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Event Notification Report for April 10, 2000

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           04/07/2000 - 04/10/2000

                              ** EVENT NUMBERS **

36811  36872  36873  36874  36875  36876  36877  36878  

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36811       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PALO VERDE               REGION:  4  |NOTIFICATION DATE: 03/17/2000|
|    UNIT:  [1] [] []                 STATE:  AZ |NOTIFICATION TIME: 20:26[EST]|
|   RXTYPE: [1] CE,[2] CE,[3] CE                 |EVENT DATE:        03/17/2000|
+------------------------------------------------+EVENT TIME:        17:30[MST]|
| NRC NOTIFIED BY:  BRAD ROBINSON                |LAST UPDATE DATE:  04/07/2000|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |DAVID GRAVES         R4      |
|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  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| DISCOVERY OF NON-CONSERVATIVE RODDED RADIAL PEAKING FACTORS IN THE CORE      |
| PROTECTION CALCULATORS AND CORE OPERATING LIMIT SUPERVISORY SYSTEM FOR       |
| GROUPS 5 AND P                                                               |
|                                                                              |
| The following text is a portion of a facsimile received from the licensee:   |
|                                                                              |
| "On 03/17/00 at approximately 1730 MST, Palo Verde Engineering determined    |
| that Non-conservative Rodded Radial Peaking Factors were installed in the    |
| Unit 1 Core Protection Calculators (CPC) and Core Operating Limit            |
| Supervisory System for Group 5 and Group P.  During the course of normal     |
| operations, Group 5 could be inserted into the core in order to compensate   |
| for Axial Shape Index.  With the current values of Rodded Radial Peaking     |
| Factors, Group 5 may be outside of its design basis.  Control room operators |
| have been briefed on contingency actions to prevent the unit from operating  |
| outside the design basis.  At this time, only Unit 1 is impacted, and the    |
| investigation is continuing."                                                |
|                                                                              |
| The licensee plans to notify the NRC resident inspector.                     |
|                                                                              |
| * * *  UPDATE AT 0009 ON 3/18/00, BY BANKS RECEIVED BY WEAVER * * *          |
|                                                                              |
| "On 3/17/00 at 2122, conservative Rodded Radial Peaking Factors were         |
| installed in unit 1, Core Protection Calculators (CPCs) channels A, B, & C   |
| and Core Operating Limit Supervisory System for Group 5 and Group P. CPC     |
| channel D remains out of service for an unrelated issue, however, before the |
| channel is placed back into service, the new conservative Rodded Radial      |
| Peaking Factor will be installed."                                           |
|                                                                              |
| The licensee informed the NRC resident inspector of this update.  The        |
| Operations Center notified the R4DO (Graves).                                |
|                                                                              |
| * * * RETRACTION ON 04/07/00 AT 1627 EDT BY DAN MARKS TAKEN BY MACKINNON * * |
| *                                                                            |
|                                                                              |
| On 04/06/00, Palo Verde Engineering personnel completed an analysis of the   |
| impact of the non-conservative Rodded Radial Peaking Factors and concluded   |
| that sufficient margin existed such that the Core Operating Limit            |
| Supervisory System and Core Protection Calculators would have maintained     |
| their safety system function and would have tripped/alarmed as required to   |
| maintain the plant within its design basis.  The evaluation demonstrated     |
| that sufficient margin would exit throughout the current operating cycle     |
| such that the specified acceptable fuel design limits would not have been    |
| violated.                                                                    |
|                                                                              |
| The NRC Resident Inspector was notified of this retraction by the licensee.  |
| R4DO (Jeff Shackelford) notified.                                            |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   36872       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  ST LOUIS UNIVERSITY HOSPITAL         |NOTIFICATION DATE: 04/07/2000|
|LICENSEE:  ST LOUIS UNIVERSITY HOSPITAL         |NOTIFICATION TIME: 16:42[EDT]|
|    CITY:  ST LOUIS                 REGION:  3  |EVENT DATE:        04/06/2000|
|  COUNTY:                            STATE:  MO |EVENT TIME:        17:36[CDT]|
|LICENSE#:  24-00196-07           AGREEMENT:  N  |LAST UPDATE DATE:  04/07/2000|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |THOMAS KOZAK         R3      |
|                                                |JOHN HICKEY          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  MARK HAENCHEN                |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| MEDICAL MISADMINISTRATION                                                    |
|                                                                              |
| A patient on a ventilator was being treated with a High Dose Radiation       |
| Remote Afterloader when the patient intervened causing a jarring motion      |
| which caused the patient's catheter to come part way out.  The catheter came |
| part way out after 13 of 14 dwell positions had been completed.  Just before |
| the commencement of the 14th dwell position the catheter was pulled out and  |
| the physicist immediately intervened and retracted the source such that the  |
| 14th dwell position was underdosed between 10 and 60%.  The worst case is    |
| that the 14th dwell position, which was outside of the tumor volume, would   |
| have received as little as 40% of the original planned dose at that          |
| location.                                                                    |
|                                                                              |
| NRC Region 3 (Kevin Null) was notified of this event by the licensee.        |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36873       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: FERMI                    REGION:  3  |NOTIFICATION DATE: 04/07/2000|
|    UNIT:  [2] [] []                 STATE:  MI |NOTIFICATION TIME: 17:15[EDT]|
|   RXTYPE: [2] GE-4                             |EVENT DATE:        04/07/2000|
+------------------------------------------------+EVENT TIME:        14:00[EDT]|
| NRC NOTIFIED BY:  S. MAREK                     |LAST UPDATE DATE:  04/07/2000|
|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |THOMAS KOZAK         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                                   
+------------------------------------------------------------------------------+
| "C" MAIN STEAM LINE FAILS LOCAL LEAK RATE TEST DUE TO EXCESSIVE LEAKAGE      |
|                                                                              |
| During Local Leak Rate Testing (LLRT) of the "C" Main Steam Line, the        |
| as-found leakage could not be quantified.  Technical Specification           |
| surveillance requirement, SR 3.6.1.3.12 limit of less than 100 scfh combined |
| MSIV leakage rate for all four main steam lines when tested at greater than  |
| 25 psig was exceeded.  Fermi 2 Main Steam Lines are equipped with a Main     |
| Steam Line Isolation Valve Leakage Control System (MSIVLCS) which is         |
| designed to maintain pressure between the MSIVs slightly above that of       |
| primary containment.  Since the leakage could not be quantified, it could    |
| not be demonstrated that the leakage did not exceed the capacity of the      |
| MSIVLCS.                                                                     |
|                                                                              |
| The NRC Resident Inspector was notified of this event by the licensee.       |
|                                                                              |
| * * * UPDATE ON 04/07/00 AT 1836 EDT BY S. MAREK TAKEN BY MACKINNON * * *    |
|                                                                              |
| During LLRT of the "D" Main Steam Line, the as-found leakage could not be    |
| quantified.  Technical Specification surveillance requirement, SR 3.6.1.3.12 |
| limit of less than 100 scfh combined MSIV leakage rate for all four main     |
| steam lines when tested at greater than 25 psig was exceeded.  Fermi 2 Main  |
| Steam Lines are equipped with a MSIVLCS which is designed to maintain        |
| pressure between the MSIVs slightly above that of primary containment.       |
| Since the leakage could not be quantified, it could not be demonstrated that |
| the leakage did not exceed the capacity of the MSIVLCS.  The "A" & "B" Main  |
| Steam Lines passed their LLRT.                                               |
|                                                                              |
| The NRC Resident Inspector was notified of this update by the licensee.      |
| R3DO (T. Kozak) was notified.                                                |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36874       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: HATCH                    REGION:  2  |NOTIFICATION DATE: 04/07/2000|
|    UNIT:  [] [2] []                 STATE:  GA |NOTIFICATION TIME: 17:56[EDT]|
|   RXTYPE: [1] GE-4,[2] GE-4                    |EVENT DATE:        04/07/2000|
+------------------------------------------------+EVENT TIME:        16:15[EDT]|
| NRC NOTIFIED BY:  BARRY COLEMAN                |LAST UPDATE DATE:  04/07/2000|
|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |STEVE CAHILL         R2      |
|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   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     N          N       0        Cold Shutdown    |0        Cold Shutdown    |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| RECEIVED PARTIAL GROUP 1 (MSIVs) AND GROUP 2 (Primary Containment) OUTBOARD  |
| ISOLATIONS.                                                                  |
|                                                                              |
| Received a partial Group 1 and Group 2 outboard isolation which caused 13    |
| outboard isolation valves to close.                                          |
| The following outboard isolation valves closed: 4  hydrogen and oxygen       |
| sample valves, 3 Fission Product Monitor sample valves, Drywell floor drain  |
| valve, Drywell equipment drain valve, Drywell Air Purge and Vent line        |
| valves, Primary Coolant Sample line valve, and a Main Steam Line drain       |
| valve.  All the outboard valves belong to Group 1 except for the last two    |
| listed which belong to Group 2.  Electricians were replacing covers on       |
| divisional separation wiring trays in the outboard isolation panel           |
| 2H11-P623.  Insulation on a wire was damaged causing a fuse to blow.  An     |
| evaluation is in progress to determined if the wire can be tapped or a new   |
| wire will be installed.                                                      |
|                                                                              |
| The NRC Resident Inspector was notified of this event by the licensee.       |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36875       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: LIMERICK                 REGION:  1  |NOTIFICATION DATE: 04/07/2000|
|    UNIT:  [1] [] []                 STATE:  PA |NOTIFICATION TIME: 17:54[EDT]|
|   RXTYPE: [1] GE-4,[2] GE-4                    |EVENT DATE:        04/07/2000|
+------------------------------------------------+EVENT TIME:        14:05[EDT]|
| NRC NOTIFIED BY:  RAYMOND L. LANDIS            |LAST UPDATE DATE:  04/07/2000|
|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |JACK MCFADDEN        R1      |
|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          N       0        Refueling        |0        Refueling        |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| BLOWN FUSE CAUSED A PARTIAL SYSTEM ISOLATION                                 |
|                                                                              |
| A partial system isolation occurred on the containment instrument gas system |
| and the drywell chilled water system.  The cause of the partial isolation is |
| a blown fuse.                                                                |
|                                                                              |
| At the time of this event, Unit 1 was in Operational Condition 5 undergoing  |
| refueling.  There was no release of radiation or loss of vessel inventory or |
| shutdown cooling.  Proper system response is being verified. The fuse will   |
| be replaced and all valves will be placed back in their proper position.     |
|                                                                              |
| The NRC Resident Inspector was notified of this event by the licensee.       |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36876       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SOUTH TEXAS              REGION:  4  |NOTIFICATION DATE: 04/07/2000|
|    UNIT:  [] [2] []                 STATE:  TX |NOTIFICATION TIME: 18:07[EDT]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        04/07/2000|
+------------------------------------------------+EVENT TIME:        10:14[CDT]|
| NRC NOTIFIED BY:  JOHN MILLIFF                 |LAST UPDATE DATE:  04/07/2000|
|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |JEFF SHACKELFORD     R4      |
|10 CFR SECTION:                                 |                             |
|NLTR                     LICENSEE 24 HR REPORT  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| POWER EXCURSION TO 104% OF THERMAL RATED POWER                               |
|                                                                              |
| Power excursion to 104% occurred when a deaerator level channel was          |
| improperly removed from service for calibration and caused a loss of         |
| deaerator level and pressure control.  This resulted in an increase in       |
| feedwater and steam flow to the deaerator, which in turn caused reactor      |
| power to increase above rated values.  Operators took action to terminate    |
| the transient and stabilized Unit 2 at 99% power.  The length of the         |
| excursion was approximately 3 minutes.                                       |
|                                                                              |
| The NRC Resident Inspector was notified of this event by the licensee.       |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36877       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SAN ONOFRE               REGION:  4  |NOTIFICATION DATE: 04/07/2000|
|    UNIT:  [] [] [3]                 STATE:  CA |NOTIFICATION TIME: 19:11[EDT]|
|   RXTYPE: [1] W-3-LP,[2] CE,[3] CE             |EVENT DATE:        04/07/2000|
+------------------------------------------------+EVENT TIME:        15:33[PDT]|
| NRC NOTIFIED BY:  BILL CONKLIN                 |LAST UPDATE DATE:  04/07/2000|
|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |JEFF SHACKELFORD     R4      |
|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   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|                                                   |                          |
|3     N          Y       100      Power Operation  |74       Power Operation  |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| TECHNICAL SPECIFICATION SHUTDOWN DUE TO A DROPPED CONTROL ELEMENT ASSEMBLY   |
| (CEA).                                                                       |
|                                                                              |
| On April 7, 2000, around 1319 PDT, an alarm was received for a control       |
| element drive mechanism control system timer.  In response to this alarm,    |
| plant operators began moving control rod subgroup 20 to the "hold" bus (4    |
| rods on the hold bus).  Shortly thereafter, CEA #84 (a full length CEA and   |
| part of shutdown bank B) dropped into the reactor core.  Technical           |
| Specification (TS) 3.1.5, "Control Element Assembly Alignment" requires all  |
| full length CEAs to be aligned to within 7 inches of all other CEAs in its   |
| group.  If this requirement can not be met within 2 hours, Action B of TS    |
| 3.1.5 requires Southern California Edison to initiate a plant shutdown.      |
|                                                                              |
| Plant operators initiated actions to realign CEA #84 with the remainder of   |
| its group.  However, to minimize potential adverse affects to the fuel,      |
| reactor engineers have recommended a CEA withdrawal rate which will not      |
| allow CEA #84 to be realigned with the remainder of its group within 2 hours |
| allowed by TS 3.1.5.  Consequently, at 1533 PDT, Southern California Edison  |
| initiated a power reduction of San Onofre Unit 3.                            |
|                                                                              |
| At 1557 PDT, CEA #84 was realigned to within 7 inches of the remainder of    |
| its group before completion of plant shutdown.                               |
|                                                                              |
| Southern California Edison believes there is no safety significance to this  |
| event as all system operated as required.  The cause of this event is under  |
| investigation.                                                               |
|                                                                              |
| The NRC Resident Inspector was notified of this event by the licensee.       |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36878       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: FARLEY                   REGION:  2  |NOTIFICATION DATE: 04/09/2000|
|    UNIT:  [1] [] []                 STATE:  AL |NOTIFICATION TIME: 12:32[EDT]|
|   RXTYPE: [1] W-3-LP,[2] W-3-LP                |EVENT DATE:        04/09/2000|
+------------------------------------------------+EVENT TIME:        10:00[CDT]|
| NRC NOTIFIED BY:  BILL ARENS                   |LAST UPDATE DATE:  04/09/2000|
|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |STEVE CAHILL         R2      |
|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          N       0        Refueling        |0        Refueling        |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| LOSS OF BOTH VITAL BUSES DURING  'B' TRAIN LOAD SHED TESTING                 |
|                                                                              |
| At 1000 CDT, during Unit 1 'B' train load shed testing (performed every 18   |
| months during a refueling outage), the 'A' startup transformer tripped,      |
| resulting in a loss of offsite power to both trains of Unit 1 vital buses,   |
| the autostart of 'A' train emergency diesel generators (EDGs) which          |
| reenergized the 'A' train buses, and the sustained deenergization of the 'B' |
| train vital buses.                                                           |
|                                                                              |
| At the time of this event, Unit 1 was defueled, with the 'B' train service   |
| water system out of service and the 'B' train EDG unavailable to Unit 1.     |
| Both trains of Unit 1 vital power were aligned to the '1A' startup           |
| transformer as part of the load shed test that was in progress.  The loss of |
| the '1A' startup transformer coincided with, and appears to be associated    |
| with, the removal of a jumper from a 'B' train sequencer relay.              |
| Investigation of this apparent cause is continuing.                          |
|                                                                              |
| The 'A' train vital buses were immediately restored to service by the 'A'    |
| train EDGs.                                                                  |
|                                                                              |
| At 1018 CDT, spent fuel pool cooling was manually restored.  Spent fuel pool |
| temperature remained at 98F throughout this event.                          |
|                                                                              |
| At 1019 CDT. the 'B' train buses were manually reenergized from the '1B'     |
| startup transformer.                                                         |
|                                                                              |
| At 1053 CDT, the 'A' train buses were transferred from the EDGs to offsite   |
| power.                                                                       |
|                                                                              |
| Unit 2 remains at 100% power and is unaffected by this event.                |
|                                                                              |
| The NRC Resident Inspector was notified of this event by the licensee.       |
+------------------------------------------------------------------------------+