Event Notification Report for January 18, 2000
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
01/14/2000 - 01/18/2000
** EVENT NUMBERS **
36517 36523 36590 36591 36592 36593 36594 36595 36596 36597 36598 36599
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36517 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: BRUNSWICK REGION: 2 |NOTIFICATION DATE: 12/16/1999|
| UNIT: [1] [2] [] STATE: NC |NOTIFICATION TIME: 16:40[EST]|
| RXTYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 12/16/1999|
+------------------------------------------------+EVENT TIME: 12:48[EST]|
| NRC NOTIFIED BY: KEN CHISM |LAST UPDATE DATE: 01/14/2000|
| HQ OPS OFFICER: STEVE SANDIN +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |ANN BOLAND R2 |
|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 |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
|2 N Y 100 Power Operation |100 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| REACTOR CORE ISOLATION COOLING SYSTEM DECLARED INOPERABLE ON BOTH UNITS DUE |
| TO UNDERSIZED THERMAL OVERLOADS INSTALLED ON THREE (3) VALVES WHICH MAY HAVE |
| PREVENTED OPERATION UNDER WORST CASE CONDITIONS. |
| |
| "On December 16, 1999, at 1248, the Reactor Core Isolation Cooling System |
| was declared inoperable because the thermal overloads on three system valves |
| were determined to be sized such that the affected valves might not operate |
| during worst case conditions. The affected valves are: 1 (2)-E51-V8 |
| (Turbine Trip and Throttle Valve), 1(2)-E51-F019 (Minimum Flow Bypass to |
| Torus Valve), and 1(2)-E51-F046 (Cooling Water Supply Valve). Analysis also |
| determined that 1(2)-E41-F059 (High Pressure Core Injection Cooling System |
| Water Supply Valve) also contains inappropriately sized thermal overloads; |
| however, the [High Pressure Coolant Injection] System has not been declared |
| inoperable because this valve have been repositioned to its accident |
| position (open), and administrative measures have been taken to maintain the |
| valve in the open position." |
| |
| "The Reactor Core Isolation Cooling system is a single-train system used to |
| prevent overheating of the reactor fuel in the event of a reactor isolation |
| accompanied by a loss of feedwater. The high pressure High Pressure Coolant |
| Injection system (approximately ten times the flow rate as the Reactor Core |
| Isolation Cooling System) remains operable. Plant technical specifications |
| allow continued operation for 14 days with the Reactor Core Isolation |
| Cooling system inoperable. The Reactor Core Isolation Cooling system is not |
| considered an engineered safety feature at the Brunswick Plant although it |
| is included in plant technical specifications. For these reasons, the |
| safety significance of this event is considered to be low. Engineering |
| calculations are currently in progress to confirm the operability of the |
| [High Pressure Coolant Injection] System. |
| |
| "Engineering and maintenance personnel are working to determine a corrective |
| action plan at this time." |
| |
| The licensee informed the NRC resident inspector. |
| |
| ********** UPDATE AT 1107 ON 01/14/00 FROM CHARLES ELBERFELD TO LEIGH |
| TROCINE ********** |
| |
| The licensee is retracting this event based upon the following text which is |
| a portion of a facsimile received from the licensee: |
| |
| "On December 16, 1999, at 1248 hours, the Reactor Core Isolation Cooling |
| (RCIC) system was declared inoperable because an analysis indicated that the |
| thermal overloads (TOL) on three system valves were sized such that the |
| affected valves might not operate as designed during worst case conditions. |
| The affected valves for both Unit 1 and 2 were as follows: |
| |
| E51-V8 (Turbine Trip and Throttle Valve) |
| E51-F019 (Minimum Flow Bypass to Torus Valve) |
| E51-F046 (Cooling Water Supply Valve) |
| |
| "Analysis also indicated that the Unit 1 and 2 Cooling Water Supply Valves |
| (E41-F059) for the High Pressure Coolant Injection (HPCI) system had TOLs |
| which were inappropriately sized; however, the HPCI system for each unit was |
| not declared inoperable because each affected valve was placed in its |
| accident position (i.e., open) and maintained in the open position under |
| administrative controls. Based on the declaration of RCIC system |
| inoperability for both units, notification (Event Number 36517) was made to |
| the NRC on December 16, 1999, at 1640 hours, in accordance with 10 CFR |
| 50.72(b)(2)(iii). |
| |
| "The affected valves were removed from service in accordance with plant |
| technical specifications and procedures, and the appropriately sized TOLs |
| were installed. Subsequent analysis of the effects of the previously |
| installed TOLs indicate that neither the RCIC nor the HPCI systems were |
| rendered inoperable. |
| |
| "The analyses which initiated this issue stemmed from a question concerning |
| the presence of holding coils in some direct current (DC) powered |
| motor-operated valve (MOV) control circuitry and how the additional current |
| draw from the holding coils affected TOL sizing. Methodology for |
| programmatically determining TOL sizing has evolved over the years as |
| industry knowledge increased due to activities related to assuring MOV |
| performance. Although much conservatism was built in to the procedural |
| guidance for TOL sizing, consideration was not given to some auxiliary loads |
| such as the holding coils. When such consideration was given to the holding |
| coils, in conjunction with the other conservative sizing assumptions; the |
| initial conclusion was that the TOL sizing was inappropriate for design of |
| the identified valves and that the valves/systems were inoperable. (i.e., |
| The presence of the additional electrical load in the circuitry could cause |
| the TOLs to actuate prematurely, preventing required valve stroking.) |
| |
| "Each of the identified valves was further analyzed with regard to design |
| and actual functional requirements under postulated accident conditions, to |
| better understand the impact of the previously installed TOLs. As found |
| testing of the TOLs indicated that actual performance was significantly |
| better (i.e., longer times to trip) than conservatively assumed from the |
| performance curves. A review of the actual stroke time histories for each |
| valve was performed to identify the longest times for each. The actual |
| running currents for each valve were reviewed. The above listed information |
| was analyzed and factored together to determine the number of strokes |
| available for each valve. These numbers were then compared to the actual |
| number of strokes required during the various accident scenarios for each |
| valve. In all cases, the valves would have met the functional requirements |
| for system operability. The results of the additional analyses concluded |
| that, although the TOL sizing was not optimum for the identified valves, the |
| valves would have performed their functions for the required postulated |
| conditions, and the operability for the RCIC and HPCI systems was not |
| adversely affected by the previously installed TOLs. |
| |
| "Based on the results of the additional analyses of each of the identified |
| valves, Carolina Power & |
| Light Company has determined that this event does not meet the 10 CFR 50.72 |
| or 10 CFR 50.73 |
| reporting criteria, and the notification for Event Number 36517 is |
| retracted. |
| |
| "Supporting information: |
| |
| "10 CFR 50.72(b)(2), Four-hour reports. If not reported under paragraphs |
| (a) or (b)(1) of this section, the licensee shall notify the NRC as soon as |
| practical and in all cases, within four hours of the occurrence of any of |
| the following: (iii) Any event or condition that alone could have prevented |
| the fulfillment of the safety function of structures or systems that are |
| needed to: (A) Shut down the reactor and maintain it in a safe shutdown |
| condition, (B) Remove residual heat, (C) Control the release of radioactive |
| material, or (D) Mitigate the consequences of an accident. |
| |
| "10 CFR 50.73(a)(2). The licensee shall report: (v) Any event or condition |
| that alone could have prevented the fulfillment of the safety function of |
| structures or systems that are needed to: (A) Shut down the reactor and |
| maintain it in a safe shutdown condition, (B) Remove residual heat, (C) |
| Control the release of radioactive material, or (D) Mitigate the |
| consequences of an accident." |
| |
| The licensee notified the NRC resident inspector. The NRC operations |
| officer notified the R2DO (Haag). |
+------------------------------------------------------------------------------+
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
+------------------------------------------------------------------------------+
|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: 01/14/2000|
| 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 01/14/99 TO 03/19/99 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. |
| |
| * * * RETRACTED AT 1407 EST ON 01/14/2000 FROM GORDON BROWNELL TO FANGIE |
| JONES * * * |
| |
| The license is retracting this event notification. After a subsequent |
| review determined that during the reported period, the main steam line |
| tunnel radiation monitor trip level setpoint was in accordance with |
| technical specification requirements, and the system would have initiated |
| safety actions consistent with system design. |
| |
| The licensee notified the NRC resident inspector, and the R1DO (Glenn Meyer) |
| was notified by the NRC Operations Officer. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36590 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: CALVERT CLIFFS REGION: 1 |NOTIFICATION DATE: 01/14/2000|
| UNIT: [1] [2] [] STATE: MD |NOTIFICATION TIME: 09:25[EST]|
| RXTYPE: [1] CE,[2] CE |EVENT DATE: 01/14/2000|
+------------------------------------------------+EVENT TIME: 08:00[EST]|
| NRC NOTIFIED BY: UMPHREY |LAST UPDATE DATE: 01/14/2000|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |GLENN MEYER R1 |
|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 HIGH SUSPENDED SOLIDS IN A SEWAGE TREATMENT |
| EFFLUENT SAMPLE |
| |
| A sewage treatment effluent sample taken on 01/03/00 was reported today to |
| have exceeded the suspended solids limit for the maximum daily value allowed |
| by the NPDES Discharge Permit. The licensee plans to inform the Maryland |
| Department of Environment that they exceeded the maximum limit of their |
| NPDES Discharge Permit. |
| |
| The NRC resident inspector was notified of this event by the licensee. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36591 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: CALVERT CLIFFS REGION: 1 |NOTIFICATION DATE: 01/14/2000|
| UNIT: [1] [] [] STATE: MD |NOTIFICATION TIME: 11:02[EST]|
| RXTYPE: [1] CE,[2] CE |EVENT DATE: 01/14/2000|
+------------------------------------------------+EVENT TIME: 09:50[EST]|
| NRC NOTIFIED BY: UMPHREY |LAST UPDATE DATE: 01/14/2000|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |GLENN MEYER R1 |
|10 CFR SECTION: | |
|ARPS 50.72(b)(2)(ii) RPS 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
+------------------------------------------------------------------------------+
| ELECTRICAL FAULT OF CONTROL ELEMENT DRIVE MECHANISM MOTOR GENERATOR SET |
| (CEDM MG SET) CAUSES A REACTOR TRIP. |
| |
| The reactor automatically tripped, and all rods fully inserted into the |
| core. Preliminary indication is that CEDM MG set #11 had an electrical |
| fault which caused a reactor trip bus undervoltage condition which picked up |
| the undervoltage relays which tripped the main turbine which caused the |
| reactor trip. One of the second stage steam supply valves to the moisture |
| separator reheater failed to close automatically (because the electrical |
| breaker for the valve opened) which required the licensee to close the main |
| steam isolation valves (MSIV). The licensee is maintaining no load T(ave) |
| temperature by dumping steam to the atmosphere via the steam generator |
| atmospheric valves and feeding the steam generators with one of the |
| motor-driven auxiliary feedwater pumps. Neither of the steam generators |
| have any leaking steam generator tubes. The licensee is making preparation |
| to open the MSIVs. All emergency core cooling systems and the emergency |
| diesel generators are fully operable if they are needed. The licensee |
| stated that the electrical grid is stable. |
| |
| The licensee is investigating the event. |
| |
| The NRC resident inspectors were notified of this event by the licensee. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 36592 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: CALIFORNIA RADIATION CONTROL PRGM |NOTIFICATION DATE: 01/14/2000|
|LICENSEE: MALLINCRODT |NOTIFICATION TIME: 13:20[EST]|
| CITY: GLENDALE REGION: 4 |EVENT DATE: 01/14/2000|
| COUNTY: LOS ANGELOS STATE: CA |EVENT TIME: 06:00[PST]|
|LICENSE#: 3219-19 AGREEMENT: Y |LAST UPDATE DATE: 01/14/2000|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |JEFF SHACKELFORD R4 |
| |JOSIE PICCONE NMSS |
+------------------------------------------------+JOE GIITTER IRO |
| NRC NOTIFIED BY: DONALD BUNN |VICTOR DRICKS OPA |
| HQ OPS OFFICER: LEIGH TROCINE |PETTY OFFICER RAINE DOT |
+------------------------------------------------+MIKE WYATT DOE |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
|NTRA TRANSPORTATION EVENT | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| AGREEMENT STATE/TRANSPORTATION EVENT INVOLVING A SPILL OF MALLINCRODT |
| RADIOPHARMACEUTICALS ON A FREEWAY IN THE LOS ANGELES VICINITY |
| |
| At 0600 PST on 01/14/99, the State Highway Patrol informed the California |
| Radiation Control Program of a radiation spill and requested assistance. |
| Apparently, a Mallincrodt radiopharmaceutical delivery vehicle was involved |
| in an accident on the Route-2 Freeway (Glendale Freeway) in the vicinity of |
| Los Angeles (believed to be in the town of Glendale). Prior to the |
| accident, the total radioactive material onboard the delivery vehicle was |
| 1.2 Ci of technetium-99m and 30 mCi of thallium-204. Some of the vehicle's |
| contents were spilled, and some of the containers were broken creating |
| contamination on the freeway. In response to the State Highway Patrol's |
| request for assistance, a California Radiation Control Program Los Angeles |
| staff representative was on the scene by approximately 0630 PST. |
| |
| At the time of this event notification, two of the four lanes had been |
| opened, and traffic was passing through. California Radiation Control |
| Program staff responders were still working to clean the hot spots in the |
| other two lanes. NRC assistance was not requested. |
| |
| The California Radiation Control Program reported that this event was being |
| broadcast by CNN. |
| |
| (Call the NRC operations officer for a California Radiation Control Program |
| contact telephone number.) |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 36593 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: MERCK CO, INC |NOTIFICATION DATE: 01/14/2000|
|LICENSEE: J. L. SHEPHERD |NOTIFICATION TIME: 16:08[EST]|
| CITY: WEST POINT REGION: 1 |EVENT DATE: 01/14/2000|
| COUNTY: STATE: PA |EVENT TIME: 10:00[EST]|
|LICENSE#: 37-01531-08 AGREEMENT: N |LAST UPDATE DATE: 01/14/2000|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |GLENN MEYER R1 |
| |KEVIN RAMSEY (FAX) NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: JOHN MILLER | |
| HQ OPS OFFICER: FANGIE JONES | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|CCCC 21.21 UNSPECIFIED PARAGRAPH | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| FAILURE OF INTERLOCK DISCOVERED DURING NORMAL MAINTENANCE CHECKS |
| |
| During the performance of annual preventative maintenance checks, a |
| technician discovered that one of the interlocks was not functioning. The |
| interlock prevents the source from being raised or exposed with the shield |
| doors open to protect the operator. The device is a J. L. Shepherd Mark-1 |
| Model 30-1 irradiator. The irradiator has been tagged out of service until |
| serviced by the vendor. The room contained audible and visible alarms that |
| were functional, thus any operator would have been alerted if the source had |
| become exposed. |
| |
| The vendor, J. L. Shepherd, has been contacted and expects to have a |
| technician on site next week. |
| |
| (Call the NRC operations officer for a contact telephone number.) |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 36594 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: UTAH DIVISION OF RADIATION CONTROL |NOTIFICATION DATE: 01/14/2000|
|LICENSEE: NUCLETRON CORP |NOTIFICATION TIME: 17:10[EST]|
| CITY: SALT LAKE CITY REGION: 4 |EVENT DATE: 01/11/2000|
| COUNTY: STATE: UT |EVENT TIME: 14:01[MST]|
|LICENSE#: UT 18-00001 AGREEMENT: Y |LAST UPDATE DATE: 01/14/2000|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |JEFF SHACKELFORD R4 |
| |KEVIN RAMSEY (FAX) NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: JULIE FELICE | |
| HQ OPS OFFICER: FANGIE JONES | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|CCCC 21.21 UNSPECIFIED PARAGRAPH | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| POSSIBLE COMPUTER PROBLEM WITH HIGH DOSE REMOTE APPLICATOR (Utah Report |
| #00-0001) |
| |
| This is a preliminary report of a possible problem existing with the |
| computer for a Nucletron Corporation, Model 105.999, MicroSelectron-HDR, |
| version 2, remote afterloader brachytherapy device, serial #31062, that |
| could lead to a medical misadministration. This device is located at the |
| University of Utah Medical Center. The problem is being investigated by the |
| vendor, and the problem is thought to be a CPU communication fault. The CPU |
| has been sent to the manufacturer for further testing. |
| |
| Utah has contacted the State of Maryland as well as Nucletron Corporation. |
| |
| (Call the NRC operations officer for a contact telephone number.) |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Hospital |Event Number: 36595 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: VA COMMONWEALTH UNIV. HOSPITAL |NOTIFICATION DATE: 01/16/2000|
|LICENSEE: VA COMMONWEALTH UNIV. HOSPITAL |NOTIFICATION TIME: 10:15[EST]|
| CITY: RICHMOND REGION: 2 |EVENT DATE: 01/15/2000|
| COUNTY: STATE: VA |EVENT TIME: 15:30[EST]|
|LICENSE#: 45-00048-17 AGREEMENT: N |LAST UPDATE DATE: 01/16/2000|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |ROBERT HAAG R2 |
| |CHARLEY HAUGHNEY NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: MARY BETH TAORMINA | |
| HQ OPS OFFICER: BOB STRANSKY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| MEDICAL MISADMINISTRATION |
| |
| A patient received a 30% underdose after one of four strands of Ir-192 seeds |
| became dislodged immediately following implantation. The activity of the |
| strands was 7.5 mCi, 8.7 mCi, 6.0 mCi, and 7.6 mCi. (The licensee did not |
| specify which strand became dislodged.) The strand was removed from the |
| patient's bed shortly thereafter when the linen was changed. The licensee is |
| currently reconstructing this event but does not believe that any employee |
| received a significant dose. |
| |
| (Call the NRC operations office for a contact telephone number.) |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36596 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SEABROOK REGION: 1 |NOTIFICATION DATE: 01/17/2000|
| UNIT: [1] [] [] STATE: NH |NOTIFICATION TIME: 06:32[EST]|
| RXTYPE: [1] W-4-LP |EVENT DATE: 01/17/2000|
+------------------------------------------------+EVENT TIME: 05:38[EST]|
| NRC NOTIFIED BY: MIKE DAVID |LAST UPDATE DATE: 01/17/2000|
| HQ OPS OFFICER: BOB STRANSKY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |GLENN MEYER R1 |
|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 Y 100 Power Operation |100 Power Operation |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| SECURITY REPORT. FITNESS-FOR-DUTY QUESTIONED DUE TO INATTENTIVENESS. |
| IMMEDIATE COMPENSATORY MEASURES TAKEN UPON DISCOVERY. CONTACT THE NRC |
| OPERATIONS CENTER FOR ADDITIONAL DETAILS. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Other Nuclear Material |Event Number: 36597 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: EXXON BIOMEDICAL SCIENCES, INC. |NOTIFICATION DATE: 01/17/2000|
|LICENSEE: EXXON BIOMEDICAL SCIENCES, INC. |NOTIFICATION TIME: 11:27[EST]|
| CITY: EAST MILLSTONE REGION: 1 |EVENT DATE: 12/08/1999|
| COUNTY: STATE: NJ |EVENT TIME: [EST]|
|LICENSE#: 29-19396-01 AGREEMENT: N |LAST UPDATE DATE: 01/17/2000|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |GLENN MEYER R1 |
| |CHARLEY HAUGHNEY NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: W. JAMES BOVER | |
| HQ OPS OFFICER: BOB STRANSKY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|BAB2 20.2201(a)(1)(ii) LOST/STOLEN LNM>10X | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| MISSING Ni-63 SEALED SOURCES |
| |
| The licensee reported that two gas chromatography detectors, each containing |
| 15 mCi of Ni-63 foil, were discovered to be missing during a recent |
| inventory. The detectors were last seen on 12/8/1999. The licensee is |
| currently in the process of moving to a new facility but was unable to find |
| the detectors after searching both facilities. The licensee will continue to |
| search for the sources. |
| |
| (Call the NRC operations officer for a licensee contact telephone number.) |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36598 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: INDIAN POINT REGION: 1 |NOTIFICATION DATE: 01/17/2000|
| UNIT: [] [3] [] STATE: NY |NOTIFICATION TIME: 12:42[EST]|
| RXTYPE: [2] W-4-LP,[3] W-4-LP |EVENT DATE: 01/17/2000|
+------------------------------------------------+EVENT TIME: 11:45[EST]|
| NRC NOTIFIED BY: BRIAN VANGOR |LAST UPDATE DATE: 01/17/2000|
| HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |GLENN MEYER R1 |
|10 CFR SECTION: | |
|AOUT 50.72(b)(1)(ii)(B) OUTSIDE DESIGN BASIS | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|3 N Y 100 Power Operation |100 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| CONFIGURATION ERROR RESULTING IN AN ALTERNATE LOW-TO-HIGH HEAD SAFETY |
| INJECTION (SI) RECIRCULATION FLOW PATH OUTSIDE DESIGN BASIS ISSUE |
| |
| The following text is a portion of a facsimile received from the licensee: |
| |
| "On 10/10/1999, prior to plant startup from the last refueling outage, [SI] |
| manual butterfly valve SI-1863 was closed as directed by refueling procedure |
| SOP-RP-20, 'Draining the Refueling Cavity.' This valve is required to be |
| open as directed by check off list COL-RHR-1, but the [check off list] was |
| performed prior to the refueling procedure. As a result, it appears that |
| the valve SI-1863 had been closed since startup from the refueling outage in |
| October 1999. [Valve] SI-1863 is located in an alternate low-to-high head |
| flow path. [Final Safety Analysis Report (FSAR)] Table 6.2-8 describes the |
| use of this flow path should the normal low-to-high head recirculation flow |
| path be unavailable (i.e., isolated in response to a passive failure). |
| Hence, the inappropriate closure of [valve] SI-1863 could [have prevented] |
| the ability of the [SI] system to accommodate a certain passive failure |
| described in the FSAR during recirculation following a postulated event. |
| This configuration error potentially placed the SI system outside its design |
| basis. This mispositioning was discovered on 01/14/2000 during an extent of |
| condition review for a suspected [chemical and volume control system] valve |
| mispositioning in the excess letdown flow path. Valve SI-1863 was opened |
| shortly after discovery. The extent of this condition for this event is |
| still ongoing. Review of this deviation event report on Monday, 01/17/2000, |
| determined that this event [was] potentially outside the system's design |
| basis." |
| |
| The licensee notified the NRC resident inspector. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36599 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: COOK REGION: 3 |NOTIFICATION DATE: 01/17/2000|
| UNIT: [] [2] [] STATE: MI |NOTIFICATION TIME: 16:49[EST]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 01/17/2000|
+------------------------------------------------+EVENT TIME: 14:30[EST]|
| NRC NOTIFIED BY: DEAN BRUCK |LAST UPDATE DATE: 01/17/2000|
| HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |BRENT CLAYTON 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 |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 N N 0 Refueling |0 Refueling |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| DISCOVERY OF A POTENTIAL CONTAINMENT LEAKAGE PATH AND DEGRADED SAFETY |
| BARRIER |
| |
| The following text is a portion of a facsimile received from the licensee: |
| |
| "This is ... American Electrical Power, D.C. Cook Plant Units 1 and 2 |
| calling with a [4]-hour notification in accordance 10 CFR 50.72(b)(2)(i) of |
| a condition which was found while the reactor is shutdown, which, had it |
| been found while the reactor was in operation, would have resulted in the |
| nuclear power plant, including its principal safety barriers, being |
| seriously degraded or being in an unanalyzed condition that significantly |
| compromises plant safety. |
| |
| "During the ongoing In-Service Program inspection of the Unit 2 containment |
| liner, an indication was found that appeared to be a weld repair. After |
| surface preparation to allow for further inspection, it was determined that |
| the indication was actually a previously repaired area on the liner plate, |
| probably dating from construction. The mechanism used for surface |
| preparation was a needle gun, and the force exerted by the needle gun |
| dislodged the weld metal that had been deposited in the damaged area. The |
| result was a through-liner hole approximately 3/16 of an inch in size that |
| is roughly circular. |
| |
| "Although the Unit 2 containment successfully passed its 10 CFR [Part] 50, |
| Appendix-J, Integrated Leak Rate Testing in 1992, concern exists that under |
| thermal stress of a postulated accident condition, the weld material could |
| have become dislodged. This would potentially represent a containment |
| leakage path and a degraded safety barrier. |
| |
| "This hole will be repaired in accordance with ASME Section XI, Repair or |
| Replacement Program, prior to startup." |
| |
| The licensee stated that both unit are currently defueled. |
| |
| The licensee notified the NRC resident inspector. |
+------------------------------------------------------------------------------+
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