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Event Notification Report for March 8, 2002

                         
                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           03/07/2002 - 03/08/2002

                              ** EVENT NUMBERS **

38602  38648  38751  38752  38753  38754  38755  

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|Power Reactor                                    |Event Number:   38602       |
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| FACILITY: CRYSTAL RIVER            REGION:  2  |NOTIFICATION DATE: 01/01/2002|
|    UNIT:  [3] [] []                 STATE:  FL |NOTIFICATION TIME: 10:08[EST]|
|   RXTYPE: [3] B&W-L-LP                         |EVENT DATE:        01/01/2002|
+------------------------------------------------+EVENT TIME:        09:19[EST]|
| NRC NOTIFIED BY:  BILL BANDHAUER               |LAST UPDATE DATE:  03/07/2002|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |ANNE BOLAND          R2      |
|10 CFR SECTION:                                 |                             |
|APRE 50.72(b)(2)(xi)     OFFSITE NOTIFICATION   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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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| OFFSITE NOTIFICATION DUE RESCUED SEA TURTLE                                  |
|                                                                              |
| EN #37902 started the biennial report period.                                |
|                                                                              |
| On January 1, 2002 at 0919, a rescued sea turtle was identified as a green   |
| sea turtle.  This is the 62nd rescue of a live sea turtle at Crystal River   |
| Unit 3 (CR-3) in this biennial period. Notification to the National Marine   |
| Fisheries Service and the Florida Fish and Wildlife Conservation Commission. |
|                                                                              |
|                                                                              |
| The licensee intends to notify the NRC Resident Inspector.                   |
|                                                                              |
| * * *  UPDATE ON 1/05/02 @ 1002 BY RAWLS TO GOULD  * * *                     |
|                                                                              |
| On January 5, 2002, at 0720, a rescued sea turtle was identified as a        |
| Loggerhead Sea Turtle. This is the 63rd rescue of a live sea turtle at       |
| Crystal River Unit 3 (CR3) in this biennial period.  This is reportable as a |
| 4-hour report under 10 CFR 50.72(b)(2)(xi) as this event is related to the   |
| protection of the environment for which a notification to other government   |
| agencies (National Marine Fisheries Service and Florida Fish and Wildlife    |
| Conservation Commission) has been or will be made.                           |
|                                                                              |
| The NRC Resident Inspector was notified.                                     |
|                                                                              |
| Reg 2 RDO (Decker) was notified.                                             |
|                                                                              |
| * * * UPDATE ON 01/09/02 @ 1107 EST BY ANDY BARNES TAKEN BY MACKINNON * * *  |
|                                                                              |
| On January 9, 2002, at 0838, a rescued sea turtle was identified as a Kemp's |
| Ridley Sea Turtle. This is the 64th rescue of a live turtle at Crystal River |
| Unit 3 (CR-3) in this biennial period. This is reportable as a 4-hour 10 CFR |
| 50.72 (b)(2)(xi) as this event is related to the protection of the           |
| environment for which a notification to other government agencies (National  |
| Marine Fisheries Service and Florida Fish and Wildlife Conservation          |
| Commission) has been or will be made.                                        |
|                                                                              |
| The NRC Resident Inspector was notified.                                     |
|                                                                              |
| Reg 2 (Brian Bonser) was notified.                                           |
|                                                                              |
| * * * UPDATE ON 02/17/02 at 0940 EST BY RICKY RAWLS TO FANGIE JONES * * *    |
|                                                                              |
| "On February 17, 2002 at 0820, a rescued injured sea turtle was identified   |
| as a Kemp's Ridley Sea Turtle. The injury will require transportation to     |
| Clearwater Marine Science Center or Florida Fish and Wildlife Conservation   |
| Refuge. The Injury appears to be from a boat propeller. This is the 65th     |
| rescue of a live sea turtle at Crystal River Unit 3 (CR-3) in this biennial  |
| period. This is Reportable as a 4-Hour Report under 10 CFR 50.72(b) (2) (xi) |
| as this event is related to the protection of the environment for which a    |
| notification to other government agencies (National Marine Fisheries Service |
| and Florida Fish and Wildlife Conservation Commission) has been or will be   |
| made. This Is an update to event 38602."                                     |
|                                                                              |
| The NRC Resident Inspector will be notified.  R2DO (Stephen Cahill) has been |
| notified.                                                                    |
|                                                                              |
| * * * UPDATE ON 03/01/02 AT 1122 EST BY RICKY RAWLS TO GERRY WAIG * * *      |
|                                                                              |
| "On March 1, 2002 at 0952, a healthy rescued sea turtle was identified as a  |
| Green Sea Turtle. This is the 66th rescue of a live sea turtle at Crystal    |
| River Unit 3 (CR-3) in this biennial period. This is Reportable as a 4-Hour  |
| Report under 10 CFR 50.72 (b) (2) (xi) as this event is related to the       |
| protection of the environment for which a notification to other government   |
| agencies (National Marine Fisheries Service and Florida Fish and Wildlife    |
| Conservation Commission) has been or will be made. This is an update to      |
| event 38602."                                                                |
|                                                                              |
| The NRC Resident Inspector was notified. R2DO (Julian) was notified.         |
|                                                                              |
| * * * UPDATE ON 03/07/02 AT 1114 EST BY CHUCK MORRIS TO MIKE NORRIS * * *    |
|                                                                              |
| "On March 7, 2002 at 0835, two healthy sea turtles rescued at CR#3 were      |
| identified as Green Sea Turtles. These are the 67th and 68th live sea turtle |
| rescues at the Crystal River Energy Complex in this biennial period. This is |
| Reportable as a 4-Hour Report under 10 CFR 50.72(b) (2) (xi) as this event   |
| is related to the protection of the environment for which a notification to  |
| other government agencies (National Marine Fisheries Service and Florida     |
| Fish and Wildlife Conservation Commission) has been or will be made. This is |
| an update to event 38602."                                                   |
|                                                                              |
| The NRC Resident Inspector was notified. R2DO (Henson) was notified.         |
+------------------------------------------------------------------------------+

!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   38648       |
+------------------------------------------------------------------------------+
                         
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| FACILITY: SUSQUEHANNA              REGION:  1  |NOTIFICATION DATE: 01/24/2002|
|    UNIT:  [1] [2] []                STATE:  PA |NOTIFICATION TIME: 18:20[EST]|
|   RXTYPE: [1] GE-4,[2] GE-4                    |EVENT DATE:        01/24/2002|
+------------------------------------------------+EVENT TIME:        11:00[EST]|
| NRC NOTIFIED BY:  GORDON ROBINSON              |LAST UPDATE DATE:  03/07/2002|
|  HQ OPS OFFICER:  BOB STRANSKY                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |PETE ESELGROTH       R1      |
|10 CFR SECTION:                                 |                             |
|AINA 50.72(b)(3)(v)(A)   POT UNABLE TO SAFE SD  |                             |
|AINB 50.72(b)(3)(v)(B)   POT RHR INOP           |                             |
|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       93       Power Operation  |93       Power Operation  |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| FAILURE OF REACTOR VESSEL WATER LEVEL SWITCH                                 |
|                                                                              |
| "At 11:00 EST, during performance of the 24 Month Calibration of Reactor     |
| Vessel Water Level Channels on Unit 2, Level Indicating Switch               |
| LIS-B21-2N031C would not properly relock following calibration. As a result  |
| of this, the switch was declared inoperable. A review of the design drawings |
| revealed that this switch provides inputs (through relays) that affect the   |
| reset logic for the 'A' and 'C' ESW pumps and the trips for the 'A' Reactor  |
| and Turbine Building Chillers on a Low Reactor Water Level signal. Without   |
| this switch functioning properly, the listed ESW pump start timers would not |
| reset as required and the listed chillers would not trip as required on the  |
| Low Reactor Water signal. The Tech Spec Basis for this instrumentation       |
| indicates that without these features, both offsite circuits and the         |
| associated Diesel Generators would be inoperable. Given this, both offsite   |
| sources and two (2) Diesel Generators were declared inoperable. SSES safety  |
| analysis requires three Operable Diesel Generators to safely shutdown the    |
| plant. Given this, this condition requires an 8 hour ENS notification in     |
| accordance with 10CFR50.72(b)(3)(v).                                         |
|                                                                              |
| "As a result of this condition, LCO 3.0.3 was entered on both Unit 1 and     |
| Unit 2 (in addition to other applicable LCO's). As of 13:00 on 01/24/02, the |
| switch was repaired and declared operable (and the associated LCO's were     |
| cleared).                                                                    |
|                                                                              |
| "There were no Diesel Generators, ECCS, or Tech Spec Electrical Distribution |
| systems out of service at the time of the event."                            |
|                                                                              |
| The NRC resident inspector has been informed of this notification by the     |
| licensee.                                                                    |
|                                                                              |
| * * * EVENT RETRACTED AT 1743 EST 3/7/02 BY GRANT FERNSLER TO GERRY WAIG * *
|
| *                                                                            |
|                                                                              |
| "A subsequent evaluation of the inoperable level switch determined that the  |
| impact, under worst case conditions, would have resulted in only one         |
| inoperable Emergency Diesel Generator. Both offsite power sources and the    |
| remaining three aligned Emergency Diesel Generators would remain operable.   |
| This is within the design basis of the plant and therefore the condition     |
| would not have resulted in a complete loss of a safety function. Based on    |
| that evaluation, ENS notification EN#38648 is retracted." The NRC Resident   |
| has been notified of the retraction by the licensee.                         |
|                                                                              |
| Notified the R1DO (Mohamed Shanbaky).                                        |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   38751       |
+------------------------------------------------------------------------------+
                         
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: CALLAWAY                 REGION:  4  |NOTIFICATION DATE: 03/07/2002|
|    UNIT:  [1] [] []                 STATE:  MO |NOTIFICATION TIME: 06:41[EST]|
|   RXTYPE: [1] W-4-LP                           |EVENT DATE:        03/07/2002|
+------------------------------------------------+EVENT TIME:        05:41[CST]|
| NRC NOTIFIED BY:  J. R. WEEKLY                 |LAST UPDATE DATE:  03/07/2002|
|  HQ OPS OFFICER:  MIKE NORRIS                  +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |DAVE LOVELESS        R4      |
|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  
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| PLANNED LOSS OF POWER TO EOF DUE TO MAINTENANCE                              |
|                                                                              |
| "During performance of planned maintenance, the Emergency Operation Facility |
| (EOF) will be de-energized. These maintenance activities, including          |
| electrical isolation and restoration are expected to last approximately 8    |
| hours. Contingency plans for emergency situations have been established.     |
|                                                                              |
| "This event is reportable per 10CFR50.72(b)(3)(xiii) since this constitutes  |
| a loss of an emergency response facility for the duration of the evolution.  |
|                                                                              |
| "The NRC Resident was previously notified that this activity was scheduled   |
| to occur and will be informed of this ENS notification."                     |
|                                                                              |
| * * * UPDATE ON 3/7/02 @ 2231 BY WEEKLEY TO GOULD * * *                      |
|                                                                              |
| Power restored at 20:34 CT.  Notified RDO(Loveless).                         |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   38752       |
+------------------------------------------------------------------------------+
                         
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: WATTS BAR                REGION:  2  |NOTIFICATION DATE: 03/07/2002|
|    UNIT:  [1] [] []                 STATE:  TN |NOTIFICATION TIME: 13:42[EST]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        03/07/2002|
+------------------------------------------------+EVENT TIME:        07:00[EST]|
| NRC NOTIFIED BY:  RICHARD KIMBROUGH            |LAST UPDATE DATE:  03/07/2002|
|  HQ OPS OFFICER:  GERRY WAIG                   +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |JAY HENSON           R2      |
|10 CFR SECTION:                                 |                             |
|NONR                     OTHER UNSPEC REQMNT    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE  
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          N       0        Refueling        |0        Refueling        |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| C-3 STEAM GENERATOR CLASSIFICATION BECAUSE GREATER THAN 1% OF THE
INSPECTED  |
| TUBES WERE DISCOVERED TO BE DEFECTIVE                                        |
|                                                                              |
| "At 0700 EST on March 7, 2002, with Watts Bar Unit 1 in Mode 6, steam        |
| generator inspections were being performed in accordance with Technical      |
| Specification (TS) 5.7.2.12, 'Steam Generator (SG) Tube Surveillance         |
| Program.' The results of the inspections performed on SG Number 4 indicated  |
| that greater than 1% of the inspected tubes were defective. Based on TS      |
| 5.7.2,12, this determination results in the classification of C-3. The       |
| current inspection results do not meet the criteria specified for steam      |
| generator tube degradation in Revision 2 of NUREG 1022, Event Reporting      |
| Guidelines 10 CFR 50.72 and 50.73. However, for classification C-3, WBN TS   |
| 5.9.9, 'SG Tube Inspection Report', requires that the results of the         |
| inspection be reported under 10 CFR 50.72.  At this time, the submittal of a |
| Licensee Event Report in accordance with 10 CFR 50.73 is not planned."       |
|                                                                              |
| The NRC Resident has been notified.                                          |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   38753       |
+------------------------------------------------------------------------------+
                         
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  ARKANSAS DEPARTMENT OF HEALTH        |NOTIFICATION DATE:
03/07/2002|
|LICENSEE:  ST BERNARDS REGIONAL HEALTH CTR      |NOTIFICATION TIME: 14:57[EST]|
|    CITY:  JONESBORO                REGION:  4  |EVENT DATE:        02/26/2002|
|  COUNTY:                            STATE:  AR |EVENT TIME:             [CST]|
|LICENSE#:  365-BP-07-97          AGREEMENT:  Y  |LAST UPDATE DATE:  03/07/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |DAVE LOVELESS        R4      |
|                                                |JANET SCHLUETER      NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  KIM WIEBECK                  |                             |
|  HQ OPS OFFICER:  GERRY WAIG                   |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| ST BERNARD'S REGIONAL MEDICAL CENTER MEDICAL MISADMINISTRATION               |
|                                                                              |
| The following event description is taken from a faxed report.                |
|                                                                              |
| "Description of Event:                                                       |
|                                                                              |
| Following initial source send, the proximal gold marker could not be         |
| discerned under fluoroscopy due to wire suture in the patients sternum.      |
| Twenty-four seconds elapsed between the arrival of the distal marker at the  |
| treatment site to source return to the delivery device. Two additional       |
| source sends were attempted with  immediate return of the sources due to the |
| inability to discern the proximal marker. Upon return of the sources to the  |
| delivery device, all sources were visible in the source chamber but the      |
| distal marker was not visualized. The treatment catheter was removed from    |
| the patient while still attached to the delivery device. The catheter and    |
| delivery device were placed into the bail-out box. The sources and distal    |
| cold marker were successfully returned to the delivery device following      |
| conclusion of the case."                                                     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   38754       |
+------------------------------------------------------------------------------+
                         
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: OCONEE                   REGION:  2  |NOTIFICATION DATE: 03/07/2002|
|    UNIT:  [1] [2] [3]               STATE:  SC |NOTIFICATION TIME: 20:03[EST]|
|   RXTYPE: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-L|EVENT DATE:        03/07/2002|
+------------------------------------------------+EVENT TIME:        14:00[EST]|
| NRC NOTIFIED BY:  RANDY TODD                   |LAST UPDATE DATE:  03/07/2002|
|  HQ OPS OFFICER:  GERRY WAIG                   +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |JAY HENSON           R2      |
|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  |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|3     N          Y       100      Power Operation  |100      Power Operation  |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| POTENTIAL LOSS OF SAFE SHUTDOWN CAPABILITY                                   |
|                                                                              |
|                                                                              |
| "At Oconee, TS 3.4.9 requires a minimum of 126 kW of Pressurizer heaters to  |
| be operable and capable of being powered from an emergency power supply.     |
| These heaters are needed to compensate for ambient heat loss from the        |
| Pressurizer in order to maintain single phase RCS natural circulation flow   |
| during various design basis events.                                          |
|                                                                              |
| In addition, TS 3.10.1 requires that the Standby Shutdown Facility (SSF) be  |
| operable for certain emergency conditions. One subsystem of the SSF is the   |
| Auxiliary Service Water (ASW) system. This system supplies a back-up         |
| emergency feedwater supply to any or all of the  three Oconee Units.         |
|                                                                              |
| The Bases for TS 3.10.1 document that, in order to maintain single phase RCS |
| natural circulation flow, an adequate number of Pressurizer heaters must be  |
| OPERABLE and capable of being powered from the SSF power supply.             |
|                                                                              |
| On March 7, 2002, Oconee Nuclear Site Engineering personnel concluded that   |
| heat transfer losses from the Reactor Coolant System Pressurizer to the      |
| reactor building environment exceeded the value previously used in system    |
| calculations and analyses. This conclusion was based on recent analysis of   |
| operational data on all three Oconee Units. There are two results of this    |
| conclusion:                                                                  |
|                                                                              |
| 1.Engineering concluded that the TS 3.4.9 requirement for a                  |
| minimum of 126 kW of heater capacity is nonconservative.                     |
| Operations personnel were notified. The operable capacity                    |
| greatly exceeds the minimum so current compliance with the                   |
| intent of TS 3.4.9 is not considered an issue.                               |
|                                                                              |
| 2.Engineering recommended to Operations that the SSF-ASW system be           |
| declared inoperable because the existing heater capacity powered             |
| from the SSF is less than the minimum needed to fully                        |
| compensate for the ambient heat losses as calculated from the                |
| recent analysis.                                                             |
|                                                                              |
| Event:                                                                       |
|                                                                              |
| At 1400 hours on March 7, 2002, Oconee Operations accepted the Engineering   |
| recommendation and conservatively declared the Standby Shutdown Facility     |
| (SSF) ASW system inoperable and entered TS 3.10.1, Condition A, which has a  |
| 7 day completion time. The SSF-ASW was declared inoperable due to the        |
| discovery by site Engineering that heat transfer losses from the Pressurizer |
| to the reactor building environment exceeded the capacity of Pressurizer     |
| heaters powered from the SSF power source.                                   |
|                                                                              |
| At the time of the discovery, there was no analysis to justify that single   |
| phase natural circulation could be maintained during all SSF design          |
| scenarios using the new loss values as inputs. Therefore Engineering         |
| concluded that there was a potential that two phase cooling might occur. At  |
| this time, the judgment of Engineering personnel is that two phase cooling   |
| would be adequate to protect the affected unit from any core damage, but two |
| phase cooling is outside the TS basis documented for TS 3.10.1.              |
|                                                                              |
| Analyses are in progress to support a revision of applicable Abnormal        |
| Procedure to provide interim compensatory guidance to Operators. It is       |
| expected that this guidance will allow the Operator to avoid two phase       |
| flow.                                                                        |
|                                                                              |
| Oconee personnel will evaluate more permanent corrective actions after       |
| additional analyses are completed.                                           |
|                                                                              |
| This event is conservatively being reported under 10 CFR 50.72(b)(3)(v) as a |
| condition that, at time of discovery, could have prevented the fulfillment   |
| of the safety function of the SSF ASW system to maintain a safe shutdown     |
| condition.                                                                   |
|                                                                              |
| The NRC Resident was notified at 1900 hours."                                |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Research Reactor                                 |Event Number:   38755       |
+------------------------------------------------------------------------------+
                         
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: UNIV OF MICHIGAN                     |NOTIFICATION DATE: 03/07/2002|
|   RXTYPE: 2000 KW POOL                         |NOTIFICATION TIME: 20:08[EST]|
| COMMENTS:                                      |EVENT DATE:        03/05/2002|
|                                                |EVENT TIME:             [EST]|
|                                                |LAST UPDATE DATE:  03/07/2002|
|    CITY:  ANN ARBOR                REGION:  3  +-----------------------------+
|  COUNTY:  WASHTENAW                 STATE:  MI |PERSON          ORGANIZATION |
|LICENSE#:  R-28                  AGREEMENT:  N  |JOHN MADERA          R3      |
|  DOCKET:  05000002                             |AL ADAMS             NRR     |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  BECKER                       |                             |
|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NPOW                     NON-POWER REACTOR EVENT|                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| 24-HOUR REPORT DUE TO TS VIOLATION INVOLVING A FUEL ELEMENT NOT
INSERTED IN  |
| ITS PROPER LOCATION DURING REFUELING                                         |
|                                                                              |
| "This is a 24-hour Notification regarding a violation of Technical           |
| Specification 3.4.3.   Following a major refueling                           |
| and rod calibrations, the reactor was started up in accordance with          |
| Operating Procedure 101, Reactor Startup.  The                               |
| reactor reached 2 MW on 6 March 2002 at 19:22 hours. The following morning 7 |
| March 2002 at 08:16 hours, the                                               |
| reactor was promptly shut down when the Day shift operating staff noted that |
| core location 77 was open, and did                                           |
| not contain a fuel element, reflector, sample holder or experimental         |
| facility as required by Technical Specification                              |
| 3.4.3."                                                                      |
|                                                                              |
| "The licensee identified safety concerns with respect to Technical           |
| Specifications 2.1.1 (safety' Limits in the Forced                           |
| Convection Mode), 2.1.1 (Safety Limits in the natural Convection Mode), and  |
| 3.1.4 (Reactivity Limits).  This                                             |
| occurrence may also involve unanalyzed conditions with respect to their      |
| Safety Analysis Report.  The safety concerns and unanalyzed conditions       |
| include: reactor operation in forced convection at 2MW with an open grid     |
| location                                                                     |
| providing bypass flow: a fuel element being in natural convection cooling    |
| mode with the reactor operating above                                        |
| 100 KW; and a fuel element outside the normal configuration while the        |
| reactor is critical."                                                        |
|                                                                              |
| "Description of Occurrence"                                                  |
|                                                                              |
| "4-5 March - Refueling during dayshift                                       |
| 5 March 18:15 - Commence reactor startup in forced convection mode for Rod   |
| Calibrations between 5 and 59 KW.                                            |
| 6 March 16:05 - Complete Rod Calibrations, shut down reactor                 |
| 17: 10 - Reactor Startup                                                     |
| 17:29 - 500 KW Checks                                                        |
| 17:32 - 1 MW, Calorimeter commenced                                          |
| 18:50 - Calorimeter completed                                                |
| 19:22 - Raise reactor power to 2 MW"                                         |
|                                                                              |
| "7 March 08:1 6 - Reactor Shutdown"                                          |
|                                                                              |
| "During this time indicated primary coolant flow was between 1053 to 1073    |
| gallons per minute.   A review of all nuclear instrument channel recorders   |
| showed no unusual indications.   The core excess reactivity and measured     |
| core worth were all normal."                                                 |
|                                                                              |
| "Core inspections were performed by many members of the operating staff as   |
| required by procedures during this                                           |
| time.  During refueling, all fuel handling was done with at least two        |
| persons observing.   A core inspection was                                   |
| performed immediately after refueling was completed.  In addition, three     |
| core inspections were performed during                                       |
| building checks while rod calibrations were in progress, a core inspection   |
| was made during the Reactor Startup's                                        |
| 500 KW checks, and core inspections were made by the Swing and Mid shifts    |
| during building checks while operating at 2 MW.  No abnormalities were noted |
| on any of these inspections.  Shortly after 08:00 on March 7, the Day shift  |
| operating staff inspected the core and noted that location 77 was open.  The |
| shift supervisor promptly shut down the reactor and informed both the        |
| On-Call Supervisor and the Reactor Manager."                                 |
|                                                                              |
| "A review of this occurrence has concluded that when grid location 77 was    |
| refueled, fuel element #304 ended up with its bottom nose cone outside the   |
| grid plate, while the bottom edge of the fuel element came to rest on the    |
| outside edge of the grid plate.  The top of the slightly tilted fuel element |
| was directly over location 77.   Thus the element appeared, when inspected   |
| from above, to be correctly seated.   Eventually, the element shifted to a   |
| vertical orientation caught between the edge of the grid plate and the       |
| nearby pneumatic tube bundle.   Once the element shifted, the open location  |
| 77 became apparent and the reactor was shut down."                           |
|                                                                              |
| "Safety Implications"                                                        |
|                                                                              |
| "Two main issues have been identified: (1) The effect of an open grid        |
| location on forced convection operation at 2 MW; and (2) the effect on the   |
| fuel element #304 of operating it in natural convection mode.   Analyses are |
| being performed on both issues.   A pool water sample was taken and          |
| analyzed.  The pool water analysis was compared to past analyses of fuel     |
| element cladding failures.  No fission products were noted.  Fuel element    |
| #304 has been temporarily secured with a line to prevent failing off the     |
| grid plate.  Procedures are being developed to remove the fuel element and   |
| will receive approval of the Safety Review Committee prior to                |
| implementation.  The reactor remains in operation as required by Technical   |
| Specifications, but is shutdown (zero power).   Analyses are being performed |
| on these conditions to determine their full impact."                         |
|                                                                              |
| "Root Causes"                                                                |
|                                                                              |
| "The Reactor Manager and Operations staff reviewed the occurrence.  The root |
| cause investigation is ongoing."                                             |
|                                                                              |
| "Immediate Corrective Actions"                                               |
|                                                                              |
| "The reactor was shut down and will not be restarted for sustained operation |
| until an operational review of this reportable occurrence is made and        |
| presented to the Safety Review Committee.   An initial outside review of     |
| this occurrence has been made by  the Dow Chemical Company, Midland,         |
| Michigan.   A closed-mouth hook (carabiner) has been lowered on a line with  |
| a stainless steel leader and attached to the handling bail of element #304   |
| to ensure it does not fall off the grid plate."                              |
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