Event Notification Report for December 20, 1999
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
12/17/1999 - 12/20/1999
** EVENT NUMBERS **
36263 36521 36522 36523 36524
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|General Information or Other |Event Number: 36263 |
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| REP ORG: SWAGELOK COMPANY |NOTIFICATION DATE: 10/06/1999|
|LICENSEE: SWAGELOK COMPANY |NOTIFICATION TIME: 09:48[EDT]|
| CITY: Solon REGION: 3 |EVENT DATE: 10/04/1999|
| COUNTY: STATE: OH |EVENT TIME: [EDT]|
|LICENSE#: AGREEMENT: N |LAST UPDATE DATE: 12/17/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |JOHN KINNEMAN R1 |
| |BRIAN BONSER R2 |
+------------------------------------------------+JOHN JACOBSON R3 |
| NRC NOTIFIED BY: BRUCE FLUSCHE (Fax) |KRISS KENNEDY R4 |
| HQ OPS OFFICER: LEIGH TROCINE |VERN HODGE NRR |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|CCCC 21.21 UNSPECIFIED PARAGRAPH | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| POSSIBLE 10-CFR-PART-21 REPORT REGARDING A POSSIBLE DEFECT IN A SWAGELOK |
| TUBE FITTING |
| |
| The following text is a portion of a facsimile submitted by Swagelok |
| Company: |
| |
| "This is a preliminary notification of a possible defect in a Swagelok tube |
| fitting, part number SS-400-3-4TTM, male branch tee. A drawing of the part |
| is included with this notification. We are also notifying each of the |
| involved utilities." |
| |
| "We became aware of this on October 4, 1999." |
| |
| "The defect is a crack in the seat of the fitting. We are continuing our |
| analysis of the part and will provide further details in accordance with NRC |
| timetables." |
| |
| "[The] following are the six utilities to whom we have sold these parts: |
| |
| Georgia Power [Company], Plant Vogtle, ... , 10 pcs. ... [;] |
| Duke Power Company, Oconee Nuclear Station, ... ,100 pcs. ... [;] |
| Arizona Public Service Co., Palo Verde Nuclear Generating Station, ... , 15 |
| pcs. ... [;] |
| North Atlantic Energy Service Co., ... , Seabrook Station, ... ,10 pcs. ... |
| [;] |
| Virginia Power, Surry Power Station, ... , 3 pcs. ... [; and] |
| Omaha Public Power District, Ft. Calhoun Nuclear Station, ... , 10 Pcs. ... |
| ." |
| |
| (Call the NRC operations officer for Swagelok contact information.) |
| |
| * * * UPDATE AT 1553 EST ON 11/04/99 FROM BRUCE FLUSCHE TO S. SANDIN * * * |
| |
| The following information was received via fax: |
| |
| "We are writing further to our preliminary notification on October 6,1999, |
| about a possible defect in a Swagelok tube fitting, part number |
| SS-400-3-4TTM, male branch tee. |
| |
| "The utilities to whom we have sold this are repeated in the appendix to |
| this letter. |
| |
| "As we reported earlier, the defect is a crack in the seat of the fitting. |
| This crank resulted from overheating during the resistive type heated |
| forging process; it was not a defect in the raw material. The estimated per |
| cent of forgings that have this condition is less than 0.03%. |
| |
| "This forging was processed in December of 1996. Since the middle of 1998 |
| we have required liquid penetrant testing on all resistive type heated |
| forgings. |
| |
| "If there are any questions, please do not hesitate to contact us." |
| |
| The NRC operations officer notified the R1DO (Mohamed Shanbaky), R2DO |
| (Pierce Skinner), R3DO (James Creed), and R4DO (Claude Johnson). This |
| report was also faxed to NRR Part 21 (Vern Hodge). |
| |
| ******************** UPDATE AT 0934 ON 12/17/99 FROM BRUCE FLUSCHE TO |
| TROCINE ******************** |
| |
| The following text is a portion of a facsimile submitted by Swagelok |
| Company: |
| |
| "Further to our notice of November 18,1999, on Swagelok part number |
| SS-400-3-4TTM, we are providing further information. As earlier reported |
| the licensee below was not notified: |
| |
| Florida Power and Light |
| P0. #00029212 |
| 5 pcs. SS-400-3-4TTM |
| Product ID. R17KLO5O9B" |
| |
| "The reason for the lack of notification was that the certification had not |
| been entered into our database. The associate responsible for entering the |
| certifications is no longer with Swagelok, and we have scheduled an audit of |
| our database for the time period from June 1997 through July 1999, as we |
| believe this is the time period that most needs to be scrutinized." |
| |
| "Whether further review of the database is necessary will be determined on |
| the findings of this audit." |
| |
| The NRC operations officer notified the R1DO (Ruland), R2DO (Boland), R3DO |
| (Gardner), and R4DO (Harrell). This report was also faxed to NRR Part 21 |
| (Vern Hodge). |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36521 |
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| FACILITY: COOK REGION: 3 |NOTIFICATION DATE: 12/17/1999|
| UNIT: [1] [] [] STATE: MI |NOTIFICATION TIME: 00:30[EST]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 12/16/1999|
+------------------------------------------------+EVENT TIME: 20:52[EST]|
| NRC NOTIFIED BY: SCOTT RICHARDSON |LAST UPDATE DATE: 12/17/1999|
| HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |RONALD GARDNER R3 |
|10 CFR SECTION: |ROBERT GALLO NRR |
|AESF 50.72(b)(2)(ii) ESF ACTUATION |FRANK CONGEL IRO |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N N 0 Refueling |0 Refueling |
| | |
| | |
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EVENT TEXT
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| AUTOMATIC STARTING AND LOADING OF AN EMERGENCY DIESEL GENERATOR FOLLOWING A |
| LOSS OF OFFSITE POWER TO THE TRAIN 'A' RESERVE AUXILIARY TRANSFORMER |
| RESULTING IN A LOSS OF SPENT FUEL POOL COOLING FOR APPROXIMATELY 38 MINUTES |
| |
| The following text is a portion of a facsimile received from the licensee: |
| |
| "[At 2052 on 12/16/99, the] Unit 1 Train 'A' [emergency diesel generator |
| (CD EDG)] automatically started and loaded following [a] loss of offsite |
| power to the 4-kV safeguards buses on Train 'A.' The apparent cause was the |
| trip of the Unit 2 Train 'A' reserve feed transformer (201CD) sudden |
| overpressurization relay. Trip of the 201CD sudden overpressurization |
| relay resulted in opening of breaker 12CD which feeds the Unit 1 reserve |
| feed transformer (101CD) as well as 201CD." |
| |
| "[Both] units were defueled at the time of the event with the Unit 1 [spent |
| fuel pit (SFP)] pump in service. The loss of offsite power in Unit 1 caused |
| the in-service SFP pump to be de-energized. The Unit 2 SFP pump was |
| [manually] started at 2130 hours. SFP temperature remained constant at 85�F |
| throughout this event." |
| |
| "The 201CD sudden overpressure relay was defeated, and offsite power was |
| restored to the 101CD transformer. The CD EDG will be unloaded once offsite |
| power is made available." |
| |
| "Actuation of the 201CD reserve transformer sudden overpressure relay was a |
| result of filling the transformer with dry nitrogen following [planned] |
| corrective maintenance activities." |
| |
| The licensee stated that both units were defueled with fuel in the common |
| SFP. At the time of this event, offsite power to Unit 2 was being supplied |
| by the normal auxiliary transformer (backfeed). All systems functioned as |
| required, and there was nothing unusual or not understood. At the time of |
| this event notification, the licensee was in the process of removing the CD |
| EDG from service and restoring the Train 'A' reserve feed transformer as the |
| offsite power supply for Unit 1. |
| |
| The licensee plans to notify the NRC resident inspector. |
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+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36522 |
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| FACILITY: SUSQUEHANNA REGION: 1 |NOTIFICATION DATE: 12/17/1999|
| UNIT: [] [2] [] STATE: PA |NOTIFICATION TIME: 11:22[EST]|
| RXTYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 12/17/1999|
+------------------------------------------------+EVENT TIME: [EST]|
| NRC NOTIFIED BY: DON ROLAND |LAST UPDATE DATE: 12/17/1999|
| HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |BILL RULAND R1 |
|10 CFR SECTION: | |
|NINF INFORMATION ONLY | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 A/R Y 19 Power Operation |0 Hot Shutdown |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| COURTESY NOTIFICATION REGARDING ENTRY INTO A FORCED MAINTENANCE OUTAGE DUE |
| TO RECIRCULATION PUMP SEAL PROBLEMS |
| |
| The following text is a portion of a facsimile received from the licensee: |
| |
| "Susquehanna Unit 2 was manually shut down on 12/17/99 [to] permit entry |
| into containment for repairs to the 2A [reactor recirculation] pump #2 seal. |
| At 2207 on 12/16/99, a controlled shutdown was commenced by reducing |
| [recirculation] flow and then inserting control rods. At 0856 on 12/17/99, |
| the main turbine was manually tripped with power at 18.5%. At 1018, with |
| power at 19%, the reactor mode switch was taken to shutdown placing the unit |
| in Mode 3. All control rods fully inserted. [Reactor] water level dropped |
| to approximately 1 inch as recorded on wide range instrumentation and was |
| restored using feedwater. There were no [emergency core cooling system] |
| initiations or diesel generator starts. No safety/relief valves lifted. |
| There were no challenges to containment or fuel as a result of the shutdown. |
| The maximum total unidentified drywell leakage was 0.87 gpm, and maximum |
| total leakage was 1.93 gpm. The leakage remained well below the [Technical |
| Specification] 3.4.4 required limits at all times." |
| |
| "The [engineered safety feature] actuation of the reactor protection system |
| and the resulting level 3 isolations are not reportable since it is |
| procedurally recognized as pre-planned." |
| |
| "The shutdown is continuing according to the forced outage schedule." |
| |
| The licensee notified the NRC resident inspector and issued a press release. |
+------------------------------------------------------------------------------+
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|Power Reactor |Event Number: 36523 |
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| FACILITY: FITZPATRICK REGION: 1 |NOTIFICATION DATE: 12/17/1999|
| UNIT: [1] [] [] STATE: NY |NOTIFICATION TIME: 12:47[EST]|
| RXTYPE: [1] GE-4 |EVENT DATE: 01/14/1999|
+------------------------------------------------+EVENT TIME: 12:00[EST]|
| NRC NOTIFIED BY: MIKE ABRAMSKI |LAST UPDATE DATE: 12/17/1999|
| HQ OPS OFFICER: DOUG WEAVER +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |BILL RULAND R1 |
|10 CFR SECTION: | |
|AINC 50.72(b)(2)(iii)(C) POT UNCNTRL RAD REL | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| MAIN STEAM RADIATION MONITORS ALARM SETPOINT SET TOO HIGH |
| |
| THE TRIP LEVEL SETTING OF THE MAIN STEAM LINE TUNNEL HIGH RADIATION MONITORS |
| IS REQUIRED TO BE <= 3X NORMAL RATED FULL POWER BACKGROUND. THE NORMAL |
| RATED FULL POWER BACKGROUND RADIATION LEVEL IS DEPENDANT ON HYDROGEN |
| INJECTION RATE. THE PLANT OPERATED FROM 1/14/99 TO 3/19/99 WITH HYDROGEN |
| INJECTION OUT OF SERVICE, AND THE MAIN STEAM LINE TUNNEL RADIATION MONITOR |
| TRIP LEVEL SETTING WAS NOT LOWERED TO <= 3X THE NORMAL RATED FULL POWER |
| BACKGROUND WITH HYDROGEN INJECTION OUT OF SERVICE. |
| |
| THE LICENSEE INFORMED THE NRC RESIDENT INSPECTOR. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Hospital |Event Number: 36524 |
+------------------------------------------------------------------------------+
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| REP ORG: WATERBURY HOSPITAL |NOTIFICATION DATE: 12/17/1999|
|LICENSEE: WATERBURY HOSPITAL |NOTIFICATION TIME: 16:53[EST]|
| CITY: WATERBURY REGION: 1 |EVENT DATE: 10/06/1999|
| COUNTY: STATE: CT |EVENT TIME: 09:15[EST]|
|LICENSE#: 06-02406-01 AGREEMENT: N |LAST UPDATE DATE: 12/17/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |BILL RULAND R1 |
| |JOHN SURMEIER NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: MARIANNE POLIZZANO | |
| HQ OPS OFFICER: STEVE SANDIN | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| MEDICAL MISADMINISTRATION INVOLVING DIAGNOSTIC I-131 USED FOR A TOTAL BODY |
| SCAN |
| |
| DURING A QUARTERLY AUDIT, THE HOSPITAL HEALTH PHYSICIST DISCOVERED THAT A |
| PATIENT WHO HAD BEEN PRESCRIBED A DOSE OF 3.0 mCi I-131 FOR A TOTAL BODY |
| SCAN RECEIVED 3.65 mCi. THE PRESCRIBING PHYSICIAN WAS INFORMED; HOWEVER, |
| THERE ARE NO PLANS TO NOTIFY THE PATIENT. THERE WERE NO ADVERSE HEALTH |
| CONSEQUENCES SINCE THE DOSE ADMINISTERED WAS WITHIN THE NORMAL RANGE OF 1-4 |
| mCi. THE LICENSEE ATTRIBUTES THE CAUSE TO PERSONNEL ERROR AND IS REVIEWING |
| WORK PRACTICES TO PREVENT RECURRENCE. |
| |
| (CALL THE NRC OPERATIONS OFFICER FOR LICENSEE CONTACT INFORMATION.) |
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Page Last Reviewed/Updated Thursday, March 25, 2021