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
+------------------------------------------------------------------------------+
|Fuel Cycle Facility |Event Number: 37408 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| 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 | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| 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). |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 37411 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| 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 |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| 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. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Hospital |Event Number: 37412 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| 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 | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| 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. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 37413 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| 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 |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| 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. |
+------------------------------------------------------------------------------+
Page Last Reviewed/Updated Wednesday, March 24, 2021
Page Last Reviewed/Updated Wednesday, March 24, 2021