Event Notification Report for August 20, 1999
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/19/1999 - 08/20/1999
EVENT NUMBERS
360553604936051360523605336072
Power Reactor
Event Number: 36055
Facility: HOPE CREEK
Region: 1 State: NJ
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: DEVON PRICE
HQ OPS Officer: WILLIAM POERTNER
Region: 1 State: NJ
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: DEVON PRICE
HQ OPS Officer: WILLIAM POERTNER
Notification Date: 08/21/1999
Notification Time: 16:27 [ET]
Event Date: 08/20/1999
Event Time: 23:58 [EDT]
Last Update Date: 08/21/1999
Notification Time: 16:27 [ET]
Event Date: 08/20/1999
Event Time: 23:58 [EDT]
Last Update Date: 08/21/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
PETER ESELGROTH (R1)
PETER ESELGROTH (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 70 | Power Operation |
24 HOUR REPORT REQUIRED BY STATION OPERATING LICENSE
On August 20, at 2358, a lightning strike caused a momentary loss of a 500kv transmission line. The resulting electrical transient caused the trip of the following equipment: "A" Reactor Feedpump, "A" Electrohydraulic Control Pump, "A" and "B" Reactor Water Cleanup Pumps, "A" Technical Support Center Chiller, "A" Control Room Chiller, "A" and "B" Main Reactor FeedpumpTurbine Lube Oil Pumps, and the Drywell Coolers. The following equipment automatically started: "B" Technical Support Center Chiller, "B" Control Room Chiller, "B" Safety Auxiliaries Cooling System Pump and the "B" Electrohydraulic Control Pump. The trip of the "A" Reactor Feed Pump and the resulting lowering Reactor water level caused an automatic Reactor Recirculation system runback to approximately 70% Reactor power.
This equipment was restored to normal operating configuration, and Reactor power was restored to 100% at 0449 on August 21,1999. At 0618, Station Operators recognized that the #6 Feedwater Heater extraction Steam isolation valves had automatically closed during the electrical transient. At that time, final feedwater temperature was approximately 365 degrees Fahrenheit. At 0646, a power reduction to 90% Reactor power was commenced and at 0826 the #6 feedwater heaters were returned to service.
Hope Creek Operating License Condition 2.C(11) states that the facility shall not be operated with a feedwater heating capacity that would result in a rated power feedwater temperature of less than 400 degrees Fahrenheit unless analyses approving such operation are submitted by the licensee and approved by the staff. Contrary to this license condition, the plant was operated at rated power with feedwater temperature less than 400 degrees Fahrenheit.
The plant is currently operating at 100% Reactor power, with feedwater temperature greater than 400 degrees Fahrenheit. The Hope Creek Staff is currently reviewing Plant response to the electrical transient. All required Safety systems are currently Operable and there are no active Limiting Conditions for Operation in effect.
The NRC resident inspector has been notified.
On August 20, at 2358, a lightning strike caused a momentary loss of a 500kv transmission line. The resulting electrical transient caused the trip of the following equipment: "A" Reactor Feedpump, "A" Electrohydraulic Control Pump, "A" and "B" Reactor Water Cleanup Pumps, "A" Technical Support Center Chiller, "A" Control Room Chiller, "A" and "B" Main Reactor FeedpumpTurbine Lube Oil Pumps, and the Drywell Coolers. The following equipment automatically started: "B" Technical Support Center Chiller, "B" Control Room Chiller, "B" Safety Auxiliaries Cooling System Pump and the "B" Electrohydraulic Control Pump. The trip of the "A" Reactor Feed Pump and the resulting lowering Reactor water level caused an automatic Reactor Recirculation system runback to approximately 70% Reactor power.
This equipment was restored to normal operating configuration, and Reactor power was restored to 100% at 0449 on August 21,1999. At 0618, Station Operators recognized that the #6 Feedwater Heater extraction Steam isolation valves had automatically closed during the electrical transient. At that time, final feedwater temperature was approximately 365 degrees Fahrenheit. At 0646, a power reduction to 90% Reactor power was commenced and at 0826 the #6 feedwater heaters were returned to service.
Hope Creek Operating License Condition 2.C(11) states that the facility shall not be operated with a feedwater heating capacity that would result in a rated power feedwater temperature of less than 400 degrees Fahrenheit unless analyses approving such operation are submitted by the licensee and approved by the staff. Contrary to this license condition, the plant was operated at rated power with feedwater temperature less than 400 degrees Fahrenheit.
The plant is currently operating at 100% Reactor power, with feedwater temperature greater than 400 degrees Fahrenheit. The Hope Creek Staff is currently reviewing Plant response to the electrical transient. All required Safety systems are currently Operable and there are no active Limiting Conditions for Operation in effect.
The NRC resident inspector has been notified.
Hospital
Event Number: 36049
Rep Org: ST. CLARES HOSPITAL/DOVER
Licensee: ST. CLARES HOSPITAL/DOVER
Region: 1
City: DOVER State: NJ
County:
License #: 29-13746-02
Agreement: N
Docket:
NRC Notified By: JOSEPH BARBIERI
HQ OPS Officer: WILLIAM POERTNER
Licensee: ST. CLARES HOSPITAL/DOVER
Region: 1
City: DOVER State: NJ
County:
License #: 29-13746-02
Agreement: N
Docket:
NRC Notified By: JOSEPH BARBIERI
HQ OPS Officer: WILLIAM POERTNER
Notification Date: 08/20/1999
Notification Time: 11:48 [ET]
Event Date: 08/20/1999
Event Time: 11:00 [EDT]
Last Update Date: 08/20/1999
Notification Time: 11:48 [ET]
Event Date: 08/20/1999
Event Time: 11:00 [EDT]
Last Update Date: 08/20/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
PETER ESELGROTH (R1)
JOHN HICKEY (NMSS)
PETER ESELGROTH (R1)
JOHN HICKEY (NMSS)
LOST I-125 SEEDS
At 0900 EDT 8/19/99, 80 seeds of I-125 were delivered to the loading dock at ST. Clares Hospital/Dover. The seeds were inadvertently sent to ST. Clares Hospital/Denvile from the loading dock. The I-125 seeds were located at 1100 EDT and secured in the ST. Clare Hospital/Denvile Nuclear Medicine Department. The activity of each seed was 0.7 mCi.
*** UPDATE AT 1454 EDT ON 8/20/99 FROM BARBIERI TO POERTNER ***
Licensee determined that loading dock person opened the cardboard package and found name of person formerly located at ST. Clares Hospital/Denvile on papers located inside the package. He then sent the package to ST. Clares Hospital/Denvile. The licensee surveyed inner package and found no contamination.
HOO notified R1DO (ESELGROTH).
At 0900 EDT 8/19/99, 80 seeds of I-125 were delivered to the loading dock at ST. Clares Hospital/Dover. The seeds were inadvertently sent to ST. Clares Hospital/Denvile from the loading dock. The I-125 seeds were located at 1100 EDT and secured in the ST. Clare Hospital/Denvile Nuclear Medicine Department. The activity of each seed was 0.7 mCi.
*** UPDATE AT 1454 EDT ON 8/20/99 FROM BARBIERI TO POERTNER ***
Licensee determined that loading dock person opened the cardboard package and found name of person formerly located at ST. Clares Hospital/Denvile on papers located inside the package. He then sent the package to ST. Clares Hospital/Denvile. The licensee surveyed inner package and found no contamination.
HOO notified R1DO (ESELGROTH).
Fuel Cycle Facility
Event Number: 36051
Facility: PADUCAH GASEOUS DIFFUSION PLANT
Region: 3 State: KY
Unit: [] [] []
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817 (301)564-3200
NRC Notified By: ERIC WALKER
HQ OPS Officer: WILLIAM POERTNER
Region: 3 State: KY
Unit: [] [] []
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817 (301)564-3200
NRC Notified By: ERIC WALKER
HQ OPS Officer: WILLIAM POERTNER
Notification Date: 08/20/1999
Notification Time: 19:06 [ET]
Event Date: 08/20/1999
Event Time: 12:15 [CDT]
Last Update Date: 08/20/1999
Notification Time: 19:06 [ET]
Event Date: 08/20/1999
Event Time: 12:15 [CDT]
Last Update Date: 08/20/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
BRENT CLAYTON (R3)
JOE HOLONICH (NMSS)
BRENT CLAYTON (R3)
JOE HOLONICH (NMSS)
NRC BULLETIN 91-01, 24 HOUR REPORT
At 1242 CDT on 8/20/99, the Plant Shift Superintendent was notified that adjacent system post-removal Non-Destructive Assay (NDA) was not performed as required by NCSA GEN-10 for the Unit 3, Cell 7, Stage 8B blowout preventer actuator removed in the C-335 cascade building. The post-removal NDA is required to be performed within 24 hours of the equipment being removed. The post-removal NDA measurement is used to independently verify the mass of any potential adjacent system deposit is less than an always safe mass and can be characterized as Uncomplicated Handling (UH). The pre-removal NDA indicated no significant deposit in the adjacent system.
The post-removal NDA measurement was subsequently performed within 4 hours of discovery which confirmed the adjacent system to be UH.
This event is being categorized as a 24 hour event in accordance with Safety Analysis Report Table 6.9-1, Criteria A.4.a and Bulletin 91-01, Supplement 1.
The NRC resident inspector has been notified.
At 1242 CDT on 8/20/99, the Plant Shift Superintendent was notified that adjacent system post-removal Non-Destructive Assay (NDA) was not performed as required by NCSA GEN-10 for the Unit 3, Cell 7, Stage 8B blowout preventer actuator removed in the C-335 cascade building. The post-removal NDA is required to be performed within 24 hours of the equipment being removed. The post-removal NDA measurement is used to independently verify the mass of any potential adjacent system deposit is less than an always safe mass and can be characterized as Uncomplicated Handling (UH). The pre-removal NDA indicated no significant deposit in the adjacent system.
The post-removal NDA measurement was subsequently performed within 4 hours of discovery which confirmed the adjacent system to be UH.
This event is being categorized as a 24 hour event in accordance with Safety Analysis Report Table 6.9-1, Criteria A.4.a and Bulletin 91-01, Supplement 1.
The NRC resident inspector has been notified.
Power Reactor
Event Number: 36052
Facility: LIMERICK
Region: 1 State: PA
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: JOHN HUNTER
HQ OPS Officer: WILLIAM POERTNER
Region: 1 State: PA
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: JOHN HUNTER
HQ OPS Officer: WILLIAM POERTNER
Notification Date: 08/21/1999
Notification Time: 12:51 [ET]
Event Date: 08/20/1999
Event Time: 16:45 [EDT]
Last Update Date: 08/21/1999
Notification Time: 12:51 [ET]
Event Date: 08/20/1999
Event Time: 16:45 [EDT]
Last Update Date: 08/21/1999
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):
PETER ESELGROTH (R1)
PETER ESELGROTH (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
MANUAL INITIATION OF HVAC CHLORINE ISOLATION MODE
At 1645 EDT on 8/20/99 an equipment operator reported a faint smell of chlorine in the Unit 2 reactor building (253 foot elevation). The floor supervisor was dispatched to investigate. The main control room personnel placed the Main Control Room (MCR) HVAC system in a chlorine isolation mode as a planned conservative measure. No indication of chlorine was ever present on the MCR HVAC chlorine detectors. The floor supervisor reported that there was a slight, barely detectable, chlorine like odor in the area but that it had dissipated. The MCR HVAC system was returned to the normal mode of operation at 2304 EDT 8/20/99. There was no adverse impact to plant operations.
A subsequent review of the reportability requirements was made on 8/21/99 at 1000 EDT and it was determined that a four hour report pursuant to 50.72(b)(2)(ii) should be made for the manual initiation of a MCR chlorine isolation.
The NRC resident inspector has been notified.
At 1645 EDT on 8/20/99 an equipment operator reported a faint smell of chlorine in the Unit 2 reactor building (253 foot elevation). The floor supervisor was dispatched to investigate. The main control room personnel placed the Main Control Room (MCR) HVAC system in a chlorine isolation mode as a planned conservative measure. No indication of chlorine was ever present on the MCR HVAC chlorine detectors. The floor supervisor reported that there was a slight, barely detectable, chlorine like odor in the area but that it had dissipated. The MCR HVAC system was returned to the normal mode of operation at 2304 EDT 8/20/99. There was no adverse impact to plant operations.
A subsequent review of the reportability requirements was made on 8/21/99 at 1000 EDT and it was determined that a four hour report pursuant to 50.72(b)(2)(ii) should be made for the manual initiation of a MCR chlorine isolation.
The NRC resident inspector has been notified.
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital
Event Number: 36053
Rep Org: UNIVERSITY OF CT HEALTH CENTER
Licensee: UNIVERSITY OF CT HEALTH CENTER
Region: 1
City: FARMINGTON State: CT
County:
License #: 0613022
Agreement: N
Docket:
NRC Notified By: KEN PRICE
HQ OPS Officer: WILLIAM POERTNER
Licensee: UNIVERSITY OF CT HEALTH CENTER
Region: 1
City: FARMINGTON State: CT
County:
License #: 0613022
Agreement: N
Docket:
NRC Notified By: KEN PRICE
HQ OPS Officer: WILLIAM POERTNER
Notification Date: 08/21/1999
Notification Time: 14:31 [ET]
Event Date: 08/20/1999
Event Time: 17:45 [EDT]
Last Update Date: 04/06/2000
Notification Time: 14:31 [ET]
Event Date: 08/20/1999
Event Time: 17:45 [EDT]
Last Update Date: 04/06/2000
Emergency Class: NON EMERGENCY
10 CFR Section:
35.33 - MED MISADMINISTRATION
10 CFR Section:
35.33 - MED MISADMINISTRATION
Person (Organization):
PETER ESELGROTH (R1)
JOE HOLONICH (NMSS)
PETER ESELGROTH (R1)
JOE HOLONICH (NMSS)
POSSIBLE MEDICAL MISADMINISTRATION
On 8/20/99, a possible medical misadministration occurred at University of CT Health Center located in Farmington, Conn. The physician prescribed a dose of 13 millicuries P-32 (Chromic Phosphate) for a lung cancer patient. After injection, it was determined that only 6.9 millicuries of P-32 had been injected. The physician issued a revised written directive for 7 millicuries of P-32 based on the patients condition.
(Call the NRC Operations Center for a licensee contact telephone number.)
* * * RETRACTION REPORTED BY KEN PRICE ON 04/06/00 AT 1622 EDT TAKEN BY MACKINNON * * *
The licensee is retracting this event after discussions with NRC Region 1 (David Dwyer). The Physician changed the written directive for the amount of dose that the patient was to have received. Therefore, this event is not reportable and is being retracted. NRC R1DO (Jack McFadden) and NMSS EO (John Hickey) notified.
On 8/20/99, a possible medical misadministration occurred at University of CT Health Center located in Farmington, Conn. The physician prescribed a dose of 13 millicuries P-32 (Chromic Phosphate) for a lung cancer patient. After injection, it was determined that only 6.9 millicuries of P-32 had been injected. The physician issued a revised written directive for 7 millicuries of P-32 based on the patients condition.
(Call the NRC Operations Center for a licensee contact telephone number.)
* * * RETRACTION REPORTED BY KEN PRICE ON 04/06/00 AT 1622 EDT TAKEN BY MACKINNON * * *
The licensee is retracting this event after discussions with NRC Region 1 (David Dwyer). The Physician changed the written directive for the amount of dose that the patient was to have received. Therefore, this event is not reportable and is being retracted. NRC R1DO (Jack McFadden) and NMSS EO (John Hickey) notified.
Other Nuclear Material
Event Number: 36072
Rep Org: US ARMY (ACALA)
Licensee: US ARMY (ACALA)
Region: 3
City: ROCK ISLAND State: IL
County:
License #: 12-00722-06
Agreement: Y
Docket:
NRC Notified By: JEFF HAVENNER
HQ OPS Officer: STEVE SANDIN
Licensee: US ARMY (ACALA)
Region: 3
City: ROCK ISLAND State: IL
County:
License #: 12-00722-06
Agreement: Y
Docket:
NRC Notified By: JEFF HAVENNER
HQ OPS Officer: STEVE SANDIN
Notification Date: 08/25/1999
Notification Time: 17:22 [ET]
Event Date: 08/20/1999
Event Time: 00:00 [CDT]
Last Update Date: 08/25/1999
Notification Time: 17:22 [ET]
Event Date: 08/20/1999
Event Time: 00:00 [CDT]
Last Update Date: 08/25/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
MELVYN LEACH (R3)
PHIL HARRELL (R4)
JOSEPHINE PICCONE (NMSS)
MELVYN LEACH (R3)
PHIL HARRELL (R4)
JOSEPHINE PICCONE (NMSS)
CHEMICAL AGENT DETECTOR CELL MODULE DISCOVERED MISSING DURING INVENTORY
AN M43A1 CHEMICAL AGENT DETECTOR CELL MODULE CONTAINING 250 MICROCURIES OF AMERICIUM-241 WAS DISCOVERED MISSING DURING AN INVENTORY CHECK COMPLETED IN AUGUST 1999 BY THE 63RD REGIONAL SUPPORT COMMAND LOCATED AT LOS ALAMITOS, CALIFORNIA. THE LAST ACTIVITY RECORDED FOR THIS PARTICULAR UNIT WAS AT FT. McCOY, WISCONSIN IN 1989. NO SEARCH FOR THE MISSING SOURCE IS PLANNED AT THIS TIME SINCE THIS PARTICULAR UNIT MAY HAVE BEEN TRANSPORTED AND USED IN DESERT STORM.
AN M43A1 CHEMICAL AGENT DETECTOR CELL MODULE CONTAINING 250 MICROCURIES OF AMERICIUM-241 WAS DISCOVERED MISSING DURING AN INVENTORY CHECK COMPLETED IN AUGUST 1999 BY THE 63RD REGIONAL SUPPORT COMMAND LOCATED AT LOS ALAMITOS, CALIFORNIA. THE LAST ACTIVITY RECORDED FOR THIS PARTICULAR UNIT WAS AT FT. McCOY, WISCONSIN IN 1989. NO SEARCH FOR THE MISSING SOURCE IS PLANNED AT THIS TIME SINCE THIS PARTICULAR UNIT MAY HAVE BEEN TRANSPORTED AND USED IN DESERT STORM.