Event Notification Report for October 19, 1999
U.S. Nuclear Regulatory Commission Operations Center Event Reports For 10/18/1999 - 10/19/1999 ** EVENT NUMBERS ** 36218 36285 36299 36305 36306 36307 36308 +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 36218 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: SUMMER REGION: 2 |NOTIFICATION DATE: 09/23/1999| | UNIT: [1] [] [] STATE: SC |NOTIFICATION TIME: 17:08[EDT]| | RXTYPE: [1] W-3-LP |EVENT DATE: 08/06/1999| +------------------------------------------------+EVENT TIME: 10:00[EDT]| | NRC NOTIFIED BY: MICHAEL ZACCONE |LAST UPDATE DATE: 10/18/1999| | HQ OPS OFFICER: FANGIE JONES +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: N/A |THOMAS DECKER R2 | |10 CFR SECTION: |VERN HODGE (FAX) NRR | |CCCC 21.21 UNSPECIFIED PARAGRAPH | | | | | | | | | | | +-----+----------+-------+--------+-----------------+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ |1 N Y 100 Power Operation |100 Power Operation | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | 10 CFR PART 21 REPORT - ABB K-LINE BREAKER DEFECT | | | | The following text is a portion of a facsimile received from the licensee: | | | | "This report is being made pursuant to 10 CFR 21.21 [in order] to identify a | | substantial safety hazard with an ABB K-line breaker." | | | | "On August 6, 1999, Virgil C. Summer Nuclear Station (VCSNS) determined that | | a substantial safety hazard could exist with ABB K-line breakers failing to | | trip. Improper routing/support of the shunt trip wires during refurbishment | | caused interference with the red trip-shaft paddle on the left side of the | | breaker. This condition was found on a breaker installed in [a] | | safety-related switchgear at VCSNS. This breaker condition was compared to | | several other ABB K-line breakers at the plant site. The other breakers | | were found to have the wires routed in a different direction, precluding | | interference with the red trip-shaft paddle." | | | | "VCSNS utilizes these breakers in many applications, including the 480-VAC, | | safety-related, electrical buses. The shunt trip wiring problem is | | considered a defect in repair. This condition represents a potential for a | | common mode failure for safety-related K-line breakers." | | | | "The vendor has been notified of the shunt trip wiring problem and has | | agreed to modify the procedure for the refurbishment of these breakers. | | VCSNS Engineering has determined that vendor procedure changes | | should prevent recurrence of this problem." | | | | The licensee notified the NRC resident inspector. | | | | ********************* UPDATE AT 0934 ON 10/18/99 FROM PHIL ROSE TO LEIGH | | TROCINE ******************** | | | | The following text is a portion of a facsimile received from the licensee: | | | | "On [10/07/99], ABB Service and VCSNS personnel inspected the affected | | breaker along with a second K-line breaker that was determined to also be | | potentially affected at VCSNS. It was determined that the following | | information should be provided to all licensees regarding this issue:" | | | | "The potentially affected breakers at ABB K-line breakers of the following | | type: | | * all electrically-operated breakers model K-1600, K-1600S, K-2000, | | K-2000S, and K-225 through K-800[; and] | | * any mechanically- or electrically-operated breakers with the above model | | numbers which have any | | auxiliary switches or a shunt trip." | | | | "The potential impact on the breakers has been assessed to be either of the | | following: | | * For breakers having the shunt trip coil wiring on top of the tripper | | paddle, a trip free condition could result. | | * For breakers which have the shunt trip coil wiring underneath the tripper | | paddle, the overload trip could be | | prevented from operating. The circuit breaker is capable of a manual or | | electrical trip. This condition | | impacts the overload trip function only." | | | | "It was also determined that this problem was not limited to the breaker | | refurbishment/repair process by ABB Service. [The licensee stated that this | | condition could occur on new breakers.]" | | | | "VCSNS has inspected 26 safety-related breakers. One breaker was found to | | be affected and another potentially affected. Corrective actions have been | | taken. VCSNS has also inspected three non-safety-related breakers with no | | further problems identified. The remaining breakers (four safety related | | and five non-safety related) have been added to the scope of the next | | refueling outage." | | | | "[Both] VCSNS and ABB Service recommend inspection of all potentially | | affected breakers as soon as they can be made available. The recommended | | corrective action is to inspect and secure any wiring that could potentially | | interfere with the proper operation of the tripper paddle." | | | | The licensee stated that a 30-day report regarding this issue is due to be | | issued this week. The licensee notified the NRC resident inspector. The | | NRC operations officer notified the R1DO (Cook), R2DO (Julian), R3DO | | (Jorgensen), R4DO (Smith), and NRR (Hodge). | +------------------------------------------------------------------------------+ !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 36285 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: PEACH BOTTOM REGION: 1 |NOTIFICATION DATE: 10/13/1999| | UNIT: [] [3] [] STATE: PA |NOTIFICATION TIME: 07:12[EDT]| | RXTYPE: [2] GE-4,[3] GE-4 |EVENT DATE: 10/13/1999| +------------------------------------------------+EVENT TIME: 03:26[EDT]| | NRC NOTIFIED BY: CAMERON CAMPBELL |LAST UPDATE DATE: 10/18/1999| | HQ OPS OFFICER: FANGIE JONES +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: N/A |JAMES NOGGLE R1 | |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 | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | |3 N N 0 Refueling |0 Refueling | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | REACTOR TRIP GENERATED DURING TESTING, PLANT ALREADY SHUTDOWN | | | | During refueling outage activities a 'Full Scram' signal was initiated while | | testing the main steam line high radiation instrumentation. No control rod | | or 'Group I' isolation valve movement occurred as a result of this signal | | since all affected equipment was in the tripped condition due to plant | | conditions. The only valve movement was the scram discharge volume vent and | | drain valves which closed per design. | | | | The 'Full Scram' and 'Group I' isolation signal resulted as a result of | | testing inadequacies. The signal was reset and the valves were opened per | | plant procedures. | | | | The NRC Resident Inspector was informed. | | | | * * * RETRACTION AT 1530 ON 10/18/1999 FROM WEILGOPOLSKI TAKEN BY STRANSKY * | | * * | | | | "This event involved a 4-hour report made for the inadvertent ESF actuation | | under 10 CFR 50.72(b)(2)(ii). The event occurred while Unit 3 was in a | | refueling outage and involved a full scram signal being initiated during | | testing of the main steam line high radiation instrumentation. The event had | | no control rod movement or Group 1 isolation valve movement since all | | affected equipment was in the tripped condition during to refueling | | activities. The only valve movement that occurred was the scram discharge | | volume (SDV) vent and drain valves which closed. | | | | "Although the SDV vent and drain valves closed and are primary containment | | isolation valves, this event is being retracted based on the following: | | * ESF actuation signal was invalid because it was caused by a procedural | | error; and | | * the SDV vent and drain valve primary containment function was properly | | removed from service as a result of | | [Point Beach Atomic Power Station (PBAPS)] Unit 3 being in a refueling | | outage (Mode 5) and the primary | | containment breached." | | | | The NRC resident inspector has been informed of this retraction. The NRC | | operations officer notified the R1DO (Cook). | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 36299 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: PALO VERDE REGION: 4 |NOTIFICATION DATE: 10/16/1999| | UNIT: [1] [2] [3] STATE: AZ |NOTIFICATION TIME: 06:55[EDT]| | RXTYPE: [1] CE,[2] CE,[3] CE |EVENT DATE: 10/16/1999| +------------------------------------------------+EVENT TIME: 03:05[MST]| | NRC NOTIFIED BY: JIM BLAZICK |LAST UPDATE DATE: 10/18/1999| | HQ OPS OFFICER: FANGIE JONES +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: UNU |GAIL GOOD R4 | |10 CFR SECTION: |WILLIAM BATEMAN NRR | |AAEC 50.72 (a) (1) (I) EMERGENCY DECLARED |FRANK CONGEL IRO | |APRE 50.72(b)(2)(vi) OFFSITE NOTIFICATION |RICHE FEMA | | |WILLIAM BRACH NMSS | | |TED MICHAELS REXB | +-----+----------+-------+--------+-----------------+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ |1 N N 0 Refueling |0 Refueling | |2 N Y 100 Power Operation |100 Power Operation | |3 N Y 100 Power Operation |100 Power Operation | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | UNUSUAL EVENT DECLARED DUE TO EARTHQUAKE FELT ON SITE. (Refer to event | | #36298 for a related event at San Onofre.) | | | | An earthquake of magnitude 7.0 occurred at 0247 MST at coordinates 34 | | degrees 35.73 minutes north, 116 degrees 16.09 minutes west. This location | | is about 32 miles north of Joshua Tree, California, and 47 miles | | east-southeast of Barstow, California. This information is from the U.S. | | Geological Survey Southern California Seismic Network. | | | | The licensee felt the earthquake, and the strong motion accelerometer | | alarmed. An approximate intensity level of 0.015g's has been determined. | | Unit 1 is defueled, and Units 2 and 3 are in operation with no problems. | | Inspections were carried out per procedures as well as the declaration of | | the Unusual Event. Engineering walkdowns and evaluations are in progress | | per procedure. | | | | The Unusual Event was entered and exited at 0305 MST. | | | | The licensee notified the NRC Resident Inspector as well and state/local | | authorities. | | | | ***************** UPDATE AT 0100 EDT ON 10/18/99 FROM DANN DAILEY TO LEIGH | | TROCINE ***************** | | | | The following text is a portion of a facsimile received from the licensee: | | | | "This is a followup of the ENS notification at 0353 MST on 10/16/99. If | | through subsequent reviews of this event, additional information is | | identified that is pertinent to this event or alters the information being | | provided at this time, another followup notification will be made via the | | ENS or under the reporting requirements of 10CFR50.73." | | | | "On [10/16/99], at approximately 0247 MST, an earthquake, referred to as the | | 'Hector Earthquake,' of approximate magnitude 7.0 occurred, its epicenter | | located about 32 miles north of Joshua Tree, California. Joshua Tree, | | California is located approximately 220 miles west of the Palo Verde Nuclear | | Generating Station. At approximately 0248 MST, the vibratory ground motion | | reached and actuated the Palo Verde Seismic Monitoring Instrumentation | | switches. Specifically, the strong motion accelerometer trigger located in | | the Unit 1 containment building tendon gallery exceeded the threshold value | | of 0.01g. The vibratory ground motion also was felt by personnel in all | | three Palo Verde control rooms. Operations personnel immediately retrieved | | data from the actuated instrument and performed analysis to determine the | | magnitude of the vibratory ground motion. Initial analysis of the Seismic | | Monitoring Instrumentation tape recordings completed at approximately 0305 | | MST indicated a seismic event of about 0.015g. This is well below the | | magnitude of the 0.10g spectra Operating Basis Earthquake (OBE) and the | | 0.20g spectra Safe Shutdown Earthquake (SSE). Based on the validation of | | the earthquake per the Emergency Action Level 6.6 Technical Bases, the Unit | | 1 Shift Manager declared (and immediately exited due to the event being | | over) a Notification of an Unusual Event (NUE) applicable to all three units | | due to a seismic event." | | | | "The NRC was notified at 0353 MST on 10/16/99 via the Emergency Notification | | System (ENS). The criteria for the ENS notification were | | 10CFR50.72(a)(1)(i) due to the declaration of an Emergency Class and | | 10CFR50.72(b)(1)(iii) due to the natural phenomenon that poses an actual | | threat to the safety of the nuclear power plant. Further analysis of the | | seismic data concluded the measured motions of structures and components | | were less than 14% of the OBE and should have no effect upon facility | | features important to safety. Based on the low magnitude of the vibratory | | ground motion and satisfactory plant walkdowns, an actual threat to safety | | did not exist. The ENS notification per 10CFR50.72(b)(1)(iii) is hereby | | retracted. The initial notification stated a press release was expected to | | be made; therefore, 10CFR50.72(b)(2)(vi) also applied. No media interest | | existed; therefore, no press release was made. The ENS notification per | | 10CFR50.72(a)(1)(i) remains valid." | | | | "Following declaration of the NUE, the Maricopa County Sheriff's Office and | | the Arizona Department of Public Safety were notified at approximately 0313 | | MST via the Notification and Alert Network (NAN). The Palo Verde Emergency | | Coordinator recommended that no protective actions be taken. No protective | | actions were implemented by state or county agencies." | | | | "Operations personnel performed an immediate walkdown of plant equipment. | | No abnormalities caused by the seismic event were observed. There were no | | structures, systems, or components that were inoperable that contributed to | | this event. There were no failures that rendered a train of a safety system | | inoperable, and no failures of components with multiple functions were | | involved. No engineered safety feature (ESF) actuations occurred, and none | | were required. The event did not result in any challenges to the fission | | product barrier or result in any releases of radioactive materials. The | | event did not adversely affect the safe operation of the plant or health and | | safety of the public." | | | | The licensee notified the NRC resident inspector. The NRC operations | | officer notified the R4DO (Good), NRR EO (Bateman), and IRO (Congel). | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 36305 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: BYRON REGION: 3 |NOTIFICATION DATE: 10/18/1999| | UNIT: [1] [2] [] STATE: IL |NOTIFICATION TIME: 12:53[EDT]| | RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 10/18/1999| +------------------------------------------------+EVENT TIME: 10:55[CDT]| | NRC NOTIFIED BY: SCOTT SWANSON |LAST UPDATE DATE: 10/18/1999| | HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: N/A |BRUCE JORGENSEN R3 | |10 CFR SECTION: | | |BAAA 20.1906(d) SURFACE CONT/ EXT RAD | | | | | | | | | | | +-----+----------+-------+--------+-----------------+--------+-----------------+ |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 93 Power Operation |93 Power Operation | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | SHIPMENT RECEIVED WITH SURFACE CONTAMINATION IN EXCESS OF SHIPPING LIMITS. | | | | A shipment containing a portable demineralizer resin tank received from the | | Point Beach Nuclear Station had external removable contamination in excess | | of shipping limits. Smears taken from the shipment were placed in a | | radiation detector, and readings of up to 52,800 dpm were observed. The | | licensee has contacted the shipper (Hitman). | | | | The NRC resident inspector has been informed of this event by the licensee. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Hospital |Event Number: 36306 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | REP ORG: ST. JOHN'S HOSPITAL |NOTIFICATION DATE: 10/18/1999| |LICENSEE: ST. JOHN'S HOSPITAL |NOTIFICATION TIME: 14:35[EDT]| | CITY: DETROIT REGION: 3 |EVENT DATE: 09/07/1999| | COUNTY: STATE: MI |EVENT TIME: [EDT]| |LICENSE#: 21-03210-01 AGREEMENT: N |LAST UPDATE DATE: 10/18/1999| | DOCKET: |+----------------------------+ | |PERSON ORGANIZATION | | |BRUCE JORGENSEN R3 | | |BRIAN SMITH NMSS | +------------------------------------------------+ | | NRC NOTIFIED BY: WALTER NIKESCH | | | HQ OPS OFFICER: BOB STRANSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: N/A | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | MEDICAL MISADMINISTRATION | | | | While performing a monthly audit, the licensee discovered that a patient, | | who had been prescribed a dose of 200 mCi of I-131 for thyroid ablation, was | | administered a dose of 264 mCi of I-131. The misadministration occurred on | | 9/7/1999. The attending physician has been informed of the | | misadministration. The licensee has also contacted NRC Region III (J. | | Cameron). | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |General Information or Other |Event Number: 36307 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | REP ORG: CALIFORNIA RADIATION CONTROL PRGM |NOTIFICATION DATE: 10/18/1999| |LICENSEE: MILLER PACIFIC ENGINEERING GROUP |NOTIFICATION TIME: 19:00[EDT]| | CITY: SANTA ROSA REGION: 4 |EVENT DATE: 10/18/1999| | COUNTY: STATE: CA |EVENT TIME: 02:00[PDT]| |LICENSE#: 5411-21 (CA) AGREEMENT: Y |LAST UPDATE DATE: 10/18/1999| | DOCKET: |+----------------------------+ | |PERSON ORGANIZATION | | |LINDA SMITH R4 | | |WAYNE HODGES NMSS | +------------------------------------------------+ | | NRC NOTIFIED BY: DONALD BUNN | | | HQ OPS OFFICER: BOB STRANSKY | | +------------------------------------------------+ | |EMERGENCY CLASS: N/A | | |10 CFR SECTION: | | |NAGR AGREEMENT STATE | | | | | | | | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | STOLEN MOISTURE/DENSITY GAUGE | | | | A representative of the California State Radiation Control Program reported | | the theft of a CPM Model MC-1DR moisture/density gauge from a state | | licensee. The gauge contains one 10-mCi Cs-137 source, and one 40-mCi | | Am-241/Be source. The local police are investigating the theft and plan to | | file a report with the state. The licensee has issued a press release | | regarding the theft. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 36308 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | FACILITY: COOPER REGION: 4 |NOTIFICATION DATE: 10/18/1999| | UNIT: [1] [] [] STATE: NE |NOTIFICATION TIME: 20:28[EDT]| | RXTYPE: [1] GE-4 |EVENT DATE: 10/18/1999| +------------------------------------------------+EVENT TIME: 15:12[CDT]| | NRC NOTIFIED BY: WILLIAM B. GREEN |LAST UPDATE DATE: 10/18/1999| | HQ OPS OFFICER: BOB STRANSKY +-----------------------------+ +------------------------------------------------+PERSON ORGANIZATION | |EMERGENCY CLASS: N/A |LINDA SMITH 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 Y 100 Power Operation |100 Power Operation | | | | | | | +------------------------------------------------------------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | SPURIOUS BUS UNDERVOLTAGE ALARM CAUSES VARIOUS ESF ACTUATIONS. | | | | "At 1512 CDT on 10/18/99, 4160 bus 1B [undervoltage annunciator] alarmed and | | 4160 bus 1B breaker 1BG, the normal power supply to essential 4160 bus 1G, | | tripped. The emergency transformer, through breaker 1GS, began supplying | | power to essential 4160 bus 1G. Diesel generator #2 automatically started on | | the undervoltage condition but did not load since essential bus 1G was being | | supplied by the emergency transformer as designed. | | | | "Primary containment isolation system (PCIS) Group isolations for [the] | | reactor water cleanup system and reactor building isolation occurred due to | | a loss of power. Emergency Operating Procedure 5A, Secondary Containment | | Control, was entered due to reactor building pressure going positive, the | | maximum value reached during the transient was +0.01 inches water gage. Both | | trains of standby gas treatment started on the Group 6 isolation and | | returned reactor building pressure to a negative value. | | | | "PCIS Group Isolations 2 and 7 had some valves reposition. These valves were | | consistent with valves that would reposition on a loss of power. However, | | two valves normally actuated by a half group isolation on the division 2 | | side did not reposition. It is believed that this condition occurred due to | | the speed of actuation of relays in the PCIS system and is being | | investigated. | | | | "Circulating water pump 1C tripped during the transient, and the steam jet | | air ejectors (SJAE) isolated during the electrical transient. These | | conditions caused main condenser vacuum to lower to a point that the turbine | | generator low vacuum pre-trip alarm was received at 25 inches Hg lowering. | | The SJAEs were reset, and vacuum in the main condenser began to rise. The | | lowest vacuum indicated was 24.5 inches Hg. Vacuum is currently 26.5 inches | | Hg. | | | | "At the time of the event, Electrical Maintenance Personnel were installing | | monitoring equipment in the condensate pump B cubicle. | | | | "4160 Bus 1G is currently being supplied from the emergency transformer, and | | diesel generator #2 [was] returned to a normal standby lineup at 1634 [CDT]. | | The electrical grid is stable, and the reactor and secondary plant are in a | | stable condition. | | | | "The undervoltage alarm for 4160 bus 1B is still actuated even though an | | actual undervoltage does not exist on the bus. A team of personnel is | | investigating the undervoltage condition at this time." | | | | The NRC resident inspector has been informed of this event by the licensee. | +------------------------------------------------------------------------------+
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