Event Notification Report for November 9, 1999
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
11/08/1999 - 11/09/1999
** EVENT NUMBERS **
36279 36379 36408 36412 36413 36414
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
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|Power Reactor |Event Number: 36279 |
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| FACILITY: FERMI REGION: 3 |NOTIFICATION DATE: 10/11/1999|
| UNIT: [2] [] [] STATE: MI |NOTIFICATION TIME: 13:07[EDT]|
| RXTYPE: [2] GE-4 |EVENT DATE: 10/11/1999|
+------------------------------------------------+EVENT TIME: 09:59[EDT]|
| NRC NOTIFIED BY: COSEO |LAST UPDATE DATE: 11/08/1999|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |JOHN JACOBSON R3 |
|10 CFR SECTION: | |
|AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION | |
|NLCO TECH SPEC LCO A/S | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|2 N Y 97 Power Operation |97 Power Operation |
| | |
| | |
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EVENT TEXT
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| VARIOUS SAFETY RELATED EQUIPMENT DECLARED INOPERABLE DUE TO LOSS OF COOLING |
| TO THE BATTERY CHARGER ROOM . |
| |
| Following startup of the Division 2 Residual Heat Removal Service Water |
| (RHRSW) pumps, it was observed that the Division 2 Emergency Equipment |
| Service Water (EESW) pump was rotating backwards. Division 2 RHRSW flow was |
| normal at greater than 9000 gpm. The Division 2 Ultimate Heat Sink (UHS) |
| service water systems discharge into a common header that can be routed to |
| the Division 2 UHS cooling tower fans or directly to the reservoir. This |
| indicates that the Division 2 EESW pump discharge check valve is not fully |
| closed. The Division 2 EESW pump control was placed in OFF/RESET (normally |
| in AUTO) at 0959 hrs on 10/11/99. The pump discharge valve was closed to |
| isolate the flow path and Division 2 EESW has been declared inoperable. This |
| results in Division 2 Emergency Equipment Cooling Water (EECW) being |
| inoperable. Division 2 EECW provides cooling to the High Pressure Coolant |
| Injection (HPCI) pump area cooler during accident conditions. Therefore, the |
| HPCI system was declared inoperable(14 day LCO) at 0959 on 10/11/99. HPCI |
| remains in standby lineup ready for automatic initiation. The Div 2 EECW |
| also provides cooling to the battery charger room. With the batteries |
| inoperable they are in an 18 hr LCO. |
| |
| The check valve internals have been inspected and preliminary findings |
| indicate that all parts are intact. The failure of the valve appears to be |
| caused by a worn disc pin in the valve. Necessary repairs are in progress. |
| |
| The Resident Inspector was notified. |
| |
| * * * UPDATE AT 1725 ON 11/8/99, BY PHILIPPON TAKEN BY WEAVER * * * |
| |
| The as found condition and repair of the Emergency Equipment Service Water |
| (EESW) pump discharge check valve, and its effect on the High Pressure |
| Coolant Injection (HPCI) room cooler were evaluated. |
| |
| The EESW system was operable in the as found condition, until it was removed |
| from service for repair. Based on engineering evaluation of the plant |
| conditions that existed when EESW was removed from service, the HPCI room |
| cooler would not have been required to support HPCI operability. The |
| evaluation showed that HPCI would be able to operate long enough to complete |
| its intended safety function (mitigate an accident) as defined in the |
| Updated Final Safety Analysis Report. Peak room temperature would not have |
| exceeded Environmental Qualification limits or the HPCI equipment room high |
| temperature isolation setpoint. With the room cooler out of service for the |
| EESW check valve repair HPCI remained capable of automatic initiation and |
| operation for the duration necessary to mitigate accidents and transients. |
| Additionally, plant procedures provide directions for bypassing the HPCI |
| equipment room high temperature trip. Consequently, there was no loss of |
| HPCI safety function. Declaring HPCI inoperable was conservative and based |
| on initial considerations. Therefore, event notification 36279 is |
| retracted. |
| |
| The licensee notified the NRC resident inspector. Notified R3DO (Parker). |
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!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
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|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: 11/08/1999|
| 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. |
| |
| SEE HOO LOG FOR ADDITIONAL INFORMATION. |
| |
| * * * UPDATE AT 1515 ON 11/8/99 BY DEPUYDT TAKEN BY WEAVER * * * |
| |
| Further evaluation of this event concluded that the guidance of Generic |
| Letter 91-03, Reporting of Safeguards Events , Enclosure 1, was applicable. |
| Specifically, Enclosure 1 states that a failed compensatory measure that |
| fails after being successfully established as an effective compensatory |
| measure for a degraded security system is a loggable event. |
| |
| Therefore, in keeping with the Guidance of GL 91-03, Event #36379 is |
| retracted as an event that must be reported within 1 hour under 10 CFR |
| 73.71, and will be instead recorded as a loggable event. |
| |
| The licensee informed the NRC resident inspector. The Operations Center |
| notified the R3DO (Parker). |
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!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
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|Power Reactor |Event Number: 36408 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: POINT BEACH REGION: 3 |NOTIFICATION DATE: 11/06/1999|
| UNIT: [1] [2] [] STATE: WI |NOTIFICATION TIME: 21:46[EST]|
| RXTYPE: [1] W-2-LP,[2] W-2-LP |EVENT DATE: 11/06/1999|
+------------------------------------------------+EVENT TIME: 18:44[CST]|
| NRC NOTIFIED BY: PHILLIP SHORT |LAST UPDATE DATE: 11/08/1999|
| HQ OPS OFFICER: STEVE SANDIN +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |JAMES CREED R3 |
|10 CFR SECTION: | |
|AMED 50.72(b)(2)(v) OFFSITE MEDICAL | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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
+------------------------------------------------------------------------------+
| INJURED POTENTIALLY CONTAMINATED WORKER TRANSPORTED TO LOCAL HOSPITAL |
| |
| "A WORKER SLIPPED AND FELL IN THE LAUNDRY ROOM. AN AMBULANCE WAS CALLED DUE |
| TO A POSSIBLE HIP INJURY. A COMPLETE FRISK OF THE INDIVIDUAL WAS NOT ABLE |
| TO BE PERFORMED PRIOR TO TRANSPORTING OFFSITE TO A LOCAL HOSPITAL. THE |
| INJURED PERSON IS BEING CONSIDERED POTENTIALLY CONTAMINATED. A RADIATION |
| PROTECTION TECHNICIAN IS ACCOMPANYING THE INJURED PERSON TO THE HOSPITAL." |
| |
| THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. |
| |
| * * * RETRACTION 0953 11/8/1999 FROM MEYER TAKEN BY STRANSKY * * * |
| |
| "This Notification is a retraction of a 4-hour Notification that was made on |
| 11/6/99. The Notification was issued yesterday when a potentially |
| contaminated worker was transported to a local hospital. At the time of the |
| notification, it was not known whether the worker or the lab coat she was |
| wearing was contaminated. The Radiation Protection Technician who |
| accompanied her determined that the worker and the lab coat were not |
| contaminated. Therefore, the Notification made on 11/6/99 is retracted." |
| |
| The NRC resident inspector has been informed of this retraction by the |
| licensee. Notified R3DO (Parker). |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Hospital |Event Number: 36412 |
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| REP ORG: DEACONESS BILLINGS CLINIC |NOTIFICATION DATE: 11/08/1999|
|LICENSEE: DEACONESS BILLNGS CLINIC |NOTIFICATION TIME: 17:16[EST]|
| CITY: BILLINGS REGION: 4 |EVENT DATE: 11/03/1999|
| COUNTY: STATE: MT |EVENT TIME: 12:00[MST]|
|LICENSE#: 25-01051-01 AGREEMENT: N |LAST UPDATE DATE: 11/08/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |PHIL HARRELL R4 |
| |WAYNE HODGES NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: DAVID SWITZER | |
| HQ OPS OFFICER: DOUG WEAVER | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
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EVENT TEXT
+------------------------------------------------------------------------------+
| MEDICAL MISADMINISTRATION |
| |
| Only two of three I-131 pills were administered to a patient on 11/3/99. |
| The intended dose was 200 mCi, and approximately 148 mCi were delivered. |
| This was an ablative thyroid dose for cancer. The patient's attending |
| physician has been notified of the error and the patient will be contacted |
| as soon as possible. The reason for the error was that two pills came in |
| one vial and only one of those pills was removed and given to the patient. |
| The other pill remained in the vial and was discovered today 11/8/99, at |
| 1300 PST. |
| |
| The patient will be monitored and treated as necessary. |
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|Power Reactor |Event Number: 36413 |
+------------------------------------------------------------------------------+
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| FACILITY: SAN ONOFRE REGION: 4 |NOTIFICATION DATE: 11/08/1999|
| UNIT: [1] [2] [3] STATE: CA |NOTIFICATION TIME: 17:24[EST]|
| RXTYPE: [1] W-3-LP,[2] CE,[3] CE |EVENT DATE: 11/08/1999|
+------------------------------------------------+EVENT TIME: 13:45[PST]|
| NRC NOTIFIED BY: G. L. PLUMLEE |LAST UPDATE DATE: 11/08/1999|
| HQ OPS OFFICER: DOUG WEAVER +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |PHIL HARRELL R4 |
|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 Decommissioned |0 Decommissioned |
|2 N Y 100 Power Operation |100 Power Operation |
|3 N Y 100 Power Operation |100 Power Operation |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| SAFEGUARDS SYSTEM DEGRADATION RELATED TO AREA BOUNDARY. IMMEDIATE |
| COMPENSATORY ACTIONS TAKEN UPON DISCOVERY. THE NRC RESIDENT INSPECTOR WILL |
| BE INFORMED BY THE LICENSEE |
| |
| CONTACT THE NRC OPERATIONS CENTER FOR ADDITIONAL DETAILS. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36414 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: POINT BEACH REGION: 3 |NOTIFICATION DATE: 11/08/1999|
| UNIT: [1] [] [] STATE: WI |NOTIFICATION TIME: 18:30[EST]|
| RXTYPE: [1] W-2-LP,[2] W-2-LP |EVENT DATE: 11/08/1999|
+------------------------------------------------+EVENT TIME: 16:00[CST]|
| NRC NOTIFIED BY: MIKE MEYER |LAST UPDATE DATE: 11/08/1999|
| HQ OPS OFFICER: DOUG WEAVER +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |MICHAEL PARKER 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
+------------------------------------------------------------------------------+
| ESF ACTUATION - SAFETY INJECTION SIGNAL INADVERTENTLY INSERTED DURING |
| TESTING |
| |
| While performing post maintenance testing on 1P-ISA (Safety Injection Pump), |
| an inadvertent ESF occurred. The 'A' Safety Injection Train actuated on |
| Unit 1 after the electrician installed a jumper which was intended to |
| simulate an Auto Start signal for 1P-ISA. The jumper terminals appear to |
| have been incorrectly identified in the work plan. All systems started as |
| designed. The SI pumps did not start because they were in pull-to-lock per |
| procedure for the existing plant conditions. The following |
| components/activations occurred: Aux feed pump start, EDG start (Train A), |
| and containment isolation. Because the affected unit was defueled, systems |
| that would normally inject into the reactor coolant system were tagged out. |
| There was no ECCS discharge. Service water was momentarily isolated to |
| Spent Fuel Pool Cooling resulting in spent fuel pool temperature increasing |
| slightly. Bulk spent fuel pool temperature remained at approximately 85�F. |
| Current calculated time to boil is 19 hours. |
| |
| The licensee notified the NRC resident inspector. |
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Page Last Reviewed/Updated Thursday, March 25, 2021