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Event Notification Report for September 14, 2000

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           09/13/2000 - 09/14/2000

                              ** EVENT NUMBERS **

37312  37313  37314  37315  37316  37317  37318  

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   37312       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: MILLSTONE                REGION:  1  |NOTIFICATION DATE: 09/13/2000|
|    UNIT:  [] [] [3]                 STATE:  CT |NOTIFICATION TIME: 07:35[EDT]|
|   RXTYPE: [1] GE-3,[2] CE,[3] W-4-LP           |EVENT DATE:        09/12/2000|
+------------------------------------------------+EVENT TIME:        07:40[EDT]|
| NRC NOTIFIED BY:  WILLIAM HOFFNER              |LAST UPDATE DATE:  09/13/2000|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |JAMES TRAPP          R1      |
|10 CFR SECTION:                                 |                             |
|HFIT 26.73               FITNESS FOR DUTY       |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|                                                   |                          |
|3     N          Y       100      Power Operation  |100      Power Operation  |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| 24 HOUR FITNESS FOR DUTY REPORT                                              |
|                                                                              |
| A licensed operator was administered a for-cause breathalyzer test after     |
| observation by operating staff that the individual's breath smelled of       |
| alcohol.  The operator was oncoming and was not allowed to take the watch.   |
| Operations management personnel directed that the individual be taken home   |
| pending management review of the situation. Corrective action for            |
| consideration of resumption of licensed duties will follow management's      |
| review.                                                                      |
|                                                                              |
| The licensee notified the NRC Resident Inspector and will notify the State   |
| of Connecticut.                                                              |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   37313       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: NINE MILE POINT          REGION:  1  |NOTIFICATION DATE: 09/13/2000|
|    UNIT:  [] [2] []                 STATE:  NY |NOTIFICATION TIME: 07:58[EDT]|
|   RXTYPE: [1] GE-2,[2] GE-5                    |EVENT DATE:        09/13/2000|
+------------------------------------------------+EVENT TIME:        04:33[EDT]|
| NRC NOTIFIED BY:  MATT WALDECKER               |LAST UPDATE DATE:  09/13/2000|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |JAMES TRAPP          R1      |
|10 CFR SECTION:                                 |                             |
|AESF 50.72(b)(2)(ii)     ESF ACTUATION          |                             |
|AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION    |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     N          N       0        Cold Shutdown    |0        Cold Shutdown    |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AUTOMATIC START OF THE HIGH PRESSURE CORE SPRAY PUMP                         |
|                                                                              |
| The licensee reported that the high pressure core spray (HPCS) pump          |
| automatically started when the pump control switch was taken out of the      |
| "pull-to-lock" position.  The HPCS system was out of service for maintenance |
| at the time of the event and had been declared inoperable on 09/12/00 at     |
| 0520 EDT.  The HPCS spray injection valve did not open, as it was            |
| deenergized closed.  The divisional diesel generator did not start as it was |
| configured in the maintenance mode.                                          |
|                                                                              |
| There was no impact on the plant. The plant is in cold shutdown with the     |
| mode switch in the refuel position.  The cause of the actuation is unknown   |
| and an investigation is in progress.                                         |
|                                                                              |
| The licensee intends to notify the NRC Resident Inspector.                   |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   37314       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: LASALLE                  REGION:  3  |NOTIFICATION DATE: 09/13/2000|
|    UNIT:  [] [2] []                 STATE:  IL |NOTIFICATION TIME: 13:15[EDT]|
|   RXTYPE: [1] GE-5,[2] GE-5                    |EVENT DATE:        09/13/2000|
+------------------------------------------------+EVENT TIME:        09:54[CDT]|
| NRC NOTIFIED BY:  OKOPNY                       |LAST UPDATE DATE:  09/13/2000|
|  HQ OPS OFFICER:  CHAUNCEY GOULD               +-----------------------------+
+------------------------------------------------+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          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| THE "2A" DIESEL GENERATOR WAS INADVERTENTLY STARTED BY THE UNIT OPERATOR     |
|                                                                              |
| Unit 2 was operating at 100% power.  A Division 2 Residual Heat Removal      |
| (RHR) Surveillance was in progress, which required the "2A" Diesel Generator |
| Cooling Water Pump to be started. The Unit Operator inadvertently placed the |
| Control Switch for the "2A" Diesel Generator to START.  The Unit Operator    |
| recognized the error and the Diesel Generator Control Switch was immediately |
| placed in STOP.  The "2A" Diesel Generator and                               |
| Diesel Generator Cooling Water Pump switches are side by side on the panel.  |
| The Diesel Generator reached at Least 150 RPM as indicated by the Auto Start |
| of the "2A" Diesel Generator Cooling Water Pump.  The Diesel Generator was   |
| returned to a Standby Operable condition.                                    |
|                                                                              |
| The NRC Resident Inspector was notified.                                     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   37315       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: WNP-2                    REGION:  4  |NOTIFICATION DATE: 09/13/2000|
|    UNIT:  [2] [] []                 STATE:  WA |NOTIFICATION TIME: 14:38[EDT]|
|   RXTYPE: [2] GE-5                             |EVENT DATE:        09/13/2000|
+------------------------------------------------+EVENT TIME:        11:19[PDT]|
| NRC NOTIFIED BY:  ARBUCKLE                     |LAST UPDATE DATE:  09/13/2000|
|  HQ OPS OFFICER:  CHAUNCEY GOULD               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |GARY SANBORN         R4      |
|10 CFR SECTION:                                 |                             |
|AOUT 50.72(b)(1)(ii)(B)  OUTSIDE DESIGN BASIS   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| PLANT OUTSIDE DESIGN BASIS FOR CONTROL ROOM EMERGENCY FILTRATION SYSTEM      |
| UNFILTERED INLEAKAGE BASED UPON TRACER GAS TESTING - IMPACT ON CONTROL ROOM  |
| DOSE CONSIDERATIONS                                                          |
|                                                                              |
| "During September 8 through 11, 2000, a series of special tests, using a     |
| tracer gas decay methodology, were performed to determine the total          |
| inleakage into the control room and the associated impact on control room    |
| dose.  These tests were performed in support of a proposed Technical         |
| Specification amendment request that is in the process of being developed    |
| for removal of main steam leakage control system test requirements and       |
| resolution of a long-standing issue pertaining to secondary                  |
| containment/standby gas treatment system performance, using alternative      |
| source term methodology.  The testing was also performed in response to      |
| NRC-industry initiative efforts to resolve the generic issue of the validity |
| of control room unfiltered air infiltration rate assumed by licensees in     |
| control room habitability assessments.                                       |
|                                                                              |
| "On September 13, 2000, test results were evaluated and a preliminary        |
| assessment shows the highest train measured unfiltered inleakage for the     |
| control room emergency filtration system, as determined by the tracer gas    |
| testing, to be 83  37 cfm.  This is in excess of the current licensing and  |
| design basis limit of 10.55 cfm.  The impact of this unfiltered inleakage    |
| increase on control room dose was evaluated and it was determined that the   |
| design basis thyroid dose of 30 rem to the control room operators would be   |
| exceeded during post-accident conditions.                                    |
|                                                                              |
| "A Follow-Up Assessment of Operability (similar to a Justification for       |
| Continued Operation) was prepared to allow continued plant operation in this |
| condition.  The operability determination, which was based upon an           |
| evaluation of control room dose for several accident scenarios, concluded    |
| that the as-found inleakage did not render the control room emergency        |
| filtration system inoperable (based upon 10CFR50, Appendix A, GDC 19). In    |
| addition, a follow-up interim compensatory measure to reduce the calculated  |
| control room thyroid dose below the 30 rem limit includes administration of  |
| potassium iodide in accordance with requirements contained in abnormal       |
| operating procedures.  Final resolution of this issue will be addressed by   |
| implementation of alternative source term methodology at WNP-2 and as part   |
| of the proposed Technical Specification amendment request.   A feasibility   |
| study, using alternative source term methodology, has shown that inleakage   |
| rates well in excess of 83  37 cfm (approximately 300 cfm) would result in  |
| control room doses below the regulatory limit. This is a design basis        |
| analysis issue and no plant hardware changes are required in the resolution  |
| of the problem.  We are continuing to follow the NRC-industry initiative     |
| efforts to resolve generic issues related to control room habitability."     |
|                                                                              |
| The NRC Resident Inspector was notified.                                     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   37316       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  UNIVERSITY OF VIRGINIA HOSPITAL      |NOTIFICATION DATE: 09/13/2000|
|LICENSEE:  UNIVERSITY OF VIRGINIA HOSPITAL      |NOTIFICATION TIME: 16:39[EDT]|
|    CITY:  CHARLOTTESVILLE          REGION:  2  |EVENT DATE:        09/07/2000|
|  COUNTY:                            STATE:  VA |EVENT TIME:             [EDT]|
|LICENSE#:                        AGREEMENT:  N  |LAST UPDATE DATE:  09/13/2000|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |STEPHEN CAHILL       R2      |
|                                                |LARRY CAMPER         NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  PICCOLO                      |                             |
|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| THE UNIVERSITY OF VIRGINIA HOSPITAL REPORTED A MEDICAL MISADMINISTRATION     |
| DURING BRACHYTHERAPY.                                                        |
|                                                                              |
| A patient being treated for cervical cancer was given a higher dose (8 gray) |
| instead of the prescribed dose (5 gray) due to human error resulting in the  |
| wrong dwell times being used.  It appears there will be no adverse affects   |
| to the patient.  The patient and the referring physician will be notified.   |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   37317       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: VERMONT YANKEE           REGION:  1  |NOTIFICATION DATE: 09/13/2000|
|    UNIT:  [1] [] []                 STATE:  VT |NOTIFICATION TIME: 17:51[EDT]|
|   RXTYPE: [1] GE-4                             |EVENT DATE:        09/13/2000|
+------------------------------------------------+EVENT TIME:        16:36[EDT]|
| NRC NOTIFIED BY:  MAY                          |LAST UPDATE DATE:  09/13/2000|
|  HQ OPS OFFICER:  CHAUNCEY GOULD               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |JAMES TRAPP          R1      |
|10 CFR SECTION:                                 |                             |
|ARPS 50.72(b)(2)(ii)     RPS ACTUATION          |                             |
|AESF 50.72(b)(2)(ii)     ESF ACTUATION          |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     M/R        Y       100      Power Operation  |0        Hot Shutdown     |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| MANUAL REACTOR SCRAM FROM 77% POWER FOLLOWING LOSS OF CONDENSER VACUUM       |
|                                                                              |
| This occurred when the plant lost condenser vacuum after the steam jet air   |
| ejector valves closed.  This valve closure was the result of a blown valve   |
| indication light bulb being changed.    The reactor was manually scrammed    |
| from 77% power when the vacuum reached 6.5" Hg and decreasing.  After the    |
| reactor scram the reactor vessel water level dipped below 127"(as low as     |
| 121") initiating groups 2, 3, 4 and 5 isolations and start of the standby    |
| gas treatment system.   All rods fully inserted, no ECCS injection occurred  |
| and no relief valves lifted.                                                 |
|                                                                              |
| The NRC Resident Inspector will be informed                                  |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   37318       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  ARIZONA RADIATION REGULATORY AGENCY  |NOTIFICATION DATE: 09/13/2000|
|LICENSEE:  UNIVERSITY OF ARIZONA                |NOTIFICATION TIME: 18:40[EDT]|
|    CITY:  TUCSON                   REGION:  4  |EVENT DATE:        07/22/2000|
|  COUNTY:                            STATE:  AZ |EVENT TIME:             [MST]|
|LICENSE#:  10-024                AGREEMENT:  Y  |LAST UPDATE DATE:  09/13/2000|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |GARY SANBORN         R4      |
|                                                |LARRY CAMPER         NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  GODWIN (VIA FAX)             |                             |
|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| TRITIUM RELEASE FROM THE UNIVERSITY OF ARIZONA                               |
|                                                                              |
| At approximately 10:30 AM, September 6, 2000, the Agency was advised by the  |
| Radiation Safety Officer of the University that a laboratory had reported    |
| approximately 100 microcuries of tritium had been picked up by the custodial |
| staff. The University Radiation Control office commenced an investigation of |
| the problem and on September 7, 2000 reported that approximately 31          |
| millicuries of tritium may have been lost out of a fume hood stack. This     |
| release was confirmed on September 11, 2000. The release occurred around     |
| July 22 - 30, 2000.                                                          |
|                                                                              |
| The University and the Agency continue to investigate this event.            |
+------------------------------------------------------------------------------+