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Event Notification Report for April 24, 2000

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           04/21/2000 - 04/24/2000

                              ** EVENT NUMBERS **

36840  36912  36913  36914  36915  36916  36917  36918  36919  36920  36921  

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36840       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SEABROOK                 REGION:  1  |NOTIFICATION DATE: 03/28/2000|
|    UNIT:  [1] [] []                 STATE:  NH |NOTIFICATION TIME: 15:21[EST]|
|   RXTYPE: [1] W-4-LP                           |EVENT DATE:        03/28/2000|
+------------------------------------------------+EVENT TIME:        12:41[EST]|
| NRC NOTIFIED BY:  MATTHEW ARSENAULT            |LAST UPDATE DATE:  04/21/2000|
|  HQ OPS OFFICER:  STEVE SANDIN                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |MICHELE EVANS        R1      |
|10 CFR SECTION:                                 |                             |
|AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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                                   
+------------------------------------------------------------------------------+
| PRIMARY COMPONENT COOLING WATER SYSTEM INOPERABLE DUE TO THE AREA            |
| VENTILATION SYSTEM INCAPABLE OF PERFORMING ITS SAFETY FUNCTION               |
|                                                                              |
| "On 03/26/00 Seabrook Station entered Tech Spec (TS) 3.0.3 due to both       |
| trains of the Primary Component Cooling Water (PCCW) system being declared   |
| inoperable. Both trains of PCCW were declared inoperable because the PCCW    |
| Area Ventilation System was determined to be incapable of performing its     |
| intended function.                                                           |
|                                                                              |
| "The PCCW system is a two train closed loop cooling system used to remove    |
| heat from plant components during plant operation, plant cooldown and during |
| various phases of an accident. The PCCW pumps are located within the Primary |
| Auxiliary Building (PAB). The operation of the PCCW pumps is supported by    |
| the PCCW Area Ventilation system. This ventilation system has redundant,     |
| automatically controlled auxiliary supply fans and associated dampers to     |
| ensure that the temperature in this area does not exceed design limits       |
| should the normal PAB ventilation system fail.                               |
|                                                                              |
| "During surveillance testing of the PCCW Area Ventilation system, an exhaust |
| damper (PAH-DP-357) failed to open as required. During a subsequent local    |
| investigation by the Shift Manager and Unit Supervisor it was determined     |
| that recent painting activities may have affected both PAB Exhaust Dampers   |
| (PAH-DP-357 and PAH-DP-358).  A subsequent test of PAH-DP-358 indicated that |
| it also failed to open as required. TS 3.0.3 was entered on 03/26/00 at      |
| 0346. TS 3.0.3 was subsequently exited at 0425 on 03/26/00 after plant       |
| personnel reestablished operability for PAH-DP-358. The subject dampers      |
| automatically open to provide an exhaust flow path for the PCCW Pump Area    |
| ventilation system which supports operation of the PCCW pumps. An initial    |
| review of this condition concluded that a report pursuant to the             |
| requirements of 10CFR50.72 was not required.  A subsequent review of this    |
| event determined that it is reportable pursuant to the requirements of       |
| 10CFR50.72(b)(2)(iii) as a condition that alone could have prevented the     |
| fulfillment of a safety function."                                           |
|                                                                              |
| The licensee will inform the NRC resident inspector.                         |
|                                                                              |
| HOO Note:  The event time was the time the licensee determined this          |
| condition to be reportable to the NRC.                                       |
|                                                                              |
| * * * RETRACTION ON 04/21/00 AT 1330 HOURS BY M. KILEY TAKEN BY MACKINNON *  |
| * *                                                                          |
|                                                                              |
| Upon further Engineering review, North Atlantic has determined that the PCCW |
| system remained capable of performing its intended function during the       |
| period when the PAB Exhaust Dampers (PAH-DP-357 and PAH-DP-358) were painted |
| between March 12, 2000 and March 26, 2000 when the condition was corrected.  |
| North Atlantic analyzed the area heat-up conditions as they pertain to the   |
| operation of the PCCW system and other associated safety-related equipment   |
| and concluded that the PCCW system would have performed its intended         |
| function even with the subject dampers isolated.  Therefore, this condition  |
| is not reportable pursuant to the requirement of 10 CFR 50.72(b)(2)(iii) as  |
| a condition that alone could have prevented the fulfillment of a safety      |
| function. R1DO (John White) notified.                                        |
|                                                                              |
| The NRC Resident Inspector has been notified of this retraction by the       |
| licensee.                                                                    |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Other Nuclear Material                           |Event Number:   36912       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  ABI LABORATORY, INC.                 |NOTIFICATION DATE: 04/21/2000|
|LICENSEE:  ABI LABORATORY, INC.                 |NOTIFICATION TIME: 09:14[EDT]|
|    CITY:  SPRINGFIELD              REGION:  1  |EVENT DATE:        04/20/2000|
|  COUNTY:                            STATE:  PA |EVENT TIME:        14:00[EDT]|
|LICENSE#:  37-30215-01           AGREEMENT:  N  |LAST UPDATE DATE:  04/21/2000|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |JOHN WHITE           R1      |
|                                                |BRIAN SMITH          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  KIMBERLY MOORE               |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|BAD1 20.2202(a)(1)       PERS OVEREXPOSURE      |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| POSSIBLE OVEREXPOSURE                                                        |
|                                                                              |
| On 04/20/00 the Radiation Safety Officer for ABI Laboratory, Inc., received  |
| a phone call from Troxler informing her that one of the film badges that     |
| they had read had a reading of 30,677 mrem (30.7 Rads). Troxler will check   |
| the film badge again on Monday, 04/24/00, since Friday is a holiday.  The    |
| film badge belongs to an ABI Laboratory, Inc.,  employee who is currently    |
| working at a construction site located at the Philadelphia International     |
| Airport .  The film badges for ABI Laboratory, Inc., are checked quarterly   |
| by Troxler.  The film badge mentioned above had been used during the         |
| December 1999 through February 2000 time period.                             |
|                                                                              |
| The  ABI Laboratory, Inc. construction site has 2 Troxler and 2 Humboldt     |
| Density Gauges. The Density Gauges were all leak tested and radiation        |
| surveys were taken inside and around the building containing the gauges. All |
| radiation surveys and leak tests were within expected values.                |
|                                                                              |
| From December 1999 through February 2000,  the employee in question used a   |
| Density Gauge on 20 different days.                                          |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   36913       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  SC DIV OF HEALTH & ENV CONTROL       |NOTIFICATION DATE: 04/21/2000|
|LICENSEE:  BANKS CONSTRUCTION COMPANY           |NOTIFICATION TIME: 13:59[EDT]|
|    CITY:  CHARLESTON               REGION:  2  |EVENT DATE:        04/21/2000|
|  COUNTY:                            STATE:  SC |EVENT TIME:        02:00[EDT]|
|LICENSE#:  SC-518                AGREEMENT:  Y  |LAST UPDATE DATE:  04/21/2000|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |ANN BOLAND           R2      |
|                                                |JOSIE PICCONE        NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  JIM PETERSON                 |                             |
|  HQ OPS OFFICER:  DICK JOLLIFFE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|NDAM                     DAMAGED GAUGE/DEVICE   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT:  DAMAGED TROXLER MOISTURE DENSITY GAUGE -            |
|                                                                              |
| At 0200 on 04/20/00, an automobile struck a Banks Construction Company       |
| (License #SC-518) truck on I-26 in Charleston, SC, damaging a Troxler        |
| Moisture Density Gauge, model #4640.  The 9 mCi Cs-137 and 44 mCi Am-241-Be  |
| sources were undamaged.  The damaged gauge, containing its undamaged         |
| sources, was placed into its transport case and will be sent to Troxler for  |
| repairs.                                                                     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   36914       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  MARYLAND DEPT OF THE ENVIRONMENT     |NOTIFICATION DATE: 04/21/2000|
|LICENSEE:  U OF MD AT BALTIMORE HOSPITAL        |NOTIFICATION TIME: 15:04[EDT]|
|    CITY:  BALTIMORE                REGION:  1  |EVENT DATE:        04/20/2000|
|  COUNTY:                            STATE:  MD |EVENT TIME:        13:00[EDT]|
|LICENSE#:  MD-07-014-05          AGREEMENT:  Y  |LAST UPDATE DATE:  04/21/2000|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |JOHN WHITE           R1      |
|                                                |JOSIE PICCONE        NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  RAY MANLEY                   |                             |
|  HQ OPS OFFICER:  DICK JOLLIFFE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT:  MEDICAL MISADMINISTRATION -                         |
|                                                                              |
| At 1300 on 04/20/00, a 52 year old female patient received a medical         |
| misadministration of a gamma knife treatment at the University of Maryland   |
| at Baltimore (UMAB) Hospital to reduce the cancerous tumor in her head.      |
|                                                                              |
| The gamma knife is a UMAB specific license that uses 201 sealed Cobalt-60    |
| sources of 30 curies each in a Model 23016 Leksell Gamma System for the      |
| radiation treatment of human patients.                                       |
|                                                                              |
| The patient received 12.6 gray to an unintended site of approximately 0.18   |
| cubic centimeters. The unintended site was approximately 4.2 centimeters     |
| from the intended site.                                                      |
|                                                                              |
| The medical directive for this treatment was defined as approximately 18     |
| gray administered over six administrations. The misadministration occurred   |
| during the first administration only. The treatment planning for the patient |
| was uneventful and was prepared and reviewed by a hospital gamma knife team  |
| of a Radiation Oncologist, a Neurosurgeon and a Medical Physicist.  It       |
| appears from preliminary interviews that when two of the team members were   |
| adjusting the coordinates on the device's steriotactic frame, the Y and Z    |
| coordinates were reversed.  This frame adjustment is accomplished by         |
| loosening the frame via the use of allen screws and manually adjusting it.   |
| One person calls out the coordinate and the other conducts the adjustment.   |
| According to the licensee procedures, this adjustment is to be checked for   |
| accuracy by a nurse and the Medical Physicist.  Normally the coordinates are |
| read out in a specific order.  The licensee indicated that the order might   |
| have been reversed due to a specific frame orientation problem that occurs   |
| approximately once in every 20 treatments.  When the licensee started to set |
| up for the second administration, the error was noted.  The treatment plan   |
| was reevaluated to include some partial dose to the tumor from the first     |
| administration and the treatment was completed in seven administrations      |
| instead of six.                                                              |
|                                                                              |
| The patient and her referring physician have been notified of this           |
| misadministration.  This misadministration constitutes no negative medical   |
| impact on the patient.                                                       |
|                                                                              |
| A MD DOE representative requested that UMAB Hospital personnel review        |
| previous medical files to assure that this switching of coordinates has not  |
| happened before without a misadministration being identified.                |
|                                                                              |
| The gamma knife is not scheduled to be used again at UMAB Hospital until     |
| 04/25/00.  On 04/24/00, a hospital management meeting has been scheduled     |
| among personnel from Hospital Administration, Oncology, Neurosurgery and the |
| Radiation Safety Office to discuss this incident.  The RSO's position at     |
| this meeting will be that all use of the gamma knife be suspended until the  |
| incident has been fully investigated and assurances are in place to prevent  |
| recurrence.                                                                  |
|                                                                              |
| A written report of this incident will be submitted to NMED within 30 days.  |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36915       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PALO VERDE               REGION:  4  |NOTIFICATION DATE: 04/21/2000|
|    UNIT:  [1] [] []                 STATE:  AZ |NOTIFICATION TIME: 16:46[EDT]|
|   RXTYPE: [1] CE,[2] CE,[3] CE                 |EVENT DATE:        04/21/2000|
+------------------------------------------------+EVENT TIME:        11:10[MST]|
| NRC NOTIFIED BY:  DAN MARKS                    |LAST UPDATE DATE:  04/21/2000|
|  HQ OPS OFFICER:  DICK JOLLIFFE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |DALE POWERS          R4      |
|10 CFR SECTION:                                 |                             |
|HFIT 26.73               FITNESS FOR DUTY       |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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                                   
+------------------------------------------------------------------------------+
| FITNESS-FOR-DUTY REPORT -                                                    |
|                                                                              |
| A licensed employee was for-cause tested for the presence of alcohol and was |
| determined not to be unfit for duty.  The employee's access authorization to |
| the plant protected area which had been suspended, was restored.             |
|                                                                              |
| The licensee notified the NRC Resident Inspector.                            |
|                                                                              |
|                                                                              |
|                                                                              |
|                                                                              |
| On April 21, 2000 at approximately 11:10 MST, the Unit I Shift Manager, a    |
| licensed senior reactor operator, opened his lunch box and discovered that   |
| it contained an unopened can of beer.  By approximately 11:15 MST, the shift |
| manager completed notifications to station management and security, and      |
| isolated the alcoholic beverage.                                             |
|                                                                              |
| Although behavior observation by supervision detected no degradation in      |
| performance, impairment, or changes in employee performance, the shift       |
| manager's access to the protected area was suspended and he was escorted to  |
| the Palo Verde health clinic for fitness-for-duty testing.  Testing          |
| for-cause, conducted in accordance with 10CFR26.24(a)(3), was negative,      |
| demonstrating that the Shift Manager was not unfit for duty due to the       |
| consumption of alcohol.  Upon completion of satisfactory testing, access to  |
| the protected area was restored.                                             |
|                                                                              |
| The unopened can of beer has been removed from the protected area.           |
|                                                                              |
| The Shift Manager stated that the can of beer, instead of a can of soda, had |
| been placed in the lunch box inadvertently by himself when preparing to come |
| to work.                                                                     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36916       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SOUTH TEXAS              REGION:  4  |NOTIFICATION DATE: 04/21/2000|
|    UNIT:  [1] [] []                 STATE:  TX |NOTIFICATION TIME: 18:38[EDT]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        04/21/2000|
+------------------------------------------------+EVENT TIME:        13:45[CDT]|
| NRC NOTIFIED BY:  BOB SCARBOROUGH              |LAST UPDATE DATE:  04/21/2000|
|  HQ OPS OFFICER:  DICK JOLLIFFE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |DALE POWERS          R4      |
|10 CFR SECTION:                                 |OTHER FEDS VIA FAX           |
|APRE 50.72(b)(2)(vi)     OFFSITE NOTIFICATION   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          N       0        Refueling        |0        Refueling        |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| - NOTIFICATION OF FEDERAL, STATE & LOCAL AGENCIES OF A HYDRAZINE CHEMICAL    |
| SPILL ONSITE -                                                               |
|                                                                              |
| At 1345 CDT on 04/21/00, Unit 1 experienced a chemical spill of 38 gallons   |
| of hydrazine that had leaked from a line that leads to an onsite storage     |
| tank.  The licensee isolated the leak, contained the spill onsite and is     |
| cleaning up the spill.                                                       |
|                                                                              |
| The licensee notified the NRC Resident Inspector and is in the process of    |
| notifying the DOT National Response Center, Texas Natural Resources          |
| Conservation Commission and the Local Emergency Planning Committee.          |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36917       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: KEWAUNEE                 REGION:  3  |NOTIFICATION DATE: 04/22/2000|
|    UNIT:  [1] [] []                 STATE:  WI |NOTIFICATION TIME: 11:08[EDT]|
|   RXTYPE: [1] W-2-LP                           |EVENT DATE:        04/22/2000|
+------------------------------------------------+EVENT TIME:        08:03[CDT]|
| NRC NOTIFIED BY:  ROY SCOTT                    |LAST UPDATE DATE:  04/22/2000|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |MARK RING            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   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          N       0        Intermediate Shut|0        Intermediate Shut|
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| MAIN STEAM ISOLATION VALVE FAILED TIMING TEST                                |
|                                                                              |
| The licensee determined that the 'B' steam generator main steam isolation    |
| valve shut in 6 seconds during testing.  The requirement is 5 seconds in the |
| surveillance test of technical specifications and in the Updated Safety      |
| Analysis Report.  The plant will remain shutdown until repairs and testing   |
| are complete.                                                                |
|                                                                              |
| The licensee notified the NRC Resident Inspector.                            |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36918       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: NINE MILE POINT          REGION:  1  |NOTIFICATION DATE: 04/22/2000|
|    UNIT:  [] [2] []                 STATE:  NY |NOTIFICATION TIME: 16:19[EDT]|
|   RXTYPE: [1] GE-2,[2] GE-5                    |EVENT DATE:        04/22/2000|
+------------------------------------------------+EVENT TIME:        15:06[EDT]|
| NRC NOTIFIED BY:  STEVE FREGEAU                |LAST UPDATE DATE:  04/22/2000|
|  HQ OPS OFFICER:  DICK JOLLIFFE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |JOHN WHITE           R1      |
|10 CFR SECTION:                                 |                             |
|AMED 50.72(b)(2)(v)      OFFSITE MEDICAL        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     N          Y       54       Power Operation  |54       Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| - POTENTIALLY CONTAMINATED PLANT EMPLOYEE TRANSPORTED TO OFFSITE HOSPITAL -  |
|                                                                              |
|                                                                              |
| A potentially contaminated plant employee who sustained a broken leg onsite, |
| was transported offsite to Oswego hospital for treatment accompanied by a    |
| plant radiation technician.                                                  |
|                                                                              |
| The licensee plans to notify the NRC Resident Inspector.                     |
|                                                                              |
| * * * UPDATE AT 1712 ON 04/22/00 BY STEVE FREGEAU TO JOLLIFFE * * *          |
|                                                                              |
| The plant radiation technician determined that the plant employee was not    |
| contaminated.                                                                |
|                                                                              |
| The licensee plans to notify the NRC Resident Inspector.                     |
|                                                                              |
| The NRC Operations Officer notified the R1DO John White.                     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36919       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: FERMI                    REGION:  3  |NOTIFICATION DATE: 04/22/2000|
|    UNIT:  [2] [] []                 STATE:  MI |NOTIFICATION TIME: 17:05[EDT]|
|   RXTYPE: [2] GE-4                             |EVENT DATE:        04/22/2000|
+------------------------------------------------+EVENT TIME:        14:28[EDT]|
| NRC NOTIFIED BY:  SANJEEV ARAB                 |LAST UPDATE DATE:  04/22/2000|
|  HQ OPS OFFICER:  DICK JOLLIFFE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |MARK RING            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   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|2     N          N       0        Refueling        |0        Refueling        |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| - SHUTDOWN COOLING LOST FOR 48 MINUTES; NO REACTOR VESSEL TEMPERATURE RISE   |
| -                                                                            |
|                                                                              |
| On 04/22/00, Unit 2 was in Condition 5 in a Refueling Outage with the        |
| reactor vessel cavity flooded up to higher than 20 feet 6 inches above the   |
| reactor vessel flange with the fuel pool gates removed.                      |
|                                                                              |
| At 1428, shutdown cooling was lost due to a technician inadvertently pulling |
| a wrong electrical fuse causing the Residual Heat Removal (RHR) shutdown     |
| inboard suction isolation valve #E1150-F009 to auto close.  The closure of   |
| this valve was in response to an invalid reactor vessel water level three    |
| signal causing the 'A' RHR pump to trip due to loss of suction flow.         |
|                                                                              |
| At 1516, shutdown cooling was restored.  No temperature rise in the reactor  |
| vessel was noted during the time that shutdown cooling was out of service.   |
|                                                                              |
| The licensee plans to notify the NRC Resident Inspector.                     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36920       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: DAVIS BESSE              REGION:  3  |NOTIFICATION DATE: 04/23/2000|
|    UNIT:  [1] [] []                 STATE:  OH |NOTIFICATION TIME: 00:38[EDT]|
|   RXTYPE: [1] B&W-R-LP                         |EVENT DATE:        04/23/2000|
+------------------------------------------------+EVENT TIME:        00:10[EDT]|
| NRC NOTIFIED BY:  STEVE ROBERTS                |LAST UPDATE DATE:  04/23/2000|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          UNU                   |M. DAPAS             R3      |
|10 CFR SECTION:                                 |DAVID MATTHEWS       NRR     |
|AAEC 50.72 (a) (1) (I)   EMERGENCY DECLARED     |JOSEPH GIITTER       IRO     |
|                                                |CEGIELSKI            FEMA    |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          N       0        Refueling        |0        Refueling        |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| UNUSUAL EVENT DECLARED DUE TO LOSS OF OFFSITE POWER                          |
|                                                                              |
| During preparation for a bus transfer test, the wrong relay was energized    |
| which caused the loss of offsite power to the 'A' and 'B' 13.8 Kv busses.    |
| An Unusual Event was declared with the loss of offsite power.  Only one of   |
| the offsite sources was energized at the time and the relay tripped during   |
| test setup causing the loss of that source.  The 4160 volt essential busses  |
| were reenergized by their respective emergency diesel generators.  The plant |
| was defueled at the time and spent fuel pool cooling was restarted.          |
|                                                                              |
| There was no release of radioactivity and no recommended protective actions  |
| necessary.                                                                   |
|                                                                              |
| The licensee is conducting a review of the event and all testing activities  |
| are suspended until completed.                                               |
|                                                                              |
| The Unusual Event was terminated at 0054 EDT with the restoration of normal  |
| power configuration.                                                         |
|                                                                              |
| The licensee notified the State of Ohio and the local counties, Ottawa and   |
| Lucas, as well as the NRC Resident Inspector.                                |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   36921       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: COOK                     REGION:  3  |NOTIFICATION DATE: 04/23/2000|
|    UNIT:  [1] [2] []                STATE:  MI |NOTIFICATION TIME: 06:49[EDT]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        04/23/2000|
+------------------------------------------------+EVENT TIME:        03:35[EDT]|
| NRC NOTIFIED BY:  BRIAN MOTZ                   |LAST UPDATE DATE:  04/23/2000|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |MARK RING            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          N       0        Refueling        |0        Refueling        |
|2     N          N       0        Cold Shutdown    |0        Cold Shutdown    |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| UNIT 1 TRAIN 'B' ESSENTIAL SERVICE WATER PUMP STARTED AUTOMATICALLY          |
|                                                                              |
| While setting up for testing the Solid State Protection System (SSPS) on     |
| Unit 2, the clearance permit did not anticipate the start of the Unit 1      |
| train 'B' Essential Service Water (ESW) Pump.                                |
|                                                                              |
| "To perform maintenance on the SSPS, a clearance to deenergize the SSPS      |
| cabinets in Unit 2 was written.  The Unit 2 SSPS was in inhibit at this      |
| time.  During the deenergization per this clearance, an automatic start of   |
| the Unit 1 East ESW Pump occurred.  The ESW Pump autostart was not           |
| anticipated or described in the clearance.                                   |
|                                                                              |
| "A Safety Injection (SI) signal through SSPS in either Unit 1 or Unit 2 will |
| cause the ESW Pumps in both units to autostart for the train effected.       |
| Similarly, the removal of power from the control room instrumentation        |
| distribution circuit, which is what occurred here, will cause the autostart  |
| of the ESW pumps.                                                            |
|                                                                              |
| "There were no adverse consequences as a result of the auto pump start and   |
| the actuation was per the system design.  No SI signal was generated."       |
|                                                                              |
| The licensee notified the NRC Resident Inspector.                            |
+------------------------------------------------------------------------------+