Event Notification Report for July 16, 2001
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
07/13/2001 - 07/16/2001
** EVENT NUMBERS **
38123 38137 38138 38139 38140 38141 38142
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
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|Power Reactor |Event Number: 38123 |
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| FACILITY: CLINTON REGION: 3 |NOTIFICATION DATE: 07/09/2001|
| UNIT: [1] [] [] STATE: IL |NOTIFICATION TIME: 13:07[EDT]|
| RXTYPE: [1] GE-6 |EVENT DATE: 07/09/2001|
+------------------------------------------------+EVENT TIME: 09:00[CDT]|
| NRC NOTIFIED BY: JAMIE BARTSCH |LAST UPDATE DATE: 07/13/2001|
| HQ OPS OFFICER: FANGIE JONES +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |DAVID HILLS R3 |
|10 CFR SECTION: | |
|AIND 50.72(b)(3)(v)(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
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| CONTROL ROOM VENTILATION SYSTEM DECLARED INOPERABLE |
| |
| The Division 2 Main Control Room Ventilation System was declared inoperable |
| at 0900 CDT on 7/9/2001 because it was not maintaining the required positive |
| pressure while running in the High Radiation Mode of operation. The system |
| was declared operable at 0913 CDT when the required positive pressure was |
| restored. During the 13 minute period Division 2 was inoperable, Division 1 |
| Main Control Room Ventilation System was inoperable due to a scheduled |
| maintenance outage. Therefore, with both systems inoperable, a condition |
| existed which could have prevented the fulfillment of the safety function of |
| the Main Control Room Ventilation System needed to mitigate the consequences |
| of an accident. The cause of the perturbation in control room pressure is |
| being investigated. |
| |
| The licensee notified the NRC Resident Inspector. |
| |
| *** RETRACTION FROM STEVEN STRICKLAN RECEIVED BY LEIGH TROCINE AT 0451 EDT |
| ON 07/13/01 *** |
| |
| The licensee is retracting this event notification. The following text is a |
| portion of a facsimile received from the licensee: |
| |
| "On 07/09/01, at approximately 0900 [CDT], the Clinton Power Station (CPS) |
| experienced a transient situation where, for a period of 13 minutes, the |
| positive pressure in the Main Control Room (MCR) was compromised. Based on |
| this condition, an ENS notification (#38123) was made in accordance with the |
| requirements of 10CFR50.72(b)(3)(v), any event or condition that at the time |
| of discovery could have prevented the fulfillment of the safety function of |
| structures or systems that are needed to: |
| (A) shut down the reactor and maintain it in a safe shutdown condition; |
| (B) remove residual heat; |
| (C) control the release of radioactive material; or |
| (D) mitigate the consequences of an accident." |
| |
| "An evaluation of the conditions present at the time positive pressurization |
| of the MCR was temporarily interrupted has been performed. The evaluation |
| results indicated that the conditions that potentially existed during this |
| event were bounded by the design basis analysis performed for the [MCR]. |
| The calculated MCR operator thyroid dose for this event was determined to be |
| approximately 23.185 Rem, which is less than the USAR calculated dose of 25 |
| Rem. The USAR dose is calculated based on a 20-minute time delay in |
| starting the system in the high radiation mode. For this event, the high |
| radiation mode was already in operation. Whole body and Beta dose for this |
| event are not governing." |
| |
| "It [has] therefore been demonstrated that, in the event of a design basis |
| event, time dose impact of the condition as it existed would be bounded by |
| the current analyses of record. As such, the safety function would be |
| fulfilled, and the ENS notification is retracted." |
| |
| "Although it has been demonstrated that the safety function would be |
| fulfilled, the situation represented a condition prohibited by Technical |
| Specifications, and this event continues to be evaluated for reportability |
| as a Licensee Event Report under 10CFR50.73(a)(2)(i)(B)." |
| |
| The licensee notified the NRC resident inspector. The NRC operations center |
| notified the R3DO (Hills). |
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|Other Nuclear Material |Event Number: 38137 |
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| REP ORG: BURLINGTON INDUSTRIES |NOTIFICATION DATE: 07/13/2001|
|LICENSEE: BURLINGTON INDUSTRIES |NOTIFICATION TIME: 14:07[EDT]|
| CITY: HURT REGION: 2 |EVENT DATE: 07/13/2001|
| COUNTY: STATE: VA |EVENT TIME: [EDT]|
|LICENSE#: 20-07181-04G AGREEMENT: N |LAST UPDATE DATE: 07/13/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |PAUL FREDRICKSON R2 |
| |DONALD COOL NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: CHARLES CROCKER | |
| HQ OPS OFFICER: BOB STRANSKY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|BAB2 20.2201(a)(1)(ii) LOST/STOLEN LNM>10X | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| LOST AM-241 SOURCE |
| |
| A source purchased from Panametrics (under general license 20-07181-04G) and |
| delivered to the facility in 1977 was inadvertently placed in a scrap metal |
| bin and picked up by a scrap metal dealer in 1997. The device contained a 10 |
| mCi Am-241 source. The scrap metal dealer was contacted, but the whereabouts |
| of the material are unknown. |
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|Power Reactor |Event Number: 38138 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PALO VERDE REGION: 4 |NOTIFICATION DATE: 07/13/2001|
| UNIT: [] [2] [] STATE: AZ |NOTIFICATION TIME: 14:51[EDT]|
| RXTYPE: [1] CE,[2] CE,[3] CE |EVENT DATE: 07/13/2001|
+------------------------------------------------+EVENT TIME: 08:21[MST]|
| NRC NOTIFIED BY: DONALD STRAKA |LAST UPDATE DATE: 07/13/2001|
| HQ OPS OFFICER: BOB STRANSKY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |CHUCK CAIN R4 |
|10 CFR SECTION: | |
|ARPS 50.72(b)(2)(iv)(B) RPS ACTUATION - CRITICA| |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 A/R Y 100 Power Operation |0 Hot Standby |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| AUTOMATIC REACTOR TRIP |
| |
| "On July 13, 2001, at approximately 08:21 MST Palo Verde Unit 2 experienced |
| an automatic reactor trip (RPS actuation) from approximately 100% rated |
| thermal power due to low Departure from Nucleate Boiling Ratio (DNBR) trip |
| generated by the Core Protection Calculators (CPCs). The DNBR trip resulted |
| from the closure of 3 of the 4 main steam isolation valves (MSIVs). Unit 2 |
| was at normal temperature and pressure prior to the trip. All CEAs inserted |
| fully into the reactor core. No ESF actuations occurred and none were |
| required. An investigation of this event has been commenced to determine why |
| the MSIVs closed. |
| |
| "Due to the MSIV closures, two of twenty main steam safety valves (MSSVs) |
| lifted to relieve secondary pressure. Operators restored reactor coolant |
| system heat removal using atmospheric dump valves and feedwater to the steam |
| generators is being supplied by the B train main feedwater pump. |
| |
| "Safety related buses remained energized during and following the reactor |
| trip. The offsite power grid is stable. No significant LCOs have been |
| entered as a result of this event. No major equipment was inoperable prior |
| to the event that contributed to the event. |
| |
| "Unit 2 is stable at normal operating temperature and pressure in Mode 3. |
| The event did not result in any challenges to fission product barriers and |
| there were no adverse safety consequences as a result of this event. The |
| event did not adversely affect the safe operation of the plant or the health |
| and safety of the public." |
| |
| The NRC resident inspector has been informed of this event by the licensee. |
+------------------------------------------------------------------------------+
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|Power Reactor |Event Number: 38139 |
+------------------------------------------------------------------------------+
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| FACILITY: PILGRIM REGION: 1 |NOTIFICATION DATE: 07/13/2001|
| UNIT: [1] [] [] STATE: MA |NOTIFICATION TIME: 14:52[EDT]|
| RXTYPE: [1] GE-3 |EVENT DATE: 07/13/2001|
+------------------------------------------------+EVENT TIME: 08:55[EDT]|
| NRC NOTIFIED BY: JOHN MacDONALD |LAST UPDATE DATE: 07/13/2001|
| HQ OPS OFFICER: STEVE SANDIN +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |ANTHONY DIMITRIADIS R1 |
|10 CFR SECTION: | |
|AINA 50.72(b)(3)(v)(A) POT UNABLE TO SAFE SD | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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
+------------------------------------------------------------------------------+
| APRM FLOW-BIASED SCRAM SETPOINTS SET NONCONSERVATIVELY |
| |
| "On July 13, 2001 at 0855 hrs, with the reactor at 100% core thermal power, |
| Pilgrim Station determined the Average Power Range Monitoring (APRM) system |
| flow-biased reactor scram setpoints were non-conservative and potentially |
| exceeded Core Operating Limit Report (COLR) analyses. Programmed Flow |
| Control Trip Reference (FCTR) cards establish the APRM flow-biased scram |
| setpoints. The FCTR cards are a plant enhancement in response to the BWR |
| stability issue. During core flow mapping for FCTR card calibration in |
| accordance with station procedure (9.17.1), it was determined by reactor |
| engineering personnel that the input setting for the FCTR card DIP switches |
| was non-conservative. In response to this event, the APRMs were declared |
| inoperable and Technical Specification 3.1 and the Actions of Table 3.1.1 |
| were initiated. TS Table 3.1.1 requires that reactor trip capability for the |
| given trip function be restored within 1 hour or initiate insertion of |
| operable control rods and complete insertion of all operable control rods |
| within 4 hours. However, Instrumentation and Controls personnel completed |
| FCTR card DIP switch adjustments in accordance with station procedure |
| (3.M.2-5.4.s) within approximately 45 minutes. All APRM RPS functions were |
| declared operable at 0946 hours and TS 3.1 was exited. The reactor remained |
| at 100% core thermal power throughout the event and there were no plant |
| transients as a result of the event. |
| |
| "The cause of the event appears to [be] a lack of administrative controls to |
| ensure the FCTR card flow mapping be performed when steady-state 100% core |
| thermal power is achieved following refueling outages or significant power |
| maneuvers." |
| |
| The licensee informed the NRC resident inspector and will inform the |
| Commonwealth of Massachusetts. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Hospital |Event Number: 38140 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: WILLIAM BEAUMONT HOSPITAL |NOTIFICATION DATE: 07/13/2001|
|LICENSEE: WILLIAM BEAUMONT HOSPITAL |NOTIFICATION TIME: 15:12[EDT]|
| CITY: ROYAL OAK REGION: 3 |EVENT DATE: 07/12/2001|
| COUNTY: STATE: MI |EVENT TIME: 19:00[EDT]|
|LICENSE#: 21-01333-01 AGREEMENT: N |LAST UPDATE DATE: 07/13/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |DAVID HILLS R3 |
| |DONALD COOL NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: SHERYL SCHULTZ | |
| HQ OPS OFFICER: BOB STRANSKY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| MEDICAL MISADMINISTRATION |
| |
| An individual prescribed a dose of 2.8 - 3.46 GBq (75.6 - 93.5 mCi) of Y-90 |
| only received 1.1 GBq (29.7 mCi) due to a procedural error. The Y-90 was in |
| the form of insoluble glass microspheres and was being injected into the |
| liver in a saline solution. The procedure was being performed under an FDA |
| approved humanitarian device exemption. During the treatment, the seal on |
| the vial containing the microspheres was not properly pierced, causing |
| backpressure to develop in the delivery lines and forcing some of the |
| microspheres to back up into the treatment device. The licensee is |
| implementing additional controls to prevent recurrence of this type of |
| event. In addition, the device vendor (MDS Nordion) will continue with |
| onsite proctoring of dose administrations until all treatment staff are |
| fully trained. |
+------------------------------------------------------------------------------+
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|Other Nuclear Material |Event Number: 38141 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: McDOWELL AND ASSOCIATES |NOTIFICATION DATE: 07/13/2001|
|LICENSEE: McDOWELL AND ASSOCIATES |NOTIFICATION TIME: 16:24[EDT]|
| CITY: FERNDALE REGION: 3 |EVENT DATE: 07/13/2001|
| COUNTY: STATE: MI |EVENT TIME: 07:30[EDT]|
|LICENSE#: 21-18724-01 AGREEMENT: N |LAST UPDATE DATE: 07/13/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |DAVID HILLS R3 |
| |JOSEPHINE PICCONE NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: MARY JARDINE | |
| HQ OPS OFFICER: BOB STRANSKY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|BAB1 20.2201(a)(1)(i) LOST/STOLEN LNM>1000X | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| STOLEN MOISTURE/DENSITY GAUGE |
| |
| A Troxler Model 3440A moisture/density gauge (S/N 14786) was stolen from its |
| locked storage case. The gauge and case were chained to the bed of a pickup |
| truck that was parked in Shelby Township, MI. The licensee has contacted |
| local law enforcement agencies and has already contacted NRC Region III |
| regarding this matter. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 38142 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: WATERFORD REGION: 4 |NOTIFICATION DATE: 07/15/2001|
| UNIT: [3] [] [] STATE: LA |NOTIFICATION TIME: 23:32[EDT]|
| RXTYPE: [3] CE |EVENT DATE: 07/15/2001|
+------------------------------------------------+EVENT TIME: 21:58[CDT]|
| NRC NOTIFIED BY: RAY PELLEGRIN |LAST UPDATE DATE: 07/16/2001|
| HQ OPS OFFICER: BOB STRANSKY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: ALERT |CHUCK CAIN R4 |
|10 CFR SECTION: |TAD MARSH NRR |
|AAEC 50.72(a) (1) (i) EMERGENCY DECLARED |NADER MAMISH IRO |
| |SAM COLLINS NRR |
| |JIM MULLINS EPA |
| |CANUPP FEMA |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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
+------------------------------------------------------------------------------+
| ALERT DECLARED DUE TO TOXIC GAS RELEASE NEAR PLANT SITE |
| |
| The licensee declared an Alert (EAL EP-4-010 "Toxic Chemical Contingency") |
| due to an anhydrous ammonia release at the Occidental Chemical facility |
| located near the site. The licensee reported that no ammonia has been |
| detected onsite; however, personnel sheltering has been implemented. The |
| release is ongoing and the chemical facility cannot estimate when the |
| release will be secured. The NRC entered Monitoring at 0012EDT on 7/16/01. |
| |
| * * * UPDATE 0300EDT ON 7/16/01 FROM LICENSEE COMMUNICATOR TO S.SANDIN * * |
| * |
| |
| The licensee terminated the Alert at 0200CDT after verifying that all |
| exiting conditions were satisfied. The licensee informed the NRC resident |
| inspector and will inform state/local agencies. The NRC exited Monitoring |
| at 0315EDT on 7/16/01. Notified FEMA(Canupp), DOE(Stambaugh), |
| EPA-DOT(Loreck), USDA(Conley) and HHS-CDC(Cruz). |
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