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Event Notification Report for February 4, 2000

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           02/03/2000 - 02/04/2000

                              ** EVENT NUMBERS **

36588  36605  36655  36656  36657  36658  

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|Power Reactor                                    |Event Number:   36588       |
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| FACILITY: PERRY                    REGION:  3  |NOTIFICATION DATE: 01/13/2000|
|    UNIT:  [1] [] []                 STATE:  OH |NOTIFICATION TIME: 17:04[EST]|
|   RXTYPE: [1] GE-6                             |EVENT DATE:        03/25/1999|
+------------------------------------------------+EVENT TIME:        03:30[EST]|
| NRC NOTIFIED BY:  STETSON                      |LAST UPDATE DATE:  02/03/2000|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |BRENT CLAYTON        R3      |
|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   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |0        Cold Shutdown    |
|                                                   |                          |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| DISCOVERY THAT A SINGLE PASSIVE FAILURE OF THE INCLINED FUEL TRANSFER SYSTEM |
| FLAP VALVE MAY HAVE RESULTED IN A LOSS OF ECCS DURING A DESIGN BASIS LOCA    |
| (HISTORICAL EVENT)                                                           |
|                                                                              |
| The following text is a portion of a facsimile received from the licensee:   |
|                                                                              |
| "With the Inclined Fuel Transfer System (IFTS) flange removed at power, a    |
| single passive failure of the IFTS flap valve may have resulted in a loss of |
| Emergency Core Cooling System (ECCS) during a design basis Loss of Coolant   |
| Accident (LOCA).  This was determined during an engineering review examining |
| the effects on containment structural capability with the IFTS Blind Flange  |
| removed."                                                                    |
|                                                                              |
| "An assumed single passive failure of the IFTS flap valve would have         |
| resulted in inventory loss from the upper containment pools with the IFTS    |
| gate removed.  The postulated water inventory loss would reduce the          |
| inventory to less than required for the makeup to the suppression pool       |
| during a LOCA.  Therefore, ECCS may not have met single failure criteria     |
| during the period when the IFTS Flange was removed at power."                |
|                                                                              |
| "The IFTS flange was removed for approximately 3 days prior to the           |
| commencement of the seventh refueling outage.  Administrative controls are   |
| in place to preclude removal of the IFTS flange at power until this issue is |
| fully evaluated."                                                            |
|                                                                              |
| The licensee stated that this event was determined to be reportable          |
| approximately 10 minutes prior to the event notification.                    |
|                                                                              |
| The licensee notified the NRC resident inspector.                            |
|                                                                              |
| *  *  * UPDATE ON 02/03/00 AT 1312 BY STERLING SANFORD TAKEN BY STEVE SANDIN |
| *  *  *                                                                      |
|                                                                              |
| The licensee made an editorial correction to the event time to show 0330     |
| hours instead of 1530 hours.                                                 |
|                                                                              |
| The licensee notified the NRC Resident Inspector.  The NRC Operations        |
| Officer notified the R3DO Tony Vegel.                                        |
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!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
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|Fuel Cycle Facility                              |Event Number:   36605       |
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| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT   |NOTIFICATION DATE: 01/19/2000|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 17:59[EST]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        01/19/2000|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        09:00[EST]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  02/03/2000|
|    CITY:  PIKETON                  REGION:  3  +-----------------------------+
|  COUNTY:  PIKE                      STATE:  OH |PERSON          ORGANIZATION |
|LICENSE#:  GDP-2                 AGREEMENT:  N  |DAVID HILLS          R3      |
|  DOCKET:  0707002                              |WAYNE HODGES         NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  DALE NOEL                    |                             |
|  HQ OPS OFFICER:  LEIGH TROCINE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|OCBB 76.120(c)(2)(ii)    EQUIP DISABLED/FAILS   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| FAILURE OF HIGH PRESSURE FIRE WATER SPRINKLER SYSTEMS TO MEET SYSTEM         |
| OPERABILITY REQUIREMENTS (24-Hour Report) - (Refer the event #36018 for a    |
| similar event at Portsmouth and refer to event #35790 and event #36552 for   |
| related events at Paducah.)                                                  |
|                                                                              |
| The following text is a portion of a facsimile received from Portsmouth:     |
|                                                                              |
| "On 01/19/00 at approximately 0900 hours during the scheduled semi-annual    |
| walkdown of the X-330 Process Building high pressure fire water (HPFW)       |
| systems, the Plant Shift Superintendent (PSS) was notified that sprinkler    |
| systems #284 and #365 were not capable of meeting system operability         |
| requirements due to corrosion problems identified on adjacent sprinkler      |
| heads."                                                                      |
|                                                                              |
| "Two adjacent heads on system #284 and three adjacent heads on system #365   |
| were identified with corrosion around the valve seat.  This condition        |
| prevents the heads from being able to actuate at normal water pressure.      |
| When two adjacent heads are inoperable, the system is considered unable to   |
| perform its design function.  The PSS declared the affected sprinkler        |
| systems inoperable, and [technical safety requirement (TSR)] required        |
| actions were initiated and completed."                                       |
|                                                                              |
| "Further inspections of the Process Building sprinkler systems are planned.  |
| This report will be updated if additional sprinkler systems are determined   |
| to be inoperable."                                                           |
|                                                                              |
| "There was no loss of hazardous/radioactive material or                      |
| radioactive/radiological contamination exposure as a result of this event."  |
|                                                                              |
| At the time of this event notification, Portsmouth personnel had completed   |
| repairs and were in the process of closing out the paperwork to be able to   |
| declare the systems operable again.                                          |
|                                                                              |
| Portsmouth personnel notified the NRC resident inspector and a Department of |
| Energy site representative.                                                  |
|                                                                              |
| (Call the NRC operations officer for a site contact telephone number.)       |
|                                                                              |
|                                                                              |
| * * * RETRACTION AT 1800 HOURS ON 02/03/00 BY ERIC SPAETH TAKEN BY MACKINNON |
| * * *                                                                        |
|                                                                              |
| The above listed sprinkler heads were replaced and taken to the USEC         |
| Laboratory for testing.  Of the seven sprinkler heads tested, all operated   |
| at the proper temperature, 5 operated at < 7 psi pressure, one operated at   |
| 12 psi pressure and one operated at 16 psi pressure.                         |
|                                                                              |
| An Engineering Evaluation (EVAL-SS-2000-0038) completed on 01/25/00,         |
| calculated that at roof level with 20 or more heads flowing, system pressure |
| would remain at 18.4 psi.  The corroded sprinkler heads were found at lower  |
| levels which have smaller pressure losses and less friction losses due to    |
| shorter piping runs.  Since the available system pressure would have been    |
| greater than 18.4 psi and the sprinkler heads all operated at 16 psi or      |
| less, it was determined that the sprinkler heads would have operated when    |
| needed and performed their intended safety function.                         |
|                                                                              |
| Since the sprinkler heads were operable, this condition is not reportable in |
| accordance with 10 CFR 76.120[c][2].  Accordingly, this event is being       |
| retracted.  R3DO (Vegel) & NMSS EO (Holonich) notified.                      |
|                                                                              |
| The NRC Resident Inspector was notified of this retraction by the            |
| certificate holder.                                                          |
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!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
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|Hospital                                         |Event Number:   36655       |
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| REP ORG:  ALLEGHENY VALLEY HOPSITAL            |NOTIFICATION DATE: 02/03/2000|
|LICENSEE:  ALLEGHENY VALLEY HOSPITAL            |NOTIFICATION TIME: 14:55[EST]|
|    CITY:  Natronia Heights         REGION:  1  |EVENT DATE:        02/02/2000|
|  COUNTY:  Allegheny                 STATE:  PA |EVENT TIME:        15:30[EST]|
|LICENSE#:  37-002584-01          AGREEMENT:  N  |LAST UPDATE DATE:  02/03/2000|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |TONY DIMITRIADIS     R1      |
|                                                |JOSIE PICCONE        NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  FRANK PTTINON                |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| INCORRECT PATIENT GIVEN TECHNETIUM-99M FOR HDP BONE SCAN                     |
|                                                                              |
| A medical technician went to room 113 on 1A level and read the patient name  |
| plate on the wall outside the room before entering the room. The medical     |
| technician entered the room and addressed the elderly patient by the name    |
| that was labeled outside her room.  The patient responded by saying yes that |
| was her name.  The medical technician injected the patient with 22           |
| millicuries of technetium-99m  HDP bone scanning agent.  When the medical    |
| technician reviewed the patient label chart she discovered that she had      |
| given the technetium-99m HDP bone scanning agent to the incorrect patient.   |
| The correct patient had been taken downstairs for the technetium-99m         |
| injection. The patient and her physician were notified of the error.  No     |
| harm will come to the patient because of the error.                          |
|                                                                              |
| * * * RETRACTION ON 02/03/00 AT 1635 HOURS BY FRANK OTTINON TAKEN BY         |
| MACKINNON * * *                                                              |
|                                                                              |
| This event is being retracted because the patient did not receive 5 rems     |
| effective dose equivalent or 50 rems dose equivalent to any individual organ |
| as a result of receiving the accidental dose of 22 millicuries of            |
| technetium-99m as specified in 10 CFR 35.2 item (6) (ii).                    |
|                                                                              |
| NRC R1DO (Tony Dimitriadis) and NMSS EO (Joe Holonich) notified.             |
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+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36656       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: QUAD CITIES              REGION:  3  |NOTIFICATION DATE: 02/03/2000|
|    UNIT:  [1] [2] []                STATE:  IL |NOTIFICATION TIME: 15:12[EST]|
|   RXTYPE: [1] GE-3,[2] GE-3                    |EVENT DATE:        02/03/2000|
+------------------------------------------------+EVENT TIME:        10:21[CST]|
| NRC NOTIFIED BY:  M MacLENNAN                  |LAST UPDATE DATE:  02/03/2000|
|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |TONY VEGEL           R3      |
|10 CFR SECTION:                                 |                             |
|AESF 50.72(b)(2)(ii)     ESF ACTUATION          |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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          N       0        Refueling        |0        Refueling        |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| INADVERTENT START OF EMERGENCY DIESEL GENERATOR (EDG) DURING SURVEILLANCE    |
| TESTING                                                                      |
|                                                                              |
| On 02/03/00 at 1021 CST while performing surveillance test QCOS 0203-06 (ADS |
| Logic Test) the Unit-1/2 EDG received an inadvertent autostart signal from   |
| Unit 2 Core Spray Logic  system.  The Unit 1/2  EDG autostart occurred       |
| during the installation of relay finger block being placed as part of the    |
| surveillance test.  The finger block was being placed on the correct relay   |
| finger.  However, during the installation, and due to the small contact      |
| clearances, a momentary relay actuation occurred and caused the EDG start.   |
| A Heightened Level of Awareness Briefing was conducted prior to the logic    |
| test, and discussed the potential for equipment actuations to occur during   |
| performance of the test.  In addition, Limitations and Actions step F.7 of   |
| QCOS 0203-06 states that inadvertent actuations may occur during the         |
| performance of this test, including the EDG autostart, and requires          |
| immediate work stoppage and notification of the Unit Supervisor and a Shift  |
| Manager review for reportability.   The EDG and associated plant systems     |
| responded as expected.  This report is being made pending further review of  |
| the UFSAR and the stated design ESF systems contained in the UFSAR.          |
|                                                                              |
| The NRC Resident Inspector was notified of this event by the licensee.       |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36657       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: RIVER BEND               REGION:  4  |NOTIFICATION DATE: 02/03/2000|
|    UNIT:  [1] [] []                 STATE:  LA |NOTIFICATION TIME: 16:08[EST]|
|   RXTYPE: [1] GE-6                             |EVENT DATE:        02/03/2000|
+------------------------------------------------+EVENT TIME:        11:14[CST]|
| NRC NOTIFIED BY:  VERN CARLSON                 |LAST UPDATE DATE:  02/03/2000|
|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |CLAUDE JOHNSON       R4      |
|10 CFR SECTION:                                 |                             |
|AESF 50.72(b)(2)(ii)     ESF ACTUATION          |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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                                   
+------------------------------------------------------------------------------+
| BOTH TRAINS OF THE POST ACCIDENT HYDROGEN ANALYZERS DECLARED                 |
| ADMINISTRATIVELY INOPERABLE.                                                 |
|                                                                              |
| During an ongoing review of calculations for "Normal and Accident Gamma and  |
| Beta Doses for Mechanical Equipment Qualifications"  it was discovered that  |
| an inaccurate assumption was made concerning the operation of the            |
| Containment and Drywell post accident hydrogen monitoring system.  This      |
| inaccurate assumption could lead to the sample isolation valves receiving    |
| more radiation exposure than assumed in the calculations curing a design     |
| bases accident.  This extra radiation exposure could cause deterioration of  |
| the valve seats and prevent them from sealing properly.  With the valves     |
| leaking the indicated hydrogen concentrations could be non-conservatively    |
| low leading to improper actions during an accident.  This condition affects  |
| both safety trains of the post accident hydrogen analyzers.  The actual      |
| affect is still indeterminate however both trains have been conservatively   |
| declared administratively inoperable.  The system is still in a standby      |
| lineup and is expected to continue to perform its function during the early  |
| stages of an accident.  Engineering is continuing to evaluate the actual     |
| affect of the increased radiation exposure on the equipment.                 |
|                                                                              |
| The NRC Resident Inspector will be informed of this event by the licensee.   |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36658       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: POINT BEACH              REGION:  3  |NOTIFICATION DATE: 02/03/2000|
|    UNIT:  [1] [2] []                STATE:  WI |NOTIFICATION TIME: 17:18[EST]|
|   RXTYPE: [1] W-2-LP,[2] W-2-LP                |EVENT DATE:        02/03/2000|
+------------------------------------------------+EVENT TIME:        15:45[CST]|
| NRC NOTIFIED BY:  ROB HARRSCH                  |LAST UPDATE DATE:  02/03/2000|
|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |GARY SHEAR           R3      |
|10 CFR SECTION:                                 |                             |
|AESS 50.72(b)(1)(v)      EMERGENCY SIREN INOP   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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                                   
+------------------------------------------------------------------------------+
| ALL ALERT AND NOTIFICATION SYSTEM SIRENS INOPERABLE AFTER INSTALLING A SIREN |
| STATUS FEEDBACK SYSTEM.                                                      |
|                                                                              |
| Loss of all 14 offsite Alert and Notification System after installation of a |
| siren status feedback system. A common failure has resulted in the inability |
| to activate any sirens.  The vendor and plant staff are actively             |
| troubleshooting. The licensee will notify state and local officials of this  |
| event.                                                                       |
|                                                                              |
| The NRC Resident Inspector was notified of this event by the licensee.       |
|                                                                              |
| * * * UPDATE ON 02/03/00 AT 1923 HOURS BY HARRSCH TAKEN BY MACKINNON * * *   |
|                                                                              |
| All Alert and Notification System sirens were returned to service at 1745    |
| CT.  A software problem caused the loss of the Alert and Notification        |
| system. State and Local officials were notified by the licensee of this      |
| update.                                                                      |
| R3DO (Tony Vegel) notified.                                                  |
|                                                                              |
| The NRC Resident Inspector was notified of this update by the licensee.      |
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