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 THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!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 |
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EVENT TEXT
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| 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. |
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|Power Reactor |Event Number: 36609 |
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| 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 |
| | |
| | |
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EVENT TEXT
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| 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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Page Last Reviewed/Updated Wednesday, March 24, 2021
Page Last Reviewed/Updated Wednesday, March 24, 2021