Event Notification Report for April 11, 2000
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
04/10/2000 - 04/11/2000
** EVENT NUMBERS **
36872 36878 36879 36880
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
+------------------------------------------------------------------------------+
|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: 04/10/2000|
| 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. |
| |
| * * * UPDATE AT 1215 ON 04/10/00 BY DAWSON RECEIVED BY WEAVER * * * |
| |
| The licensee has requested that this event be retracted after discussions |
| with NRC Region III. The dose did not deviate by greater than 20% from the |
| intended dose and no dose was delivered to unintended sites. |
| |
| The NRC Operations Officer notified the R3DO (Hiland) and NMSS (Hickey). |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|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: 04/10/2000|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: UNU |STEVE CAHILL R2 |
|10 CFR SECTION: | |
|AAEC 50.72 (a) (1) (I) EMERGENCY DECLARED | |
|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. |
| |
| * * * UPDATE AT 1615 ON 4/10/00, BY COLLINS RECEIVED BY WEAVER * * * |
| |
| The following is an update to the above non-emergency report: |
| |
| The purpose of this emergency notification is to retroactively declare and |
| terminate a Notice of Unusual Event (NOUE) that occurred on April 9, 2000. |
| As of 1000 CDT on April 9, 2000, a NOUE was declared due to a loss of |
| offsite power to the Unit 1 vital buses. The emergency declaration was |
| terminated at 1019 CDT on April 9, 2000 at which time one train of vital |
| power was reestablished from offsite power supply. During this event, one |
| train of vital power was automatically supplied from an EDG. |
| |
| At the time of the event, Unit 1 was defueled. The 'B' train EDG was not |
| available due to routine outage activities and the Unit 1 'A' startup |
| transformer was supplying both trains of vital buses from offsite power. |
| |
| At 1000 CDT on April 9, 2000, the Unit 1 'A' startup transformer tripped for |
| unknown reason, resulting in a loss of power to both trains of vital |
| electrical buses. Both 'A' train EDGs automatically started and reenergized |
| the Unit 1 'A' train vital buses within seconds. The Unit 1 'B' train vital |
| buses remained deenergized for about 19 minutes until the Unit 1 'B' startup |
| transformer was aligned by the operators to supply power to them. The cause |
| of the Unit 1 ' A' startup transformer trip is unknown and being |
| investigated. |
| |
| This event resulted in a brief loss of spent fuel pool cooling. Spent fuel |
| pool cooling was restored by the operators at 1018 CDT on April 9, 2000 in |
| accordance with plant procedures. The temperature of the spent fuel pool |
| remained constant at 98�F throughout this event. Following a walkdown for |
| faults, the Unit 1 'B' train vital buses were reenergized from offsite power |
| at 1019 CDT from the Unit 1 'B' startup transformer. Offsite electrical |
| power was restored to the 'A' train vital buses at 1053 CDT and the EDGs |
| were secured and returned to normal standby alignment. The operations shift |
| crew evaluated this event and reported it to the NRC as a four hour |
| non-emergency report per 10CFR50.72. The operations shift crew recognized |
| the momentary loss of power to the vital buses but after reviewing the |
| emergency implementation procedures and Technical Specifications concluded |
| that a loss of both trains of offsite power had not occurred. That was |
| concluded since the operators were readily able to align the Unit 1 'B' |
| startup transformer to supply the 'B' train vital buses. Further evaluation |
| of the event on April 10, 2000, concluded that a NOUE was appropriate since |
| offsite power was momentarily lost to the vital electrical buses. |
| |
| Unit 2 remained at 100% power during this event and was unaffected by this |
| event. |
| |
| The licensee informed the NRC resident inspector of this notification. |
| |
| The NRC Operations Officer notified the R2DO (Cahill), NRR EO (Marsh), IRO |
| (Giitter) and FEMA (Steindruff). |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Fuel Cycle Facility |Event Number: 36879 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 04/10/2000|
| RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 20:57[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 04/10/2000|
| 6903 ROCKLEDGE DRIVE |EVENT TIME: 14:00[EDT]|
| BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 04/10/2000|
| CITY: PIKETON REGION: 3 +-----------------------------+
| COUNTY: PIKE STATE: OH |PERSON ORGANIZATION |
|LICENSE#: GDP-2 AGREEMENT: N |PATRICK HILAND R3 |
| DOCKET: 0707002 |JOHN HICKEY NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: RICK LARSON | |
| HQ OPS OFFICER: DOUG WEAVER | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NBNL RESPONSE-BULLETIN | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| NRC BULLETIN 91-01, 24 HOUR REPORT |
| |
| "AT 1400 HOURS ON APRIL 10, 2000, X-710 LABORATORY PERSONNEL WERE CONDUCTING |
| A SELF ASSESSMENT REVIEW OF NCSA-710-025.A00 (HANDLING AND STORAGE OF |
| SAMPLES FROM ES&H ANALYTICAL LABS) WHEN THEY DISCOVERED THAT REQUIREMENT #4 |
| (SPACING) WAS NOT BEING MAINTAINED IN A SPECIFIED STORAGE AREA WITHIN THE |
| FACILITY. REQUIREMENT #4 STATES: 'A |
| MINIMUM SPACING OF TWO FEET SHALL BE MAINTAINED BETWEEN GROUPS OF SAMPLES, |
| EXCLUDING EXEMPTED SAMPLES.' THE FACT THAT THIS REQUIREMENT WAS NOT BEING |
| MAINTAINED RESULTED IN A LOSS OF ONE CONTROL (SPACING). THIS CONSTITUTES A |
| LOSS OF CONTROL 'A' (SPACING) AS IDENTIFIED IN THE DOUBLE CONTINGENCY MATRIX |
| A/B.7.1. CONTROL 'B' (MASS + VOLUME + ENRICHMENT) WAS MAINTAINED THROUGHOUT |
| THIS EVENT. |
| |
| "AT THE DIRECTION OF THE PLANT SHIFT SUPERINTENDENT, THE REQUIREMENTS FOR AN |
| ANOMALOUS CONDITION WERE ESTABLISHED PER PLANT PROCEDURES. AT 1630 HOURS ON |
| 04/10/2000, DOUBLE CONTINGENCY CONTROLS WERE REESTABLISHED (SPACING) UNDER |
| THE DIRECTION OF ONSCENE NUCLEAR CRITICALITY SAFETY PERSONNEL. |
| |
| "AT THE DIRECTION OF THE PLANT SHIFT SUPERINTENDENT, THE X-710 MANAGEMENT |
| STAFF WILL CONDUCT BRIEFINGS WITH THE RESPECTIVE PERSONNEL TO PREVENT |
| RECURRENCE." |
| |
| THE LICENSEE NOTIFIED THE NRC RESIDENT INSPECTOR. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Fuel Cycle Facility |Event Number: 36880 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 04/10/2000|
| RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 21:03[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 04/10/2000|
| 6903 ROCKLEDGE DRIVE |EVENT TIME: 09:47[CDT]|
| BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 04/10/2000|
| CITY: PADUCAH REGION: 3 +-----------------------------+
| COUNTY: McCRACKEN STATE: KY |PERSON ORGANIZATION |
|LICENSE#: GDP-1 AGREEMENT: Y |PATRICK HILAND R3 |
| DOCKET: 0707001 |JOHN HICKEY NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: CALVIN PITTMAN | |
| HQ OPS OFFICER: DOUG WEAVER | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|OCBB 76.120(c)(2)(ii) EQUIP DISABLED/FAILS | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| SAFETY EQUIPMENT FAILURE (CRITICALITY ALARM SYSTEM TROUBLE) |
| |
| "At 0947 CDT on 04/10/00, the Plant Shift Superintendent was informed of a |
| trouble alarm on the C-337A Criticality Accident Alarm System (CAAS) |
| cluster. Investigation of trouble alarm revealed that all three modules on |
| the 'N' CAAS cluster were in a 'Fault' condition. With all three modules in |
| this condition, the system was unable to perform its intended safety |
| function, rendering the system inoperable. The system is required to be |
| operable according to TSR 2.2.4.3 for the current mode of operation in |
| twelve rad areas covered by CAAS systems. Overlapping coverage for the |
| C-337A facility was provided by the C-337 'X' and 'V' CAAS clusters. |
| However, the C-360/C-337 tie line CAAS coverage is provided by the 'N' |
| cluster. The system was inoperable for approximately seven minutes until it |
| could be reset per procedure. A portion of the C-337/C-360 tie line was |
| without CAAS coverage as required by TSR 2.2.4.3 during the time of cluster |
| inoperability." |
| |
| The NRC Senior Resident Inspector has been notified of this event, |
+------------------------------------------------------------------------------+
Page Last Reviewed/Updated Thursday, March 25, 2021
Page Last Reviewed/Updated Thursday, March 25, 2021