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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 THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!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  !!!!!!!
+------------------------------------------------------------------------------+
|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).                                                  |
+------------------------------------------------------------------------------+

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
+------------------------------------------------------------------------------+
|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       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| 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  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   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.                      |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36413       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| 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 85F.  |
| Current calculated time to boil is 19 hours.                                 |
|                                                                              |
| The licensee notified the NRC resident inspector.                            |
+------------------------------------------------------------------------------+