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Event Notification Report for September 27, 1999

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           09/24/1999 - 09/27/1999

                              ** EVENT NUMBERS **

36220  36221  36222  36223  36224  36225  36226  36227  36228  36229  36230  36231 
36232  

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36220       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: LIMERICK                 REGION:  1  |NOTIFICATION DATE: 09/23/1999|
|    UNIT:  [1] [2] []                STATE:  PA |NOTIFICATION TIME: 20:15[EDT]|
|   RXTYPE: [1] GE-4,[2] GE-4                    |EVENT DATE:        09/23/1999|
+------------------------------------------------+EVENT TIME:        20:00[EDT]|
| NRC NOTIFIED BY:  PHIL CHASE                   |LAST UPDATE DATE:  09/24/1999|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          UNU                   |ROBERT SUMMERS       R1      |
|10 CFR SECTION:                                 |JOHN HANNON          NRR     |
|AAEC 50.72 (a) (1) (I)   EMERGENCY DECLARED     |CHARLES MILLER       IRO     |
|AESF 50.72(b)(2)(ii)     ESF ACTUATION          |DAN RISHE            FEMA    |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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                                   
+------------------------------------------------------------------------------+
| PLANT ENTERED AN UNUSUAL EVENT - TOXIC GAS DETECTED IN UNIT 2 TURBINE        |
| ENCLOSURE                                                                    |
|                                                                              |
| An Unusual Event was declared at 2000 EDT due to readings of 65 ppm hydrogen |
| sulfide (HS) and 115 ppm carbon monoxide (CO) in the Unit 2 Turbine          |
| Enclosure.                                                                   |
|                                                                              |
| The oncoming shift reported the smell of rotten eggs when they arrived on    |
| site.  Inspection around the site determined the only place toxic gas was    |
| detectable was in the Unit 2 Turbine Enclosure.  There were no detectable    |
| levels of any toxic gas existing anywhere else around the plant.             |
| Inspections are on going around the plant.  The Unit 2 Turbine Enclosure has |
| been evacuated after an inspection for a source of the gasses.               |
|                                                                              |
| The licensee isolated the control room by manually initiating chlorine       |
| isolation as a precaution at 1922 EDT, this is an Engineered Safety Feature  |
| activation and reportable as a 4-hour notification.                          |
|                                                                              |
| The licensee notified the NRC Resident Inspector and the state/local         |
| government agencies.                                                         |
|                                                                              |
| * * * UPDATE AT 2321 EDT ON 9/23/99 BY TOM DOUGHERTY TO JOHN MacKINNON * *   |
| *                                                                            |
|                                                                              |
| The site de-escalated from the Unusual Event at 2312 EDT.  The toxic gas     |
| levels were verified to be nominal 0% in all areas inside and outside the    |
| power block.  The source of the toxic gas is still unknown and under         |
| investigation.  The licensee notified the NRC Resident Inspector and the     |
| state/local government agencies.  The R1DO (Robert Summers), NRR EO (John    |
| Hannon), IRO Manager (Charles Miller), and FEMA (Cegielski) have been        |
| informed.                                                                    |
|                                                                              |
| * * * UPDATE AT 1429 EDT ON 9/24/99 BY STAN GAMBLE TO FANGIE JONES * * *     |
|                                                                              |
| The licensee submitted a written summary of the event as a follow-up per     |
| their procedure guidance for NUREG-0654.  The source of the gas is still     |
| unknown, but the investigation continues.  The summary was sent to NRC       |
| Region 1.                                                                    |
|                                                                              |
| R1DO (Robert Summers) and NRR (Tad Marsh)                                    |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36221       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: DIABLO CANYON            REGION:  4  |NOTIFICATION DATE: 09/24/1999|
|    UNIT:  [1] [] []                 STATE:  CA |NOTIFICATION TIME: 02:13[EDT]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        09/23/1999|
+------------------------------------------------+EVENT TIME:        17:52[PDT]|
| NRC NOTIFIED BY:  STEVE WILSON                 |LAST UPDATE DATE:  09/24/1999|
|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |JOSEPH TAPIA         R4      |
|10 CFR SECTION:                                 |                             |
|AESF 50.72(b)(2)(ii)     ESF ACTUATION          |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          N       0        Hot Standby      |0        Hot Standby      |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| A TRANSFER IN OFFSITE POWER SOURCES CAUSED THE TURBINE DRIVEN AUXILIARY      |
| FEEDWATER PUMP TO AUTOMATICALLY START AND DISCHARGE WATER INTO THE STEAM     |
| GENERATORS.                                                                  |
|                                                                              |
| During restoration of relaying in the 500 kV switchyard an actuation caused  |
| the opening of the PCB breakers (Main Generator Breakers) supplying Unit 1   |
| from Auxiliary Power System).  Unit 1 power automatically transferred to the |
| Start-Up  power supply. The momentary loss of power during the transfer      |
| caused the Turbine Driven Auxiliary Feedwater Pump to start from an ESF      |
| actuation signal (12 kV Buses) and discharge into the Main Steam Generators. |
|                                                                              |
|                                                                              |
| Reactor Coolant Temperature decreased approximately 7 degrees F due to the   |
| operation of the Turbine Driven Auxiliary Feedwater Pump (Tave no load is    |
| 547 degrees F).  The Turbine Driven Auxiliary Feedwater pump operated for    |
| approximately 18 minutes before it was secured.  A Reactor Operator          |
| immediately closed the Turbine Driven Auxiliary Feedwater discharge valve(s) |
| to secure auxiliary feedwater to the Steam Generators, so there was very     |
| little discharge of auxiliary feedwater into the Steam Generators.  Reactor  |
| Coolant System cooldown was mainly due to the Turbine Driven Auxiliary       |
| Feedwater Turbine using the steam from the Steam Generators for its motive   |
| force.                                                                       |
|                                                                              |
| The NRC Resident Inspector will be informed of this event by the licensee.   |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   36222       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  HINES VA HOSPITAL                    |NOTIFICATION DATE: 09/24/1999|
|LICENSEE:  HINES VA HOSPITAL                    |NOTIFICATION TIME: 11:16[EDT]|
|    CITY:  MAYWOOD                  REGION:  3  |EVENT DATE:        09/23/1999|
|  COUNTY:                            STATE:  IL |EVENT TIME:        12:36[CDT]|
|LICENSE#:  12-01087-07           AGREEMENT:  Y  |LAST UPDATE DATE:  09/24/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |ROGER LANKSBURY      R3      |
|                                                |DON COOL             NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  L CASE                       |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| PATIENT'S ESOPHAGUS WAS RADIATED IN 11 DIFFERENT POSITIONS BUT IT WAS LATER  |
| DISCOVERED THAT THE AFTERLOADER WAS INITIALLY OFF BY 60 MILLIMETER AT THE    |
| START OF THE TREATMENT.                                                      |
|                                                                              |
|                                                                              |
| A patient was placed in the wrong site for radioactive treatment of his      |
| esophagus using a GammaMedIIi (afterloader). The patient's site was          |
| initially off by 60 millimeters when the afterloader started treatment of 11 |
| positions of  the patients esophagus.  The patient received 5 grays to 11    |
| positions in his esophagus but each one of the doses was off from the        |
| correct area to be irradiated by 60 millimeters.  The patient's physician    |
| was notified and the patient will be informed in writing within 15 days of   |
| the error.  The caller stated that the patient was not harmed by being       |
| irradiated in the incorrect areas of his esophagus.  The patient is          |
| scheduled for a second treatment  and during his next treatment the correct  |
| areas will be irradiated for a total dose of 5 grays times 2 fractions to 11 |
| the positions that were not treated in the first treatment because of the 60 |
| millimeter error.  The GammaMedIIi contains a 10 curie iridium-192 source.   |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36223       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SALEM                    REGION:  1  |NOTIFICATION DATE: 09/24/1999|
|    UNIT:  [1] [] []                 STATE:  NJ |NOTIFICATION TIME: 11:39[EDT]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        09/24/1999|
+------------------------------------------------+EVENT TIME:        07:54[EDT]|
| NRC NOTIFIED BY:  MIKE GWIRTZ                  |LAST UPDATE DATE:  09/24/1999|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |ROBERT SUMMERS       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          N       0        Refueling        |0        Refueling        |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| CONTAINMENT GASEOUS ACTIVITY MONITOR ALARM DURING DETENSIONING OF THE        |
| REACTOR VESSEL HEAD IN PREPARATION FOR A HEAD LIFT                           |
|                                                                              |
| The following text is a portion of a facsimile received from the licensee:   |
|                                                                              |
| "At 0754, with normal maintenance activities in progress, the 1R12A, [which  |
| is] the containment gaseous activity monitor, went into alarm.  The alarm    |
| setpoint is two times background per technical specifications, and [it] is   |
| set at 135 counts per minute.  The containment purge and  pressure relief    |
| valves were already closed, so no actuations occurred, although this was a   |
| valid signal.  Other containment area monitors showed no rise in activity    |
| levels other than one [local] area monitor on [the] 78 elevation which       |
| showed a slight increase.  No release [is in] progress.  We will continue to |
| monitor levels and investigate the source of the increase."                  |
|                                                                              |
| The licensee stated that the normal maintenance activities in progress at    |
| the time of the alarm involved detensioning of the reactor vessel head in    |
| preparation for a head lift.  The unit is not currently in a technical       |
| specification limiting condition for operation as a result of this event due |
| to the current mode of operation (Refueling).                                |
|                                                                              |
| The licensee plans to notify the NRC resident inspector and the Lower        |
| Alloways Creek Township.                                                     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   36224       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  TEXAS DEPARTMENT OF HEALTH           |NOTIFICATION DATE: 09/24/1999|
|LICENSEE:  RONE ENGINEERS                       |NOTIFICATION TIME: 11:52[EDT]|
|    CITY:  DALLAS                   REGION:  4  |EVENT DATE:        09/23/1999|
|  COUNTY:                            STATE:  TX |EVENT TIME:        11:00[CDT]|
|LICENSE#:                        AGREEMENT:  Y  |LAST UPDATE DATE:  09/24/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |JOSEPH TAPIA         R4      |
|                                                |DON COOL             NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  JAMES OGDEN                  |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|BAB1 20.2201(a)(1)(i)    LOST/STOLEN LNM>1000X  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT - STOLEN TROXLER GAUGE                                |
|                                                                              |
| "Another stolen Troxler Gauge Model 3401, Serial Number 9934, with two       |
| sources:  1) 7.8 mCi Cs-137, Serial Number 40-7404 and 2) 40 mCi AmBe-241,   |
| Serial Number 46-1316.                                                       |
|                                                                              |
| "Stolen Dallas, Texas, 09/23/99 at approximately 11:00 a.m. from Rone        |
| Engineers, 11234 Goodnight Lane, Dallas, Texas 75229, (817) 831-6211.        |
| Stolen from company pickup truck.  Lock cut and chain and device removed     |
| from truck while driver/operator at lunch.                                   |
|                                                                              |
| "Note:  This is the 7th gauge stolen/missing in the Dallas/North Texas area  |
| since March 1999.  Two more in the Houston area since October 1998.  Posting |
| notice to all Texas Licensees using MD gauges on BRC Website and in our      |
| Radiation Report (Winter Edition) concerning increased security needs for    |
| users of gauges."                                                            |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   36225       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  WESTVACO BLEACHBOARD DIVISION        |NOTIFICATION DATE: 09/24/1999|
|LICENSEE:  OHMART                               |NOTIFICATION TIME: 15:39[EDT]|
|    CITY:  COVINGTON                REGION:  2  |EVENT DATE:        09/23/1999|
|  COUNTY:                            STATE:  VA |EVENT TIME:        11:00[EDT]|
|LICENSE#:  45-01568-01           AGREEMENT:  N  |LAST UPDATE DATE:  09/24/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |THOMAS DECKER        R2      |
|                                                |KEVIN RAMSEY (FAX)   NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  RAYMOND HUNDLEY              |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|CCCC 21.21               UNSPECIFIED PARAGRAPH  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| 10 CFR PART 21 REPORT - FAILURE, SOURCE SHUTTER STUCK OPEN                   |
|                                                                              |
| During the performance of the six month surveillances of sources, one        |
| source's shutter was discovered to be stuck open.  The device is an Ohmart   |
| SH-F2-0, serial number 4612GK, with a sealed source of 1000 mCi of Cs-137.   |
| There is no indication of what the problem might be, no rust or apparent     |
| damage.  The shutter mechanism could not be moved manually.                  |
|                                                                              |
| The manufacturer was contacted and they directed the licensee to lubricate   |
| the shutter and if that did not free up the shutter mechanism, they would    |
| send representatives to the site.                                            |
|                                                                              |
| The device is used on the manufacturing line, it is a fixed installation.    |
| There is little or no safety implications to personnel as installed.         |
|                                                                              |
| * * * UPDATE AT 1626 EDT ON 9/24/99 BY RAYMOND HUNDLEY TO FANGIE JONES * *   |
| *                                                                            |
|                                                                              |
| The shutter mechanism was treated with lubricating oil and it was freed.     |
| The device is working properly.  A written report will follow within 30      |
| days.                                                                        |
|                                                                              |
| R2DO (Thomas Decker) and NMSS (Kevin Ramsey) have been contacted.            |
+------------------------------------------------------------------------------+

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36226       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: DRESDEN                  REGION:  3  |NOTIFICATION DATE: 09/24/1999|
|    UNIT:  [1] [2] []                STATE:  IL |NOTIFICATION TIME: 15:40[EDT]|
|   RXTYPE: [1] GE-1,[2] GE-3,[3] GE-3           |EVENT DATE:        09/24/1999|
+------------------------------------------------+EVENT TIME:        14:00[CDT]|
| NRC NOTIFIED BY:  PAUL SALGADO                 |LAST UPDATE DATE:  09/25/1999|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |ROGER LANKSBURY      R3      |
|10 CFR SECTION:                                 |                             |
|AOUT 50.72(b)(1)(ii)(B)  OUTSIDE DESIGN BASIS   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       99       Power Operation  |99       Power Operation  |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| VENTILATION DAMPER FOUND TO FAIL OPEN INSTEAD OF CLOSED                      |
|                                                                              |
| "During an engineering review of an industry event it was determined that a  |
| design flaw of a ventilation damper that feeds the Aux electric equipment    |
| room fails open instead of failing closed.  With this valve failing open it  |
| introduces 15000 CFM of air to the AEER and causes it to become positive in  |
| pressure with respect to the control room emergency  zone.  This allows a    |
| leak path into the control room and can affect the dose to the control room  |
| operators.  Compensatory measures are being planned that will gag closed     |
| this damper to rectify the problem."                                         |
|                                                                              |
| The gagging of the damper is the temporary fix, a long term fix is being     |
| investigated.                                                                |
|                                                                              |
| The licensee notified the NRC Resident Inspector.                            |
|                                                                              |
| * * * RETRACTED AT 1927 EDT ON 9/25/99 BY BRIAN SAMPSON TO FANGIE JONES * *  |
| *                                                                            |
|                                                                              |
| Upon further review of the damper operation by Dresden Operations and        |
| Engineering personnel, it was determined that the damper in question will    |
| fail closed, which is the desired position for post-accident conditions.     |
| Therefore the condition is not outside design basis, and is not reportable.  |
| This event report is retracted.                                              |
|                                                                              |
| The licensee notified the NRC Resident Inspector.  The R3DO (Roger           |
| Lanksbury) has been notified.                                                |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Fuel Cycle Facility                              |Event Number:   36227       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT   |NOTIFICATION DATE: 09/24/1999|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 17:15[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        09/24/1999|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        13:30[EDT]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  09/24/1999|
|    CITY:  PIKETON                  REGION:  3  +-----------------------------+
|  COUNTY:  PIKE                      STATE:  OH |PERSON          ORGANIZATION |
|LICENSE#:  GDP-2                 AGREEMENT:  N  |ROGER LANKSBURY      R3      |
|  DOCKET:  0707002                              |JOHN SURMEIER        NMSS    |
+------------------------------------------------+CHARLES MILLER       IRO     |
| NRC NOTIFIED BY:  RICK LARSON                  |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NBNL                     RESPONSE-BULLETIN      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| 4 HOUR NRC 91-01 BULLETIN REPORT                                             |
|                                                                              |
| "ON 9/24/99 AT 1330 AN ANALYSIS OF A TACKY TEXTURED SUBSTANCE FOUND IN THE   |
| SIDE PURGE PIPING DURING REPAIRS TO THIS SYSTEM REVEALS A URANIUM COMPOUND   |
| THAT IS UNPRECEDENTED IN CASCADE OPERATIONS.  THE COMPOUND UO2CL(OH).2H2O    |
| HAS A H/U RATIO OF 5.  THE ASSUMED PROCESS MODERATION CONDITION FOR          |
| NCSA-PLANT 062.AO2 HAS BEEN EXCEEDED, RESULTING IN A LOSS OF ONE LEG OF      |
| DOUBLE CONTINGENCY.  THE OTHER LEG OF DOUBLE CONTINGENCY (MASS CONTROL) HAS  |
| BEEN MAINTAINED.                                                             |
|                                                                              |
| "THIS IS REPORTABLE PER NRC BL 91-01 FOR 'OCCURRENCE OF ANY UNANTICIPATED OR |
| UNANALYZED EVENT FOR WHICH  THE CORRECTIVE ACTIONS TO RE-ESTABLISH DOUBLE    |
| CONTINGENCY ARE NOT READILY IDENTIFIABLE..                                   |
|                                                                              |
|                                                                              |
| "SAFETY SIGNIFICANCE OF EVENTS:                                              |
|                                                                              |
| "THE PRESENCE OF UO2CL(0H).2H2O (H/U = 5) RESULTS IN THE LOSS OF MODERATION  |
| CONTROL IN THE SECTION OF THE SIDE PURGE PIPING WHERE THE COMPOUND IS        |
| PRESENT (i.e., THE ASSUMED NORMAL MODERATION PROCESS CONDITION WAS           |
| EXCEEDED.) THE PREDOMINANT ENRICHMENT OF URANIUM-BEARING MATERIAL INSIDE THE |
| PIPE IS APPROXIMATELY 6%.  HOWEVER, THERE ARE NO GREATER THAN SAFE MASS      |
| DEPOSITS IN THE AREA NEAR THIS MATERIAL, NOR IS THERE A POTENTIAL FOR        |
| DEPOSIT MOVEMENT (e.g., VIA FLAKING) WHICH COULD CREATE A GREATER THAN SAFE  |
| MASS DEPOSIT.  THEREFORE, MASS CONTROL IS STILL MAINTAINED, AND A            |
| CRITICALITY CANNOT OCCUR WITHOUT THE ADDITION OF MORE URANIUM MASS.  THIS IS |
| HIGHLY UNLIKELY IF NOT INCREDIBLE BECAUSE THE SIDE PURGE CASCADE PIPING IS   |
| CURRENTLY ISOLATED FROM THE OPERATING CASCADE, AND IS AT A HIGHER PRESSURE   |
| THAN THE SURROUNDING OPERATING EQUIPMENT.  THE FORMATION OF THIS COMPOUND    |
| WAS ONLY POSSIBLE BECAUSE OF THE CONDITIONS PRESENT DURING THE X-326 FIRE;   |
| THEREFORE, OTHER CASCADE EQUIPMENT IS NOT IMPACTED BY THE PRESENCE OF THIS   |
| COMPOUND.  BASED ON THIS. IT IS CONCLUDED THAT THE SAFETY SIGNIFICANCE OF    |
| THIS EVENT IS LOW.                                                           |
|                                                                              |
| "POTENTIAL CRITICALITY PATHWAYS INVOLVED (BRIEF SCENARIO[S] OF HOW           |
| CRITICALITY COULD OCCUR);                                                    |
|                                                                              |
| "THE ONLY WAY THAT A CRITICALITY COULD OCCUR IS IF ADDITIONAL URANIUM MASS   |
| IS ADDED TO THE SIDE PURGE PIPE, CREATING A GREATER THAN SAFE MASS DEPOSIT.  |
| AS DISCUSSED ABOVE, THIS IS HIGHLY UNLIKELY IF NOT INCREDIBLE BECAUSE THE    |
| SIDE PURGE.  CASCADE PIPING IS CURRENTLY ISOLATED FROM THE OPERATING         |
| CASCADE, AND IS AT A HIGHER PRESSURE THAN THE SURROUNDING OPERATING          |
| EQUIPMENT.  THEREFORE, A VALVING ERROR WOULD HAVE TO OCCUR AT THE SAME TIME  |
| AS A MAJOR CASCADE UPSET CAUSING INCREASED PRESSURES IN THE SURROUNDING      |
| OPERATING CASCADE EQUIPMENT.  IN ORDER FOR THE MORE MASS TO ENTER THIS       |
| PIPE.                                                                        |
|                                                                              |
| "CONTROLLED PARAMETERS (MASS, MODERATION, GEOMETRY, CONCENTRATION, ETC.):    |
|                                                                              |
| "MASS MAINTAINED,  MODERATION-LOST                                           |
|                                                                              |
| "ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL (INCLUDE PROCESS    |
| LIMIT AND % WORST CASE OF CRITICAL MASS):                                    |
|                                                                              |
| "THE PREDOMINANT ENRICHMENT OF THE MATERIAL IN THE PIPE IS APPROXIMATELY 6%. |
| THE COMPOUND OF CONCERN IS IN THE FORM OF UO2CL(OH).2H2O (H/U=5).  THE MASS  |
| OF THE LARGEST DEPOSIT IN THE AREA IS APPROXIMATELY 159 GRAMS 235U, WHICH IS |
| WELL BELOW A SAFE MASS OF 740 GRAMS 235U.  THE SAFE MASS ASSUMES 6%          |
| ENRICHMENT OPTIMUM SPHERICAL GEOMETRY OPTIMUM MODERATION, AND FULL           |
| REFLECTION, AND INCLUDES A SAFETY MARGIN OF APPROXIMATELY A FACTOR OF 2 FROM |
| THE ACTUAL CRITICAL MASS.                                                    |
|                                                                              |
| "NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION  |
| OF THE FAILURES OR DEFICIENCIES:                                             |
|                                                                              |
| "THE NCSA PROVIDES CONTROLS ON MASS AND MODERATION.  THE PRESENCE OF         |
| UO2CL(OH).2H2O (H/U=5) RESULTS TS IN A LOSS OF CONTROL OF THE PROCESS        |
| CONDITION.  MASS CONTROLS WERE MAINTAINED.                                   |
|                                                                              |
| "CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEM AND WHEN EACH WAS IMPLEMENTED:  |
|                                                                              |
| "THE FOLLOWING CORRECTIONS ACTIONS ARE BEING TAKEN:  AREA WILL REMAIN        |
| BOUNDARIED, NCSA-PLANT 062 MAINTENANCE ACTIVITIES WILL REMAIN SUSPENDED, AND |
| NCS WILL DEVELOP AN NCSA TO COVER THIS OPERATION."                           |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   36228       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  WASHINGTON DEPARTMENT OF HEALTH      |NOTIFICATION DATE: 09/24/1999|
|LICENSEE:  WHEELABRATOR                         |NOTIFICATION TIME: 18:55[EDT]|
|    CITY:  SPOKANE                  REGION:  4  |EVENT DATE:        09/09/1999|
|  COUNTY:                            STATE:  WA |EVENT TIME:             [PDT]|
|LICENSE#:                        AGREEMENT:  Y  |LAST UPDATE DATE:  09/24/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |LAWRENCE YANDELL     R4      |
|                                                |JOHN SURMEIER        NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  TERRY FRAZEE                 |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| WASTE-TO-ENERGY FACILITY HAD RADIATION ALARM ON INCOMING LOAD                |
|                                                                              |
| Agreement State Event Report #WA-99-025                                      |
|                                                                              |
| The following text is a portion of E-mail received from the Washington       |
| Department of Health, Division of Radiation Protection:                      |
|                                                                              |
| "A waste-to-energy facility in Spokane reported a radiation alarm on an      |
| incoming load of residential waste.  The facility separated the load,        |
| finding a plastic bag with "kitty litter" reading about 8 mR/hr on contact.  |
| They notified DOH and isolated the material in their locked storage area. On |
| September 15, 1999, DOH staff identified the offending radionuclide to be    |
| I-131 and confirmed that the contents appeared to be cat litter.  There was  |
| no accompanying waste that could identify the origin of the waste.  It is    |
| presumed that a local cat was receiving                                      |
| treatment for a thyroid condition and had been released to its owner with a  |
| small amount of residual radioactivity (only a few microcuries were present  |
| in the litter).   The material is being held for decay.                      |
|                                                                              |
| "Activity and Isotope(s) involved: An unknown (but small) amount of I-131"   |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   36229       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  WASHINGTON DEPARTMENT OF HEALTH      |NOTIFICATION DATE: 09/24/1999|
|LICENSEE:  UNIVERSITY OF WASHINGTON HOSPITAL    |NOTIFICATION TIME: 19:02[EDT]|
|    CITY:  SEATTLE                  REGION:  4  |EVENT DATE:        09/17/1999|
|  COUNTY:                            STATE:  WA |EVENT TIME:             [PDT]|
|LICENSE#:  WN-C001-1             AGREEMENT:  Y  |LAST UPDATE DATE:  09/24/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |LAWRENCE YANDELL     R4      |
|                                                |JOHN SURMEIER        NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  ROBERT VERELLEN              |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| THREE I-125 BRACHYTHERAPY SOURCES LOST                                       |
|                                                                              |
| Agreement State Event Report #WA-99-027                                      |
|                                                                              |
| The following text is a portion of E-mail received from the Washington       |
| Department of Health, Division of Radiation Protection:                      |
|                                                                              |
| "THE LICENSEE REPORTED THE LOSS OF THREE I-125 BRACHY SOURCES, AMERSHAM      |
| MODEL 6720, 0.529 MICROCURIE EACH [1.587 MICROCURIES TOTAL].  THE SOURCES    |
| COME FROM THE MANUFACTURER IN A SET OF TEN SEEDS (SOURCES) IN A DICYL        |
| SUTURE.  FOR THE APPROPRIATE NUMBER OF SEEDS TO MEET THE INDIVIDUALIZED      |
| TREATMENT PLAN IT IS COMMON FOR THE SUTURE TO BE TRIMMED.  IN THIS CASE      |
| THREE SEEDS WERE TRIMMED BUT WERE UNACCOUNTED FOR DURING A SOURCE COUNT      |
| PERFORMED ON THE 17 SEPT. 1999.  UPON DISCOVERY OF THE MISSING SOURCES THE   |
| LICENSEE HAS PERFORMED SURVEY OF ALL POSSIBLE AREAS WITHIN THE HOSPITAL BUT  |
| DID NOT FIND THEM.  THEY REPORT THAT THE SOURCES WERE PROBABLY  LOST, MIXED  |
| WITH SOME OF THE OPERATING ROOM MATERIALS, WHICH HAD BEEN AUTOCLAVED AND     |
| DISPOSED OF IN A DUMPSTER WHICH HAD BEEN PICKED UP BEFORE THEY WERE AWARE OF |
| THE MISSING SOURCES.  AN INVESTIGATION IS ONGOING MORE DETAILS WILL BE       |
| FORTHCOMING."                                                                |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36230       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SAN ONOFRE               REGION:  4  |NOTIFICATION DATE: 09/25/1999|
|    UNIT:  [1] [2] []                STATE:  CA |NOTIFICATION TIME: 12:41[EDT]|
|   RXTYPE: [1] W-3-LP,[2] CE,[3] CE             |EVENT DATE:        09/24/1999|
+------------------------------------------------+EVENT TIME:        20:10[PDT]|
| NRC NOTIFIED BY:  CLAY WILLIAMS                |LAST UPDATE DATE:  09/25/1999|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |LAWRENCE YANDELL     R4      |
|10 CFR SECTION:                                 |                             |
|NLTR                     LICENSEE 24 HR REPORT  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
|  24 HOUR REPORT UNDER CONDITION OF LICENSE REGARDING FOR UNUSUAL FISH KILL   |
|                                                                              |
| A periodic heat treatment, the temperature of the intake structure is raised |
| in order to limit biological fouling.  After the heat treatment a fish kill  |
| was discovered.  The total weight, 4800 pounds, is greater than the          |
| reporting limit of 4500 pounds.                                              |
|                                                                              |
| The licensee notified the NRC Resident Inspection.                           |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36231       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SALEM                    REGION:  1  |NOTIFICATION DATE: 09/26/1999|
|    UNIT:  [1] [] []                 STATE:  NJ |NOTIFICATION TIME: 00:52[EDT]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        09/25/1999|
+------------------------------------------------+EVENT TIME:        23:30[EDT]|
| NRC NOTIFIED BY:  S. SAUER                     |LAST UPDATE DATE:  09/26/1999|
|  HQ OPS OFFICER:  BOB STRANSKY                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |ROBERT SUMMERS       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          N       0        Refueling        |0        Refueling        |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| CONTAINMENT VENTILATION ISOLATION                                            |
|                                                                              |
| An automatic containment ventilation isolation (CVI) was initiated by the    |
| containment air particulate monitor (1R11A). The containment purge system    |
| was in service at the time, and the system isolated as designed. The         |
| licensee is currently evaluating the cause of this isolation, and is         |
| obtaining and analyzing grab samples to determine whether an increase in     |
| particulate activity may have occurred.                                      |
|                                                                              |
| The NRC resident inspector will be informed of this event by the licensee.   |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36232       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: VOGTLE                   REGION:  2  |NOTIFICATION DATE: 09/26/1999|
|    UNIT:  [] [2] []                 STATE:  GA |NOTIFICATION TIME: 06:45[EDT]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        09/26/1999|
+------------------------------------------------+EVENT TIME:        03:30[EDT]|
| NRC NOTIFIED BY:  CHARLIE MEYER                |LAST UPDATE DATE:  09/26/1999|
|  HQ OPS OFFICER:  BOB STRANSKY                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |THOMAS DECKER        R2      |
|10 CFR SECTION:                                 |                             |
|AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     N          Y       93       Power Operation  |93       Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| BOTH TRAINS OF THE SAFETY INJECTION SYSTEM DECLARED INOPERABLE               |
|                                                                              |
| Both trains of the safety injection (SI) system were declared inoperable due |
| to the discovery of excessive volumes of air from both SI pump casings. The  |
| air was discovered during performance of the monthly ECCS flow path          |
| verification surveillance procedure. Both pumps were subsequently vented and |
| declared operable at 0610 9/26/1999. The licensee is investigating the cause |
| of the entrapped air.                                                        |
|                                                                              |
| The NRC resident inspector has been informed of this event by the licensee.  |
+------------------------------------------------------------------------------+