Event Notification Report for November 1, 1999
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
10/29/1999 - 11/01/1999
** EVENT NUMBERS **
35790 36369 36370 36371 36372 36373 36374 36375 36376 36377 36378 36379
+------------------------------------------------------------------------------+
|Fuel Cycle Facility |Event Number: 35790 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 06/03/1999|
| RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 14:44[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 06/02/1999|
| 6903 ROCKLEDGE DRIVE |EVENT TIME: 16:30[CDT]|
| BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 10/31/1999|
| CITY: PADUCAH REGION: 3 +-----------------------------+
| COUNTY: McCRACKEN STATE: KY |PERSON ORGANIZATION |
|LICENSE#: GDP-1 AGREEMENT: Y |DAVID HILLS R3 |
| DOCKET: 0707001 |DON COOL NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: THOMAS WHITE | |
| HQ OPS OFFICER: FANGIE JONES | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|OCBA 76.120(c)(2)(i) ACCID MT EQUIP FAILS | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| THREE SPRINKLER SYSTEMS DECLARED INOPERABLE DUE TO CORRODED HEADS (24-hour |
| report) |
| |
| "On 06/02/99 at 1630 CDT, the Plant Shift Superintendent (PSS) was notified |
| that numerous sprinkler heads were corroded, affecting 16 sprinkler systems |
| in C-337 and one system in C-333, such that the ability of the sprinklers to |
| flow sufficient water was called into question. Subsequently, these |
| sprinkler systems were declared inoperable, and TSR-required actions |
| establishing roving fire patrols were initiated. This deficiency was |
| detected during scheduled system inspections conducted by Fire Protection |
| personnel. Currently, functionality of the sprinkler heads has not been |
| fully evaluated by Fire Protection personnel, and the remaining cascade |
| buildings are currently being inspected, and if necessary, this report will |
| be updated to identify any additional areas. It has been determined that |
| this event is reportable under 10CFR76.120(c)(2) as an event in which |
| equipment is disabled or fails to function as designed." The NRC resident |
| inspector has been notified of this event. |
| |
| * * * UPDATE AT 1022 EDT ON 06/04/99 FROM CAGE TO TROCINE * * * |
| |
| "Two sprinkler heads on system D-1 in C-337 and two sprinkler heads on |
| system 27 in C-335 were identified to also be corroded. These were |
| identified to the PSS on 06/03/99 at 1600 CDT and 1601 CDT, respectively, |
| and determined to require an update to this report by the PSS. It has been |
| determined that this event is reportable under 10CFR76.120(c)(2) as an event |
| in which equipment is disabled or fails to function as designed." Paducah |
| personnel notified the NRC resident inspector of this update. The NRC |
| operations officer notified the R3DO (Hills) and NMSS EO (Combs). |
| |
| * * * UPDATE AT 2152 EDT ON 06/17/99 FROM WALKER TO POERTNER * * * |
| |
| "Three sprinkler heads on system C-15 and five sprinkler heads on system B-8 |
| in C-333 were identified to also be corroded. The PSS was notified of this |
| condition at 1300 CDT on 06/17/99 and determined that an update to this |
| report was required. It has been determined that this event is reportable |
| under 10CFR76.120(c)(2) as an event in which equipment is disabled or fails |
| to function as designed." Paducah personnel notified the NRC resident |
| inspector of this update. The NRC operations officer notified the R3DO |
| (Madera). |
| |
| * * * UPDATE 1440 EDT 6/18/1999 FROM UNDERWOOD TAKEN BY STRANSKY * * * |
| |
| "Two sprinkler heads on system C-15 and one sprinkler head on system B-8 in |
| C-333 were identified to have corrosion. The PSS was notified of this |
| condition at 1350 CDT on 06/18/99. The area of the fire patrol for system |
| C-15 was expanded to include the two heads identified as corroded. The one |
| head on system B-8 was in the area already being patrolled. The PSS |
| determined that an update to this report was required." The NRC resident |
| inspector has been informed of this update. Notified R3DO (Madera). |
| |
| * * * UPDATE 1315 EDT 6/25/1999 FROM WALKER TAKEN BY STRANSKY * * * |
| |
| "Two sprinkler heads on system D-8 and three sprinkler heads on system D-7 |
| in C-337 were identified to have corrosion. The PSS was notified of the |
| condition on system D-8 at 0125 CDT on 06/25/99 and at 1019 CDT on 06/25/99 |
| for system D-7. Both systems were immediately declared inoperable and LCO |
| fire patrol actions were implemented. It was determined that an update to |
| this report was required." The NRC resident inspector has been informed of |
| this update. Notified R3DO (Jordan). |
| |
| * * * UPDATE 2119 EDT 7/30/1999 FROM CAGE TAKEN BY STRANSKY * * * |
| |
| "Five sprinkler heads and one sprinkler piping tee on C-337 system D-7 were |
| identified to have corrosion. The PSS was notified of these corroded system |
| parts and declared the system inoperable at 0931 CDT on 07/30/99. LCO |
| required fire patrols of the affected area were initiated. The PSS |
| determined that an update to this event report was required." The NRC |
| resident inspector has been informed of this update. Notified R3DO |
| (Wright). |
| |
| * * * UPDATE 1655 EDT 7/31/1999 FROM WHITE TAKEN BY STRANSKY * * * |
| |
| "Two sprinkler heads on C-337 System D-1 were identified to have corrosion. |
| The PSS was notified of these corroded system parts and declared the system |
| inoperable at 1155 CDT on 7/31/99. LCO required fire patrols of the |
| affected area were initiated. The PSS determined that an update to this |
| report was required." The NRC resident inspector has been informed of this |
| update. Notified R3DO (Wright). |
| |
| * * * UPDATE 1546 EDT 8/10/1999 FROM WHITE TAKEN BY STRANSKY * * * |
| |
| "Two sprinkler heads on C-337 system C-15 were identified to have corrosion. |
| The PSS was notified of these corroded system parts and declared the system |
| inoperable at 1130 CDT on 8/10/99. LCO required fire patrols of the |
| affected area were initiated. The PSS determined that an update to this |
| report was required." The NRC resident inspector has been informed of this |
| update. Notified R3DO (Burgess). |
| |
| * * * UPDATE AT 1154 EDT 8/22/99 FROM WALKER TO POERTNER * * * |
| |
| Four adjacent sprinkler heads on C-333 System B-1 were identified to have |
| corrosion. The PSS was notified of the corroded system parts and declared |
| the system inoperable at 0918 CDT on 8/22/99. LCO required fire patrols |
| were initiated. The PSS determined that an update to this report was |
| required. It has been determined that this event is reportable under |
| 10CFR76.120(c)(2) as an event in which equipment is disabled or fails to |
| function as designed. The NRC resident inspector will be notified. The NRC |
| operations officer notified the R3DO (Clayton). |
| |
| * * * UPDATE 2015 EDT ON 8/28/99 FROM W. F. GAGE TO S. SANDIN * * * |
| |
| "Two adjacent sprinkler heads on C-337 System D-11 were identified to have |
| corrosion. The PSS was notified of these corroded system parts and declared |
| the system inoperable at 1420 CDT on 8/28/99. LCO required fire patrols of |
| the affected area were initiated. The PSS determined that an update to this |
| report was required." |
| Paducah personnel informed the NRC resident inspector. The NRC operations |
| officer notified the R3DO (Leach) and NMSS EO (Piccone). |
| |
| * * * UPDATE 2037 EDT ON 8/29/99 FROM KEVIN BEASLEY TO S. SANDIN * * * |
| |
| "Two adjacent sprinkler heads on C-337 System D-15 were identified to have |
| corrosion and the PSS declared the system inoperable at 0925 [CDT] on |
| 8/29/99. Also two adjacent heads on C-337 System D-10 were identified to |
| have corrosion and the PSS declared the system inoperable at 1450. LCO |
| required fire patrols for both of the affected areas were initiated in the |
| time frame required by TSR. The PSS determined that an update to this |
| report was required." Paducah personnel informed the NRC resident |
| inspector. The NRC operations officer notified the R3DO (Leach) and NMSS EO |
| (Piccone). |
| |
| * * * UPDATE AT 0930 EDT ON 9/1/99 BY ERIC WALKER TO FANGIE JONES * * * |
| |
| Add two adjacent sprinkler heads on C-337 D-14. Paducah personnel informed |
| the NRC Resident Inspector. The NRC operations officer notified the R3DO |
| (David Hills) and NMSS (Robert Pierson). |
| |
| * * * UPDATE AT 1133 EDT ON 9/8/99 BY TOM WHITE TO FANGIE JONES * * * |
| |
| Add two adjacent sprinkler heads on C-331 System 26, system declared |
| inoperable at 2155 CDT on 9/7/99. An LCO required fire patrol for the |
| affected area was initiated in the time frame required by the TSR. Paducah |
| personnel informed the NRC Resident Inspector. The NRC operations officer |
| notified the R3DO (Monte Phillips) and NMSS (Josie Piccone). |
| |
| * * * UPDATE AT 0948 ON 9/30/99 BY ERIC WALKER TO DOUG WEAVER * * * |
| |
| Add two adjacent sprinkler heads on C-333 System B-15 were identified to |
| have corrosion and the PSS declared the system inoperable at 0815 CDT on |
| 9/30/99. An LCO required fire patrol for the affected area was initiated in |
| the time frame required by the TSR. The PSS determined that an update to |
| this report was required. |
| Paducah personnel informed the NRC resident inspector. The NRC operations |
| officer notified the R3DO (Vegel) and NMSS (Cool). |
| |
| * * * UPDATE AT 1600 ON 10/13/99 BY WALKER TO GOULD * * * |
| |
| Two adjacent sprinkler heads on C-333 System A-11 were Identified to have |
| corrosion and the PSS declared the system inoperable at 1307 CDT on |
| 10/13/99. An LCO required fire patrol for the affected area was initiated |
| in the time frame required by the TSR, The PSS determined that an update to |
| this report was required. Paducah personnel informed the NRC resident |
| inspector. The NRC operations officer notified the R3DO (Madera) and NMSS |
| (Moore). |
| |
| * * * UPDATE AT 1520 ON 10/19/99 FROM UNDERWOOD TAKEN BY STRANSKY * * * |
| |
| Six sprinkler heads on C-337 System D-16 were identified to have corrosion |
| and the PSS declared the system inoperable at 1052 CDT on 10/19/99. An LCO |
| required fire patrol for the affected area was initiated in the time frame |
| required by the TSR. The PSS determined that an update to this report was |
| required. The NRC resident inspector has been informed of this update. The |
| NRC Operations Officer notified R3DO (Jorgensen). |
| |
| * * * UPDATE AT 2140 ON 10/19/99 FROM WALKER TAKEN BY STRANSKY * * * |
| |
| Seven sprinkler heads on C-337 System A-7 were identified to have corrosion, |
| and another four had been painted over. In addition, three adjacent |
| sprinkler heads on C-337 System A-8 were identified to have corrosion. The |
| PSS declared the systems inoperable at 1900 CDT on 10/19/99. An LCO |
| required fire patrols for the affected areas were initiated in the time |
| frame required by the TSR. The PSS determined that an update to this report |
| was required. The NRC resident inspector has been informed of this update. |
| The NRC Operations Officer notified R3DO (Wright). |
| |
| * * * UPDATE AT 1713 ON 10/21/99 FROM CAGE TAKEN BY JOLLIFFE * * * |
| |
| Four sprinkler heads on C-337 System A-5, twelve sprinkler heads on C-337 |
| System A-8, three sprinkler heads on C-337 System A-9, and six sprinkler |
| heads on C-337 System B-8 were identified to have corrosion. On 10/21/99, |
| the PSS declared System A-5 and A-9 inoperable at 1028 CDT, System A-8 |
| inoperable at 1227 CDT and System B-8 inoperable at 1406 CDT. An LCO |
| required fire patrol for the affected areas was initiated in the time frame |
| required by the TSR.. The PSS determined that an update to this report was |
| required. The NRC Resident Inspector has been informed of this update. The |
| NRC Operations Officer notified the R3DO Bruce Jorgensen. |
| |
| * * * UPDATE AT 2128 ON 10/22/99 FROM ERIC WALKER TAKEN BY JOLLIFFE * * * |
| |
| At 1400 CDT on 10/22/99, the PSS was notified that numerous corroded |
| sprinkler heads were discovered in C-337 on sprinkler systems B-1, B-3, B-5, |
| B-6, B-7, B-11 and D-17. Due to the number of systems called into question, |
| the PSS declared all of the sprinkler systems in C-337 on the cell floor (a |
| total of 66 systems) inoperable and TSR required actions establishing roving |
| fire patrols were initiated within the required time frame. The PSS |
| determined that an update to this report was required. It has been |
| determined that this event Is reportable under 10CFR76.120(c)(2) as an event |
| in which equipment is disabled or fails to function as designed. |
| The NRC Resident lnspector has been informed of this update. The NRC |
| Operations Officer notified the R3DO Bruce Jorgensen. |
| |
| * * * UPDATE AT 1239 ON 10/24/99 FROM TOM WHITE TAKEN BY JOLLIFFE * * * |
| |
| At 1200 CDT on 10/23/99, the PSS was notified that numerous corroded |
| sprinkler heads were discovered in C-337 on sprinkler systems B-13 and B-14 |
| on the ground floor, The PSS declared these systems inoperable and TSR |
| required actions establishing roving fire patrols were initiated within the |
| required time frame. At 1600 CDT on 10/23/99, the PSS was notified that |
| numerous corroded sprinkler heads were discovered in C-337 on sprinkler |
| systems A-16, B-12, C-8, C-12, C-15, D-5 and D-8 on the cell floor, These |
| systems have already been declared inoperable and fire patrols are already |
| being performed. The PSS determined that an update to this report was |
| required. It has been determined that this event is reportable under |
| I0CFR76.120(c)(2) as an event in which equipment is disabled or fails to |
| function as designed. The NRC resident inspector has been informed of this |
| update. The NRC Operations Officer notified the R3DO Bruce Jorgensen. |
| |
| * * * UPDATE AT 1117 ON 10/25/99 FROM W. F. CAGE TAKEN BY SANDIN * * * |
| |
| At 1940 CDT on 10/24/99, the PSS was notified that numerous corroded |
| sprinkler heads had been discovered on High Pressure Fire Water systems C-4, |
| C-5, C-6 and C-8, located in the C-337 building. These systems had |
| previously been declared inoperable, and fire patrols were already being |
| performed at the time of discovery. The PSS determined that an update to |
| this report was required. It has been determined that this event is |
| reportable under 10CFR76.120(c)(2) as an event in which equipment is |
| disabled or fails to function as designed. |
| The NRC Resident Inspector has been notified of this update. The NRC |
| Operations Officer notified R3DO (Lanksbury) and NMSS (Brain Smith). |
| |
| * * * UPDATE AT 2235 ON 10/27/99 BY WHITE TAKEN BY MACKINNON * * * |
| |
| At 1517 CDT on 10/27/99, the PSS was notified that 9 corroded sprinkler |
| heads had been discovered on High Pressure Fire Water System A-12 located in |
| the C-333 building. This system has been declared inoperable and fire |
| patrols have been initiated. The PSS determined that an update to this |
| report was required. The NRC Resident Inspector has been notified of this |
| update. The NRC Operations Officer notified R3DO (Jordan) and NMSS EO |
| (Hickey). |
| |
| |
| * * * UPDATE AT 2150 ON 10/30/99 BY UNDERWOOD TAKEN BY WEAVER * * * |
| At 1950 on 10/30/1999, The Plant Shift Superintendent (PSS) was notified |
| that numerous corroded sprinkler heads had been discovered on High Pressure |
| Fire Water Systems A-5, A-9, A-11, C-5, and C-7 In C-333 building. |
| Reference ATR-1 1999-6699 and 6702. These systems have been declared |
| inoperable and fire patrols have been initiated. Also, due to the number of |
| inoperable sprinkler heads, the remaining systems on the cell floor of C-333 |
| were called into question and declared inoperable. Fire patrols for the |
| entire cell floor have been initialed. The PSS determined that an update to |
| this report was required. |
| |
| It has been determined that this event is reportable under 10CFR76.120(c)(2) |
| as an event in which equipment is disabled or fails to function as designed. |
| The NRC Operations Officer notified R3DO (Jordan) and NMSS EO (Hickey). |
| |
| The NRC resident inspector has been notified of this event. |
| |
| * * * UPDATE AT 2111 ON 10/31/99 BY UNDERWOOD TAKEN BY WEAVER * * * |
| At 1412 on 10/31/99, the PSS was notified that five corroded sprinkler heads |
| had been discovered on High Pressure Fire Water System 9 in C-335 building. |
| There were two adjacent corroded heads discovered in two separate locations |
| and a third individual head at a different location. The system was |
| declared inoperable and fire patrols were initiated. The corroded heads |
| have since been replaced and the system returned to operable status. The |
| license notified the NRC resident inspector. The NRC Operations Officer |
| notified R3DO (Jordan) and NMSS EO (Hickey). |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36369 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SAINT LUCIE REGION: 2 |NOTIFICATION DATE: 10/29/1999|
| UNIT: [1] [] [] STATE: FL |NOTIFICATION TIME: 02:14[EST]|
| 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[EST]|
| 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. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 36371 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: ARIZONA RADIATION REGULATORY AGENCY |NOTIFICATION DATE: 10/29/1999|
|LICENSEE: FOREE & VANN, INC |NOTIFICATION TIME: 09:29[EST]|
| CITY: PHOENIX REGION: 4 |EVENT DATE: 10/28/1999|
| COUNTY: STATE: AZ |EVENT TIME: [MST]|
|LICENSE#: 7-263 (AZ) AGREEMENT: Y |LAST UPDATE DATE: 10/29/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |CHARLES MARSCHALL R4 |
| | |
+------------------------------------------------+ |
| NRC NOTIFIED BY: LINDA HOWELL (R4) | |
| HQ OPS OFFICER: BOB STRANSKY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE |
| |
| The following report from the State of Arizona was forwarded to the |
| Operations Center by NRC Region IV: |
| |
| At approximately 8:00 p.m. 10/27/99 to 5:45 a.m. 10/28/99, a Troxler |
| moisture density gauge, model 3411B, serial number 12764, containing less |
| than 50 millicuries of americium-241/beryllium and less than 10 millicuries |
| of cesium-137 was stolen from 8907 N. 53rd Drive, Glendale, AZ 85302. The |
| Glendale Police were notified by the licensee as was the Arizona Highway |
| Patrol. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Hospital |Event Number: 36372 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: LIBERTY HOSPITAL |NOTIFICATION DATE: 10/29/1999|
|LICENSEE: LIBERTY HOSPITAL |NOTIFICATION TIME: 10:37[EST]|
| CITY: LIBERTY REGION: 3 |EVENT DATE: 10/27/1999|
| COUNTY: STATE: MO |EVENT TIME: [CDT]|
|LICENSE#: AGREEMENT: N |LAST UPDATE DATE: 10/29/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |MIKE JORDAN R3 |
| | |
+------------------------------------------------+ |
| NRC NOTIFIED BY: TOM BROWN | |
| HQ OPS OFFICER: BOB STRANSKY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| MEDICAL MISADMINISTRATION |
| |
| On 10/27/1999, a patient was to receive a dose of 120 Gy (12,000 rad) by way |
| of implanted palladium seeds. The seeds that were ordered and delivered to |
| the hospital each had an activity of 1.05 millicuries each, instead of 1.4 |
| millicuries, which would have been needed to obtain the prescribed dose. The |
| physicians treating the patient made a decision to implant the seeds anyway, |
| resulting in a dose of 90 Gy, and to supplement the dose by external beam. |
| However, the written prescription kept in the hot lab was not annotated to |
| include this change in treatment. |
| |
| Therefore, this condition is being reported as a medical misadministration, |
| in that the actual dose was 25% less than that prescribed. The licensee |
| will contact the NRC Region III office regarding this issue. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36373 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: RIVER BEND REGION: 4 |NOTIFICATION DATE: 10/29/1999|
| UNIT: [1] [] [] STATE: LA |NOTIFICATION TIME: 15:38[EST]|
| RXTYPE: [1] GE-6 |EVENT DATE: 10/29/1999|
+------------------------------------------------+EVENT TIME: 12:55[CDT]|
| NRC NOTIFIED BY: HUSTON |LAST UPDATE DATE: 10/29/1999|
| 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 | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 A/R Y 100 Power Operation |0 Hot Shutdown |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| GENERATOR TRIP - REACTOR SCRAM |
| |
| On October 29, 1999, at 1255 with the plant at 100% reactor power and in |
| Mode 1, a generator trip followed by a reactor scram occurred at River Bend |
| Station. The plant responded as expected, except that recirculation pump |
| 'A' failed to downshift to slow speed and tripped to off. The plant is |
| stable, and currently in Mode 3. Hot -Shutdown. Plant personnel continue |
| with an orderly shutdown. Work activities were in progress in the |
| switchyard at the time of the event. These activities are included in an |
| investigation of the cause of the event. |
| |
| The licensee notified the NRC resident inspector. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 36374 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: SCIENTECH, INC. |NOTIFICATION DATE: 10/29/1999|
|LICENSEE: NUSI |NOTIFICATION TIME: 16:05[EST]|
| CITY: GAITHERSBURG REGION: 1 |EVENT DATE: 10/22/1999|
| COUNTY: MONTGOMERY STATE: MD |EVENT TIME: 12:00[EDT]|
|LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 10/29/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |MARK LESSER R2 |
| |VERN HODGE NRR |
+------------------------------------------------+ |
| NRC NOTIFIED BY: PAUL LOCH | |
| HQ OPS OFFICER: DOUG WEAVER | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|CCCC 21.21 UNSPECIFIED PARAGRAPH | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| PART 21 REPORT |
| |
| SCIENTECH, Inc.'s subsidiary NUS Instruments, Inc. (NUSI) has determined |
| that a Basic Component, supplied to Carolina Power & Light Robinson Nuclear |
| Plant under CP&L purchase orders 8Q3800CM and 9D3530CJ, contains a deviation |
| that is reportable under 10CFR21. NUSI became aware of this potential |
| deviation on October 22, 1999. SCIENTECH, Inc's. President was informed |
| October 28, 1999. CP&L is aware of this problem and the components have |
| been removed from service. A formal written report will be provided within |
| 30 days of this notification. The components, Low Level Amplifier |
| M/N:RTL850, P/N:NUS-A002PA-1/3, Rev. 1 (1 ea.) and P/N:NUS-A002PA-1, Rev. 0 |
| (12 ea.), were manufactured by NUSI. These components have been supplied to |
| no other utility for use in Safety Related Systems. NUSI has opened a |
| 10CFR21 file concerning this component and has numbered it as 21-99-01. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36375 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SAINT LUCIE REGION: 2 |NOTIFICATION DATE: 10/30/1999|
| UNIT: [1] [] [] STATE: FL |NOTIFICATION TIME: 07:28[EST]|
| RXTYPE: [1] CE,[2] CE |EVENT DATE: 10/30/1999|
+------------------------------------------------+EVENT TIME: 06:42[EDT]|
| NRC NOTIFIED BY: FIELDS |LAST UPDATE DATE: 10/30/1999|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |MARK LESSER R2 |
|10 CFR SECTION: | |
|ARPS 50.72(b)(2)(ii) RPS ACTUATION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 M/R Y 3 Startup |0 Hot Standby |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| PLANT HAD A MANUAL TRIP FROM 3% POWER. |
| |
| DURING PLANT STARTUP WITH THE REACTOR CRITICAL ABOVE THE POINT OF ADDING |
| HEAT, THE "1A" STEAM GENERATOR LEVEL DECREASED WHILE BEING FED WITH THE |
| AUXILIARY FEED SYSTEM. THE REACTOR WAS MANUALLY TRIPPED WHEN THE STEAM |
| GENERATOR LEVEL DECREASED BELOW THE PRE-TRIP SETPOINT. ALL RODS FULLY |
| INSERTED, NO ECCS INJECTION OCCURRED AND NO RELIEF VALVES LIFTED. THE CAUSE |
| OF THE DECREASE IN STEAM GENERATOR LEVEL IS BEING INVESTIGATED. THE HEAT |
| SINK IS THE ATMOSPHERIC DUMP VALVES. |
| |
| THE RESIDENT INSPECTOR WAS NOTIFIED. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Fuel Cycle Facility |Event Number: 36376 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 10/30/1999|
| RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 10:38[EST]|
| COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 10/29/1999|
| 6903 ROCKLEDGE DRIVE |EVENT TIME: 10:40[EDT]|
| BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 10/30/1999|
| CITY: PIKETON REGION: 3 +-----------------------------+
| COUNTY: PIKE STATE: OH |PERSON ORGANIZATION |
|LICENSE#: GDP-2 AGREEMENT: N |MIKE JORDAN R3 |
| DOCKET: 0707002 |JOHN HICKEY NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: SPAETH | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NBNL RESPONSE-BULLETIN | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| 24 HOUR 91-01 BULLETIN |
| |
| On 10/29/99 at 1040 hours, the Plant Shift Superintendent (PSS) was notified |
| that Procedure XP2-GP-MM2000, Rev. 1, "Operation of the Negative Air |
| Machine" was activated and used prior to the implementation of Nuclear |
| Criticality Safety Approval (NCSA) PLANT068.A01. Procedure (XP2-GP-MM2000, |
| Rev. 0) was revised (Rev. 1) and implemented on 9/1/99. This revised |
| procedure contained the flowdown requirements from the new |
| revision or the NCSA, without the NCSA being implemented. Several |
| requirements of the original NCSA were removed in the revision process, |
| including the requirement to have a second, knowledgeable person VERIFY that |
| the Negative Air Machine (NAM) is only used on equipment containing 5.25% |
| U235 enrichment or less. |
| |
| Since personnel operating the NAM were utilizing the newly revised |
| procedure, which reflects the requirements of the revised NCSA, they failed |
| to complete the requirement for the second person verification. This lack of |
| verification is deemed to be the loss of one control because the governing |
| NCSA (Rev.0) still lists this verification as a requirement. |
| |
| The Negative Air Machine was immediately tagged out of service, Procedure |
| XP2-GP-MM2000, Rev. 1 was placed on hold, and the previously approved |
| procedure was reactivated until NCSA PLANT068A01 is activated. This |
| Criticality Safety Incident is a Level 3 Severity Index (Loss of controls |
| such that only one double contingency control remains in place). |
| |
| SAFETY SIGNIFICANCE |
| |
| The safety significance, or this event is very low. The lack of documented |
| verification of enrichment for the Negative Air Machine since 9/10/99 did |
| not result in a loss of the enrichment parameter. Virtually all of the |
| equipment in X-333 is operated below 5.25% assay. A review of equipment |
| worked on with the NAM was performed and none of the equipment worked on had |
| been operated above 5.25% U-235 enrichment in the time period of interest. |
| |
| POTENTIAL CRITICALITY PATHWAYS |
| |
| The components of the negative air machine are not favorable geometry for |
| all enrichments. Current approved analysis limits uranium to 5.25%. however |
| a revised analysis which has been PORC approved has shown that an enrichment |
| up to 20% U-235 is safe in the Negative Air Machine. Therefore, an |
| enrichment above 20% would have to be present for a criticality to be |
| possible. However, this is extremely unlikely In the X-333 Facility. |
| |
| CONTROLLED PARAMETERS |
| |
| Enrichment is controlled with a first check arid a second verification. |
| Interaction Is controlled and mass is inherently controlled through the |
| physical limits of the filtration system to tolerate significant plugging. |
| Neither mass nor interaction were violated in this event. |
| |
| ESTIMATED AMOUNT, ENRICHMENT |
| |
| The filter units at PORTS typically contain less than 10 grams U-235 (<1.5% |
| critical mass). Since the negative air machine is used primarily to protect |
| personnel from hydrogen fluoride fumes, no significant mass of U-235 is |
| expected in the equipment. Due to the enrichment limits on the cascade |
| equipment In the X-333, enrichment is not expected to exceed 5%. |
| |
| NUCLEAR CRITICALITY SAFETY CONTROLS |
| |
| The control on this system included a first and second check to ensure the |
| enrichment limit was not violated for the negative air machine. The |
| requirement to perform the second check was removed from the procedure |
| without implementing a new analysis to support its removal. The second check |
| was not performed on over 15 maintenance jobs. |
| |
| CORRECTIVE ACTION |
| |
| At the direction of the Plant Shift Superintendent, the Negative Air Machine |
| was immediately tagged out of service and the procedure was placed on hold. |
| |
| THERE WAS NO LOSS OF HAZARDOUS/RADIOACTIVE MATERIAL OR |
| RADIOACTIVE/RADIOLOGICAL CONTAMINATION EXPOSURE AS THE RESULT OF THIS |
| EVENT. |
| |
| THE NRC RESIDENT INSPECTOR WAS NOTIFIED. THE DOE REPRESENTATIVE WILL BE |
| NOTIFIED. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36377 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: LASALLE REGION: 3 |NOTIFICATION DATE: 10/31/1999|
| UNIT: [1] [2] [] STATE: IL |NOTIFICATION TIME: 14:00[EST]|
| RXTYPE: [1] GE-5,[2] GE-5 |EVENT DATE: 10/31/1999|
+------------------------------------------------+EVENT TIME: 12:03[CST]|
| NRC NOTIFIED BY: SHANE MARIK |LAST UPDATE DATE: 10/31/1999|
| HQ OPS OFFICER: DOUG WEAVER +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |MIKE JORDAN R3 |
|10 CFR SECTION: | |
|AARC 50.72(b)(1)(v) OTHER ASMT/COMM INOP | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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 |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| Station Vent Stack Monitoring Inoperable. |
| |
| The Station Vent Stack Wide Range Gaseous Monitor is deenergized for planned |
| maintenance. At 1203 the Pre-planned alternate Particulate Iodine and Noble |
| Gas (PING) was found to have its sample pump tripped. Initial attempts to |
| restart the sample pump were unsuccessful. Instrument Maintenance |
| Department repairs are in progress. Chemistry personnel are preparing |
| alternate sampling capability. |
| |
| The licensee will notify the NRC resident inspector. |
| |
| * * * UPDATE AT 1705 ON 10/31/99 BY COVEYOU TAKEN BY WEAVER * * * |
| Repairs have been made to the pre-planned alternate (PING) and functional |
| testing has been completed as of 1527 CST. The PING was declared operable |
| at that time. Normal sampling of the Station Vent Stack has been resumed |
| via this alternate method. The NRC resident inspector will be informed. |
| The HOO notified the R3DO (Jordan). |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36378 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SURRY REGION: 2 |NOTIFICATION DATE: 10/31/1999|
| UNIT: [1] [2] [] STATE: VA |NOTIFICATION TIME: 22:14[EST]|
| RXTYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 10/31/1999|
+------------------------------------------------+EVENT TIME: 20:24[EST]|
| NRC NOTIFIED BY: BILL WEBSTER |LAST UPDATE DATE: 10/31/1999|
| HQ OPS OFFICER: DOUG WEAVER +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |MARK LESSER R2 |
|10 CFR SECTION: | |
|AINB 50.72(b)(2)(iii)(B) POT RHR INOP | |
|AINA 50.72(b)(2)(iii)(A) POT UNABLE TO SAFE SD | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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
+------------------------------------------------------------------------------+
| TWO DIESEL GENERATORS INOPERABLE DURING TESTING |
| |
| During performance of the monthly testing of the #3 Emergency Diesel |
| Generator (EDG), the voltage regulator (control power) would not adjust |
| incoming voltage lower than 120 volts. The diesel was declared inoperable |
| pending further troubleshooting of the voltage regulator. |
| |
| As required by Surry Technical Specifications, the #1 EDG and the #2 EDG |
| were scheduled for operability testing on a daily basis. The #1 EDG was |
| inoperable from 2024 hours to 2203 hours for required testing which rendered |
| inoperable both EDGs for Unit 1. The #1 EDG was available at all times |
| during testing, however, it would have required operator action to load on |
| the bus. |
| |
| This report is being made pursuant 10CFR50.72(b)(2)(iii)(A) & (D) for a |
| condition that alone could have prevented the fulfillment of safety |
| structures or systems needed to shut down the reactor and maintain it in a |
| safe condition and mitigate the consequences of an accident. |
| |
| The licensee will notify the NRC resident inspector. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36379 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: COOK REGION: 3 |NOTIFICATION DATE: 11/01/1999|
| UNIT: [1] [] [] STATE: MI |NOTIFICATION TIME: 01:50[EST]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 10/31/1999|
+------------------------------------------------+EVENT TIME: 20:30[EST]|
| NRC NOTIFIED BY: MUTZ |LAST UPDATE DATE: 11/01/1999|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |MIKE JORDAN R3 |
|10 CFR SECTION: | |
|DDDD 73.71 UNSPECIFIED PARAGRAPH | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N N 0 Refueling |0 Refueling |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| SAFEGUARDS DEGRADATION RELATED TO MONITORING A CONTROL ACCESS |
| |
| COMPENSATORY MEASURES TAKEN. |
| |
| THE NRC RESIDENT INSPECTOR WAS NOTIFIED. |
+------------------------------------------------------------------------------+
Page Last Reviewed/Updated Thursday, March 25, 2021