Event Notification Report for May 18, 2001
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
05/17/2001 - 05/18/2001
** EVENT NUMBERS **
38000 38001 38002 38003 38004 38005 38006
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|Power Reactor |Event Number: 38000 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SURRY REGION: 2 |NOTIFICATION DATE: 05/17/2001|
| UNIT: [1] [2] [] STATE: VA |NOTIFICATION TIME: 01:38[EDT]|
| RXTYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 05/16/2001|
+------------------------------------------------+EVENT TIME: 22:59[EDT]|
| NRC NOTIFIED BY: TIM WESPHALL |LAST UPDATE DATE: 05/17/2001|
| HQ OPS OFFICER: DOUG WEAVER +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |CHARLES R. OGLE R2 |
|10 CFR SECTION: | |
|*COM 50.72(b)(3)(xiii) LOSS COMM/ASMT/RESPONSE| |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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 N 0 Cold Shutdown |0 Cold Shutdown |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| SAFETY PARAMETER DISPLAY SYSTEM (SPDS) INOPERABLE |
| |
| At 2259 hours on 5/16/01, the SPDS portion of the Emergency Response |
| Facilities Computer System (ERFCS) was noted to be inoperable because the |
| system time was not updating. The Technical Support Center (TSC) keyboard |
| is not available nor is the Control Room Unit keyboard available for either |
| Unit. Both Local Emergency Operations Facility (LEOF) and Central |
| Emergency Operations Facility (CEOF) SPDS data links were unavailable. |
| Initial indication of loss of ERFCS function was computer linkage failure at |
| 2159 hours on 5/16/01. The ERFCS was rebooted satisfactorily with a new |
| power supply. All portions of the system were noted to be functioning |
| correctly at 0120 hours on 5/17/01. |
| |
| The licensee notified the NRC resident inspector. |
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+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 38001 |
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| FACILITY: WATERFORD REGION: 4 |NOTIFICATION DATE: 05/17/2001|
| UNIT: [3] [] [] STATE: LA |NOTIFICATION TIME: 07:21[EDT]|
| RXTYPE: [3] CE |EVENT DATE: 05/17/2001|
+------------------------------------------------+EVENT TIME: 05:47[CDT]|
| NRC NOTIFIED BY: HO NGUYEN |LAST UPDATE DATE: 05/17/2001|
| HQ OPS OFFICER: DOUG WEAVER +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: UNU |BLAIR SPITZBERG R4 |
|10 CFR SECTION: |ROBERT SKELTON NRR |
|DDDD 73.71 UNSPECIFIED PARAGRAPH |BOB PIERSON NMSS |
| |GAIL GOOD R4 |
| |BAGWELL FEMA |
| |ZWOLINSKI NRR |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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
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| UNUSUAL EVENT DECLARED - UNAUTHORIZED ACCESS INTO THE PROTECTED AREA. |
| |
| Immediate compensatory actions taken upon discovery. The licensee contacted |
| the St. Charles Parish Sheriff's Office. The NRC resident inspector was |
| notified. The unusual event was declared at 0547 and terminated at 0556. |
+------------------------------------------------------------------------------+
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|General Information or Other |Event Number: 38002 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: MD DEPT OF THE ENVIRONMENT |NOTIFICATION DATE: 05/17/2001|
|LICENSEE: FRANKLIN SQUARE HOSPITAL |NOTIFICATION TIME: 08:19[EDT]|
| CITY: BALTIMORE REGION: 1 |EVENT DATE: 05/10/2001|
| COUNTY: STATE: MD |EVENT TIME: 14:30[EDT]|
|LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 05/17/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |JOHN ROGGE R1 |
| |JOHN HICKEY NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: ALAN JACOBSON | |
| HQ OPS OFFICER: DOUG WEAVER | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| MEDICAL MISADMINISTRATION |
| |
| On Tuesday, May 8, at 4:30 PM, at Franklin Square Hospital a patient was |
| given a vaginal implant consisting of 10 ribbons each with 8 Ir-192 seeds. |
| The activity per seed was about .495 mgRaEq, for a total implant of 39.6 |
| mgRaEq (71.0 mCi). The intent was to deliver 60 cGy/hr to the periphery of |
| the implanted treatment volume (4 cm diameter 8 cm long, for V= 100 cm3) for |
| 50 hours for a total implant dose of 3000 cGy. This dose was to add to the |
| already delivered external beam dose to that volume of 4500 cGy, for a total |
| of 7500 cGy. |
| |
| The patient was checked by the physician on Wednesday at 2:30 PM (after 22 |
| hours) and all the needles were in place. The next check by the physician |
| was at the time of removal, at 6:30 PM on Thursday. He found one needle |
| with its ribbon of 8 seeds lying loosely on the folds of the bed sheet by |
| the patient's hip, and 3 additional needles had also backed out by about 3 |
| cm from their implanted positions. The patient was judged to be unable to |
| describe the circumstances of the displacements. |
| |
| Computer reconstruction showed that the reduction in the total tumor dose |
| from the ribbon displacements was less than 10% and affected less than 15% |
| of the implanted volume. And the corresponding increase in the position of |
| the 50% isodose line at the other end of the implant was only about .5 cm. |
| The physician has stated that he believes the patient had adequate |
| brachytherapy treatment, and that no further interventions would be |
| necessary. As for the dose to the patient from the dislodged ribbon, the |
| physician has stated that there should not be significant dose to any |
| viscera but to the skin and soft tissues. He does not think it has clinical |
| significance for this patient. |
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|Power Reactor |Event Number: 38003 |
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| FACILITY: INDIAN POINT REGION: 1 |NOTIFICATION DATE: 05/17/2001|
| UNIT: [] [3] [] STATE: NY |NOTIFICATION TIME: 11:43[EDT]|
| RXTYPE: [2] W-4-LP,[3] W-4-LP |EVENT DATE: 04/16/2001|
+------------------------------------------------+EVENT TIME: 14:15[EDT]|
| NRC NOTIFIED BY: BRIAN ROKES |LAST UPDATE DATE: 05/17/2001|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |JOHN ROGGE 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 N 0 Refueling |0 Cold Shutdown |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| FOR CAUSE TESTING |
| |
| A non-licensed employee was determined to be under the influence of illegal |
| drugs during for cause testing. The employee's unescorted access to the |
| plant has been terminated. |
| |
| Ask the HOO of further information |
| |
| The NRC Resident Inspector will be notified of this event by the licensee. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 38004 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: BRUNSWICK REGION: 2 |NOTIFICATION DATE: 05/17/2001|
| UNIT: [1] [] [] STATE: NC |NOTIFICATION TIME: 13:47[EDT]|
| RXTYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 03/22/2001|
+------------------------------------------------+EVENT TIME: 07:07[EDT]|
| NRC NOTIFIED BY: CHARLES ELBERFELD |LAST UPDATE DATE: 05/17/2001|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |CHARLES R. OGLE R2 |
|10 CFR SECTION: | |
|*INV 50.73(a)(1) INVALID SPECIF SYSTEM A| |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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
+------------------------------------------------------------------------------+
| This report is being made in accordance with 50.73a)(1), which states, in |
| part, "In the case of an invalid actuation reported under �50.73 (a)(2)(iv), |
| other than actuation of the reactor protection system (RPS) when the reactor |
| is critical, the licensee may, at its option, provide a telephone |
| notification to the NRC Operations Center within 60 days after discovery of |
| the event instead of submitting a written LER." These invalid actuations are |
| being reported under �50.73 (a)(2)(iv)(A). |
| |
| On March 22, 2001, at 0707 hours, during the performance of Maintenance |
| Surveillance Test (1MST-DG13R), "DG-3 Loading Test," steps performed out of |
| sequence resulted in invalid actuation of Primary Containment Isolation |
| system (PCIS) Group 6 valves and Secondary Containment Isolation dampers due |
| to interruption of electrical power to the Emergency Bus E3. During a "dry |
| run" of the test, instrumentation and controls technicians inserted the |
| actual test signals before the Unit 1 "CAC Purge Vent Isol Ovrd Switch," |
| 1-CAC-CS-5519, was placed in the "OVERRIDE" position, as required by the |
| procedure. The purpose of placing the switch in the "OVERRIDE" position is |
| to prevent a P015 Group 6 isolation, Secondary Containment isolation, and |
| Standby Gas Treatment (SBGT) system actuations when Emergency Bus E3 is |
| de-energized as part of the test. The actuations of PCIS Group 6 valves and |
| Secondary Containment Isolation dampers were complete and the affected |
| equipment responded as designed to the invalid signal (i.e., the valves and |
| dampers that were open, at the time of the event, closed). At 0715 hours, |
| Emergency Bus E3 was energized by its normal power source. By 0726 hours, |
| the PCIS Group 6 isolation logic was reset, the Reactor Building Ventilation |
| system was returned to service (i.e., the Secondary Containment isolation |
| was reset), and both SBGT trains A and B were placed in standby. |
| |
| PCIS Group 6 valves include isolation valves from the Containment Atmosphere |
| Control, Containment Atmosphere Dilution, Containment Atmosphere Monitoring, |
| and Post Accident Sampling systems. Discussion of the causes and corrective |
| actions associated with this event are documented in the corrective action |
| program in AR 29889. |
| |
| The NRC Resident Inspector was notified of this 60-Day report by the |
| licensee. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 38005 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: INDIAN POINT REGION: 1 |NOTIFICATION DATE: 05/17/2001|
| UNIT: [] [3] [] STATE: NY |NOTIFICATION TIME: 14:46[EDT]|
| RXTYPE: [2] W-4-LP,[3] W-4-LP |EVENT DATE: 05/08/2001|
+------------------------------------------------+EVENT TIME: 02:10[EDT]|
| NRC NOTIFIED BY: FIRTH |LAST UPDATE DATE: 05/17/2001|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |JOHN ROGGE R1 |
|10 CFR SECTION: |JOHN TAPPERT NRR |
|*INB 50.72(b)(3)(v)(B) POT RHR INOP | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|3 N N 0 Refueling |0 Refueling |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| INTERRUPTION OF THE COOLING FUNCTION PERFORMED BY THE PRIMARY LOOP OF THE |
| BACKUP SPENT FUEL POOL COOLING SYSTEM OCCURRED FOR 20 MINS. |
| |
| "On May 8, 2001 P3 was in RO-11, and the reactor was de-fueled with all |
| discharged fuel in the Spent Fuel Pool (SFP). SFP cooling was provided by |
| the Backup Spent Fuel Pool Cooling system (B/U SFPCS) because the normal |
| Spent Fuel Cooling system was out of service for maintenance. At |
| approximately 0210 hours on May 8, 2001, the water supply to the secondary |
| loop of the B/U SFPCS was interrupted due to a loss of power involving P3's |
| demineralized water source. This water interruption subsequently caused a |
| low differential pressure trip of the primary loop pump of the B/U SFPCS. |
| Operator response re-gained the dernineralized water supply to the secondary |
| loop. SFP cooling from this system was restored. The cooling function |
| performed by the primary loop of the B/U SFPCS was interrupted for |
| approximately 20 minutes total. A Root Cause Team investigation was |
| commenced the morning of May 8, 2001 to review this event. This event is |
| being considered potentially reportable under 10 CFR 50.72 (b)(3)(v)(B). |
| Investigation into the cause and reportability of this event is ongoing and |
| this ENS report is being made at this time due to the continuing |
| investigation of reportability." |
| |
| Temperature increased from 151 to 155�F. |
| |
| The NRC Resident Inspector was notified along with state and local agencies. |
| Their US Congressman was also notified. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 38006 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: OCONEE REGION: 2 |NOTIFICATION DATE: 05/17/2001|
| UNIT: [1] [2] [3] STATE: SC |NOTIFICATION TIME: 22:14[EDT]|
| RXTYPE: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-L|EVENT DATE: 05/17/2001|
+------------------------------------------------+EVENT TIME: 20:40[EDT]|
| NRC NOTIFIED BY: BALDWIN |LAST UPDATE DATE: 05/17/2001|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |CHARLES R. OGLE R2 |
|10 CFR SECTION: |RICHARD ROSANO IAT |
|*PRE 50.72(b)(2)(xi) OFFSITE NOTIFICATION |CHUCK CASTO R2 |
| |ROBERTA WARREN IAT |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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 N 0 Refueling |0 Refueling |
|3 N Y 100 Power Operation |100 Power Operation |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| NOTIFICATION OF THE OCONEE COUNTY SHERIFF'S OFFICE |
| |
| The switchboard was notified by an individual of a possible bomb threat |
| concerning the Oconee site that was left on her home answering machine. The |
| licensee notified the Oconee County Sheriffs Department to investigate. No |
| other law enforcement agencies have been notified. They do not consider it |
| a credible threat. |
| |
| The NRC Resident Inspector will be notified. |
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