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 THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
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|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. |
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+------------------------------------------------------------------------------+
|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 98�F 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. |
+------------------------------------------------------------------------------+
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