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 +------------------------------------------------------------------------------+ |Power Reactor |Event Number: 38602 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | 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 +------------------------------------------------------------------------------+ | 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 | +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ +------------------------------------------------------------------------------+ | 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." | +------------------------------------------------------------------------------+
Page Last Reviewed/Updated Wednesday, March 24, 2021
Page Last Reviewed/Updated Wednesday, March 24, 2021