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Event Notification Report for May 22, 2000

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           05/19/2000 - 05/22/2000

                              ** EVENT NUMBERS **

36945  36984  37009  37012  37013  37014  37015  

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
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|Power Reactor                                    |Event Number:   36945       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: MILLSTONE                REGION:  1  |NOTIFICATION DATE: 04/29/2000|
|    UNIT:  [] [2] []                 STATE:  CT |NOTIFICATION TIME: 23:38[EDT]|
|   RXTYPE: [1] GE-3,[2] CE,[3] W-4-LP           |EVENT DATE:        04/29/2000|
+------------------------------------------------+EVENT TIME:        22:34[EDT]|
| NRC NOTIFIED BY:  STEPHEN BAKER                |LAST UPDATE DATE:  05/19/2000|
|  HQ OPS OFFICER:  LEIGH TROCINE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |JAMES NOGGLE         R1      |
|10 CFR SECTION:                                 |                             |
|AESF 50.72(b)(2)(ii)     ESF ACTUATION          |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     N          N       0        Refueling        |0        Refueling        |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| UNEXPECTED ISOLATION OF CONTAINMENT PURGE                                    |
|                                                                              |
| A containment purge valve closed due to a loss of power to a radiation       |
| monitor.  The licensee stated that the cause was deenergization of the power |
| panel per procedures for that radiation monitor.                             |
|                                                                              |
| Apparently, this was the first time this procedure had been performed since  |
| it had been revised, and there was no caution in the procedure indicating    |
| that if a purge is in effect, it would be secured.  The licensee plans to    |
| change the procedures to reflect the possibility of isolation so that it can |
| be isolated before the radiation monitor is deenergized.                     |
|                                                                              |
| The licensee notified the NRC resident inspector as well as state and local  |
| authorities.                                                                 |
|                                                                              |
| * * * RETRACTION 1336 5/19/2000 FROM MYER TAKEN BY STRANSKY * * *            |
|                                                                              |
| "On 4/29/00 a Containment Purge Valve Isolation signal (CPVIS) was generated |
| due to a loss of power to a radiation monitor. The CPVIS automatically       |
| closed the Containment Purge system supply and exhaust valves. This          |
| condition was conservatively reported as an event that resulted in an        |
| automatic actuation of an Engineered Safety Feature (ESF).                   |
|                                                                              |
| "Subsequent investigation determined that the Containment Gaseous Radiation  |
| Monitor, RM-8123B, had been properly removed from service at 0801 on April   |
| 28, 2000 in accordance [with] the applicable Operating Procedure. The        |
| actuation signal from RM-8123B was the direct result of a planned loss of    |
| power to VA-30 and was not the result of a valid high radiation condition    |
| with the Containment. Therefore, the actuation signal was invalid.           |
|                                                                              |
| "The actuation only involved the automatic closure of the supply and exhaust |
| valves within the Containment Purge system. The Containment Purge system is  |
| equivalent to 'Reactor Building Ventilation System' as defined in IEEE Std   |
| 805-1984. Therefore, the Containment Purge system is equivalent to 'Reactor  |
| Building Ventilation System' identified in 10CFR50.72(b)(2)(ii).             |
|                                                                              |
| "Section 10CFR50.72(b)(2)(ii) states that the licensee shall report any      |
| event or condition that resulted in a manual or automatic actuation of an    |
| Engineered Safety Feature (ESF) including the Reactor Protection System      |
| (RPS), except when:                                                          |
|                                                                              |
| "(B) The actuation was invalid and                                           |
|                                                                              |
| "     (1) Occurred while the system was properly removed from service (or),  |
|                                                                              |
| "     (2) Occurred after the safety function had been already completed or   |
|                                                                              |
| "     (3) Involved only the following specific ESFs or their equivalent      |
| systems                                                                      |
| iii Reactor Building Ventilation system.                                     |
|                                                                              |
| "Since the actuation was invalid and since the event occurred after the      |
| applicable sensor had been properly removed from service in accordance with  |
| approved plant procedures and the actuation involved only the Containment    |
| Purge system, a system which can be shown to be equivalent to the Engineered |
| Safety Feature provided by the Reactor Building Ventilation system, this     |
| event is not reportable pursuant to either 10CFR50.72(b)(2)(ii)(B) or        |
| 10CFR50.73(a)(2)(iv)(B) and the Immediate Notification for this condition is |
| retracted."                                                                  |
|                                                                              |
| The NRC resident inspector has been informed of this retraction. Notified    |
| R1DO (Lew).                                                                  |
+------------------------------------------------------------------------------+

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
+------------------------------------------------------------------------------+
|Fuel Cycle Facility                              |Event Number:   36984       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT      |NOTIFICATION DATE: 05/08/2000|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 17:22[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        05/05/2000|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        21:30[CDT]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  05/19/2000|
|    CITY:  PADUCAH                  REGION:  3  +-----------------------------+
|  COUNTY:  McCRACKEN                 STATE:  KY |PERSON          ORGANIZATION |
|LICENSE#:  GDP-1                 AGREEMENT:  Y  |BRENT CLAYTON        R3      |
|  DOCKET:  0707001                              |JOSEPHINE PICCONE    NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  ERIC WALKER                  |                             |
|  HQ OPS OFFICER:  DOUG WEAVER                  |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|OCBA 76.120(c)(2)(i)     ACCID MT EQUIP FAILS   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| SAFETY EQUIPMENT FAILURE (CELL 2)                                            |
|                                                                              |
| At 2130 CDT on 5/05/2000, the C-337 Unit 3 Cell 2 Freezer/Sublimer A-valve   |
| failed to open while in TSR mode F/S 3 which requires operability of the     |
| A-valve in order for the valve to open if required to do so upon actuation   |
| of the Freezer/Sublimer High-High Weight Trip System.   An operator was      |
| attempting to place the Freezer/Sublimer into mode F/S 2 which does not      |
| require operability of the High-High Weight Trip System.  The                |
| Freezer/Sublimer was unable to enter Mode F/S 2 due to inability to open     |
| A-valve because of mechanical failure.  Actuation of High- High Weight Trip  |
| system did not occur.  However, had it been required to do so while in mode  |
| F/S 3, there is potential that the A-valve would not have opened as required |
| if actuation of system occurred.  Upon discovery of valve failure,           |
| Freezer/Sublimer was placed in mode F/S 4 which does not require operability |
| of the High-High Weight Trip system.  The valve failure was caused by a      |
| failure of the motor operator in this six inch valve.                        |
|                                                                              |
| The NRC Senior Resident Inspector has been notified of this event.  See      |
| related event 36985.                                                         |
|                                                                              |
| * * * RETRACTION 1718 5/19/2000 FROM MIKE UNDERWOOD TAKEN BY BOB STRANSKY *  |
| * *                                                                          |
|                                                                              |
| "On May 18, 2000, troubleshooting and functional testing of the F/S in the   |
| failed condition determined that the valve was opening in response to DPCS   |
| demands, but the limit switches were not correctly communicating the valve   |
| position to the DPCS. This caused the DPCS to indicate a mode equipment      |
| state failure on May 5, 2000. In addition the F/S was subjected to the       |
| high-high weight trip safety system functional test while in cold standby    |
| and with the system engineer visually monitoring the A-valve. The valve      |
| operated as designed, but due to the failed limit switches, the DPCS tripped |
| the unit into hot standby, recreating the events of May 5, 2000. Thus, the   |
| A-valve was capable of performing its intended function if required, and the |
| reporting requirements of 10CFR76.120(c) (2) were not met.                   |
|                                                                              |
| "Based on this evaluation, this event has been retracted."                   |
|                                                                              |
| The NRC resident inspector has been informed of this retraction. Notified    |
| R3DO (Madera).                                                               |
+------------------------------------------------------------------------------+

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   37009       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  INDIANA UNIVERSITY MEDICAL CENTER    |NOTIFICATION DATE: 05/17/2000|
|LICENSEE:  INDIANA UNIVERSITY MEDICAL CENTER    |NOTIFICATION TIME: 15:41[EDT]|
|    CITY:  INDIANAPOLIS             REGION:  3  |EVENT DATE:        04/18/2000|
|  COUNTY:                            STATE:  IN |EVENT TIME:             [CST]|
|LICENSE#:  13-02752-03           AGREEMENT:  N  |LAST UPDATE DATE:  05/19/2000|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |JOHN MADERA          R3      |
|                                                |BILL REAMER          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  MACK RICHARD                 |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|BAB2 20.2201(a)(1)(ii)   LOST/STOLEN LNM>10X    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| LOST ONE SEED CONTAINING 0.5 MILLICURIE OF IRIDIUM-192                       |
|                                                                              |
| After applicator removal and the seeds were inventoried, it was determined   |
| that one seed out of sixty four seeds was missing.  Each of the seeds        |
| contained 0.5 mCi of Ir-192.  A survey of the patient and room did not find  |
| the missing seed.  An investigation is ongoing to find the lost seed.  It is |
| possible that the right number of seeds were not implanted.  The applicator  |
| was removed with the seed intact, the seeds are contained in ribbons and the |
| ribbons are retained in the applicator, making it unlikely that the seed     |
| would have been lost during the treatment.                                   |
|                                                                              |
| The patient has been discharged and there is no problem with dose            |
| administered with one seed missing at the beginning.  Also, there is little  |
| safety implications to the public.                                           |
|                                                                              |
| * * * RETRACTION 1533 5/19/2000 FROM MARK RICHARD TAKEN BY BOB STRANSKY * *  |
| *                                                                            |
|                                                                              |
| The licensee reported that the seed was not missing. The initial count of    |
| seeds was erroneous. When the seeds were independently recounted, all seeds  |
| were present. Notified R3DO (Madera).                                        |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   37012       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: OYSTER CREEK             REGION:  1  |NOTIFICATION DATE: 05/19/2000|
|    UNIT:  [1] [] []                 STATE:  NJ |NOTIFICATION TIME: 12:23[EDT]|
|   RXTYPE: [1] GE-2                             |EVENT DATE:        05/19/2000|
+------------------------------------------------+EVENT TIME:        11:38[EDT]|
| NRC NOTIFIED BY:  JERRY FREEMAN                |LAST UPDATE DATE:  05/19/2000|
|  HQ OPS OFFICER:  BOB STRANSKY                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |DAVID LEW            R1      |
|10 CFR SECTION:                                 |                             |
|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          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| OFFSITE NOTIFICATION REGARDING SPURIOUS SIREN ACTIVATION                     |
|                                                                              |
| At 1138, the licensee was notified that prompt notification siren #4 in      |
| Barnegat Township had spuriously activated. The siren was deactivated at     |
| 1210, and a faulty circuit board was identified in the siren. The licensee   |
| contacted the Barnegat Township Police Department, the Ocean County          |
| Sheriff's office and the New Jersey State Police of the siren activation.    |
| The NRC resident inspector has been informed of this event by the licensee.  |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   37013       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: QUAD CITIES              REGION:  3  |NOTIFICATION DATE: 05/19/2000|
|    UNIT:  [1] [2] []                STATE:  IL |NOTIFICATION TIME: 14:34[EDT]|
|   RXTYPE: [1] GE-3,[2] GE-3                    |EVENT DATE:        05/19/2000|
+------------------------------------------------+EVENT TIME:        10:45[CDT]|
| NRC NOTIFIED BY:  DARYL CLARK                  |LAST UPDATE DATE:  05/19/2000|
|  HQ OPS OFFICER:  BOB STRANSKY                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |JOHN MADERA          R3      |
|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  |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| CONTROL ROOM EMERGENCY VENTILATION SYSTEM REFRIGERATION CONTROL UNIT         |
| INOPERABLE                                                                   |
|                                                                              |
| "On May 19, 2000, at 1045 hours, while performing the Control Room Emergency |
| Ventilation System monthly operability test. the refrigeration control unit  |
| failed to start. The cause of the failure is unknown, and troubleshooting is |
| in progress. Technical Specification 3.8.D, Action 1.b was entered, placing  |
| both units in a 30 day LCO.                                                  |
|                                                                              |
| "This is being reported per 10 CFR 50.72(b)(2)(iii)(D), loss of a safety     |
| function needed to mitigate the consequences of art accident."               |
|                                                                              |
| The NRC resident inspector will be informed of this event by the licensee.   |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Other Nuclear Material                           |Event Number:   37014       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  CROW BUTTE RESOURCES                 |NOTIFICATION DATE: 05/19/2000|
|LICENSEE:  CROW BUTTE RESOURCES                 |NOTIFICATION TIME: 16:55[EDT]|
|    CITY:  CRAWFORD                 REGION:  4  |EVENT DATE:        05/19/2000|
|  COUNTY:                            STATE:  NE |EVENT TIME:             [CDT]|
|LICENSE#:  SUA-1534              AGREEMENT:  Y  |LAST UPDATE DATE:  05/19/2000|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |BILL JONES           R4      |
|                                                |TOM ESSIG            NMSS    |
+------------------------------------------------+BILL REAMER          NMSS    |
| NRC NOTIFIED BY:  MIKE GRIFFIN                 |                             |
|  HQ OPS OFFICER:  BOB STRANSKY                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NLTR                     LICENSEE 24 HR REPORT  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| EVAPORATION POND LINER LEAKING                                               |
|                                                                              |
| The licensee reported that the inner liner of evaporation pond #4 appears to |
| be leaking. Increased conductivity has been detected in the underdrain       |
| system. The pond contains a brine solution with trace amounts of Ra-226 and  |
| uranium.                                                                     |
|                                                                              |
| The licensee believes that the leakage is through a poor weld on a six inch  |
| patch of the inner liner located just above the waterline. High winds in the |
| area have been pushing the water level above the patch. Samples taken from a |
| standpipe located near the patch indicate conductivity approaching that of   |
| the brine solution. The licensee is pumping down the pond for a liner        |
| inspection. No leakage into the soil has occurred.                           |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   37015       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PERRY                    REGION:  3  |NOTIFICATION DATE: 05/22/2000|
|    UNIT:  [1] [] []                 STATE:  OH |NOTIFICATION TIME: 04:48[EDT]|
|   RXTYPE: [1] GE-6                             |EVENT DATE:        05/22/2000|
+------------------------------------------------+EVENT TIME:        02:53[EDT]|
| NRC NOTIFIED BY:  BOB KIDDER                   |LAST UPDATE DATE:  05/22/2000|
|  HQ OPS OFFICER:  DICK JOLLIFFE                +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |JOHN MADERA          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          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| - ESF ACTUATION OF REACTOR WATER CLEANUP SYSTEM FOR UNKNOWN REASONS -        |
|                                                                              |
| At 0253 on 05/22/00, the plant experienced an isolation of the Reactor Water |
| Cleanup System on a Division 2 isolation signal when the Residual Heat       |
| Removal heat exchanger vent valve closed unexpectedly.  An apparent          |
| electrical power supply spike to the Division 2 isolation instrumentation    |
| occurred.  No testing or maintenance activities or electrical storms were    |
| occurring at the time of the isolation.  The licensee is investigating the   |
| cause of the isolation.                                                      |
|                                                                              |
| The licensee notified the NRC Resident Inspector.                            |
+------------------------------------------------------------------------------+