHEMICAL AGENT MONITOR (CAM) EXCEEDED LEAK TEST |
| |
| CAM exceeded leak test. 62 nano curies of removable contamination (Ni 63) |
| was detected on the drift tube module which is a component located in the |
| CAM. 5 nano curies was the limit for a leaking source according to license |
| condition 16D. Exterior and interior container showed no signs of |
| contamination. |
| |
| CAM has been bagged and placed in the Radioactive waste holding area. |
| |
| The CAM originated in South Korea. The licensee is in the process of |
| notifying the RPO in South Korea. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Other Nuclear Material |Event Number: 35909 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: COGEMA MINING, INC. |NOTIFICATION DATE: 07/09/1999|
|LICENSEE: COGEMA MINING, INC. |NOTIFICATION TIME: 18:13[EDT]|
| CITY: Linch REGION: 4 |EVENT DATE: 07/09/1999|
| COUNTY: Campbell STATE: WY |EVENT TIME: 12:00[MDT]|
|LICENSE#: SUA-1341 AGREEMENT: N |LAST UPDATE DATE: 07/09/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |CHARLES MARSCHALL R4 |
| |JOHN SURMEIER NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: CRAIG TOAL | |
| HQ OPS OFFICER: DOUG WEAVER | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NCFR NON CFR REPORT REQMNT | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| MONITOR WELL EXCEEDED TWO OF ITS THREE UPPER CONTROL LIMITS |
| |
| A routine bi-weekly water sample collected on July 8, 1999, from monitor |
| well 6MW46 exceeded two of its three upper control limits (UCLs). A |
| confirmation sample was collected on July 9, 1999, which also exceeded two |
| of the three UCLs. Monitor well 6MW46 was then placed on excursion status |
| as per license Section 11.2 and its sampling frequency was increased to |
| weekly. 6MW46 is a perimeter ore zone monitor well located approximately |
| 480 feet north of the Mine Unit 6 boundary at the Christensen Mine, Campbell |
| County, Wyoming. The nearest community is Linch, Wyoming, approximately 15 |
| miles to the southeast. |
| |
| Analysis |
| Date Chloride Conductivity (umhos/cm2) |
| Alkalinity (mg/l) Uranium (mg/l) |
| 7-8-99 21.0 1651 |
| 197.0 <0.4 |
| 7-9-99 20.7 1630 |
| 202.6 <0.4 |
| |
| The upper control limits respectively, are 20.3, 2427, 89.2 and Uranium has |
| no UCL. |
| |
| Over-recovery pumping of 15 gpm has begun in the wellfield nearest 6MW46. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Fuel Cycle Facility |Event Number: 35910 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 07/09/1999|
| RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 21:01[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 07/08/1999|
| 6903 ROCKLEDGE DRIVE |EVENT TIME: 22:00[EDT]|
| BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 07/09/1999|
| CITY: PIKETON REGION: 3 +-----------------------------+
| COUNTY: PIKE STATE: OH |PERSON ORGANIZATION |
|LICENSE#: GDP-2 AGREEMENT: N |THOMAS KOZAK R3 |
| DOCKET: 0707002 |JOHN SURMEIER NMSS |
+------------------------------------------------+CHARLES MILLER IRO |
| NRC NOTIFIED BY: JEFF CASTLE | |
| HQ OPS OFFICER: DOUG WEAVER | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NLTR LICENSEE 24 HR REPORT | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| 24 HOUR BULLETIN 91-01 REPORT |
| |
| At 2200 hours on 7/8/1999, a Nuclear Criticality Safety Analysis (NCSA) |
| PLANT_062.A00 control was lost. Requirement #6 of the NCSA was not |
| maintained when a cover was not placed over cell 31-4-1 stage 3 |
| converter-flange after maintenance, leaving the system open to atmosphere |
| and therefore losing the control for moderation. This constituted loss of |
| one contingency in a situation protected by the double contingency |
| principle. Control #6 of NCSA-Plant062.A00 was re-established at 0027 hours |
| on 7/9/1999, at which time a plug was installed In the opening. |
| |
| The licensee notified the NRC resident inspector. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 35911 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: DRESDEN REGION: 3 |NOTIFICATION DATE: 07/10/1999|
| UNIT: [] [] [3] STATE: IL |NOTIFICATION TIME: 19:15[EDT]|
| RXTYPE: [1] GE-1,[2] GE-3,[3] GE-3 |EVENT DATE: 07/10/1999|
+------------------------------------------------+EVENT TIME: 16:55[CDT]|
| NRC NOTIFIED BY: SALGADO |LAST UPDATE DATE: 07/10/1999|
| HQ OPS OFFICER: DOUG WEAVER +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |THOMAS KOZAK R3 |
|10 CFR SECTION: | |
|AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION | |
|NLCO TECH SPEC LCO A/S | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
| | |
|3 N Y 100 Power Operation |100 Power Operation |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| ISOLATION CONDENSER INOPERABLE |
| |
| During quarterly valve time testing, the isolation condenser reactor return |
| valve failed to open. The valve is required to be open for the isolation |
| condenser to perform its function. The cause of the failure has not been |
| determined and is under investigation. The plant entered a 14 day LCO based |
| on having the isolation condenser inoperable. No other ECCS equipment is |
| inoperable. |
| |
| The licensee will notify the resident inspector. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 35912 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: LIMERICK REGION: 1 |NOTIFICATION DATE: 07/12/1999|
| UNIT: [] [2] [] STATE: PA |NOTIFICATION TIME: 05:16[EDT]|
| RXTYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 07/12/1999|
+------------------------------------------------+EVENT TIME: 01:46[EDT]|
| NRC NOTIFIED BY: O'MALLEY |LAST UPDATE DATE: 07/12/1999|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |JIM TRAPP R1 |
|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 |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| PLANT HAD ISOLATION OF CONTAINMENT SAMPLE VALVES. |
| |
| CONTAINMENT SAMPLE ISOLATION VALVES "SV-057-233", "SV-057-283" AND |
| "SV-057-291" ISOLATED INADVERTENTLY DUE TO A BLOWN FUSE IN THE ISOLATION |
| LOGIC. THE FUSE WAS REPLACED AND THE ISOLATION LOGIC WAS RESET WITHIN 3 |
| HOURS 21 MINS. AN INVESTIGATION INTO THE CAUSE OF THE BLOWN FUSE IS |
| ONGOING. |
| |
| THE RESIDENT INSPECTOR WILL BE NOTIFIED. |
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