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Event Notification Report for November 29, 1999

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           11/26/1999 - 11/29/1999

                              ** EVENT NUMBERS **

36464  36465  36466  36467  36468  36469  36470  36471  

+------------------------------------------------------------------------------+
|Fuel Cycle Facility                              |Event Number:   36464       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT   |NOTIFICATION DATE: 11/26/1999|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 06:46[EST]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        11/26/1999|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        03:00[EST]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  11/26/1999|
|    CITY:  PIKETON                  REGION:  3  +-----------------------------+
|  COUNTY:  PIKE                      STATE:  OH |PERSON          ORGANIZATION |
|LICENSE#:  GDP-2                 AGREEMENT:  N  |RONALD GARDNER       R3      |
|  DOCKET:  0707002                              |BRIAN SMITH          NMSS    |
+------------------------------------------------+FRANK CONGEL         IRO     |
| NRC NOTIFIED BY:  RON CRABTREE                 |                             |
|  HQ OPS OFFICER:  LEIGH TROCINE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NBNL                     RESPONSE-BULLETIN      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| NRC BULLETIN 91-01 RESPONSE (4-HOUR REPORT) - LOSS OF SPACING AND MODERATION |
| CONTROLS                                                                     |
|                                                                              |
| The following text is a portion of a facsimile received from Portsmouth:     |
|                                                                              |
| "On 11/26/99 at 0341 hours, the Plant Shift Superintendent (PSS) was         |
| notified that NCSA-PLANT062.A02 Nuclear Criticality Safety Approval (NCSA)   |
| requirements were not being met.  A conical section of pipe removed during   |
| maintenance activities on cell 33-5-10 was staged less than 2 feet from      |
| other uranium-bearing piping in the cell housing.  It was also identified    |
| that the flanged openings of the conical transition piece were not covered   |
| as required by NCSA-PLANT062.A02.  [These issues were discovered at 0300     |
| hours.]"                                                                     |
|                                                                              |
| "This violated requirement #3 of NCSA-PLANT062.A02, which states in part:    |
| 'Both favorable and unfavorable types of uncomplicated handling (UH)         |
| equipment shall be spaced a minimum of 2 feet edge-to-edge from other        |
| uranium-bearing equipment.'  Requirement #4, which states that               |
| openings/penetrations made during maintenance activities shall be covered to |
| minimize the potential for moderator collection and moist air exposure when  |
| unattended, was also violated."                                              |
|                                                                              |
| "This is reportable under NRC Bulletin 91-01, 4-hour criticality control."   |
|                                                                              |
| "There was no loss of hazardous/radioactive material or                      |
| radioactive/radiological contamination exposure as a result of this event."  |
|                                                                              |
| Portsmouth personnel notified the NRC resident inspector and plan to notify  |
| the Department of Energy site representative.                                |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36465       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SAINT LUCIE              REGION:  2  |NOTIFICATION DATE: 11/26/1999|
|    UNIT:  [1] [2] []                STATE:  FL |NOTIFICATION TIME: 09:12[EST]|
|   RXTYPE: [1] CE,[2] CE                        |EVENT DATE:        11/26/1999|
+------------------------------------------------+EVENT TIME:        08:00[EST]|
| NRC NOTIFIED BY:  DAVE WILLIAMS                |LAST UPDATE DATE:  11/26/1999|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |LEN WERT             R2      |
|10 CFR SECTION:                                 |                             |
|APRE 50.72(b)(2)(vi)     OFFSITE NOTIFICATION   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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                                   
+------------------------------------------------------------------------------+
| OFFSITE NOTIFICATION REGARDING A LIVE SEA TURTLE REMOVED FROM THE INTAKE     |
| CANAL BARRIER NET                                                            |
|                                                                              |
| The following text is a portion of a facsimile received from the licensee:   |
|                                                                              |
| "At approximately 0730 on 11/26/99, a live juvenile loggerhead sea turtle    |
| was removed from the barrier net in the common plant intake canal.  The      |
| Florida Department of Environmental Protection was notified at approximately |
| 0800 for transfer to a rehabilitation facility."                             |
|                                                                              |
| The licensee notified the NRC resident inspector.                            |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36466       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: CALLAWAY                 REGION:  4  |NOTIFICATION DATE: 11/26/1999|
|    UNIT:  [1] [] []                 STATE:  MO |NOTIFICATION TIME: 17:16[EST]|
|   RXTYPE: [1] W-4-LP                           |EVENT DATE:        11/26/1999|
+------------------------------------------------+EVENT TIME:        12:27[CST]|
| NRC NOTIFIED BY:  GARY OLMSTEAD                |LAST UPDATE DATE:  11/26/1999|
|  HQ OPS OFFICER:  STEVE SANDIN                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |BLAIR SPITZBERG      R4      |
|10 CFR SECTION:                                 |                             |
|ARPS 50.72(b)(2)(ii)     RPS ACTUATION          |                             |
|AESF 50.72(b)(2)(ii)     ESF ACTUATION          |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     A/R        Y       100      Power Operation  |0        Hot Standby      |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| Unit experienced an automatic reactor trip following a momentary loss of     |
| power to an I&C power supply that resulted in a low Steam Generator water    |
| level.                                                                       |
|                                                                              |
| "This event is being reported in accordance with 10CFR50.72(b)(2)(ii) due to |
| an automatic Reactor Trip and subsequent Aux Feedwater actuation and         |
| Feedwater isolation:                                                         |
|                                                                              |
| "On 11/26/99 at 1227 CST with Callaway plant at 100% reactor power, a        |
| Reactor Trip occurred on low Steam Generator 'A' level due to an apparent    |
| momentary loss of power in Control Cabinet [Relay Panel] RP043.  At 1204,    |
| annunciator 93A 'Power Control System (PCS) Power Failure' alarmed due to a  |
| failed RP043 primary power supply. Initial investigation revealed a failed   |
| fuse in the RP043 primary power supply. The secondary power supply           |
| immediately picked up load without incident.                                 |
|                                                                              |
| "Subsequent to the primary power supply failure, I&C technicians were sent   |
| to the RP043 cabinet and the Primary Equipment Operator was sent to RP043    |
| supply breaker PG19GCR218 to investigate.  During this investigation, Main   |
| Feedwater Regulating valve [MFRV] 'A' went shut and both Main Feedwater      |
| Pumps [MFPs] went to their low speed stops.  Attempts by the Reactor         |
| Operator to take manual control of 'A'  MFRV and the MFPs were unsuccessful  |
| resulting in the aforementioned Reactor Trip.                                |
|                                                                              |
| "Discussions with I&C personnel stationed at RP043 indicated the secondary   |
| power supplies appeared energized throughout the event.  Discussions with    |
| the Primary EO indicated he checked PG19GCR218 in the closed position        |
| coincident with the trip.  Plant personnel are currently investigating       |
| PG19GCR218 and the apparent momentary loss of power to RP043.  The plant is  |
| currently stable in Mode 3 with RCS pressure at 2237 psig and RCS            |
| temperature at 557.8 F.                                                      |
|                                                                              |
| "Additional information: The NRC Senior Resident Inspector was contacted at  |
| 1310 and responded to the Control Room."                                     |
|                                                                              |
| Auxiliary Feedwater is currently supplying the Steam Generators with steam   |
| flow to the Main Condenser for decay heat removal.  All control rods fully   |
| inserted.                                                                    |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36467       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SAINT LUCIE              REGION:  2  |NOTIFICATION DATE: 11/26/1999|
|    UNIT:  [1] [2] []                STATE:  FL |NOTIFICATION TIME: 17:34[EST]|
|   RXTYPE: [1] CE,[2] CE                        |EVENT DATE:        11/26/1999|
+------------------------------------------------+EVENT TIME:        17:12[EST]|
| NRC NOTIFIED BY:  DAVE WILLIAMS                |LAST UPDATE DATE:  11/26/1999|
|  HQ OPS OFFICER:  STEVE SANDIN                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |LEN WERT             R2      |
|10 CFR SECTION:                                 |                             |
|APRE 50.72(b)(2)(vi)     OFFSITE NOTIFICATION   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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                                   
+------------------------------------------------------------------------------+
| OFFSITE NOTIFICATION TO STATE AGENCY  REGARDING DEAD SEA TURTLE FOUND IN     |
| BARRIER NET OF THE INTAKE CANAL                                              |
|                                                                              |
| "[A] NOTIFICATION [WAS] MADE TO [THE] FLORIDA DEPARTMENT OF ENVIRONMENTAL    |
| PROTECTION (DEP) REGARDING [THE] REMOVAL OF [A] DEAD SUB-ADULT LOGGERHEAD    |
| SEA TURTLE FROM THE BARRIER NET IN THE COMMON PLANT INTAKE CANAL.  THE       |
| TURTLE WAS REMOVED AT APPROXIMATELY 1700 [HOURS] ON 11/26/99, AND THE        |
| FLORIDA DEP WAS NOTIFIED AT 1710 HOURS.  [THE] ANIMAL WAS FOUND WITH         |
| MONOFILAMENT FISHING LINE AROUND [THE] FRONT FLIPPERS AND [THE] MORTALITY IS |
| NOT BELIEVED TO BE CAUSALLY RELATED TO PLANT OPERATIONS.  THE LICENSEE WILL  |
| NOTIFY THE NRC RESIDENT INSPECTOR."                                          |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   36468       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  FAIRVIEW SOUTHDALE HOSPITAL          |NOTIFICATION DATE: 11/26/1999|
|LICENSEE:  FAIRVIEW SOUTHDALE HOSPITAL          |NOTIFICATION TIME: 23:46[EST]|
|    CITY:  EDINA                    REGION:  3  |EVENT DATE:        11/25/1999|
|  COUNTY:                            STATE:  MN |EVENT TIME:        07:05[CST]|
|LICENSE#:  22-00015-02           AGREEMENT:  N  |LAST UPDATE DATE:  11/26/1999|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |RONALD GARDNER       R3      |
|                                                |JOE HOLONICH         NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  DR. L. LEWANOWSKI            |                             |
|  HQ OPS OFFICER:  STEVE SANDIN                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| FEMALE PATIENT RECEIVED LESS THAN THE PRESCRIBED DOSE DUE TO TECHNICIAN      |
| ERROR                                                                        |
|                                                                              |
| A FEMALE PATIENT UNDERGOING TREATMENT FOR ENDOMETRIAL CANCER RECEIVED 5072   |
| RATHER THAN THE 6500 CENTIGRAY PRESCRIBED DUE TO TECHNICIAN ERROR IN LOADING |
| TWO (2) OLD CESIUM-137 SOURCES INTO THE APPLICATOR.  THE NEWER SOURCES (25   |
| MILLIGRAMS RADIUM EQUIVALENT EACH) WERE CLEARLY LABELED AND INDICATED ON THE |
| HOSPITAL FORMS.  THE PRESCRIBING PHYSICIAN WAS INFORMED AND REQUESTED THAT   |
| THE PATIENT NOT BE NOTIFIED PENDING AN EVALUATION OF  WHETHER ADDITIONAL     |
| TREATMENT IS REQUIRED.  THE LICENSEE WILL SUBMIT A WRITTEN REPORT WITHIN     |
| FIFTEEN DAYS.                                                                |
|                                                                              |
| CALLTHE HEADQUARTERS OPERATIONS OFFICER FOR CONTACT INFORMATION.             |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36469       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: WATERFORD                REGION:  4  |NOTIFICATION DATE: 11/27/1999|
|    UNIT:  [3] [] []                 STATE:  LA |NOTIFICATION TIME: 07:00[EST]|
|   RXTYPE: [3] CE                               |EVENT DATE:        11/27/1999|
+------------------------------------------------+EVENT TIME:        05:33[CST]|
| NRC NOTIFIED BY:  P. BOCSKOV/B. LIETZKE        |LAST UPDATE DATE:  11/27/1999|
|  HQ OPS OFFICER:  DICK JOLLIFFE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          ALE                   |BLAIR SPITZBERG      R4      |
|10 CFR SECTION:                                 |ELINOR ADENSAM       NRR     |
|AAEC 50.72 (a) (1) (I)   EMERGENCY DECLARED     |FRANK CONGEL         IRO     |
|                                                |THOMAS MCKENNA       RCT     |
|                                                |SUE GAGNER           OPA     |
|                                                |KEN CIBOCH           FEMA    |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|3     N          N       0        Hot Shutdown     |0        Hot Shutdown     |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| - ALERT DUE TO SUDDEN DEPRESSURIZATION OF RCS AND LOSS OF 3000 GALLONS FROM  |
| RCS -                                                                        |
|                                                                              |
| ON 11/26/99, WATERFORD WAS SHUT DOWN FROM 100% POWER TO REPAIR A LEAK ON A   |
| MAIN STEAM LINE DRAIN LINE.                                                  |
|                                                                              |
| AT 0500 CST ON 11/27/99, WITH THE PLANT IN MODE 4 (HOT SHUTDOWN), THE        |
| LICENSEE OPENED THE SUCTION VALVE (#SI-407B) TO THE TRAIN 'B' LOW PRESSURE   |
| SAFETY INJECTION PUMP TO PLACE THE PLANT ON SHUTDOWN COOLING.  CONTROL ROOM  |
| OPERATORS HEARD A LOUD NOISE.  APPROXIMATELY 3000 GALLONS DRAINED FROM THE   |
| REACTOR COOLANT SYSTEM (RCS) INTO THE REFUELING WATER STORAGE POOL IN ABOUT  |
| 2 MINUTES.  THE WATER LEVEL IN THE PRESSURIZER DROPPED FROM 35% TO 0%.  THE  |
| PRESSURIZER HEATERS TRIPPED.  RCS PRESSURE DROPPED FROM 350 PSIG TO 100      |
| PSIG.  RCS TEMPERATURE REMAINED AT 295F.  THE LICENSEE CLOSED THE VALVE     |
| WHICH STOPPED THE DRAIN FROM THE RCS AND REFILLED THE PRESSURIZER TO 53%     |
| USING THE HIGH PRESSURE SAFETY INJECTION PUMP.                               |
|                                                                              |
| AT 0533 CST ON 11/27/99, THE LICENSEE DECLARED AN ALERT DUE TO A             |
| PRECAUTIONARY STATEMENT IN THE EMERGENCY OPERATING PROCEDURE DUE TO THE      |
| SUDDEN DEPRESSURIZATION OF THE RCS.  THE LICENSEE NOTIFIED STATE AND LOCAL   |
| OFFICIALS AND THE NRC SENIOR RESIDENT INSPECTOR.  THE LICENSEE CALLED        |
| PERSONNEL TO COME TO THE PLANT TO STAFF THEIR EMERGENCY OPERATIONS FACILITY  |
| AND TECHNICAL SUPPORT CENTER AND ACTIVATED THEIR EMERGENCY RESPONSE DATA     |
| SYSTEM.                                                                      |
|                                                                              |
| THE PLANT IS IN NATURAL CIRCULATION TO STEAM GENERATOR (S/G) #2 TO THE MAIN  |
| CONDENSER.  S/G #1 IS INOPERABLE.  THERE WAS NO RELEASE OF RADIATION AND NO  |
| PERSONNEL WERE INJURED.                                                      |
|                                                                              |
| AT 0640 CST ON 11/27/99, THE NRC ENTERED THE MONITORING PHASE OF NORMAL      |
| RESPONSE MODE.  NRC REGION 4 STAFFED THEIR INCIDENT RESPONSE CENTER.  THE    |
| LICENSEE IS PREPARING A PRESS RELEASE.                                       |
|                                                                              |
| THE PLANT IS STABLE IN MODE 4 (HOT SHUTDOWN).                                |
|                                                                              |
| SUBSEQUENTLY, THE LICENSEE DISCOVERED THAT A 6 INCH MANUAL RECIRC VALVE      |
| (#SI-417B) WAS OPEN, BUT WAS INDICATING CLOSED.  THE REACH ROD TO THE VALVE  |
| WAS BROKEN.  THE LICENSEE DETERMINED THAT THE VALVE HAD BEEN OPEN FOR ABOUT  |
| A WEEK.                                                                      |
|                                                                              |
| AT 1100 EST ON 11/27/99, A COMMISSIONERS' ASSISTANTS BRIEFING WAS HELD WITH  |
| THE FOLLOWING ATTENDEES:  IRO FRANK CONGEL, JOE GIITTER; NRR PROJECT         |
| DIRECTOR STU RICHARDS; OPA BETH HAYDEN; OSP PAUL LOHAUS; OIP RON HAUBER; OCA |
| LAURA GERKE; EDO DAVE LANGE; DEDMRS PAPERIELLO; SECY ANNETTE VIETTI-COOK;    |
| CHAIRMAN MESERVE (GLEN TRACY); COMM DICUS (TOM HILTZ); COMM McGAFFIGAN       |
| (JANET SCHLUETER); COMM DIAZ (TONY HSIA); COMM MERRIFIELD (BRIAN McCABE);    |
| REGION 4 TOM ANDREWS, CHRIS KENNEDY, ELLIS MERSCHOFF, KEN BROCKMAN           |
| (BRIEFER); SRI TOM FARNHOLTZ.                                                |
|                                                                              |
| * * * UPDATE AT 1335 EST ON 11/27/99 FROM MIKE MASON TO S. SANDIN * * *      |
|                                                                              |
| THE LICENSEE EXITED THE ALERT AT 1226 CST AFTER VERIFYING THAT THE PLANT WAS |
| IN MODE 5 AND STABLE (TERMINATION CRITERIA).  THE LICENSEE INFORMED          |
| STATE/LOCAL AGENCIES AND THE NRC RESIDENT INSPECTOR.  THE NRC OPERATIONS     |
| OFFICER NOTIFIED R4(MERSCHOFF), EO(ADENSAM), IRO(CONGEL), PAO(GAGNER,        |
| JASINSKI), EDO(PAPERIELLO), CHAIRMAN MESERVE(TRACY), FEMA(SULLIVAN),         |
| DOE(YOUNG), EPA(DiGIORGIO), USDA(CONLEY) AND HHS(BERGER).                    |
|                                                                              |
| AT 1345 EST THE NRC EXITED THE MONITORING PHASE OF NORMAL RESPONSE MODE PER  |
| A 1315 EST CONFERENCE CALL INVOLVING R4(MERSCHOFF), NRR(COLLINS, RICHARDS),  |
| IRO(CONGEL) AND EDO(TRAVERS).                                                |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36470       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: DUANE ARNOLD             REGION:  3  |NOTIFICATION DATE: 11/28/1999|
|    UNIT:  [1] [] []                 STATE:  IA |NOTIFICATION TIME: 02:13[EST]|
|   RXTYPE: [1] GE-4                             |EVENT DATE:        11/27/1999|
+------------------------------------------------+EVENT TIME:        22:35[CST]|
| NRC NOTIFIED BY:  DAVE SCHUSSLER               |LAST UPDATE DATE:  11/28/1999|
|  HQ OPS OFFICER:  DICK JOLLIFFE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |RONALD GARDNER       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          Y       1        Startup          |1        Startup          |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| - SAFETY/RELIEF VALVE OPENED FOR 1 MINUTE DURING MAINTENANCE ACTIVITIES -    |
|                                                                              |
| DURING A REACTOR STARTUP WITH REACTOR AT 1% POWER, MAINTENANCE TECHNICIANS   |
| WERE PREPARING TO PERFORM AN INSPECTION ON THE 125 VDC DIVISION I ELECTRICAL |
| DISTRIBUTION SYSTEM BY USING A SCOUT GROUND DETECTION DEVICE TO TROUBLESHOOT |
| A SYSTEM GROUND.  DURING THE MAINTENANCE INSPECTION, THE SCOUTING DEVICE     |
| CAUSED SAFETY/RELIEF VALVE (SRV) (#PSV-4402) (ADS VALVE) TO OPEN AS          |
| INDICATED BY "TAILPIPE HI TEMP" ALARM.  THE OPENING OF THE SRV CAUSED THE    |
| REACTOR VESSEL WATER LEVEL TO SWELL FROM A NORMAL LEVEL OF 190 INCHES TO 200 |
| INCHES.  OTHER ALARMS ASSOCIATED WITH THE TROUBLESHOOTING WERE ALSO RECEIVED |
| IN THE CONTROL ROOM.  MAINTENANCE ACTIVITIES ON 125 VDC DIVISION I           |
| ELECTRICAL DISTRIBUTION SYSTEM WERE QUICKLY HALTED AND THE SRV COMPLETELY    |
| CLOSED ABOUT ONE MINUTE AFTER OPENING CAUSING THE REACTOR VESSEL WATER LEVEL |
| TO DROP TO 178 INCHES. THE CONDENSATE SYSTEM WAS USED TO RESTORE WATER LEVEL |
| TO ITS NORMAL LEVEL OF 186 TO 195 INCHES.                                    |
|                                                                              |
| THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR.                            |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36471       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PALISADES                REGION:  3  |NOTIFICATION DATE: 11/28/1999|
|    UNIT:  [1] [] []                 STATE:  MI |NOTIFICATION TIME: 19:50[EST]|
|   RXTYPE: [1] CE                               |EVENT DATE:        11/28/1999|
+------------------------------------------------+EVENT TIME:        15:45[EST]|
| NRC NOTIFIED BY:  DALE ENGLE                   |LAST UPDATE DATE:  11/28/1999|
|  HQ OPS OFFICER:  STEVE SANDIN                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |RONALD GARDNER       R3      |
|10 CFR SECTION:                                 |                             |
|ADAS 50.72(b)(2)(i)      DEG/UNANALYZED COND    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          N       0        Cold Shutdown    |0        Cold Shutdown    |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| "B" TRAIN LOW PRESSURE SAFETY INJECTION (LPSI) FLOW RATES FOUND DEGRADED     |
| DURING SURVEILLANCE TESTING.                                                 |
|                                                                              |
| "WHILE PERFORMING QO-8B (LOW PRESSURE SAFETY INJECTION FLOW TESTING), IT WAS |
| DETERMINED THAT FLOW TO TWO (2) OF FOUR (4) LOOPS (VALVES-MO-3012 & MO-3014  |
| [RIGHT CHANNEL]) WAS INADEQUATE.  THE FLOW RATES WERE BELOW THE DESIGN BASIS |
| FOR ACCIDENT CONDITIONS.  [THIS] CONDITION WAS DISCOVERED DURING             |
| SURVEILLANCE TESTING WHILE THE PLANT WAS IN COLD SHUTDOWN.  THIS IS          |
| REPORTABLE PER 50.72(b)(2)(I)."                                              |
|                                                                              |
| THE DESIGN FLOW RATE IS 1720 GPM.  THE AS-FOUND FLOW RATES THROUGH VALVES    |
| 3012 & 3014 WERE 1650 AND 1500 GPM, RESPECTIVELY.  THE "B" TRAIN LPSI HAS    |
| BEEN DECLARED INOPERABLE PENDING CORRECTIVE ACTION WHICH IS TO BE            |
| DETERMINED.  THE UNIT IS NOT IN A TECH SPEC ACTION STATEMENT IN THAT LPSI IS |
| NOT REQUIRED FOR CURRENT PLANT CONDITIONS.  THE SURVEILLANCE TEST WHICH      |
| IDENTIFIED THIS CONDITION IS PERFORMED EACH REFUELING OUTAGE (APPROXIMATELY  |
| EVERY 18 MONTHS).  THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR.         |
+------------------------------------------------------------------------------+