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Event Notification Report for January 21, 2000

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           01/20/2000 - 01/21/2000

                              ** EVENT NUMBERS **

36595  36607  36608  36609  36610  

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
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|Hospital                                         |Event Number:   36595       |
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| 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:  01/20/2000|
|  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  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| 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.)             |
|                                                                              |
| * * * UPDATE 0838 EST ON 1/20/00 FROM MARY BETH TAORMINA TO S. SANDIN  * *   |
| *                                                                            |
|                                                                              |
| The licensee is retracting this report based on a re-evaluation of the       |
| patient treatment plan which concluded that the underdose was 15% and, as    |
| such, did not meet the 20% criteria for a misadministration.  This finding   |
| was discussed with Region 2.  Notified R2DO (Fredrickson) and NMSS (Moore).  |
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|Power Reactor                                    |Event Number:   36607       |
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| FACILITY: ZION                     REGION:  3  |NOTIFICATION DATE: 01/18/2000|
|    UNIT:  [1] [2] []                STATE:  IL |NOTIFICATION TIME: 19:15[EST]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        01/18/2000|
+------------------------------------------------+EVENT TIME:        18:02[CST]|
| NRC NOTIFIED BY:  R. T. THORTON                |LAST UPDATE DATE:  01/20/2000|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |DAVID HILLS          R3      |
|10 CFR SECTION:                                 |ROBERTA WARREN       IAT     |
|DDDD 73.71               UNSPECIFIED PARAGRAPH  |JIM CREED            IAT     |
|                                                |JIM BELANGER         IAT     |
|                                                |DICK ROSANO          IAT     |
|                                                |STEVE REYNOLDS       R3      |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          N       0        Decommissioned   |0        Decommissioned   |
|2     N          N       0        Decommissioned   |0        Decommissioned   |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| SECURITY REPORT                                                              |
|                                                                              |
| UNSUBSTANTIATED BOMB THREAT.  COMPENSATORY MEASURES TAKEN.  LICENSEE         |
| INFORMED THE LOCAL POLICE DEPARTMENT.                                        |
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+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36608       |
+------------------------------------------------------------------------------+
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| FACILITY: SAN ONOFRE               REGION:  4  |NOTIFICATION DATE: 01/20/2000|
|    UNIT:  [] [] [3]                 STATE:  CA |NOTIFICATION TIME: 17:31[EST]|
|   RXTYPE: [1] W-3-LP,[2] CE,[3] CE             |EVENT DATE:        01/20/2000|
+------------------------------------------------+EVENT TIME:        14:00[PST]|
| NRC NOTIFIED BY:  WILLIAMS                     |LAST UPDATE DATE:  01/20/2000|
|  HQ OPS OFFICER:  CHAUNCEY GOULD               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |LINDA SMITH          R4      |
|10 CFR SECTION:                                 |                             |
|AOUT 50.72(b)(1)(ii)(B)  OUTSIDE DESIGN BASIS   |                             |
|NLCO                     TECH SPEC LCO A/S      |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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                                   
+------------------------------------------------------------------------------+
| CABLES AND CONDUITS IN THE SALT WATER  COOLING PIPE TUNNEL FOUND WITHOUT A   |
| PORTION OF THEIR FIRE WRAPS.                                                 |
|                                                                              |
| ON 1/19/00, FOLLOWING A PLANT WALKDOWN, IT WAS DISCOVERED THAT SOME CABLES   |
| AND CONDUITS IN THE SALT WATER COOLING PIPE TUNNEL  WERE MISSING PORTIONS OF |
| THEIR FIRE WRAPS.   AFTER REVIEW OF PLANT DOCUMENTATION, IT WAS DETERMINED   |
| THAT THIS CONDITION AFFECTED BOTH TRAIN "A" AND "B"  SALT WATER COOLING      |
| PUMPS FOR UNIT 3.  CONSEQUENTLY ON 1/20/00 @ 1400 PST IT WAS CONCLUDED THIS  |
| CONDITION DID NOT MEET THE REQUIREMENTS OF APPENDIX "R" TO ASSURE ONE TRAIN  |
| OF SAFE SHUTDOWN EQUIPMENT FREE OF FIRE DAMAGE IN THE EVENT OF A DESIGN      |
| BASIS FIRE.                                                                  |
|                                                                              |
| THE LICENSEE IMMEDIATELY ENSURED THAT A ROVING FIRE WATCH HAD BEEN           |
| POSTED(AND WAS ALREADY IN PLACE FOR OTHER UNRELATED REASONS).  THIS ACTION   |
| SATISFIED THEIR LCO ACTION STATEMENT REQUIREMENT.                            |
|                                                                              |
| IN THE EVENT OF A FIRE, PLANT OPERATORS WOULD HAVE BEEN ABLE TO RESTORE      |
| POWER TO THE SALT WATER COOLING SYSTEM(BY ISOLATING THE AFFECTED CABLES AND  |
| STARTING A PUMP FROM ITS SECOND POINT OF CONTROL).   ADDITIONALLY, THE       |
| COMBUSTIBLE LOADING IN THE AFFECTED AREA IS EXTREMELY LOW(2 MINUTE FIRE      |
| DURATION), AND THAT AREA IS PROTECTED BY FIRE SPRINKLERS AND FIRE            |
| DETECTORS.                                                                   |
|                                                                              |
| THE NRC RESIDENT INSPECTOR WILL BE NOTIFIED.                                 |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36609       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: BEAVER VALLEY            REGION:  1  |NOTIFICATION DATE: 01/20/2000|
|    UNIT:  [] [2] []                 STATE:  PA |NOTIFICATION TIME: 19:05[EST]|
|   RXTYPE: [1] W-3-LP,[2] W-3-LP                |EVENT DATE:        01/20/2000|
+------------------------------------------------+EVENT TIME:        18:17[EST]|
| NRC NOTIFIED BY:  HYNES                        |LAST UPDATE DATE:  01/20/2000|
|  HQ OPS OFFICER:  CHAUNCEY GOULD               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |FELICIA HINSON       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   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| INADEQUATE SHORT CIRCUIT PROTECTION ON CONTROL WIRING ASSOCIATED WITH THE    |
| LINE STARTER FOR MAIN TURBINE DRAIN VALVES                                   |
|                                                                              |
| While performing a design analysis on Beaver Valley Unit 2 (BV-2) to confirm |
| adequate electrical fault protection, as follow-up to an Engineering fire    |
| protection self-assessment completed in May 1999, it was determined that the |
| control wiring associated with the line starter for the nine main turbine    |
| drain valves is not adequately protected from short circuits. This           |
| protection inadequacy results from a lack of required fuse protection and/or |
| current limiting features described in Section 9.5.A.1.2.1.5(4) of the       |
| Updated Final Safety Analysis Report.  Due to this lack of adequate current  |
| limiting protection, an electrical fault on this circuit could result in a   |
| fire in multiple fire areas including the common Unit 1/2 Control Room, BV-2 |
| Service Building, BV-2 Cable Vault, BV-2 Cable Tunnel, and BV-2 Turbine      |
| Building.  The lack of current limiting protection for this circuitry        |
| introduces the possibility of a potential fire in these multiple areas,      |
| which is a violation of fire protection licensing basis commitments          |
| regarding safe shutdown capability.                                          |
|                                                                              |
| The subject main turbine drain valves are non-safety related and not         |
| required for safe shutdown. As an interim measure, the circuit has been      |
| de-energized and will remain de-energized until adequate electrical          |
| protection can be provided.                                                  |
|                                                                              |
| The NRC Resident Inspector was notified.                                     |
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|Power Reactor                                    |Event Number:   36610       |
+------------------------------------------------------------------------------+
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| FACILITY: POINT BEACH              REGION:  3  |NOTIFICATION DATE: 01/21/2000|
|    UNIT:  [1] [] []                 STATE:  WI |NOTIFICATION TIME: 04:21[EST]|
|   RXTYPE: [1] W-2-LP,[2] W-2-LP                |EVENT DATE:        01/21/2000|
+------------------------------------------------+EVENT TIME:        02:39[CST]|
| NRC NOTIFIED BY:  JOHN SELL                    |LAST UPDATE DATE:  01/21/2000|
|  HQ OPS OFFICER:  STEVE SANDIN                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |DAVID HILLS          R3      |
|10 CFR SECTION:                                 |                             |
|ASHU 50.72(b)(1)(i)(A)   PLANT S/D REQD BY TS   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     M/R        Y       40       Power Operation  |0        Hot Standby      |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| UNIT 1 MANUALLY TRIPPED FROM 40% POWER DUE TO A DECREASING FOREBAY LEVEL     |
|                                                                              |
| "UNIT 1 WAS MANUALLY TRIPPED FROM 40% POWER AFTER AN ANTICIPATORY POWER      |
| REDUCTION AT 0239CST DUE TO DECREASING LEVEL IN THE CIRC. WATER INLET        |
| FOREBAY.  DECREASING LEVEL WAS APPARENTLY DUE TO ICING OF THE INTAKE         |
| STRUCTURE.  UNIT 1 CIRC. WATER SYSTEM HAS BEEN SECURED AND FOREBAY LEVEL HAS |
| INCREASED.  THE UNIT 1 CIRC. WATER SYSTEM WAS SECURED TO MAINTAIN            |
| OPERABILITY OF THE SERVICE WATER SYSTEM.  UNIT 2 REMAINS AT 100% POWER AND   |
| IS STABLE."                                                                  |
|                                                                              |
| FOREBAY LEVEL HAD DECREASED TO -11 FT FROM THE NORMAL OPERATING -8 FT.  THE  |
| -11 FT CORRESPONDS TO THE MINIMUM DESIGN LIMIT FOR THE SERVICE WATER SYSTEM. |
| CURRENTLY, LEVEL IS -6 FT 4 INCHES.  STEAM GENERATORS USING THE ATMOSPHERIC  |
| DUMPS ARE PROVIDING THE HEAT SINK FOR DECAY HEAT REMOVAL SINCE THE CONDENSER |
| IS NOT IN SERVICE.  ALL CONTROL RODS FULLY INSERTED FOLLOWING THE MANUAL     |
| TRIP.                                                                        |
|                                                                              |
| THE LICENSEE WILL INFORM THE NRC RESIDENT INSPECTOR.                         |
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