The U.S. Nuclear Regulatory Commission is in the process of rescinding or revising guidance and policies posted on this webpage in accordance with Executive Order 14151 Ending Radical and Wasteful Government DEI Programs and Preferencing, and Executive Order 14168 Defending Women From Gender Ideology Extremism and Restoring Biological Truth to the Federal Government. In the interim, any previously issued diversity, equity, inclusion, or gender-related guidance on this webpage should be considered rescinded that is inconsistent with these Executive Orders.

Event Notification Report for January 22, 2001

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           01/19/2001 - 01/22/2001

                              ** EVENT NUMBERS **

37671  37672  37673  

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   37671       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: NORTH ANNA               REGION:  2  |NOTIFICATION DATE: 01/19/2001|
|    UNIT:  [] [2] []                 STATE:  VA |NOTIFICATION TIME: 11:58[EST]|
|   RXTYPE: [1] W-3-LP,[2] W-3-LP                |EVENT DATE:        01/19/2001|
+------------------------------------------------+EVENT TIME:        11:45[EST]|
| NRC NOTIFIED BY:  ALEX BLANCHARD               |LAST UPDATE DATE:  01/19/2001|
|  HQ OPS OFFICER:  STEVE SANDIN                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          UNU                   |LOUIS REYES          R2      |
|10 CFR SECTION:                                 |BOB DENNIG           EO      |
|                                                |JOSEPH GIITTER       IRO     |
|                                                |SULLIVAN             FEMA    |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     N          Y       99       Power Operation  |99       Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| UNIT 2 DECLARED AN UNUSUAL EVENT BASED ON IDENTIFIED REACTOR COOLANT SYSTEM  |
| (RCA) LEAKAGE > 10 GPM                                                       |
|                                                                              |
| At 1145EST on 1/19/01, Unit 2 declared an Unusual Event based on RCS leakage |
| of 10.0015 gpm.  The location of the leakage is the "C" loop unit bypass     |
| valve 2-RC-MOV-2587.  The leakage is through the packing leakoff line to the |
| primary drain tank.  There are minor elevated rad levels in the stripper     |
| cubicle where the drain tank is located.  HP personnel are monitoring this   |
| area.  The licensee expects to have Unit 2 offline by 1600EST today.  Tech   |
| Spec 3.4.6.2 requires that identified RCS leakage be less than 10 gpm or     |
| that the unit be placed in cold shutdown by 0300EST on 1/21/01.  The         |
| licensee anticipates completing repairs while in mode 3 at which time they   |
| will exit the Unusual Event.                                                 |
|                                                                              |
| The licensee informed both state/local agencies and the NRC resident         |
| inspector.                                                                   |
|                                                                              |
| * * * UPDATE AT 2314 on 1/19/01, BY BROWN, RECEIVED BY WEAVER * * *          |
|                                                                              |
| 2-RC-MOV-2587 was opened electrically and manually backseated.  This reduced |
| RCS leakage below 10 gpm and the unusual event was terminated at 2323EST.    |
| The plant is stable in mode 3 and the licensee is developing a plan to       |
| repair the valve.  Repairs may be done with the plant in mode 3.  The        |
| licensee will notify the NRC resident inspector.                             |
|                                                                              |
| The operations center notified the RDO (Rodgers); EO (Leeds); FEMA           |
| (Steindurf)                                                                  |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   37672       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  FROEDTERT MEMORIAL LUTHERAN HOSP     |NOTIFICATION DATE: 01/19/2001|
|LICENSEE:  FROEDTERT MEMORIAL LUTHERAN HOSP     |NOTIFICATION TIME: 16:59[EST]|
|    CITY:  MILWAUKEE                REGION:  3  |EVENT DATE:        01/17/2001|
|  COUNTY:                            STATE:  WI |EVENT TIME:        18:30[CST]|
|LICENSE#:  48-04193              AGREEMENT:  N  |LAST UPDATE DATE:  01/19/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |ROGER LANKSBURY      R3      |
|                                                |ERIC LEEDS           NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  MARCUM MARTZ                 |                             |
|  HQ OPS OFFICER:  DOUG WEAVER                  |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          N/A                   |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| POTENTIAL MEDICAL MISADMINISTRATION                                          |
|                                                                              |
| A patient being treated with a Leksell gamma system model 23004 type B       |
| received a treatment to the wrong site.  The intended dose or dose delivered |
| were not available.  The dose was delivered to the wrong location because    |
| the head frame had been installed in the wrong position.  The correct site   |
| was subsequently treated.  The hospital is in the process of informing the   |
| patient and the referring physician.  The attending physician did not        |
| believe the mistake would pose a problem to the patient.                     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   37673       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: COOPER                   REGION:  4  |NOTIFICATION DATE: 01/21/2001|
|    UNIT:  [1] [] []                 STATE:  NE |NOTIFICATION TIME: 18:29[EST]|
|   RXTYPE: [1] GE-4                             |EVENT DATE:        01/21/2001|
+------------------------------------------------+EVENT TIME:        15:28[CST]|
| NRC NOTIFIED BY:  WILLIAM GREEN                |LAST UPDATE DATE:  01/21/2001|
|  HQ OPS OFFICER:  DOUG WEAVER                  +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          N/A                   |KRISS KENNEDY        R4      |
|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                                   
+------------------------------------------------------------------------------+
| CONTROL ROOM EMERGENCY FILTRATION SYSTEM INOPERABLE                          |
|                                                                              |
| At 1528 the Control Room Emergency Filtration System (CREFS) was declared    |
| inoperable when fire door H305 was noted to hang open instead of fully       |
| closing when personnel passed through the door.   BLDG-DOOR-H305 is a        |
| Control Room Envelope Door.  CREFS is a single train system.   When CREFS    |
| was determined to be inoperable Technical Specification LCO 3.7.4 condition  |
| A was entered.  This LCO requires the restoration of CREFS to OPERABLE       |
| status within 7 days or be in MODE 3 within 12 hours and MODE 4 within 36    |
| hours.                                                                       |
|                                                                              |
| Following the transfer of CREFS to DIV 1 power at 13:30, it was subsequently |
| noted that the control room blast doors seemed harder to open than normal.   |
| The ventilation lineup for the Control Building was verified to be correct.  |
| During this verification it was determined that BLDG-DOOR-H305 would not     |
| operate properly and the door and CREFS were declared inoperable.            |
|                                                                              |
| Ventilation flow through other Control Room Boundary Doors appears [to]be    |
| abnormal for the present ventilation lineup.  A Fire Watch has been          |
| stationed at BLDG-DOOR-H305.  A Problem Identification Report has been       |
| initiated to identify that BLDG-DOOR-H305 will not close by itself from the  |
| fully open position. The ventilation lineup has not been changed since the   |
| discovery of this condition for evidence preservation.  The Ventilation      |
| System Engineer is responding to the Site to assist with troubleshooting of  |
| the ventilation system.                                                      |
|                                                                              |
| The licensee notified the NRC resident inspector.                            |
+------------------------------------------------------------------------------+


Page Last Reviewed/Updated Wednesday, March 24, 2021