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 THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!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