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Event Notification Report for October 6, 2000

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           10/05/2000 - 10/06/2000

                              ** EVENT NUMBERS **

37408  37411  37412  37413  

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|Fuel Cycle Facility                              |Event Number:   37408       |
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| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT      |NOTIFICATION DATE: 10/04/2000|
|   RXTYPE: URANIUM ENRICHMENT FACILITY          |NOTIFICATION TIME: 09:33[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER                   |EVENT DATE:        10/03/2000|
|           6903 ROCKLEDGE DRIVE                 |EVENT TIME:        15:28[CDT]|
|           BETHESDA, MD 20817    (301)564-3200  |LAST UPDATE DATE:  10/05/2000|
|    CITY:  PADUCAH                  REGION:  3  +-----------------------------+
|  COUNTY:  McCRACKEN                 STATE:  KY |PERSON          ORGANIZATION |
|LICENSE#:  GDP-1                 AGREEMENT:  Y  |JOHN MADERA          R3      |
|  DOCKET:  0707001                              |BRIAN SMITH          NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  M C PITTMAN                  |                             |
|  HQ OPS OFFICER:  JOHN MacKINNON               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|OCBA 76.120(c)(2)(i)     ACCID MT EQUIP FAILS   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| LOAD CELL CALIBRATION DATA FOR SOME FREEZER SUBLIMERS FOUND TO BE  NON -     |
| CONSERVATIVE.                                                                |
|                                                                              |
| At 1528 on 10/03/00, the Plant Shift Superintendent (PSS) was notified by    |
| engineering that load cell calibration data for some freezer sublimers was   |
| suspected to be in error.  The load cells are part of the High High Weight   |
| Trip System for the freezer sublimers which is required by Technical Safety  |
| Requirement (TSR) to be operable.  Data for many of the load cells           |
| calibrated on site shows the identified load cells do not meet the           |
| specifications credited in the existing setpoint calculations and the        |
| calibration procedures.  The problem appears to be consistent among the load |
| cells.  The load cells data indicates less weight than what was actually     |
| applied.  It has been determined that this deficiency may affect the ability |
| of the freezer sublimers' ability to actuate the High High Weight Trip       |
| System at the required Limited Control Setting (LCS).  This deficiency would |
| not affect the ability of the freezer sublimers to actuate the High High     |
| Weight Trip System below the Safety Limit (SL). There are 30 of the 10,000   |
| lb. Capacity and 4 of the 20,000 lb. capacity load cells that are affected.  |
| Investigation revealed that none of the four 20,000 lb. Load cells have been |
| installed.  The 20,000 lb. Load cells are being controlled to ensure they    |
| are not installed.  The affected in service freezer sublimers were declared  |
| inoperable by the PSS.  Engineering is reviewing work package data and the   |
| freezer sublimers that do not contain suspected load cells are being         |
| returned to service.  Resolution of this issue is being pursued by           |
| Operations, Maintenance, and Engineering.                                    |
|                                                                              |
| The equipment is required by TSR to be available and operable and should     |
| have been operating.  No redundant equipment is available and operable to    |
| perform the required safety function.                                        |
|                                                                              |
| The NRC Resident Inspector has been notified of this event.                  |
|                                                                              |
| * * * UPDATE 2140EDT ON 10/5/00 FROM ERIC WALKER TO S. SANDIN * * *          |
|                                                                              |
| "UPDATE: During the investigation of the initiating event, a more detailed   |
| review of load cell data, including vendor calibration data, was performed   |
| with additional load cells being called into question. The vendor data       |
| indicated levels which were in the non-conservative direction. The location  |
| of the additional load cells was determined and 8 additional freezer         |
| sublimers were declared inoperable (two of these 8 were already inoperable). |
| 6 freezer sublimers had been in operation with the suspect load cells        |
| installed, and the High High Weight Trip System was required, but would not  |
| have operated as required by the TSR. This deficiency would not have allowed |
| the freezer sublimer to exceed the TSR Safety Limit.  No redundant equipment |
| was available to perform the intended safety functions. This is reportable   |
| as required by 10 CFR 76.120(c)(2)."                                         |
|                                                                              |
| The NRC Resident Inspector and DOE Site Representative have been informed.   |
| Notified R3DO(Madera) and EO(Hodges).                                        |
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|Power Reactor                                    |Event Number:   37411       |
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| FACILITY: PALO VERDE               REGION:  4  |NOTIFICATION DATE: 10/05/2000|
|    UNIT:  [] [2] []                 STATE:  AZ |NOTIFICATION TIME: 15:48[EDT]|
|   RXTYPE: [1] CE,[2] CE,[3] CE                 |EVENT DATE:        10/04/2000|
+------------------------------------------------+EVENT TIME:        23:00[MST]|
| NRC NOTIFIED BY:  DAN MARKS                    |LAST UPDATE DATE:  10/05/2000|
|  HQ OPS OFFICER:  STEVE SANDIN                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |DAVE LOVELESS        R4      |
|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   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     N          N       0        Hot Shutdown     |0        Cold Shutdown    |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| EVIDENCE OF RCS PRESSURE BOUNDARY LEAKAGE DISCOVERED DURING INSERVICE        |
| INSPECTION OF PRESSURIZER HEATER NOZZLE SLEEVE                               |
|                                                                              |
| "The following event description is based on information currently           |
| available. If through subsequent reviews of this event, additional           |
| information is identified that is pertinent to this event or alters the      |
| information being provided at this time, a follow-up notification will be    |
| made via the ENS or under the reporting requirements of 10CFR50.73.          |
|                                                                              |
| "On October 4, 2000 at approximately 23:00 MST, Palo Verde Nuclear           |
| Generating Station (PVNGS) Unit 2 inservice inspection personnel discovered  |
| evidence of reactor coolant system (RCS) pressure boundary leakage. PVNGS    |
| Unit 2 was shutdown in Mode 4 conducting cooldown and depressurization into  |
| its ninth refueling outage at the time of discovery. Currently, PVNGS Unit 2 |
| is in Mode 5.  RCS temperature is approximately 170 degrees Fahrenheit and   |
| RCS pressure is approximately 350 psia.                                      |
|                                                                              |
| "The leakage was discovered at pressurizer heater nozzle sleeve A06 during   |
| inservice inspection (ISI) activities. The leakage was detected in the form  |
| of a small deposit of boron accumulation at the sleeve.  PVNGS has conducted |
| inspections of these heater sleeves during each refueling outage since the   |
| discovery that Inconel alloy 600 heater sleeves are susceptible to cracking. |
| No evidence of leakage was detected when inspected during the last outage    |
| approximately 18 months ago. The apparent cause is primary water stress      |
| corrosion cracking (PWSCC) from the inside diameter of the sleeve.           |
|                                                                              |
| "The timing of this ENS report was based on the determination at 10:30 MST   |
| on October 5, 2000 that the boron accumulation represented a serious         |
| degradation of a principal safety barrier.  PVNGS Unit 2 Technical           |
| Specification Limiting Condition for Operation (LCO) 3.4.14 (RCS Operational |
| Leakage) permits no reactor coolant system pressure boundary leakage. It was |
| therefore conservatively concluded that any evidence of pressure boundary    |
| leakage, regardless of magnitude, represents serious degradation of a        |
| principal safety barrier. Technical Specification Limiting Condition for     |
| Operation 3.4.14 is applicable in Modes 1, 2, 3 and 4.  Unit 2 entered Mode  |
| 5 at 01:50 MST on October 5, 2000, in compliance with LCO 3.4.14 ACTION B.2. |
| The sleeve will be repaired or replaced prior to re-entering Mode 4.         |
|                                                                              |
| "No ESF actuations occurred and none were required. No structures, systems   |
| or components were inoperable that contributed to this event, particularly   |
| the fuel cladding and the containment fission product barriers.  The event   |
| did not result in the release of radioactivity to the environment and did    |
| not adversely affect the safe operation of the plant or the health and       |
| safety of the public."                                                       |
|                                                                              |
| The licensee informed the NRC resident inspector.                            |
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|Hospital                                         |Event Number:   37412       |
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| REP ORG:  WILLS EYE HOSPITAL                   |NOTIFICATION DATE: 10/05/2000|
|LICENSEE:  WILLS EYE HOSPITAL                   |NOTIFICATION TIME: 16:48[EDT]|
|    CITY:  PHILADELPHIA             REGION:  1  |EVENT DATE:        10/04/2000|
|  COUNTY:                            STATE:  PA |EVENT TIME:             [EDT]|
|LICENSE#:  37-00783-05           AGREEMENT:  N  |LAST UPDATE DATE:  10/05/2000|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |JAMES LINVILLE       R1      |
|                                                |M. WAYNE HODGES      NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  BEVERLY DOWNES               |                             |
|  HQ OPS OFFICER:  STEVE SANDIN                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| POTENTIAL MEDICAL MISADMINISTRATION INVOLVING MISTARGETED GAMMA-KNIFE        |
| TREATMENT                                                                    |
|                                                                              |
| A PATIENT UNDERGOING GAMMA-KNIFE TREATMENT FOR AN ACOUSTIC TUMOR, RECEIVED   |
| APPROXIMATELY 4 GRAY TO TISSUE 8 MILLIMETERS ABOVE THE TARGET DUE TO AN      |
| ERROR INPUTTING ONE OF THREE COORDINATES DURING THE FIRST OF THREE SHOTS ON  |
| 10/4/00.  THE ERROR WAS RECOGNIZED WHILE SETTING UP FOR THE REMAINING TWO    |
| SHOTS.  THE PHYSICIAN WAS INFORMED AND THE TREATMENT PLAN MODIFIED SO THAT   |
| THE TARGET WOULD RECEIVE THE CORRECT DOSE.  THE LICENSEE PLANS ON CONTACTING |
| NRC REGION I TO DISCUSS REPORTABILITY OF THIS EVENT.                         |
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|Power Reactor                                    |Event Number:   37413       |
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| FACILITY: WATERFORD                REGION:  4  |NOTIFICATION DATE: 10/05/2000|
|    UNIT:  [3] [] []                 STATE:  LA |NOTIFICATION TIME: 16:52[EDT]|
|   RXTYPE: [3] CE                               |EVENT DATE:        10/05/2000|
+------------------------------------------------+EVENT TIME:        15:00[CDT]|
| NRC NOTIFIED BY:  OSCAR PIPKINS                |LAST UPDATE DATE:  10/05/2000|
|  HQ OPS OFFICER:  STEVE SANDIN                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |DAVE LOVELESS        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   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|3     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
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                                   EVENT TEXT                                   
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| UNIT OUTSIDE DESIGN BASIS OF FIRE PROTECTION PROGRAM                         |
|                                                                              |
| "During evaluations associated with a condition (CR-WF3-2000-1088),          |
| previously reported in a one hour call on 9/18/00 (Event #37341 ), it was    |
| determined today that a similar condition exists in Fire Area 39. The        |
| condition found today, assuming  a hypothetical Appendix R fire in the area, |
| could conceivably have resulted in the loss  of all three charging pumps.    |
| The Waterford 3 FSAR (Section 9.5.1) states that (for Fire Area 39) 'in the  |
| event that an unmitigated fire is in the charging pump area, either Charging |
| Pump A or Charging Pump B and AB will be available for reactivity control    |
| and reactor coolant makeup...'.  This availability is based on an exemption  |
| granted per SSER 8 and LP&L exemption request letter W3P84-0709.  The        |
| exemption for part height firewalls around charging pump 'A' cable trays and |
| conduit being provided with fire wrap. It was determined today that the      |
| conduits and cable trays for Charging Pump A and AHI8A (which provides       |
| cooling to the charging pump 'A' area) have not been completely wrapped.     |
| Thus an appendix R fire in fire area RAB39 has the potential to disable all  |
| three charging pumps. The charging pumps are required for cold shutdown      |
| actions and as such per Appendix R, repairs are allowed. However in order to |
| take credit for repair actions, specific procedures and staged materials for |
| such repairs are required. These provisions were not in place. This          |
| condition is being reported as being outside the design basis of the fire    |
| protection program. The cables and conduits were immediately identified as   |
| impaired and compensatory actions were established (hourly fire watches).    |
| The condition has been entered into the plant corrective action program      |
| (CR-WF3-2000-1169)."                                                         |
|                                                                              |
| The licensee informed the NRC resident inspector.                            |
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