Event Notification Report for August 27, 2001
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
08/24/2001 - 08/27/2001
** EVENT NUMBERS **
38230 38231 38232 38233 38234
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|Power Reactor |Event Number: 38230 |
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| FACILITY: PEACH BOTTOM REGION: 1 |NOTIFICATION DATE: 08/24/2001|
| UNIT: [2] [3] [] STATE: PA |NOTIFICATION TIME: 02:29[EDT]|
| RXTYPE: [2] GE-4,[3] GE-4 |EVENT DATE: 08/23/2001|
+------------------------------------------------+EVENT TIME: 21:43[EDT]|
| NRC NOTIFIED BY: NILS BAHLIN |LAST UPDATE DATE: 08/24/2001|
| HQ OPS OFFICER: FANGIE JONES +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |JAMES NOGGLE R1 |
|10 CFR SECTION: | |
|ACOM 50.72(b)(3)(xiii) LOSS COMM/ASMT/RESPONSE| |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|2 N Y 100 Power Operation |100 Power Operation |
|3 N Y 80 Power Operation |80 Power Operation |
| | |
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EVENT TEXT
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| LOSS OF ELECTRICAL POWER TO THE TECHNICAL SUPPORT CENTER |
| |
| An unexpected electrical breaker trip has caused a loss of power to the |
| Technical Support Center (TSC). |
| |
| On 08/23/01 at 21:43 the main control room was notified that the TSC, which |
| is located in a building adjacent to the protected area, was without power. |
| Communications were verified available from the TSC. |
| |
| An investigation revealed that an offsite breaker controlled by the power |
| system director had tripped. Further investigation is in progress to |
| identify and repair any deficiencies. |
| |
| The station procedures for contingency actions were put in place if an |
| event requiring the TSC were to occur during the loss of power. Power was |
| restored to the TSC at 0130 EDT on 08/24/01 from an alternate offsite |
| source. |
| |
| The licensee notified the NRC Resident Inspector. |
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|General Information or Other |Event Number: 38231 |
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| REP ORG: ROSEMOUNT NUCLEAR INSTRUMENTS INC |NOTIFICATION DATE: 08/24/2001|
|LICENSEE: ROSEMOUNT NUCLEAR INSTRUMENTS INC |NOTIFICATION TIME: 12:46[EDT]|
| CITY: EDEN PRAIRIE REGION: 3 |EVENT DATE: 08/24/2001|
| COUNTY: STATE: MN |EVENT TIME: [CDT]|
|LICENSE#: AGREEMENT: N |LAST UPDATE DATE: 08/24/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |RONALD GARDNER R3 |
| |BILL JONES R4 |
+------------------------------------------------+VERN HODGE NRR |
| NRC NOTIFIED BY: CLEVELAND | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|CCCC 21.21 UNSPECIFIED PARAGRAPH | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| PART 21 FOR A POTENTIAL NONCONFORMANCE RELATED TO REMOTE DIAPHRAGM SEALS |
| |
| Pursuant to 10CFR Part 21 Paragraph 21.21(b), Rosemount Nuclear Instruments, |
| Inc. (RNII) is writing to inform you of a potential nonconformance related |
| to two model 1159 remote diaphragm seals. The two remote diaphragm seals are |
| connected to a single Rosemount nuclear qualified transmitter with serial |
| number 0521038. The two remote diaphragm seals are used to measure |
| differential process pressure or liquid level while preventing the process |
| fluid from contacting the transmitter diaphragm. The remote seals contain |
| discrepant fill fluid screws. The fill fluid screws are part of the |
| pressure boundary of the remote seal system. The nonconformance was due to |
| an oversight during assembly, which has been corrected. |
| |
| The material specification for the qualified fill screws is 416 SST. The |
| unqualified fill screws are 416 SST with a ball tip that is AISA E52100. |
| The ball tip allows multiple insertions. The qualified screw does not |
| possess the bearing feature. |
| |
| 1.0 Affected customer - Grand Gulf |
| |
| 2.0 Identification of items supplied - Model 1159 Remote Diaphragm Seals |
| |
| 3.0 Identification of firm supplying the Item - Rosemount Nuclear |
| Instruments, Inc. |
| |
| 4.0 Nature of the failure and potential safety hazard: |
| |
| This notification relates to two Model 1159 Remote Diaphragm Seals, which |
| contain discrepant fill fluid seal screws. These screws are part of the |
| pressure boundary of the remote diaphragm seal system. |
| |
| This notification is not applicable to other remote diaphragm seal systems. |
| |
| RNII has determined that there is no safety impact related to plant |
| applications. RNII does not feel Licensees with installed Model 1159 Remote |
| Diaphragm Seals need to address this issue. |
| |
| 5.0 The corrective action which is taken, the name of the individual or |
| organization responsible for that action and the length of time taken to |
| complete that action: |
| |
| RNII immediately contacted the affected customer, and the nonconforming |
| seals were returned to RNII prior to installation into the customer's |
| facility. The unit will be reworked to conform to the qualification |
| requirements. |
| |
| RNII internal corrective actions: |
| |
| 1. Revised the non-standard filling procedure for remote seals to ensure |
| that qualified fill screws are installed during the filling process. |
| |
| 2. Training of engineering, manufacturing and quality personnel involved in |
| the preparation, review and approval of non-standard procedures and |
| processes to reemphasize the need to specifically address the material |
| requirements. |
| |
| 6.0 Any advice related to the potential failure of the item: |
| |
| This notification applies to a single transmitter with two Model 1159C20A |
| Remote Diaphragm Seals. This unit was returned to RNII prior to |
| installation; therefore, does not pose a potential failure. |
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|Hospital |Event Number: 38232 |
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| REP ORG: PROVIDENCE HOSPITAL |NOTIFICATION DATE: 08/24/2001|
|LICENSEE: PROVIDENCE HOSPITAL |NOTIFICATION TIME: 15:03[EDT]|
| CITY: WASHINGTON REGION: 1 |EVENT DATE: 08/24/2001|
| COUNTY: STATE: DC |EVENT TIME: [EDT]|
|LICENSE#: 08-01728-01 AGREEMENT: N |LAST UPDATE DATE: 08/24/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |JAMES NOGGLE R1 |
| |SUSAN FRANT NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: PAUL SMITH | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| PROVIDENCE HOSPITAL REPORTED MEDICAL MISADMINISTRATIONS OCCURRING BETWEEN |
| 1996 AND 2000 |
| |
| The hospital reported that during the period from 8/7/96 to 10/18/00 |
| fourteen medical misadministrations of strontium-90 occurred during clinical |
| procedures using a strontium-90 eye applicator. The same ophthalmologist |
| was the operator of the applicator during all fourteen incidences. It |
| appears that there was a misinterpretation of what the affect the shield had |
| on the radiation reaching the eye. There was a supposition that the use of |
| the shield reduced the radiation to the eye by a minimum of 50% and up to |
| 80%. Therefore, the amount of administration time for the procedures was |
| doubled. The amount of radiation given(in the range of 3,000 rads) was well |
| within the therapeutic range for the procedure, but it was not what the |
| physician had written. The amount of rads given was doubled of what was |
| prescribed. |
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|Power Reactor |Event Number: 38233 |
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| FACILITY: COLUMBIA GENERATING STATIREGION: 4 |NOTIFICATION DATE: 08/24/2001|
| UNIT: [2] [] [] STATE: WA |NOTIFICATION TIME: 17:05[EDT]|
| RXTYPE: [2] GE-5 |EVENT DATE: 08/24/2001|
+------------------------------------------------+EVENT TIME: 13:05[PDT]|
| NRC NOTIFIED BY: FISHER |LAST UPDATE DATE: 08/24/2001|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |BILL JONES R4 |
|10 CFR SECTION: | |
|DDDD 73.71 UNSPECIFIED PARAGRAPH | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|2 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
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EVENT TEXT
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| SAFEGUARDS SYSTEM DEGRADATION RELATED TO AREA BOUNDARY |
| |
| IMMEDIATE COMPENSATORY MEASURES TAKEN UPON TO DISCOVERY |
| |
| THE NRC RESIDENT INSPECTOR WILL BE NOTIFIED |
| |
| CONTACT THE HEADQUARTERS OPERATION CENTER FOR ADDITIONAL DETAILS. |
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|Power Reactor |Event Number: 38234 |
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| FACILITY: VOGTLE REGION: 2 |NOTIFICATION DATE: 08/25/2001|
| UNIT: [1] [] [] STATE: GA |NOTIFICATION TIME: 00:34[EDT]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 08/24/2001|
+------------------------------------------------+EVENT TIME: 23:07[EDT]|
| NRC NOTIFIED BY: ROBERT DORMAN |LAST UPDATE DATE: 08/25/2001|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |EDWARD MCALPINE R2 |
|10 CFR SECTION: | |
|ARPS 50.72(b)(2)(iv)(B) RPS ACTUATION - CRITICA| |
|AESF 50.72(b)(3)(iv)(A) VALID SPECIF SYS ACTUAT| |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 A/R Y 100 Power Operation |0 Hot Standby |
| | |
| | |
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EVENT TEXT
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| LOSS OF EXCITATION TO THE MAIN GENERATOR RESULTS IN A REACTOR TRIP. |
| |
| Unit 1 was operating at approximately 100% power. While the main generator |
| rectifier bank # 1 was being placed back in service after repairs when the |
| main generator had a loss of excitation to the generator resulting in a |
| generator trip, turbine trip and reactor trip. All rods fully inserted into |
| the core. An investigation is in progress to determine when excitation was |
| lost when attempting to place main generator rectifier bank # 1 back in |
| service. An Auxiliary Feedwater Actuation Signal was generated on Lo-Lo |
| Steam Generator Water Levels and AMSAC. Both Motor Driven Feedwater Pumps |
| and the Turbine Driven Auxiliary Feedwater Pump started. The plant is |
| currently stable in mode 3 (Hot Standby). An evaluation is in progress to |
| determine what work will be done with the unit shut down and to develop a |
| schedule for returning to power operation. |
| |
| The NRC Resident Inspector was notified of this event by the licensee. |
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