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Event Notification Report for November 04, 1999

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
11/03/1999 - 11/04/1999

EVENT NUMBERS
363953639636397363983639936400

Power Reactor
Event Number: 36395
Facility: PRAIRIE ISLAND
Region: 3     State: MN
Unit: [1] [] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: TODD STRAIN
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/04/1999
Notification Time: 14:09 [ET]
Event Date: 11/04/1999
Event Time: 11:36 [CST]
Last Update Date: 11/04/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(ii) - ESF ACTUATION
Person (Organization):
JAMES CREED (R3)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
Event Text
INADVERTENT SAFEGUARDS ACTUATIONS DURING PLANNED ELECTRICAL MAINTENANCE

"AT 1136CST ON 11/4/99, SAFEGUARDS 4.16KV BUS '16' DE-ENERGIZED UNEXPECTEDLY WHEN THE OFFSITE SOURCE SUPPLYING THE BUS TRIPPED. THE BUS WAS AUTOMATICALLY REPOWERED WITH THE AUTOMATIC CLOSURE OF ANOTHER OFFSITE SOURCE BREAKER. [THE] CAUSE OF THE DE-ENERGIZATION WAS AN INADVERTENT 'CT11' (NORMAL OFFSITE SUPPLY TO SAFEGUARDS BUS '16') LOCKOUT, DUE TO A BUMPED RELAY WHILE RE-INSTALLING A 4KV BREAKER INTO ITS CUBICLE.

"AUTO ACTUATIONS AS A RESULT OF THE MOMENTARY DE-ENERGIZATION WERE:

1. AUTOSTART OF THE OPPOSITE TRAIN COMPONENT COOLING WATER PUMP, AND
2. AUTO SEQUENCING OF BUS '16' TO AN ALTERNATE SOURCE."

THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR.


!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital
Event Number: 36396
Rep Org: PRINCETON MEDICAL CENTER
Licensee: PRINCETON MEDICAL CENTER
Region: 1
City: PRINCETON   State: NJ
County:
License #: 29-06750-01
Agreement: N
Docket:
NRC Notified By: EDWARD BACZA
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/04/1999
Notification Time: 14:30 [ET]
Event Date: 11/04/1999
Event Time: 09:15 [EST]
Last Update Date: 12/30/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
35.33 - MED MISADMINISTRATION
Person (Organization):
MOHAMED SHANBAKY (R1)
JOSIE PICCONE (NMSS)
Event Text
POTENTIAL MISADMINISTRATION INVOLVING DISLODGED BRACHYTHERAPY SOURCE

AT APPROXIMATELY 0915EST AN ELDERLY FEMALE PATIENT NOTIFIED HOSPITAL STAFF THAT A BRACYTHERAPY SOURCE (Cs-137 - 21.8 MILLIGRAM RADIUM EQUIVALENT) HAD BECOME DISLODGED. HOSPITAL STAFF CONTACTED THE PHYSICIAN THAT HAD INSERTED THE SOURCE AND WAS INSTRUCTED TO RELOCATE THE APPLICATOR TO THE FOOT OF THE BED. THE HOSPITAL PHYSICIST ESTIMATES THAT THE SOURCE WAS IN THE VICINITY OF THE PATIENT'S THIGH FOR APPROXIMATELY 15 MINUTES AND AT THE FOOT THE BED FOR ANOTHER 18 MINUTES BEFORE BEING PLACED IN A LEAD PIG. THE ATTENDING PHYSICIAN DOES NOT INTEND ANY ADDITIONAL EXPOSURE SINCE THE SOURCE REMAINED IN PLACE FOR 18.45 OF THE 22.79 HOURS PRESCRIBED. NO ADVERSE HEALTH CONSEQUENCES ARE EXPECTED.


* * * UPDATE AT 0900 ON 12/30/99 BY BACZA, TAKEN BY WEAVER * * *

THE LICENSEE REQUESTED THIS EVENT BE RETRACTED. REGIONAL INSPECTORS CONDUCTED AN INVESTIGATION OF THIS EVENT AND DETERMINED THAT NO MISADMINISTRATION HAD OCCURRED.
HOO NOTIFIED RDO (BELLAMY).


!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 36397
Facility: PERRY
Region: 3     State: OH
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: BRIAN STETSON
HQ OPS Officer: DOUG WEAVER
Notification Date: 11/04/1999
Notification Time: 15:06 [ET]
Event Date: 11/04/1999
Event Time: 10:00 [EST]
Last Update Date: 11/30/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
Person (Organization):
JAMES CREED (R3)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
Event Text
CONTROL ROD WITHDRAWAL LIMITER DISCOVERED INOPERABLE DURING ROD TESTING

"It has been discovered that following the insertion of a control rod, the Rod Withdrawal Limiter is inoperable until that control rod is deselected and reselected from the Rod Control & Information System control panel.

"We have reasonable knowledge that we have withdrawn control rods in the past, while the Rod Withdrawal Limiter has been inoperable. We have specific knowledge that on 10/31/99, a control rod was withdrawn with the Rod Withdrawal Limiter inoperable. This is a violation of Technical Specification 3.3.2.1 Action A.1.

"This report is required due to the requirements of the Operating License for a violation of Technical Specifications."

This condition was discovered by operators during performance of control rod speed adjustment of a single rod. Control rod motion continued past the withdrawal notch limit of 4. The operator immediately let go of the withdraw push button causing the rod to stop at the notch 6 position. The licensee suspects this condition has existed since initial construction and has imposed administrative controls specifically referencing Technical Specifications requirements.

The licensee informed the NRC Resident Inspector.

* * * UPDATE AT 1007 ON 11/30/99 BY BRUCE LUTHENEN TO JOLLIFFE * * *

Licensee engineering personnel determined that the control rod withdrawal limiter was operable at the time of the event and would have fulfilled its specific safety function. A revised operability determination was completed on 11/29/99. Therefore, a condition prohibited by plant tech specs did not exist. Thus, the licensee desires to retract this event and is considering submitting a licensee event report on this issue. The licensee plans to notify the NRC Resident Inspector.

The NRC Operations Officer notified the R3DO Geoffrey Wright.


Fuel Cycle Facility
Event Number: 36398
Facility: PORTSMOUTH GASEOUS DIFFUSION PLANT
Region: 3     State: OH
Unit: [] [] []
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
6903 ROCKLEDGE DRIVE
BETHESDA, MD 20817 (301)564-3200
NRC Notified By: JIM McCLEERY
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/04/1999
Notification Time: 17:04 [ET]
Event Date: 11/04/1999
Event Time: 08:25 [EST]
Last Update Date: 11/04/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
76.120(c)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
JAMES CREED (R3)
WAYNE HODGES (NMSS)
Event Text
SAFETY EQUIPMENT FAILURE DURING AUTOCLAVE HEATUP

"ON 11/4/99 AT 0825 [HOURS] OPERATORS IN THE X-344 NOTICED CONDENSATE LEAKING FROM THE AUTOCLAVE #2 LOCKING RING AREA WHILE IN MODE II (HEATING). THE AUTOCLAVE WAS PLACED IN MODE VII (SHUTDOWN) 15 MINUTES AFTER THE DISCOVERY OF THE LEAK. INITIAL INVESTIGATION SHOWS A PIECE OF COPPER TUBING MAY HAVE BEEN LODGED ON THE SEALING SURFACE OF THE LOCKING RING. THE AUTOCLAVE WAS MADE INOPERABLE IMMEDIATELY. THERE WAS NO ACTUATION OF A SAFETY SYSTEM DURING THIS OPERATION. THIS IS REPORTABLE UNDER CONDITION 76.120 (C)(2)(i), AN EVENT IN WHICH EQUIPMENT IS DISABLED OR FAILS TO FUNCTION AS DESIGNED WHEN THE EQUIPMENT IS REQUIRED BY A TSR [TECHNICAL SAFETY REQUIREMENT] TO PREVENT RELEASES.

"THERE WAS NO LOSS OF HAZARDOUS/RADIOACTIVE MATERIAL OR RADIOACTIVE/RADIOLOGICAL CONTAMINATION EXPOSURE AS A RESULT OF THIS EVENT."

OPERATION'S STAFF NOTIFIED THE NRC RESIDENT INSPECTOR AND DOE SITE REPRESENTATIVE.


Power Reactor
Event Number: 36399
Facility: POINT BEACH
Region: 3     State: WI
Unit: [1] [] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: JOHN SELL
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/04/1999
Notification Time: 18:29 [ET]
Event Date: 11/04/1999
Event Time: 14:00 [CST]
Last Update Date: 11/04/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - DEG/UNANALYZED COND
Person (Organization):
JAMES CREED (R3)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling
Event Text
TWO MAIN STEAM SAFETY VALVES (MSSVs) EXCEEDED ACCEPTANCE CRITERIA DURING SETPOINT TESTING

"DURING THE POINT BEACH NUCLEAR PLANT (PBNP) UNIT 1 R25 OUTAGE, TWO (2) MAIN STEAM SAFETY VALVES WERE SENT TO WYLE LABS FOR SETPOINT TESTING. MS-02013 LIFTED AT 2.4% ABOVE NAMEPLATE SETPOINT OF 1125 PSIG. THE OWNER ACCEPTANCE CRITERIA IS 1.93%. THIS VALVE DID NOT EXCEED THE ASME ACCEPTANCE CRITERIA OF 3%.

"MS-02012 LIFTED AT 3.7% ABOVE THE NAMEPLATE SETPOINT OF 1125 PSIG. THIS EXCEEDS BOTH THE OWNER ESTABLISHED ACCEPTANCE CRITERIA AND THE ASME XI CRITERIA.

"PBNP TECH SPECS REQUIRE AN ADDITIONAL NUMBER OF VALVES TO BE TESTED EQUAL TO THE NUMBER ORIGINALLY TESTED. SINCE FOUR (4) MSSVs WERE SENT FOR TESTING THIS OUTAGE, THE REMAINING FOUR (4) MSSVs WILL NEED TO BE TESTED.

"BOTH MS-02012 AND MS-02013 MAY HAVE HAD THEIR SETPOINTS ADJUSTED INCORRECTLY IN 1995."

THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR.


Power Reactor
Event Number: 36400
Facility: POINT BEACH
Region: 3     State: WI
Unit: [1] [] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: RICK ROBBINS
HQ OPS Officer: JOHN MacKINNON
Notification Date: 11/05/1999
Notification Time: 04:07 [ET]
Event Date: 11/04/1999
Event Time: 20:30 [CST]
Last Update Date: 11/05/1999
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - DEG/UNANALYZED COND
Person (Organization):
JAMES CREED (R3)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling
Event Text
0.25 INCH LONG CRACK WAS FOUND ON "1A" STEAM GENERATOR HEAD DRAIN VALVE.

During a liquid penetrant examination of a weld on the top side of valve 1R-526A, the '1A' Steam Generator head drain, a 0.25" long crack was found. This appears to be a crack in the weld metal only, through wall of the Reactor Coolant System pressure boundary.

During initial screening of this condition at 2030 hours on 11/04/99 it was not considered seriously degraded as no leak was detected while at power (boric acid crystals were found in the vicinity of the valve). Upon further review at 0200 hours on 11/05/99 this 4 hour non-emergency report was made.

The NRC Resident Inspector will be notified of this event by the licensee.