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 THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!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. |
+------------------------------------------------------------------------------+
Page Last Reviewed/Updated Wednesday, March 24, 2021
Page Last Reviewed/Updated Wednesday, March 24, 2021