United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated With Events > Event Notification Reports > 1999

Event Notification Report for August 19, 1999

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           08/18/1999 - 08/19/1999

                              ** EVENT NUMBERS **

36036  36037  36038  36039  36040  36041  

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36036       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: HARRIS                   REGION:  2  |NOTIFICATION DATE: 08/16/1999|
|    UNIT:  [1] [] []                 STATE:  NC |NOTIFICATION TIME: 21:06[EDT]|
|   RXTYPE: [1] W-3-LP                           |EVENT DATE:        08/14/1999|
+------------------------------------------------+EVENT TIME:        16:00[EDT]|
| NRC NOTIFIED BY:  MAURICE GRIFFIN              |LAST UPDATE DATE:  08/18/1999|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |CHARLES OGLE         R2      |
|10 CFR SECTION:                                 |                             |
|AESS 50.72(b)(1)(v)      EMERGENCY SIREN INOP   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| LOSS OF EMERGENCY SIRENS IN HARNETT COUNTY DUE TO A LIGHTNING STRIKE         |
|                                                                              |
| The following text is a portion of a facsimile received from the licensee:   |
|                                                                              |
| "All sirens in Harnett County were lost from 1600 to 1730 on 08/14/99 ...    |
| due to a lightning strike [that took out a 911 repeater].  The backup        |
| repeater was placed in service at 1730 [on 08/14/99].  The primary repeater  |
| was placed in service at 1200 on 08/16/99.  The backup repeater is not       |
| tested routinely, and it is unknown if it would have actuated the sirens     |
| from 1730 [on] 08/14/99 until 1200 [on] 08/16/99.  This feature will be      |
| tested tomorrow to determine if the sirens were operable on the backup       |
| repeater."                                                                   |
|                                                                              |
| The licensee stated that there are a total of 81 sirens associated with the  |
| Harris facility and that all 7 sirens in Harnett County were lost.  This     |
| event was determined to be reportable at 2040 on 08/16/99.                   |
|                                                                              |
| The licensee plans to notify the NRC resident inspector.                     |
|                                                                              |
| ******************** UPDATE AT 1606 ON 08/18/99 FROM MARK ELLINGTON TO       |
| TROCINE ********************                                                 |
|                                                                              |
| The following text is a portion of a facsimile received from the licensee:   |
|                                                                              |
| "A test signal was successfully transmitted to and received by the Harnett   |
| County sirens on 08/17/99 at 0740 using the current configuration.  This     |
| test verifies that the siren system was operable when the primary repeater   |
| was returned to service at 1200 on 08/16/99.  No additional testing with the |
| backup repeater is planned."                                                 |
|                                                                              |
| The licensee notified the NRC resident inspector.  The NRC operations        |
| officer notified the R2DO (Barr).                                            |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36037       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PERRY                    REGION:  3  |NOTIFICATION DATE: 08/18/1999|
|    UNIT:  [1] [] []                 STATE:  OH |NOTIFICATION TIME: 09:00[EDT]|
|   RXTYPE: [1] GE-6                             |EVENT DATE:        08/17/1999|
+------------------------------------------------+EVENT TIME:        09:10[EDT]|
| NRC NOTIFIED BY:  BOB KIDDER                   |LAST UPDATE DATE:  08/18/1999|
|  HQ OPS OFFICER:  BOB STRANSKY                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |BRENT CLAYTON        R3      |
|10 CFR SECTION:                                 |FEMA, DOE, USDA, HHS FAX     |
|APRE 50.72(b)(2)(vi)     OFFSITE NOTIFICATION   |EPA, DOT (VIA NRC)   FAX     |
|NLTR                     LICENSEE 24 HR REPORT  |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| RELEASE OF CHLORINATED WATER TO STORM DRAIN AND OFFSITE NOTIFICATION         |
|                                                                              |
| The licensee discovered that, due to valve leakage, a small amount of        |
| chlorine was released to a storm drain. The following information was        |
| submitted to the NRC Operations Center by facsimile:                         |
|                                                                              |
| "The service water backwash valve on strainer 'd' was experiencing severe    |
| leakage past the valve. The system engineer estimated approximately 200 gpm  |
| leakage occurred. During this time, the system chlorination evolution        |
| occurred for 40 minutes. The forebay water was treated to a concentration of |
| 1 ppm. The result is that an estimated 0.067 lbs of chlorine was discharged  |
| to the storm drain. The reportable quantity for chlorine is 10 lbs. There is |
| no reportability requirement for CERCLA; however, an NPDES noncompliance did |
| occur. Reportability is being investigated. The strainer valve has been      |
| isolated to prevent it from operating until repairs are complete."           |
|                                                                              |
| This event is reportable to the NRC within 24 hours in accordance with       |
| Section 4.1 of the site Environmental Protection Plan. In addition, the      |
| licensee is notifying the US EPA of this release. The NRC resident inspector |
| has been informed of this notification.                                      |
+------------------------------------------------------------------------------+

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   36038       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  ST. LUKE'S MEDICAL CENTER            |NOTIFICATION DATE: 08/18/1999|
|LICENSEE:  ST. LUKE'S MEDICAL CENTER            |NOTIFICATION TIME: 09:09[EDT]|
|    CITY:  MILWAUKEE                REGION:  3  |EVENT DATE:        08/17/1999|
|  COUNTY:                            STATE:  WI |EVENT TIME:        14:00[CDT]|
|LICENSE#:  48-01338-01           AGREEMENT:  N  |LAST UPDATE DATE:  08/18/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |BRENT CLAYTON        R3      |
|                                                |SCOTT MOORE          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  DOUGLAS SIMPKIN              |                             |
|  HQ OPS OFFICER:  BOB STRANSKY                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| MEDICAL MISADMINISTRATION                                                    |
|                                                                              |
| A patient receiving an interstitial iridium-192 brachytherapy treatment was  |
| implanted with eight ribbons containing Ir-192 seeds. At 1400 CDT on         |
| 8/17/99, hospital personnel discovered that the patient had removed three of |
| the ribbons. The hospital is conducting an investigation to determine the    |
| time when the ribbons were removed in order to determine the dosage          |
| received. The licensee plans to contact the patient's attending physician.   |
|                                                                              |
| ****************** UPDATE AT 1528 EDT ON 08/18/99 FROM DOUGLAS SIMPKIN TO    |
| TROCINE *****************                                                    |
|                                                                              |
| After reviewing this event and having discussions with NRC Region 3 (Daryl   |
| Wiedeman), it was determined that this event was not a misadministration in  |
| accordance with 10 CFR 35.33.  The patient removed three of the ribbons, and |
| the analyzed dose does not meet the 20% threshold for misadministrations.    |
| Therefore, the licensee is retracting this event notification.               |
|                                                                              |
| The patient's attending physician and radiation oncologist were both         |
| contacted to discuss any medical ramifications, and it was determined that   |
| there none.                                                                  |
|                                                                              |
| (Call the NRC Operations Center for a contact telephone number.)             |
|                                                                              |
| The NRC operations officer notified the R3DO (Clayton) and NMSS EO           |
| (Piccone).                                                                   |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36039       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: HOPE CREEK               REGION:  1  |NOTIFICATION DATE: 08/18/1999|
|    UNIT:  [1] [] []                 STATE:  NJ |NOTIFICATION TIME: 12:09[EDT]|
|   RXTYPE: [1] GE-4                             |EVENT DATE:        08/17/1999|
+------------------------------------------------+EVENT TIME:        12:53[EDT]|
| NRC NOTIFIED BY:  CHRIS SERATA                 |LAST UPDATE DATE:  08/18/1999|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |PETER ESELGROTH      R1      |
|10 CFR SECTION:                                 |                             |
|NLTR                     LICENSEE 24 HR REPORT  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| DISCOVERY OF AN OPEN FLOOR DRAIN VALVE WHICH MAY NOT HAVE PREVENTED CO2 FIRE |
| SUPPRESSION AGENT DISSIPATION IN THE EVENT OF A FIRE IN THE CABLE SPREADING  |
| ROOM                                                                         |
|                                                                              |
| Hope Creek Operating License Condition 2.c(7) requires PSE&G to implement    |
| and maintain in effect all provisions of the approved Fire Protection        |
| Program as described in the Updated Final Safety Analysis Report (UFSAR) for |
| the facility through Amendment 15.  One of those provisions (UFSAR Section   |
| 9.5.1.1.9) requires the control equipment mezzanine floor drain isolation    |
| valve to remain closed to prevent CO2 fire suppression agent dissipation.    |
| Contrary to this requirement, the control equipment mezzanine floor drain    |
| isolation valve was found open at 1253 on 08/17/99.  This notification is    |
| being made in accordance with License Condition 2.f because no provision had |
| been implemented to maintain the control equipment mezzanine floor drain     |
| valve in the closed position.                                                |
|                                                                              |
| The control equipment mezzanine contains electrical and control power        |
| cabling to and from the control room and remote control panels and           |
| equipment.  Had a fire occurred in this room with the control equipment      |
| mezzanine floor drain valve open, the CO2 system may not have maintained the |
| minimum level of CO2 concentration necessary to extinguish the fire.         |
| However, a manual water deluge system was also available to provide backup   |
| to the CO2 system.  Preliminary analysis indicates that the combination of   |
| the remaining CO2 and water deluge would have precluded a fire postulated in |
| the control equipment mezzanine from impacting redundant safety-related      |
| equipment.  The remote shutdown panel remained available to achieve and      |
| maintain the reactor in the shutdown condition remotely from the control     |
| room.                                                                        |
|                                                                              |
| The control equipment mezzanine floor drain valve was closed at 1259 on      |
| 08/17/99.  The floor drain valves in the emergency diesel generator (EDG)    |
| area and diesel fuel oil storage tank areas (which are identified in the     |
| same UFSAR section) have been verified closed as required.  The control      |
| equipment mezzanine floor drain valve has been added to the tagging system   |
| to ensure that it is controlled and maintained closed.  Additional           |
| investigation into the extent of the condition is ongoing.                   |
|                                                                              |
| The 'D' EDG is currently inoperable with activities ongoing to clean one of  |
| its two fuel oil storage tanks.  The 'D' EDG remains available to start in   |
| an emergency condition, and it has adequate fuel oil for 3 days of           |
| operation.  All other EDGs and safety-related equipment are operable at this |
| time.                                                                        |
|                                                                              |
| The licensee stated that it appears that the control equipment mezzanine     |
| floor drain isolation valve had been open for an extended period of time     |
| (possibly for the life of the plant).  The licensee also stated that this    |
| issue was identified by the NRC resident inspector during performance of an  |
| assessment of the licensee's Fire Protection Program.                        |
|                                                                              |
| NOTE:  The valve is located in a 4" drain line.  The control equipment       |
| mezzanine floor drains are equipped with                                     |
| drain traps.                                                                 |
|                                                                              |
| The licensee plans to notify the NRC resident inspector and the NRC Region 1 |
| office.                                                                      |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36040       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: OCONEE                   REGION:  2  |NOTIFICATION DATE: 08/18/1999|
|    UNIT:  [1] [] []                 STATE:  SC |NOTIFICATION TIME: 21:04[EDT]|
|   RXTYPE: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-L|EVENT DATE:        08/18/1999|
+------------------------------------------------+EVENT TIME:        19:56[EDT]|
| NRC NOTIFIED BY:  PHIL NORTH                   |LAST UPDATE DATE:  08/18/1999|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |KENNETH BARR         R2      |
|10 CFR SECTION:                                 |                             |
|ARPS 50.72(b)(2)(ii)     RPS ACTUATION          |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     A/R        Y       100      Power Operation  |0        Hot Shutdown     |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AUTOMATIC REACTOR TRIP DUE TO A GENERATOR LOCKOUT FOR UNKNOWN REASONS        |
|                                                                              |
| At 1956 on 08/18/99, Oconee Unit 1 automatically tripped from 100% power,    |
| and the cause of the trip is currently under investigation.  At this time,   |
| the licensee believes that an electrical generator lockout (for unknown      |
| reasons) cause a turbine trip and subsequent reactor trip.  Post-trip        |
| response was normal.  All control rods fully inserted.  There were no        |
| emergency core cooling system or engineered safety feature actuations, and   |
| none were required.  The main steam safety valves lifted and reseated as     |
| expected.  There were no maintenance or surveillance activities occurring at |
| the time of the generator lockout.  There were no storms in the area, and    |
| the weather was stable and hot.  All systems functioned as required, and the |
| cause of the generator lockout is the only thing that is not understood at   |
| this time.                                                                   |
|                                                                              |
| The reactor is currently subcritical, and shutdown margin is within          |
| technical specification limits.  Reactor coolant system inventory control is |
| being provided via normal makeup.  The power-operated relief valves and      |
| pressurizer code safety valves are closed.  Primary system transport is      |
| being controlled by forced circulation via all four reactor coolant pumps.   |
| Secondary steam is being dumped to the main condenser via the turbine bypass |
| valves, and main feedwater is supplying water to the steam generators.       |
|                                                                              |
| The licensee notified the NRC resident inspector.                            |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36041       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: HADDAM NECK              REGION:  1  |NOTIFICATION DATE: 08/19/1999|
|    UNIT:  [1] [] []                 STATE:  CT |NOTIFICATION TIME: 02:48[EDT]|
|   RXTYPE: [1] W-4-LP                           |EVENT DATE:        08/19/1999|
+------------------------------------------------+EVENT TIME:        01:00[EDT]|
| NRC NOTIFIED BY:  BOB MORGAN                   |LAST UPDATE DATE:  08/19/1999|
|  HQ OPS OFFICER:  BOB STRANSKY                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |PETER ESELGROTH      R1      |
|10 CFR SECTION:                                 |                             |
|APRE 50.72(b)(2)(vi)     OFFSITE NOTIFICATION   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          N       0        Refueling        |0        Refueling        |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| OFFSITE NOTIFICATION OF ONSITE CHEMICAL SPILL                                |
|                                                                              |
| The licensee notified the Connecticut state Environmental Protection Agency  |
| regarding an onsite spill of sodium hypochlorite. Approximately 50 gallons   |
| of 50% sodium hypochlorite solution leaked from a barrel in the turbine      |
| building. The licensee reported that the leakage has stopped, and that the   |
| solution is flowing into floor drains which connect to an isolated sump (the |
| licensee has disabled pumpout capability). A hazardous materials contractor  |
| has been retained to clean up the spill. The licensee plans to contact the   |
| National Response Center regarding this event.                               |
+------------------------------------------------------------------------------+