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 +------------------------------------------------------------------------------+ |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 +------------------------------------------------------------------------------+ | 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. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 38001 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | 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 +------------------------------------------------------------------------------+ | 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. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |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 +------------------------------------------------------------------------------+ | 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. | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 38003 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | 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. | +------------------------------------------------------------------------------+
Page Last Reviewed/Updated Wednesday, March 24, 2021
Page Last Reviewed/Updated Wednesday, March 24, 2021