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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 THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
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|Hospital                                         |Event Number:   36872       |
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| 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  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| 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).     |
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|Power Reactor                                    |Event Number:   36878       |
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| 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        |
|                                                   |                          |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| 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.       |
|                                                                              |
| * * * 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 98F 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).                                            |
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+------------------------------------------------------------------------------+
|Fuel Cycle Facility                              |Event Number:   36879       |
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| 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      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| 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.                            |
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|Fuel Cycle Facility                              |Event Number:   36880       |
+------------------------------------------------------------------------------+
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| 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   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   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,           |
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