Event Notification Report for October 17, 2001
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/16/2001 - 10/17/2001
EVENT NUMBERS
384003840238398383993882838557
Power Reactor
Event Number: 38400
Facility: SEABROOK
Region: 1 State: NH
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: STEVE MORRISEY
HQ OPS Officer: FANGIE JONES
Region: 1 State: NH
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: STEVE MORRISEY
HQ OPS Officer: FANGIE JONES
Notification Date: 10/17/2001
Notification Time: 15:05 [ET]
Event Date: 10/17/2001
Event Time: 06:50 [EDT]
Last Update Date: 10/17/2001
Notification Time: 15:05 [ET]
Event Date: 10/17/2001
Event Time: 06:50 [EDT]
Last Update Date: 10/17/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
JOHN ROGGE (R1)
JOHN ROGGE (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Hot Standby | 0 | Hot Standby |
OFFSITE NOTIFICATION DUE TO SMALL OIL SPILL
The licensee notified the New Hampshire Environmental Services of an oil spill of less than or equal to 25 gallons. There was no oil discharged from the site nor did any enter a waterway. Also, no impact to groundwater was observed. The licensee is removing the contaminated soil.
The licensee is in the process of replacing some oil bearing piping. A section of that piping contained residue of oil, which was washed out by heavy rains yesterday. The amount of oil is small and this notification is conservative based on the fact that it was not possible to accurately determine the quantity. Oil was observed in the rainwater inside an excavation.
The licensee notified the NRC Resident Inspector.
The licensee notified the New Hampshire Environmental Services of an oil spill of less than or equal to 25 gallons. There was no oil discharged from the site nor did any enter a waterway. Also, no impact to groundwater was observed. The licensee is removing the contaminated soil.
The licensee is in the process of replacing some oil bearing piping. A section of that piping contained residue of oil, which was washed out by heavy rains yesterday. The amount of oil is small and this notification is conservative based on the fact that it was not possible to accurately determine the quantity. Oil was observed in the rainwater inside an excavation.
The licensee notified the NRC Resident Inspector.
Power Reactor
Event Number: 38402
Facility: COOPER
Region: 4 State: NE
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: JAMES DEDIC
HQ OPS Officer: FANGIE JONES
Region: 4 State: NE
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: JAMES DEDIC
HQ OPS Officer: FANGIE JONES
Notification Date: 10/17/2001
Notification Time: 17:56 [ET]
Event Date: 10/17/2001
Event Time: 14:02 [CDT]
Last Update Date: 10/17/2001
Notification Time: 17:56 [ET]
Event Date: 10/17/2001
Event Time: 14:02 [CDT]
Last Update Date: 10/17/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
BILL JONES (R4)
BILL JONES (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 99 | Power Operation | 99 | Power Operation |
HPSI SYSTEM DECLARED INOPERABLE.
"At 1415 on 10/17/01, the HPCI steam stop valve did not reopen upon release of the local turbine trip knob. This condition was discovered during surveillance testing. The surveillance procedure directs declaring the HPCI system inoperable if this condition occurs. The HPCI system was originally declared inoperable at 1402 on 10/17/01 for surveillance testing. This is being reported as a failure of a single train system such that it cannot perform its safety function of mitigating the consequences of an accident. All other Emergency Core Cooling Systems are operable. This event is being entered into the corrective action and work control programs for investigation and resolution."
The licensee notified the NRC Resident Inspector.
"At 1415 on 10/17/01, the HPCI steam stop valve did not reopen upon release of the local turbine trip knob. This condition was discovered during surveillance testing. The surveillance procedure directs declaring the HPCI system inoperable if this condition occurs. The HPCI system was originally declared inoperable at 1402 on 10/17/01 for surveillance testing. This is being reported as a failure of a single train system such that it cannot perform its safety function of mitigating the consequences of an accident. All other Emergency Core Cooling Systems are operable. This event is being entered into the corrective action and work control programs for investigation and resolution."
The licensee notified the NRC Resident Inspector.
Power Reactor
Event Number: 38398
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: PRICE
HQ OPS Officer: CHAUNCEY GOULD
Region: 3 State: IA
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: PRICE
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 10/17/2001
Notification Time: 10:44 [ET]
Event Date: 10/17/2001
Event Time: 06:11 [CDT]
Last Update Date: 10/17/2001
Notification Time: 10:44 [ET]
Event Date: 10/17/2001
Event Time: 06:11 [CDT]
Last Update Date: 10/17/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
ANTON VEGEL (R3)
ANTON VEGEL (R3)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | M/R | Y | 100 | Power Operation | 0 | Hot Shutdown |
REACTOR WAS MANUALLY SCRAMMED FROM 100% POWER.
At approximately 0610 on October 17, Instrument AC bus 1Y11 failed due to an inverter failure. One of the two reactor feed pumps tripped due to a low suction pressure caused by its minimum flow valve failing open on the loss of instrument power. The Reactor was then manually scrammed in anticipation of a Reactor low level trip. All rods were inserted, no relief valves lifted and the plant response was as designed with the exception that one main generator breaker failed to trip (the transmission system isolated the generator as designed). Containment isolation Groups 2 through 4 were initiated when reactor level decreased below 170 above top of active fuel and a Group 5 isolation was initiated by the loss of instrument power. Reactor level was restored and maintained using the RCIC system initially (auto initiation) and subsequently the reactor feed system. The plant is currently in Mode 3 with plans to go to Mode 4.
The NRC Resident Inspector was notified.
At approximately 0610 on October 17, Instrument AC bus 1Y11 failed due to an inverter failure. One of the two reactor feed pumps tripped due to a low suction pressure caused by its minimum flow valve failing open on the loss of instrument power. The Reactor was then manually scrammed in anticipation of a Reactor low level trip. All rods were inserted, no relief valves lifted and the plant response was as designed with the exception that one main generator breaker failed to trip (the transmission system isolated the generator as designed). Containment isolation Groups 2 through 4 were initiated when reactor level decreased below 170 above top of active fuel and a Group 5 isolation was initiated by the loss of instrument power. Reactor level was restored and maintained using the RCIC system initially (auto initiation) and subsequently the reactor feed system. The plant is currently in Mode 3 with plans to go to Mode 4.
The NRC Resident Inspector was notified.
Power Reactor
Event Number: 38399
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: DAVID YOUNG
HQ OPS Officer: LEIGH TROCINE
Region: 4 State: LA
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: DAVID YOUNG
HQ OPS Officer: LEIGH TROCINE
Notification Date: 10/17/2001
Notification Time: 11:10 [ET]
Event Date: 10/17/2001
Event Time: 02:48 [CDT]
Last Update Date: 10/17/2001
Notification Time: 11:10 [ET]
Event Date: 10/17/2001
Event Time: 02:48 [CDT]
Last Update Date: 10/17/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
BILL JONES (R4)
BILL JONES (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 80 | Power Operation | 80 | Power Operation |
UNEXPECTED LOSS OF POWER TO A SAFETY-RELATED SWITCHGEAR
The following text is a portion of a facsimile received from the licensee:
"At approximately 2:48 am CDT, the normal supply breaker to the Division 2 4160-volt safety-related switchgear opened unexpectedly, causing a loss of power to the Division 2 electrical systems. This event is being reported in accordance with 10CFR50.72(b)(3)(iv)(A) as a valid actuation of safety systems."
"The Division 2 diesel generator responded as expected by automatically starting and restoring power to the Division 2 switchgear. Also, containment isolation valves actuated as expected in the following systems due to the loss of power: reactor water cleanup, reactor building floor and equipment drains, reactor coolant sampling, containment airlock air supply, and containment ventilation systems. Automatic actuations occurred as expected in the following systems: standby gas control, annulus mixing, control building ventilation, and fuel building ventilation."
"Following the event, the containment isolation logic was reset and ventilation systems were returned to their normal configuration."
"The Division 2 diesel generator remains in service supplying the Division 2 switchgear. The cause of the trip of the normal supply breaker to the 4160[-volt] standby switchgear is being investigated."
The licensee notified the NRC resident inspector.
The following text is a portion of a facsimile received from the licensee:
"At approximately 2:48 am CDT, the normal supply breaker to the Division 2 4160-volt safety-related switchgear opened unexpectedly, causing a loss of power to the Division 2 electrical systems. This event is being reported in accordance with 10CFR50.72(b)(3)(iv)(A) as a valid actuation of safety systems."
"The Division 2 diesel generator responded as expected by automatically starting and restoring power to the Division 2 switchgear. Also, containment isolation valves actuated as expected in the following systems due to the loss of power: reactor water cleanup, reactor building floor and equipment drains, reactor coolant sampling, containment airlock air supply, and containment ventilation systems. Automatic actuations occurred as expected in the following systems: standby gas control, annulus mixing, control building ventilation, and fuel building ventilation."
"Following the event, the containment isolation logic was reset and ventilation systems were returned to their normal configuration."
"The Division 2 diesel generator remains in service supplying the Division 2 switchgear. The cause of the trip of the normal supply breaker to the 4160[-volt] standby switchgear is being investigated."
The licensee notified the NRC resident inspector.
General Information or Other
Event Number: 38828
Rep Org: ILLINOIS DEPT OF NUCLEAR SAFETY
Licensee: RUSH-PRESBYTERIAN-ST. LUKE'S MEDICAL CENTER
Region: 3
City: CHICAGO State: IL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: THOMAS SEIF
HQ OPS Officer: RICH LAURA
Licensee: RUSH-PRESBYTERIAN-ST. LUKE'S MEDICAL CENTER
Region: 3
City: CHICAGO State: IL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: THOMAS SEIF
HQ OPS Officer: RICH LAURA
Notification Date: 04/03/2002
Notification Time: 16:05 [ET]
Event Date: 10/17/2001
Event Time: 00:00 [CST]
Last Update Date: 04/03/2002
Notification Time: 16:05 [ET]
Event Date: 10/17/2001
Event Time: 00:00 [CST]
Last Update Date: 04/03/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
DAVID HILLS (R3)
PATRICIA HOLAHAN (NMSS)
DAVID HILLS (R3)
PATRICIA HOLAHAN (NMSS)
AGREEMENT STATE REPORT OF MEDICAL MISADMINISTRATION
"On October 17, 2001 a patient was being treated with a P-32 impregnated balloon. This balloon is part of an FDA study sponsored by Radiance. This treatment is designed to be a sequence of inflations and deflations at the treatment site. During the record review on March 21, 2001, the patient was feeling significant discomfort, so the Doctor ordered for the balloon to be deflated. Since there was a deviation in protocol, all records were appropriately documented.
"During the record review on March 21, 2002, it was noted that the order for the treatment to be given in the deflated state was approximately half of the original order. The order was supposed to be that the entire treatment time would be in the deflated stage, but unfortunately, only the deflated stage was administered. The dose was approximately 11 Gy (55%) of the original order of 20 Gy. No other deviations were noted.
"The patient and primary physician have been notified. Procedures are in the process of being reviewed to ensure future compliance. The name and identification number of the patient involved has been attached on a separate sheet."
"On October 17, 2001 a patient was being treated with a P-32 impregnated balloon. This balloon is part of an FDA study sponsored by Radiance. This treatment is designed to be a sequence of inflations and deflations at the treatment site. During the record review on March 21, 2001, the patient was feeling significant discomfort, so the Doctor ordered for the balloon to be deflated. Since there was a deviation in protocol, all records were appropriately documented.
"During the record review on March 21, 2002, it was noted that the order for the treatment to be given in the deflated state was approximately half of the original order. The order was supposed to be that the entire treatment time would be in the deflated stage, but unfortunately, only the deflated stage was administered. The dose was approximately 11 Gy (55%) of the original order of 20 Gy. No other deviations were noted.
"The patient and primary physician have been notified. Procedures are in the process of being reviewed to ensure future compliance. The name and identification number of the patient involved has been attached on a separate sheet."
Power Reactor
Event Number: 38557
Facility: CATAWBA
Region: 2 State: SC
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ED BREWER
HQ OPS Officer: LEIGH TROCINE
Region: 2 State: SC
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ED BREWER
HQ OPS Officer: LEIGH TROCINE
Notification Date: 12/11/2001
Notification Time: 17:16 [ET]
Event Date: 10/17/2001
Event Time: 10:39 [EST]
Last Update Date: 12/11/2001
Notification Time: 17:16 [ET]
Event Date: 10/17/2001
Event Time: 10:39 [EST]
Last Update Date: 12/11/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
LEONARD WERT (R2)
LEONARD WERT (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | A | N | 0 | Cold Shutdown | 0 | Cold Shutdown |
INVALID ACTUATION OF THE REACTOR PROTECTION SYSTEM WHILE THE UNIT WAS IN COLD SHUTDOWN (60-Day Report)
The following text is a portion of a facsimile received from the licensee:
"This 60-day optional report, as allowed by 10CFR50.73(a)(1), is being made under the reporting requirement in 10CFR50.73(a)(2)(iv)(A) to describe an invalid actuation of a specified system, specifically the reactor protection system (RPS). On October 17, 2001, at 1039 with Unit 2 in MODE 5 with a boron concentration of 2531 ppm, an invalid reactor trip signal was generated from 2 out of 4 logic for overtemperature delta-T. The reactor trip breakers opened as designed upon receipt of the invalid reactor trip signal. All control rods and shutdown rods were already fully inserted before the invalid reactor trip signal trip signal was generated. At the time of the invalid reactor trip signal, reactor protection channel III had been properly removed from service for maintenance testing. Other maintenance technicians were in the process of setting up test equipment in reactor protection channel I for upcoming resistance temperature detector cross calibrations. The technicians thought that the place where they were connecting the test equipment was isolated from the circuit and would have no effect on the plant. During the connections, a momentary spike occurred on reactor protection channel I. This completed the 2 out of 4 logic for an overtemperature delta-T reactor trip, and a reactor trip occurred. The control room operators entered appropriate procedures and verified proper equipment operation for the existing plant conditions. Both trains A [and] B of the reactor protection system actuated. This was a complete actuation, and the system performed as designed for the existing plant conditions. This event has been entered into the site-specific corrective action program for resolution."
The licensee notified the NRC resident inspector and plans to notify applicable state, county, and local agencies.
The following text is a portion of a facsimile received from the licensee:
"This 60-day optional report, as allowed by 10CFR50.73(a)(1), is being made under the reporting requirement in 10CFR50.73(a)(2)(iv)(A) to describe an invalid actuation of a specified system, specifically the reactor protection system (RPS). On October 17, 2001, at 1039 with Unit 2 in MODE 5 with a boron concentration of 2531 ppm, an invalid reactor trip signal was generated from 2 out of 4 logic for overtemperature delta-T. The reactor trip breakers opened as designed upon receipt of the invalid reactor trip signal. All control rods and shutdown rods were already fully inserted before the invalid reactor trip signal trip signal was generated. At the time of the invalid reactor trip signal, reactor protection channel III had been properly removed from service for maintenance testing. Other maintenance technicians were in the process of setting up test equipment in reactor protection channel I for upcoming resistance temperature detector cross calibrations. The technicians thought that the place where they were connecting the test equipment was isolated from the circuit and would have no effect on the plant. During the connections, a momentary spike occurred on reactor protection channel I. This completed the 2 out of 4 logic for an overtemperature delta-T reactor trip, and a reactor trip occurred. The control room operators entered appropriate procedures and verified proper equipment operation for the existing plant conditions. Both trains A [and] B of the reactor protection system actuated. This was a complete actuation, and the system performed as designed for the existing plant conditions. This event has been entered into the site-specific corrective action program for resolution."
The licensee notified the NRC resident inspector and plans to notify applicable state, county, and local agencies.