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. |
+------------------------------------------------------------------------------+
Page Last Reviewed/Updated Wednesday, March 24, 2021