Event Notification Report for October 29, 1999
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
10/28/1999 - 10/29/1999
** EVENT NUMBERS **
36358 36359 36360 36361 36362 36363 36364 36365 36366 36367 36368 36369
36370
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36358 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: LIMERICK REGION: 1 |NOTIFICATION DATE: 10/28/1999|
| UNIT: [1] [2] [] STATE: PA |NOTIFICATION TIME: 03:45[EDT]|
| RXTYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 10/28/1999|
+------------------------------------------------+EVENT TIME: 03:35[EDT]|
| NRC NOTIFIED BY: BENDER |LAST UPDATE DATE: 10/28/1999|
| HQ OPS OFFICER: BOB STRANSKY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: UNU |DAVID LEW R1 |
|10 CFR SECTION: |DAVID MATTHEWS NRR |
|AAEC 50.72 (a) (1) (I) EMERGENCY DECLARED |CHARLES MILLER IRO |
|DDDD 73.71 UNSPECIFIED PARAGRAPH |ROBERTA WARREN IAT |
| |RICHARD ROSANO IAT |
| |GREG SMITH IAT |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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 21 Power Operation |21 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| UNUSUAL EVENT DECLARED DUE TO BOMB THREAT |
| |
| Contact the NRC Operations Center for additional details. The NRC resident |
| inspector will be informed. |
| |
| * * * COMMISSIONERS' ASSISTANTS BRIEFING HELD AT 0630 EDT * * * |
| |
| Briefer: H. Miller. Participants: C. Miller (IRO), Adensam, Matthews (NRR), |
| Ten Eyck (NMSS), Beecher (OPA), Lohaus (OSP), Hauber (OIP), Madden (OCA), |
| Tschiltz (EDO), Paperiello (DEDE), Boyce, Olencz (Dicus), Sharkey |
| (McGaffigan), Castleman (Diaz), Doane (Merrifield), Rosano, Warren (IAT), |
| Screnci (R1PAO). |
| |
| * * * UPDATE 1134 10/28/1999 FROM JOHN HUNTER TAKEN BY STRANSKY * * * |
| |
| The licensee terminated the Unusual Event at 1124 EDT. Searches of the plant |
| protected area were completed without the discovery of any suspicious |
| devices. In addition, the threat, initially determined to be credible, has |
| been determined not to be credible. The NRC resident inspector has been |
| informed of this update by the licensee. Notified R1DO (Lew), NRR EO |
| (Lyons), FEMA (Sullivan). |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36359 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SOUTH TEXAS REGION: 4 |NOTIFICATION DATE: 10/28/1999|
| UNIT: [1] [] [] STATE: TX |NOTIFICATION TIME: 10:13[EDT]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 04/22/1999|
+------------------------------------------------+EVENT TIME: 21:00[CDT]|
| NRC NOTIFIED BY: JIM MORRIS |LAST UPDATE DATE: 10/28/1999|
| HQ OPS OFFICER: BOB STRANSKY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |CHARLES MARSCHALL 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 N 0 Refueling |0 Refueling |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| 24-HOUR REPORT REQUIRED BY FACILITY OPERATING LICENSE |
| |
| "24-hour Report regarding Violation of Operating License NPF-76 for |
| performing Core Alterations in Unit 1 while Containment Equipment Hatch was |
| open. |
| |
| "In accordance with Technical Specification 3.9.4, Containment Building |
| Penetrations, the equipment hatch must be closed and held in place by at |
| least four bolts during Core Alterations or movement of irradiated fuel |
| within the containment. |
| |
| "The South Texas Project Technical Specifications define Core Alterations as |
| the movement or manipulation of any component within the reactor pressure |
| vessel with the vessel head removed and fuel in the vessel. The insertion of |
| the incore detector thimbles into the core is considered a Core Alteration. |
| |
| "It has been determined that during Unit 1 refueling outage 1RE08, between |
| 2100 hours on April 22, 1999, and 0030 hours on April 23, 1999, the incore |
| detector thimbles were inserted into the reactor core after the containment |
| equipment hatch was opened. At this time all fuel assemblies had been |
| reloaded into the reactor core and refueling cavity level had been reduced |
| to permit setting the reactor vessel head. |
| |
| "This notification is being made pursuant to Operating License NPF-76 |
| Condition 2.G for operation or condition prohibited by Technical |
| Specifications." |
| |
| The licensee discovered this occurrence as the result of a review of a |
| Condition Report. |
| The NRC resident inspector has been informed of this event by the licensee. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36360 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: OCONEE REGION: 2 |NOTIFICATION DATE: 10/28/1999|
| UNIT: [1] [2] [3] STATE: SC |NOTIFICATION TIME: 10:54[EDT]|
| RXTYPE: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-L|EVENT DATE: 10/28/1999|
+------------------------------------------------+EVENT TIME: 08:20[EDT]|
| NRC NOTIFIED BY: PAULINE BEATTY |LAST UPDATE DATE: 10/28/1999|
| HQ OPS OFFICER: BOB STRANSKY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |MARK LESSER R2 |
|10 CFR SECTION: | |
|HFIT 26.73 FITNESS FOR DUTY | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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 |
|3 N Y 100 Power Operation |100 Power Operation |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| FITNESS FOR DUTY EVENT |
| |
| A licensed operator tested positive for illegal drug use during a random |
| screening. The individual's site access has been suspended, and the |
| individual will be referred to the Employee Assistance Program for |
| evaluation. The NRC resident inspector has been informed of this event by |
| the licensee. Contact the NRC Operations Center for additional details. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36361 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: ROBINSON REGION: 2 |NOTIFICATION DATE: 10/28/1999|
| UNIT: [2] [] [] STATE: SC |NOTIFICATION TIME: 11:14[EDT]|
| RXTYPE: [2] W-3-LP |EVENT DATE: 10/28/1999|
+------------------------------------------------+EVENT TIME: 10:19[EDT]|
| NRC NOTIFIED BY: DAVE BLAKENEY |LAST UPDATE DATE: 10/28/1999|
| HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |MARK LESSER R2 |
|10 CFR SECTION: | |
|DDDD 73.71 UNSPECIFIED PARAGRAPH | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|2 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| SECURITY EVENT - |
| |
| UNESCORTED ACCESS GRANTED INAPPROPRIATELY TO A CONTRACTOR EMPLOYEE. |
| COMPENSATORY ACTIONS TAKEN IMMEDIATELY UPON DISCOVERY. CONTACT THE NRC |
| HEADQUARTERS OPERATIONS OFFICER FOR ADDITIONAL DETAILS. THE LICENSEE |
| NOTIFIED THE NRC RESIDENT INSPECTOR. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36362 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: FERMI REGION: 3 |NOTIFICATION DATE: 10/28/1999|
| UNIT: [2] [] [] STATE: MI |NOTIFICATION TIME: 11:57[EDT]|
| RXTYPE: [2] GE-4 |EVENT DATE: 10/27/1999|
+------------------------------------------------+EVENT TIME: 17:00[EDT]|
| NRC NOTIFIED BY: SANJEEV ARAB |LAST UPDATE DATE: 10/28/1999|
| HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |MIKE JORDAN R3 |
|10 CFR SECTION: | |
|NLTR LICENSEE 24 HR REPORT | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|2 N Y 97 Power Operation |97 Power Operation |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| - PLANT FIRE PROTECTION PROGRAM PROCEDURES DID NOT INCLUDE CERTAIN FIRE |
| ZONES - |
| |
| During the performance of a licensee Fire Protection Audit, it was |
| discovered that an error existed in plant procedures designed to shut the |
| plant down in the event of a fire in plant areas where hot shorts could |
| challenge safe plant operation. In 1994, a new style air-operated HPCI/RCIC |
| test return valve was installed in the plant. At the time, it was |
| recognized that due to cable run locations, hot shorts could be created in |
| the event of a fire in certain areas that would cause the valve to open |
| inadvertently. This would cause bypass of standby feedwater flow to the |
| condensate storage tank instead of the reactor pressure vessel (RPV) and |
| challenge the ability to maintain RPV level. Plant procedures for dedicated |
| shutdown were revised to isolate air to that valve to prevent this response |
| for fires in specified zones. However, during a recent licensee audit, it |
| was discovered that hot shorts for the test valve could exist for fires in |
| some plant zones not previously identified. This was discovered at 1700 on |
| 10/27/99. The procedure has since been corrected to add these zones. |
| |
| This event constitutes a non-compliance with the approved Fire Protection |
| Program which could have adversely affected the plant's ability to achieve |
| and maintain safe shutdown in the event of a fire. This is reportable as a |
| condition not in compliance with Fermi 2 Operating License NPF-43, License |
| Condition 2.C.9. This notification is required to be submitted within 24 |
| hours in accordance with NRC License NPF-43, Section 2.F. |
| |
| The licensee plans to notify the NRC Resident Inspector. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36363 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SALEM REGION: 1 |NOTIFICATION DATE: 10/28/1999|
| UNIT: [1] [2] [] STATE: NJ |NOTIFICATION TIME: 15:33[EDT]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 10/28/1999|
+------------------------------------------------+EVENT TIME: 15:00[EDT]|
| NRC NOTIFIED BY: JOHN F. GARECHT |LAST UPDATE DATE: 10/28/1999|
| HQ OPS OFFICER: DOUG WEAVER +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |DAVID LEW R1 |
|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 45 Power Operation |45 Power Operation |
|2 N Y 100 Power Operation |100 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| OUTSIDE DESIGN BASIS BASED ON APPENDIX R ISSUE |
| |
| During an ongoing review of the current Salem Post-fire Safe Shutdown |
| Analysis a concern was identified with the 125 VDC control circuits for the |
| 4KV circuit breakers in the post fire Alternate Shutdown Area. Alternate |
| Shutdown (ASD) is implemented in the event of a fire in the Control Room, |
| Relay Room or the ceiling of the 460 V Switchgear room (ASD area). |
| Operators implement the ASD methodology in accordance with procedures |
| S1(2).OP-AB.CR-0002. The procedures require that 125 VDC control power to |
| required 4KV breakers be isolated by opening the main bus feeder breaker |
| local to the switchgear. The 4KV breakers are then manually operated at the |
| switchgear as necessary to shed and load the 4KV buses in the event of loss |
| of offsite power. |
| |
| In the event of a postulated fire in the ASD area, cables associated with |
| the 4KV breaker 125 VDC control circuits could experience a hot short on the |
| positive side of the open/close coils. Such a short occurring in |
| combination with multiple grounds (occurring due to the postulated fire on |
| negative 125 VDC circuit legs could result in energization of the closing or |
| trip coils. This effectively bypasses the isolation provided by opening the |
| control power breaker. This fire induced circuit failure (due to a |
| combination of one hot short and two shorts to ground) could result in the |
| inability to locally operate one or more 4KV breakers as required for |
| alternate shutdown unless the hot short is removed. This scenario could |
| lead to loss of vital buses (worst case). This event is applicable to 460 V |
| Switchgear room and relay room. It is not applicable to the fire in control |
| room because the affected cables are not routed in the control room. This |
| condition does not satisfy the 10CFR50 Appendix R performance goal of |
| providing necessary electrical support functions for post fire safe |
| shutdown. |
| |
| Immediate corrective action is an hourly roving fire watch established in |
| accordance with the fire protection program. Long term corrective action |
| includes evaluating plant modifications and/or licensing/design basis |
| changes, and a review of other components relied upon for ASD of the plant |
| to determine if there are any other ungrounded DC control circuits which |
| could malfunction in the same manner. |
| |
| The licensee will notify the NRC resident inspector. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Fuel Cycle Facility |Event Number: 36364 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 10/28/1999|
| RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 16:16[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 10/27/1999|
| 6903 ROCKLEDGE DRIVE |EVENT TIME: 17:05[CDT]|
| BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 10/28/1999|
| CITY: PADUCAH REGION: 3 +-----------------------------+
| COUNTY: McCRACKEN STATE: KY |PERSON ORGANIZATION |
|LICENSE#: GDP-1 AGREEMENT: Y |MIKE JORDAN R3 |
| DOCKET: 0707001 |JOHN HICKEY NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: W.F. CAGE | |
| HQ OPS OFFICER: DOUG WEAVER | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NLTR LICENSEE 24 HR REPORT | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| Safety System Actuation |
| |
| At 1705 CDT on 10/27/99, the Plant Shift Superintendent's (PSS) office was |
| notified that a primary condensate alarm was received on the C-360 position |
| 2 autoclave Water Inventory Control (WIC) System. The WIC system is |
| required to be operable while heating in mode 5 according to TSR 2.1.4.3. |
| The autoclave was checked according to the alarm response procedure, removed |
| from service and declared inoperable by the PSS. Troubleshooting was |
| initiated and is continuing in order to determine the reason for the alarm. |
| |
| The safety system actuation is reportable to the NRC as required by Safety |
| Analysis Report, section 6.9, table 1 criteria J.2, Safety System actuation |
| due to a valid signal as a 24-hour event notification. |
| |
| The NRC resident inspector has been notified. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Other Nuclear Material |Event Number: 36365 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: COGEMA MINING, INC. |NOTIFICATION DATE: 10/28/1999|
|LICENSEE: COGEMA MINING, INC. |NOTIFICATION TIME: 16:29[EDT]|
| CITY: LINCH REGION: 4 |EVENT DATE: 10/28/1999|
| COUNTY: STATE: WY |EVENT TIME: [MDT]|
|LICENSE#: SUA-1341 AGREEMENT: N |LAST UPDATE DATE: 10/28/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |CHARLES MARSCHALL R4 |
| |JOHN HICKEY NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: CRAIG TOAL | |
| HQ OPS OFFICER: DOUG WEAVER | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NONR OTHER UNSPEC REQMNT | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| MONITOR WELL IN EXCURSION STATUS |
| |
| A routine biweekly water sample collected on 10/26/99 from monitor well |
| #6MW21 exceeded all three of its upper control limits (UCLs). A |
| confirmation sample was collected on 10/26/99 and it also exceeded all three |
| of its UCLs. Well #6MW21 has been placed in excursion status per license |
| Section 11.2 and its sampling frequency increased to weekly. Well #6MW21 is |
| a perimeter ore zone monitor well located approximately 300 feet south of |
| the Mine Unit 6 boundary at the Christensen Mine, Campbell County, Wyoming. |
| The nearest community is Lint, Wyoming, approximately 15 miles to the |
| southeast. |
| |
| Analysis: |
| Date Chloride |
| Conductivity Alkalinity Uranium |
| Sampled (mg/I) |
| (umhos/cm2) (mg/l) (mg/I U-308) |
| |
| UCL 120.0 UCL 1576 UCL 95.2 |
| UCL none |
| 10-26-99 32.2 |
| 1800 329.4 0.5 |
| 10-28-99 29.2 |
| 1746 305.8 0.5 |
| |
| Health and Environmental Hazards: |
| None |
| |
| Corrective Action: |
| Over-recovery pumping of the wellfield area nearest Mine #6MW21 |
| |
| Written Notification: |
| A written notification will be submitted to NRC Uranium Recovery Branch |
| Chief within 7 days. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36366 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: DIABLO CANYON REGION: 4 |NOTIFICATION DATE: 10/28/1999|
| UNIT: [1] [2] [] STATE: CA |NOTIFICATION TIME: 18:20[EDT]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 10/28/1999|
+------------------------------------------------+EVENT TIME: 13:59[PDT]|
| NRC NOTIFIED BY: JOY SKAGGS |LAST UPDATE DATE: 10/28/1999|
| HQ OPS OFFICER: DOUG WEAVER +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |CHARLES MARSCHALL R4 |
|10 CFR SECTION: | |
|ARPS 50.72(b)(2)(ii) RPS ACTUATION | |
|AESF 50.72(b)(2)(ii) ESF ACTUATION | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 M/R Y 70 Power Operation |0 Hot Standby |
|2 M/R Y 30 Power Operation |0 Hot Standby |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| MANUAL REACTOR TRIPS OF BOTH UNITS |
| |
| UNIT 1: Manual reactor trip initiated due to loss of both circulating water |
| pumps during heavy sea conditions. Following the reactor trip, auxiliary |
| feedwater pumps 2-2 and 2-3 auto started. Auxiliary feedwater pump 2-1 was |
| already running for a scheduled surveillance test. A feedwater isolation |
| actuation occurred on reactor trip with low T-avg signal. The reactor is |
| currently stable in hot standby with the MSIVs closed. All control rods |
| fully inserted on the trip and reactor coolant pumps continued to run |
| throughout the event. Decay heat is being removed by steaming the |
| generators through the atmospheric dumps. The unit will remain in hot |
| standby until heavy sea conditions have subsided. |
| |
| UNIT 2: Manual reactor trip initiated due to loss of both circulating water |
| pumps during heavy sea conditions. Following the reactor trip, all |
| auxiliary feedwater pumps auto started, a feedwater isolation actuation |
| occurred on reactor trip with low T-avg signal, and emergency diesel |
| generators 1-1 and 1-3 auto started but did not load. The reactor is |
| currently stable in hot standby with MSIVs closed. All control rods fully |
| inserted on the trip and reactor coolant pumps continued to run throughout |
| the event. Decay heat is being removed by steaming the generators through |
| the atmospheric dumps. The unit will remain in hot standby until heavy sea |
| condition have subsided. |
| |
| The licensee notified the NRC resident inspector, the San Luis Obispo |
| Sheriff's Office and the California State Office of Emergency Services. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Hospital |Event Number: 36367 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: QUEENS MEDICAL CENTER |NOTIFICATION DATE: 10/28/1999|
|LICENSEE: QUEENS MEDICAL CENTER |NOTIFICATION TIME: 19:18[EDT]|
| CITY: HONOLULU REGION: 4 |EVENT DATE: 10/27/1999|
| COUNTY: STATE: HI |EVENT TIME: 16:16[HST]|
|LICENSE#: 53-16533-02 AGREEMENT: N |LAST UPDATE DATE: 10/28/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |CHARLES MARSCHALL R4 |
| |JOHN HICKEY NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: ALAN CASSADY | |
| HQ OPS OFFICER: DOUG WEAVER | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| MEDICAL MISADMINISTRATION |
| |
| A patient received a fractional dose to the wrong area because of problems |
| with the measuring device used to locate the dose. The reference point used |
| was 950 mm, but it should have been 995 mm. The error resulted from the |
| measuring device "snagging" on a kink in the cable, thus preventing complete |
| insertion. The net result was an error of approximately 4.5 cm. The 380 |
| cGy fraction was delivered to the end of the nose vice further in as |
| prescribed. The fraction was one of four planned with a total intended dose |
| of 1520 cGy. The source involved was 6.8 Ci of Ir-192. |
| |
| The patient and doctor have been informed of the error. No adverse |
| consequences are expected for the patient. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36368 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: QUAD CITIES REGION: 3 |NOTIFICATION DATE: 10/28/1999|
| UNIT: [1] [2] [] STATE: IL |NOTIFICATION TIME: 19:45[EDT]|
| RXTYPE: [1] GE-3,[2] GE-3 |EVENT DATE: 09/10/1999|
+------------------------------------------------+EVENT TIME: 14:45[CDT]|
| NRC NOTIFIED BY: DARYL CLARK |LAST UPDATE DATE: 10/28/1999|
| HQ OPS OFFICER: DOUG WEAVER +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |MIKE JORDAN 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 100 Power Operation |100 Power Operation |
|2 N Y 100 Power Operation |100 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| OUTSIDE DESIGN BASIS - HIGH CONTROL ROOM EMERGENCY FILTRATION SYSTEM FLOW |
| |
| On September 10, 1999, while performing the Control Room Emergency |
| Filtration System monthly surveillance, the system flow rate was found to be |
| 2317 scfm. The required Tech Spec flow rate is 2000 scfm +/-10%. The |
| condition was immediately corrected at the time of discovery by |
| repositioning the ventilation damper. This event is still being evaluated |
| by the licensee. |
| |
| The licensee notified the NRC resident inspector. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36369 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SAINT LUCIE REGION: 2 |NOTIFICATION DATE: 10/29/1999|
| UNIT: [1] [] [] STATE: FL |NOTIFICATION TIME: 02:14[EDT]|
| RXTYPE: [1] CE,[2] CE |EVENT DATE: 10/29/1999|
+------------------------------------------------+EVENT TIME: 01:29[EDT]|
| NRC NOTIFIED BY: EMLING |LAST UPDATE DATE: 10/29/1999|
| HQ OPS OFFICER: BOB STRANSKY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |MARK LESSER R2 |
|10 CFR SECTION: | |
|ARPS 50.72(b)(2)(ii) RPS ACTUATION | |
|AESF 50.72(b)(2)(ii) ESF 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 Standby |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| AUTOMATIC TURBINE TRIP/REACTOR TRIP DUE TO LOSS OF MAIN TURBINE BEARING OIL |
| PRESSURE |
| |
| The reactor automatically tripped from 100% power when the main turbine |
| tripped due to low bearing oil pressure. All control rods inserted |
| completely, and all systems functioned as expected. The auxiliary feedwater |
| system automatically started to feed the steam generators. |
| |
| The licensee reported that a main turbine low bearing oil pressure alarm had |
| been received in the control room several minutes before the trip. An |
| operator had just been dispatched to investigate the cause of the alarm when |
| the main turbine automatically tripped. |
| |
| The NRC resident inspector will be informed of this event by the licensee. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36370 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: DUANE ARNOLD REGION: 3 |NOTIFICATION DATE: 10/29/1999|
| UNIT: [1] [] [] STATE: IA |NOTIFICATION TIME: 04:41[EDT]|
| RXTYPE: [1] GE-4 |EVENT DATE: 10/29/1999|
+------------------------------------------------+EVENT TIME: 02:45[CDT]|
| NRC NOTIFIED BY: MIKE DAVIS |LAST UPDATE DATE: 10/29/1999|
| HQ OPS OFFICER: BOB STRANSKY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |MIKE JORDAN R3 |
|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
+------------------------------------------------------------------------------+
| STANDBY DIESEL GENERATOR AUTOSTART DUE TO LIGHTNING STRIKE |
| |
| The licensee reported that one of the standby diesel generators autostarted, |
| but did not load, due to a lightning strike. The load dispatcher informed |
| the site that numerous strikes were also taken on the electrical grid in the |
| vicinity of the site, causing some breaker repositioning. However, the site |
| was unaffected, except for the autostart of the diesel generator. |
| |
| The NRC resident inspector has been informed of this event by the licensee. |
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Page Last Reviewed/Updated Thursday, March 25, 2021
Page Last Reviewed/Updated Thursday, March 25, 2021