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Event Notification Report for August 23, 1999

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           08/20/1999 - 08/23/1999

                              ** EVENT NUMBERS **

35790  36040  36045  36049  36050  36051  36052  36053  36054  36055  36056  36057 


+------------------------------------------------------------------------------+
|Fuel Cycle Facility                              |Event Number:   35790       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT      |NOTIFICATION DATE: 06/03/1999|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 14:44[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        06/02/1999|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        16:30[CDT]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  08/22/1999|
|    CITY:  PADUCAH                  REGION:  3  +-----------------------------+
|  COUNTY:  McCRACKEN                 STATE:  KY |PERSON          ORGANIZATION |
|LICENSE#:  GDP-1                 AGREEMENT:  Y  |DAVID HILLS          R3      |
|  DOCKET:  0707001                              |DON COOL             NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  THOMAS WHITE                 |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|OCBA 76.120(c)(2)(i)     ACCID MT EQUIP FAILS   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| THREE SPRINKLER SYSTEMS DECLARED INOPERABLE DUE TO CORRODED HEADS (24-hour   |
| report)                                                                      |
|                                                                              |
| The following text is a portion of a facsimile received from Paducah:        |
|                                                                              |
| "On 06/02/99 at 1630 CDT, the Plant Shift Superintendent (PSS) was notified  |
| that numerous sprinkler heads were corroded, affecting 16 sprinkler systems  |
| in C-337 and one system in C-333, such that the ability of the sprinklers to |
| flow sufficient water was called into question.  Subsequently, these         |
| sprinkler systems were declared inoperable, and TSR-required actions         |
| establishing roving fire patrols were initiated.  This deficiency was        |
| detected during scheduled system inspections conducted by Fire Protection    |
| personnel.  Currently, functionality of the sprinkler heads has not been     |
| fully evaluated by Fire Protection personnel, and the remaining cascade      |
| buildings are currently being inspected, and if necessary, this report will  |
| be updated to identify any additional areas.                                 |
|                                                                              |
| "It has been determined that this event is reportable under                  |
| 10CFR76.120(c)(2) as an event in which equipment is disabled or fails to     |
| function as designed."                                                       |
|                                                                              |
| The NRC resident inspector has been notified of this event.                  |
|                                                                              |
|                                                                              |
| * * * UPDATE AT 1022 ON 06/04/99 FROM CAGE TO TROCINE * * *                  |
|                                                                              |
| "Two sprinkler heads on system D-1 in C-337 and two sprinkler heads on       |
| system 27 in C-335 were identified to also be corroded.  These were          |
| identified to the PSS on 06/03/99 at 1600 CDT and 1601 CDT, respectively,    |
| and determined to require an update to this report by the PSS.               |
|                                                                              |
| "It has been determined that this event is reportable under                  |
| 10CFR76.120(c)(2) as an event in which equipment is disabled or fails to     |
| function as designed."                                                       |
|                                                                              |
| Paducah personnel notified the NRC resident inspector of this update.  The   |
| NRC operations officer notified the R3DO (Hills) and NMSS EO (Combs).        |
|                                                                              |
| * * * UPDATE AT 2152 ON 06/17/99 FROM WALKER TO POERTNER * * *               |
|                                                                              |
| "Three sprinkler heads on system C-15 and five sprinkler heads on system B-8 |
| in C-333 were identified to also be corroded.  The PSS was notified of this  |
| condition at 1300 CDT on 06/17/99 and determined that an update to this      |
| report was required."                                                        |
|                                                                              |
| "It has been determined that this event is reportable under                  |
| 10CFR76.120(c)(2) as an event in which equipment is disabled or fails to     |
| function as designed."                                                       |
|                                                                              |
| Paducah personnel notified the NRC resident inspector of this update.  The   |
| NRC operations officer notified the R3DO (Madera).                           |
|                                                                              |
| * * * UPDATE 1440 6/18/1999 FROM UNDERWOOD TAKEN BY STRANSKY * * *           |
|                                                                              |
| "Two sprinkler heads on system C-15 and one sprinkler head on system B-8 in  |
| C-333 were identified to have corrosion.  The PSS was notified of this       |
| condition at 1350 CDT on 06/18/99.  The area of the fire patrol for system   |
| C-15 was expanded to include the two heads identified as corroded.  The one  |
| head on system B-8 was in the area already being patrolled.  The PSS         |
| determined that an update to this report was required."                      |
|                                                                              |
| The NRC resident inspector has been informed of this update.  Notified R3DO  |
| (Madera).                                                                    |
|                                                                              |
| * * * UPDATE 1315 6/25/1999 FROM WALKER TAKEN BY STRANSKY * * *              |
|                                                                              |
| "Two sprinkler heads on system D-8 and three sprinkler heads on system D-7   |
| in C-337 were identified to have corrosion.  The PSS was notified of the     |
| condition on system D-8 at 0125 CDT on 06/25/99 and at 1019 CDT on 06/25/99  |
| for system D-7.  Both systems were immediately declared inoperable and LCO   |
| fire patrol actions were implemented.  It was determined that an update to   |
| this report was required."                                                   |
|                                                                              |
| The NRC resident inspector has been informed of this update.  Notified R3DO  |
| (Jordan).                                                                    |
|                                                                              |
| * * * UPDATE 2119 7/30/1999 FROM CAGE TAKEN BY STRANSKY * * *                |
|                                                                              |
| "Five sprinkler heads and one sprinkler piping tee on C-337 system D-7 were  |
| identified to have corrosion. The PSS was notified of these corroded system  |
| parts and declared the system inoperable at 0931 CDT on 07/30/99.  LCO       |
| required fire patrols of the affected area were initiated.  The PSS          |
| determined that an update to this event report was required."                |
|                                                                              |
| The NRC resident inspector has been informed of this update.  Notified R3DO  |
| (Wright).                                                                    |
|                                                                              |
| * * * UPDATE 1655 7/31/1999 FROM WHITE TAKEN BY STRANSKY * * *               |
|                                                                              |
| "Two sprinkler heads on C-337 System D-1 were identified to have corrosion.  |
| The PSS was notified of these corroded system parts and declared the system  |
| inoperable at 1155 CDT on 7/31/99.  LCO required fire patrols of the         |
| affected area were initiated.  The PSS determined that an update to this     |
| report was required."                                                        |
|                                                                              |
| The NRC resident inspector has been informed of this update. Notified R3DO   |
| (Wright).                                                                    |
|                                                                              |
| * * * UPDATE 1546 8/10/1999 FROM WHITE TAKEN BY STRANSKY * * *               |
|                                                                              |
| "Two sprinkler heads on C-337 system C-15 were identified to have corrosion. |
| The PSS was notified of these corroded system parts and declared the system  |
| inoperable at 1130 CDT on 8/10/99.  LCO required fire patrols of the         |
| affected area were initiated.  The PSS determined that an update to this     |
| report was required."                                                        |
|                                                                              |
| The NRC resident inspector has been informed of this update. Notified R3DO   |
| (Burgess).                                                                   |
|                                                                              |
| * * * UPDATE AT 1154 8/22/99 FROM WALKER TO POERTNER * * *                   |
|                                                                              |
| Four adjacent sprinkler heads on C-333 System B-1 were identified to have    |
| corrosion.  The PSS was notified of the corroded system parts and declared   |
| the system inoperable at 0918 CDT on 8/22/99.  LCO required fire patrols     |
| were initiated.  The PSS determined that an update to this report was        |
| required.                                                                    |
|                                                                              |
| It has been determined that this event is reportable under 10CFR76.120(c)(2) |
| as an event in which equipment is disabled or fails to function as           |
| designed.                                                                    |
|                                                                              |
| The NRC resident inspector will be notified.                                 |
|                                                                              |
| The NRC operations officer notified the R3DO (Clayton).                      |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|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:  08/20/1999|
|  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.                            |
|                                                                              |
| *** UPDATE AT 1242 EDT ON 8/20/99 FROM NICHOLSON TO POERTNER ***             |
|                                                                              |
| The original cause of the Oconee Unit 1 trip on 8/18/99 was believed to have |
| been an electrical generator lockout based on annunciation available at the  |
| time.  Subsequent evaluation has concluded that the trip was caused by an    |
| internal voltage problem within the solid state programmer for the group 5   |
| control rods.  This voltage anomaly caused the Group 5 rods to drop into the |
| core.  The entire programmer has been replaced, with the defective equipment |
| being returned to the manufacturer for additional evaluation.                |
|                                                                              |
| The NRC resident inspector has been notified.                                |
|                                                                              |
| The HOO notified the R2DO (BARR)                                             |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   36045       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  IDAHO NAT ENGR & ENVIRONMENTAL LAB   |NOTIFICATION DATE: 08/19/1999|
|LICENSEE:  IDAHO NAT ENGR & ENVIRONMENTAL LAB   |NOTIFICATION TIME: 16:24[EDT]|
|    CITY:  IDAHO FALLS              REGION:  4  |EVENT DATE:        08/19/1999|
|  COUNTY:                            STATE:  ID |EVENT TIME:        13:34[MDT]|
|LICENSE#:                        AGREEMENT:  N  |LAST UPDATE DATE:  08/20/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |LINDA HOWELL         R4      |
|                                                |JOSIE PICCONE        NMSS    |
+------------------------------------------------+JOSEPH GIITTER       IRO     |
| NRC NOTIFIED BY:  SCOTT SCHUM                  |WILLIAM BEECHER      PAO     |
|  HQ OPS OFFICER:  WILLIAM POERTNER             |YATES                DOE     |
+------------------------------------------------+BLANCHARD            EPA     |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NINF                     INFORMATION ONLY       |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| DOE ALERT DECLARED DUE TO A FIRE IN THE DESERT ON DOE CONTROLLED PROPERTY.   |
|                                                                              |
| This event was classified as an alert at 1334 MDT in accordance with         |
| Department of Energy (DOE) procedures.  This is not a classification driven  |
| by the Three Mile Island Independent Spent Fuel Storage Facility (ISFSI)     |
| emergency plan.                                                              |
|                                                                              |
| A range fire occurred on DOE controlled property.  The Idaho Nuclear         |
| Engineering and Environmental Laboratory (INEEL) fire department and Bureau  |
| of Land Management (BLM) are fighting the fire.  The fire is not threatening |
| any site area.  The fire is presently located 12 miles east of the ISFSI     |
| facility and is traveling north, away from the facility.  Eight BLM rigs are |
| in route to the fire.                                                        |
|                                                                              |
| DOE made notifications per procedures to activate the Emergency Operations   |
| Center (EOC) and Emergency Control Center (ECC).  DOE notified State and     |
| Local Authorities.                                                           |
|                                                                              |
| NRC assistance was not requested.                                            |
|                                                                              |
| *** UPDATE AT 2039 EDT ON 8/20/99 FROM SCHUM TO POERTNER ***                 |
|                                                                              |
| The DOE Alert was terminated at 1833 MDT when the range fire was             |
| extinguished.                                                                |
|                                                                              |
| HOO notified R4DO (Howell), NMSS EO (Holonich), IRO (Giitter), PAO           |
| (Beecher), FEMA (Bagwell), HHS-CDC (Davis), EPA-NRC (Gauter), DOE (Young),   |
| and USDA (Conley)                                                            |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   36049       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  ST. CLARES HOSPITAL/DOVER            |NOTIFICATION DATE: 08/20/1999|
|LICENSEE:  ST. CLARES HOSPITAL/DOVER            |NOTIFICATION TIME: 11:48[EDT]|
|    CITY:  DOVER                    REGION:  1  |EVENT DATE:        08/20/1999|
|  COUNTY:                            STATE:  NJ |EVENT TIME:        11:00[EDT]|
|LICENSE#:  29-13746-02           AGREEMENT:  N  |LAST UPDATE DATE:  08/20/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |PETER ESELGROTH      R1      |
|                                                |JOHN HICKEY          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  JOSEPH BARBIERI              |                             |
|  HQ OPS OFFICER:  WILLIAM POERTNER             |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:                                |                             |
|10 CFR SECTION:                                 |                             |
|BAB1 20.2201(a)(1)(i)    LOST/STOLEN LNM>1000X  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| 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 formally 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)                                                |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   36050       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  TEXAS DEPARTMENT OF HEALTH           |NOTIFICATION DATE: 08/20/1999|
|LICENSEE:  UNIVERSITY OF TEXAS                  |NOTIFICATION TIME: 12:00[EDT]|
|    CITY:  HOUSTON                  REGION:  4  |EVENT DATE:        03/10/1999|
|  COUNTY:                            STATE:  TX |EVENT TIME:             [CDT]|
|LICENSE#:  L00466                AGREEMENT:  Y  |LAST UPDATE DATE:  08/20/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |LINDA HOWELL         R4      |
|                                                |JOE DECICCO          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  JIM OGDEN (FAX)              |                             |
|  HQ OPS OFFICER:  WILLIAM POERTNER             |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:                                |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT OF A MEDICAL MISADMINISTRATION AT ANDERSON CANCER     |
| CENTER IN HOUSTON TEXAS.                                                     |
|                                                                              |
| The following text is a portion of a facsimile received from the Texas       |
| Department of Health Bureau of Radiation Control:                            |
|                                                                              |
| " Incident 7471 - Broad License L00466, The university of Texas, M.D.        |
| Anderson Cancer Center, Houston, Texas"                                      |
|                                                                              |
| "Date of Event: March 9, 1999."                                              |
|                                                                              |
| "Initial Report: Telephonic report March 10, 1999. (Lost)"                   |
|                                                                              |
| "On the afternoon of March 9, 1999, a patient was loaded with a 51.25 mgRaeq |
| (127.35 millicurie Cesium-137) gynecological implant for a planned treatment |
| time of 44.77 hours. Late that evening the patient was discovered to have    |
| removed the implant. The implant was discovered in the bed beside the        |
| patient's hand/arm at hip level. Nursing staff removed the loading to the    |
| far side of the room, placed a rolling lead shield between the source and    |
| the patient, then notified the Gynecological physician on duty and the       |
| Brachytherapy Services staff. Estimated treatment time was only about 8.833  |
| hours. This treatment time differed from the prescribed treatment dose by    |
| more than 10%. The patient treatment was terminated without additional       |
| treatment. The event was reported telephonically on the afternoon of March   |
| 10, 1999. This message was never delivered to the proper authorities within  |
| the Agency. An initial written report filed by the hospital stated that the  |
| facility Radiation Safety Committee did not consider this a                  |
| misadministration but a refusal of treatment by the patient. The 10% rule    |
| was considered by the Agency and a full report was filed by the hospital."   |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Fuel Cycle Facility                              |Event Number:   36051       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT      |NOTIFICATION DATE: 08/20/1999|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 19:06[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        08/20/1999|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        12:15[CDT]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  08/20/1999|
|    CITY:  PADUCAH                  REGION:  3  +-----------------------------+
|  COUNTY:  McCRACKEN                 STATE:  KY |PERSON          ORGANIZATION |
|LICENSE#:  GDP-1                 AGREEMENT:  Y  |BRENT CLAYTON        R3      |
|  DOCKET:  0707001                              |JOE HOLONICH         NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  ERIC WALKER                  |                             |
|  HQ OPS OFFICER:  WILLIAM POERTNER             |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NBNL                     RESPONSE-BULLETIN      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| 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.                                |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36052       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: LIMERICK                 REGION:  1  |NOTIFICATION DATE: 08/21/1999|
|    UNIT:  [1] [2] []                STATE:  PA |NOTIFICATION TIME: 12:51[EDT]|
|   RXTYPE: [1] GE-4,[2] GE-4                    |EVENT DATE:        08/20/1999|
+------------------------------------------------+EVENT TIME:        16:45[EDT]|
| NRC NOTIFIED BY:  JOHN HUNTER                  |LAST UPDATE DATE:  08/21/1999|
|  HQ OPS OFFICER:  WILLIAM POERTNER             +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |PETER ESELGROTH      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   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| 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.                                |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   36053       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  UNIVERSITY OF CT HEALTH CENTER       |NOTIFICATION DATE: 08/21/1999|
|LICENSEE:  UNIVERSITY OF CT HEALTH CENTER       |NOTIFICATION TIME: 14:31[EDT]|
|    CITY:  FARMINGTON               REGION:  1  |EVENT DATE:        08/20/1999|
|  COUNTY:                            STATE:  CT |EVENT TIME:        17:45[EDT]|
|LICENSE#:  0613022               AGREEMENT:  N  |LAST UPDATE DATE:  08/21/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |PETER ESELGROTH      R1      |
|                                                |JOE HOLONICH         NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  KEN PRICE                    |                             |
|  HQ OPS OFFICER:  WILLIAM POERTNER             |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| 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.)    |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36054       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: COOK                     REGION:  3  |NOTIFICATION DATE: 08/21/1999|
|    UNIT:  [1] [2] []                STATE:  MI |NOTIFICATION TIME: 16:18[EDT]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        08/21/1999|
+------------------------------------------------+EVENT TIME:        15:05[EDT]|
| NRC NOTIFIED BY:  STEVE KOSHAR                 |LAST UPDATE DATE:  08/21/1999|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |BRENT CLAYTON        R3      |
|10 CFR SECTION:                                 |                             |
|ADAS 50.72(b)(2)(i)      DEG/UNANALYZED COND    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          N       0        Refueling        |0        Refueling        |
|2     N          N       0        Refueling        |0        Refueling        |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| DISCOVERY THAT THE TECH SPEC ALLOWABLE LIMIT FOR DEGRADED BUS VOLTAGE        |
| SETTINGS MAY NOT PROTECT ALL SAFEGUARDS LOADS FROM THE EFFECTS OF AN         |
| UNDERVOLTAGE CONDITION UNDER ALL ACCIDENT CONDITIONS                         |
|                                                                              |
| The following text is a portion of a facsimile received from the licensee:   |
|                                                                              |
| "At 1305 [hours EDT on] 08/21/99, [the licensee] determined that the         |
| technical specification allowable limit for degraded bus voltage settings    |
| may not protect all safeguards loads from the effects of an undervoltage     |
| condition under all accident conditions.  A recent calculation has verified  |
| that under certain plant conditions, the current degraded bus undervoltage   |
| settings are below that required to insure proper operation of equipment     |
| powered by our 600-volt safeguards buses.  Safeguards loads on our 600-volt  |
| buses consists primarily of valves and ventilation equipment."               |
|                                                                              |
| "Currently, both units are in a defueled condition.  In the current mode,    |
| the degraded bus voltage function is not required.  Also, since the          |
| safeguards buses are lightly loaded during shutdown conditions, the impact   |
| due to low grid voltage is low.  An operability determination has been       |
| performed to demonstrate that the condition does not affect the operability  |
| of the safeguards buses while the plant is in a shutdown condition."         |
|                                                                              |
| "Actions are in progress to correct the low degraded bus voltage settings as |
| well as the limit specified in technical specifications."                    |
|                                                                              |
| The licensee notified the NRC resident inspector.                            |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36055       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: HOPE CREEK               REGION:  1  |NOTIFICATION DATE: 08/21/1999|
|    UNIT:  [1] [] []                 STATE:  NJ |NOTIFICATION TIME: 16:27[EDT]|
|   RXTYPE: [1] GE-4                             |EVENT DATE:        08/20/1999|
+------------------------------------------------+EVENT TIME:        23:58[EDT]|
| NRC NOTIFIED BY:  DEVON PRICE                  |LAST UPDATE DATE:  08/21/1999|
|  HQ OPS OFFICER:  WILLIAM POERTNER             +-----------------------------+
+------------------------------------------------+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  |70       Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| 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.                                |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36056       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: LASALLE                  REGION:  3  |NOTIFICATION DATE: 08/22/1999|
|    UNIT:  [] [2] []                 STATE:  IL |NOTIFICATION TIME: 02:32[EDT]|
|   RXTYPE: [1] GE-5,[2] GE-5                    |EVENT DATE:        08/21/1999|
+------------------------------------------------+EVENT TIME:        22:55[CDT]|
| NRC NOTIFIED BY:  BENNETT                      |LAST UPDATE DATE:  08/22/1999|
|  HQ OPS OFFICER:  CHAUNCEY GOULD               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |BRENT CLAYTON        R3      |
|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   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     A/R        Y       78       Power Operation  |0        Hot Shutdown     |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| THE PLANT HAD A REACTOR SCRAM AT 78% POWER ON A LOW REACTOR WATER LEVEL      |
| SIGNAL.                                                                      |
|                                                                              |
| AN AUTOMATIC REACTOR SCRAM OCCURRED ON A LOW REACTOR WATER LEVEL(LEVEL 3,    |
| 12.5")  AND WAS THE RESULT OF A FEEDWATER TRANSIENT WHICH OCCURRED DURING A  |
| PLANNED LOAD REDUCTION(REDUCTION IN REACTOR POWER).  DURING THE PLANNED      |
| POWER REDUCTION, OSCILLATIONS WERE NOTED ON THE REACTOR FEEDWATER PUMPS, SO  |
| THE REACTOR OPERATOR TOOK MANUAL CONTROL OF REACTOR WATER LEVEL IN AN        |
| ATTEMPT TO STABILIZE THE VESSEL LEVEL.  MANUAL CONTROL OF THE REACTOR LEVEL  |
| FAILED TO CONTROL LEVEL AND THE LEVEL REACHED THE AUTOMATIC SCRAM SETPOINT   |
| OF LEVEL 3 AND THE AUTOMATIC SCRAM OCCURRED.  THE REMAINDER OF THE PLANT     |
| RESPONDED AS EXPECTED AND LEVEL WAS RESTORED TO NORMAL BAND.  ALL RODS FULLY |
| INSERTED AND NO ECCS INJECTION OCCURRED OR SAFETY RELIEF VALVES LIFTED.  THE |
| CAUSE OF THE EVENT IS BEING INVESTIGATED.                                    |
|                                                                              |
| THE RESIDENT INSPECTOR WAS NOTIFIED.                                         |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Fuel Cycle Facility                              |Event Number:   36057       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT      |NOTIFICATION DATE: 08/22/1999|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 09:30[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        08/21/1999|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        19:55[CDT]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  08/22/1999|
|    CITY:  PADUCAH                  REGION:  3  +-----------------------------+
|  COUNTY:  McCRACKEN                 STATE:  KY |PERSON          ORGANIZATION |
|LICENSE#:  GDP-1                 AGREEMENT:  Y  |BRENT CLAYTON        R3      |
|  DOCKET:  0707001                              |JOE HOLONICH         NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  WALKER                       |                             |
|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|OCBB 76.120(c)(2)(ii)    EQUIP DISABLED/FAILS   |                             |
|NLTR                     LICENSEE 24 HR REPORT  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| THE CRITICALITY ACCIDENT ALARM SYSTEM (CAAS) HORN DID NOT PASS TESTING       |
| CRITERIA.                                                                    |
|                                                                              |
| At 1824 on 8/21/99, the Plant Shift Superintendent was notified that there   |
| may be a problem with a specific model of CAAS horn.  During testing of the  |
| new CAAS system in C-746-Q. the 30 watt AC/DC CAAS horn did not pass the     |
| testing criteria for horn actuation time. (Currently the new CAAS horns in   |
| C-748-Q building are not inservice and the building is serviced by the old   |
| System which does lot use these 30 watt AC/DC horns and remains operable)    |
| ANSI/ANS 8.3 identities that the CAAS System shall automatically initiate an |
| evacuation alarm signal within one half second of the alarm setpoint being   |
| exceeded.  Preliminary testing Indicated that the 30 watt AC/DC CAAS horn    |
| will not actuate in the required time frame (it takes 0.6 - 0.9 seconds).    |
| The C-710 facility uses the 30 watt AC/DC CAAS horn in its current inservice |
| configuration. During the initial investigation of this event, it was        |
| identified that when this type CAAS horn was installed in C-710, it was not  |
| tested for response time, however the 15 watt AC horns which are also        |
| installed in C-710 were tested within an acceptable time frame.  At that     |
| time, engineering did not suspect a deviation in horn activation response    |
| time between the two different horn types.  Since reasonable assurance of    |
| operability is not maintained for the 30 watt AC/DC CAAS horn, the C-710     |
| building was declared inoperable at 1955 on 8/21/99.                         |
|                                                                              |
| This event is reportable as "equipment is disabled and equipment Is required |
| by a TSR to be available and operable and no redundant equipment is          |
| available and operable".                                                     |
|                                                                              |
| Corrective actions have not yet been determined.                             |
|                                                                              |
| The NRC resident inspector has been notified of this event.                  |
+------------------------------------------------------------------------------+