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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).                                                                |
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+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36521       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| 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        |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| 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 85F |
| 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.                     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36522       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| 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                                   
+------------------------------------------------------------------------------+
| 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. |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36523       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| 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                                   
+------------------------------------------------------------------------------+
| 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       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| 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                                   
+------------------------------------------------------------------------------+
| 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.)          |
+------------------------------------------------------------------------------+