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Event Notification Report for July 9, 2002

                         
                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           07/08/2002 - 07/09/2002

                              ** EVENT NUMBERS **

38992  39021  39040 39045  39047  
.
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
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|Power Reactor                                    |Event Number:   38992       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: NINE MILE POINT          REGION:  1  |NOTIFICATION DATE: 06/14/2002|
|    UNIT:  [] [2] []                 STATE:  NY |NOTIFICATION TIME: 11:24[EDT]|
|   RXTYPE: [1] GE-2,[2] GE-5                    |EVENT DATE:        06/13/2002|
+------------------------------------------------+EVENT TIME:        11:30[EDT]|
| NRC NOTIFIED BY:  DOUG RICHARDSON              |LAST UPDATE DATE:  07/08/2002|
|  HQ OPS OFFICER:  RICH LAURA                   +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |LAWRENCE DOERFLEIN   R1      |
|10 CFR SECTION:                                 |JOHN DAVIDSON        IAT     |
|NONR                     OTHER UNSPEC REQMNT    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE  
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| 24 HOUR REPORT ON LICENSE CONDITION 2F                                       |
|                                                                              |
| " At 1130 hours on 6/13/02 it was discovered that the Safety Relief Valve    |
| (SRV) Position Indication Channel for one of the SRVs controlled from the    |
| Remote Shutdown Panel was inoperable. The inoperability was due to both      |
| alarm card inhibit switches for associated acoustic monitoring channel being |
| found to be in the inhibit  position. These switches are normally in the     |
| "alarm"  position. With the switches in the "inhibit" position the SRV       |
| position indication from a high vibration condition would not provide an     |
| open position indication for the SRV in the Control Room or at the Remote    |
| Shutdown Panel. Immediate Action was to return the switches to the  alarm    |
| position and all other SRV acoustic monitoring switches were verified to be  |
| in the correct "alarm" position.                                             |
|                                                                              |
| "Technical Specification LCO 3.3.3.2 requires that the Remote Shutdown       |
| System Functions shall be OPERABLE. With this channel inoperable, Required   |
| Actions require restoration to OPERABLE status within 30 days OR placing the |
| Unit in Mode 3 within the following 12 hours. Since the potential exists     |
| that this condition has existed in excess of the 30-day requirement this     |
| event may be considered a Condition Prohibited by Technical Specifications.  |
|                                                                              |
| "This report is being made in accordance with Section 2F of Operating        |
| License NPF-69 for Nine-Mile Point Unit 2. Section 2F requires that the      |
| initial notification of a violation of any requirement contained in Section  |
| 2C to the Operating License (License Conditions) be reported to the NRC      |
| Operations Center via the Emergency Notification System within 24 hours with |
| written follow-up with 30 days. License Condition 2C requires that Nine Mile |
| Point Nuclear Station, LLC shall operate the facility in accordance with the |
| Technical Specifications."                                                   |
|                                                                              |
| The NRC Resident Inspector has been notified.                                |
|                                                                              |
| ****Retraction on 07/08/02 at 1634 ET by Mr. Cigler taken by MacKinnon ****  |
|                                                                              |
|                                                                              |
| "A subsequent investigation concluded that there is no firm evidence that    |
| the switches were in the wrong position in excess of 30 days.  Based on the  |
| guidance of NUREG 1022, Rev 2, section 3.2.2, the previous report made is    |
| being retracted."   R1DO (Brian McDermott)                                   |
|                                                                              |
| The NRC Resident Inspector was notified of this retraction by the licensee.  |
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.
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED  !!!!!!!
+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   39021       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: OYSTER CREEK             REGION:  1  |NOTIFICATION DATE: 06/27/2002|
|    UNIT:  [1] [] []                 STATE:  NJ |NOTIFICATION TIME: 06:45[EDT]|
|   RXTYPE: [1] GE-2                             |EVENT DATE:        06/26/2002|
+------------------------------------------------+EVENT TIME:        22:52[EDT]|
| NRC NOTIFIED BY:  ERIC DEMONCH                 |LAST UPDATE DATE:  07/08/2002|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |MICHAEL MODES        R1      |
|10 CFR SECTION:                                 |                             |
|AINC 50.72(b)(3)(v)(C)   POT UNCNTRL RAD REL    |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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                                   
+------------------------------------------------------------------------------+
| BOTH CHANNELS OF OFFGAS RADIATION MONITORS DECLARED INOPERABLE              
|
|                                                                              |
| Both channels of offgas radiation monitors declared inoperable due to a      |
| common mode failure.  Both channels detect offgas radiation levels in the    |
| same sample volume.  The sample volume filled with condensate suppressing    |
| the radiation levels.  The offgas radiation monitors provide for isolation   |
| of the main condensers on indications of fuel element failure.  This puts    |
| the licensee in a 72 hour clock allowing for repairs or shutdown, per        |
| Technical Specification Table 3.1.1 Instrument Operability.                  |
|                                                                              |
| The licensee intends to notify the NRC Resident Inspector.                   |
|                                                                              |
| * * * RETRACTED AT 1412 EDT ON 7/8/02 BY STEVE FULLER TO FANGIE JONES * * *  |
|                                                                              |
| The licensee is retracting the event notification after reviewing the event  |
| and determining that the monitors do not perform a safety function that is   |
| relied on in the safety analysis of the plant.  Also, the monitors do not    |
| affect the plant or its safety barriers.                                     |
|                                                                              |
| The licensee intends to notify the NRC Resident Inspector.  The R1DO (Brian  |
| McDermott)                                                                   |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   39040       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  COLORADO DEPT OF HEALTH              |NOTIFICATION DATE: 07/03/2002|
|LICENSEE:  SWEDISH MEDICAL CENTER               |NOTIFICATION TIME: 12:09[EDT]|
|    CITY:  DENVER                   REGION:  4  |EVENT DATE:        06/24/2002|
|  COUNTY:                            STATE:  CO |EVENT TIME:             [MDT]|
|LICENSE#:                        AGREEMENT:  Y  |LAST UPDATE DATE:  07/03/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |DALE POWERS          R4      |
|                                                |                     NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  STATE OF COLORADO            |                             |
|  HQ OPS OFFICER:  GERRY WAIG                   |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION                           |
|                                                                              |
| The following is taken, in-part, from a facsimile report:                    |
|                                                                              |
| "A patient received 5 fractions of brachytberapy using an lr-192 HDR unit    |
| and a tandem/ovoids applicator. During the treatment planning process, an    |
| incorrect magnification factor for the orthogonal films on which the         |
| Dosimetry was based had been used. This resulted in an underdose of          |
| approximately 50% or more depending on the part of the treatment volume used |
| for comparison.                                                              |
|                                                                              |
| "The initial and corrected dosimetry has been reviewed by 3 additional       |
| physicists. The corrected Dosimetry has been verified using an independent   |
| film digitization system and TPS. A composite Dosimetry summary of the       |
| treatment as delivered has been prepared and verified. Based on that         |
| information the prescribing physician will administer an additional          |
| brachytherapy application to compensate for the lower than prescribed dose   |
| from the initial 5 fractions.                                                |
|                                                                              |
| [The original prescribing physician] "contacted the patient tonight, 2 July  |
| 2002.  He reported the underdose, recommended an additional brachytherapy    |
| procedure and described the misadministration report."                       |
+------------------------------------------------------------------------------+
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+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   39045       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SOUTH TEXAS              REGION:  4  |NOTIFICATION DATE: 07/08/2002|
|    UNIT:  [] [2] []                 STATE:  TX |NOTIFICATION TIME: 02:57[EDT]|
|   RXTYPE: [1] W-4-LP,[2] W-4-LP                |EVENT DATE:        07/07/2002|
+------------------------------------------------+EVENT TIME:        23:12[CDT]|
| NRC NOTIFIED BY:  STEVEN KASPER                |LAST UPDATE DATE:  07/08/2002|
|  HQ OPS OFFICER:  RICH LAURA                   +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |DALE POWERS          R4      |
|10 CFR SECTION:                                 |                             |
|ARPS 50.72(b)(2)(iv)(B)  RPS ACTUATION - CRITICA|                             |
|AESF 50.72(b)(3)(iv)(A)  VALID SPECIF SYS ACTUAT|                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE  
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|2     A/R        Y       100      Power Operation  |0        Hot Standby      |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AUTOMATIC REACTOR TRIP                                                       |
|                                                                              |
| "At 2312 on 07/07/2002 Unit 2 Reactor automatically tripped from full power  |
| due to a high high Steam Generator Level In the 2B Steam Generator. Prior to |
| the trip Vital distribution panel 1202 lost power when it's normal power     |
| supply inverter failed. All of the controlling channels of Steam Generator   |
| level were powered from this distribution panel and failed low on the loss   |
| of power. Operators were in the process of taking manual control of all Feed |
| Water Regulating valves when the Main Turbine trip was actuated due to the   |
| high high level in Steam Generator 28. A Reactor Trip occurred due to        |
| Turbine Trip above 50% power. The unit is stable in Mode 3 with RCS          |
| temperature at 567 degrees Fahrenheit, and RCS pressure of 2235 pslg.        |
|                                                                              |
| "We also make the following report per 10CFR50.72(b)(3)(iv): Following the   |
| Reactor Trip the Auxiliary Feed Water System automatically actuated on low   |
| Steam Generator level. This is normal for a trip in Unit 2 from full power   |
| with the Model E Steam Generators.                                           |
|                                                                              |
| "The following information is also provided:                                 |
|                                                                              |
| "Did the control rods fully insert? Yes                                      |
|                                                                              |
| "Did steam bypass to the condenser or to atmosphere? The Steam Dump system   |
| automatically operated to maintain temperature. No steam bypass to           |
| atmosphere occurred.                                                         |
|                                                                              |
| "Did any primary/secondary relief valve lift? NO                             |
|                                                                              |
| "Any significant TS LCOs entered? TS 3.8.3.1 Action b. was entered due to    |
| vital DP 1202 not being powered from its normal power supply inverter. We    |
| must reenergize the AC distribution panel from its associated inverter       |
| connected to its associated D.C. bus within 24 hours or be in at least HOT   |
| Standby within the next 6 hours and in Cold Shutdown within the following 30 |
| hours.                                                                       |
|                                                                              |
| "Item not understood: Channel 1 of P-13 Reactor Trip System interlock status |
| light is currently blinking. This condition must be understood and corrected |
| prior to restart."                                                           |
|                                                                              |
| The NRC resident inspector was notified.                                     |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   39047       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: MILLSTONE                REGION:  1  |NOTIFICATION DATE: 07/08/2002|
|    UNIT:  [] [] [3]                 STATE:  CT |NOTIFICATION TIME: 16:42[EDT]|
|   RXTYPE: [1] GE-3,[2] CE,[3] W-4-LP           |EVENT DATE:        07/08/2002|
+------------------------------------------------+EVENT TIME:        16:00[EDT]|
| NRC NOTIFIED BY:  BARRETT NICHOLS              |LAST UPDATE DATE:  07/08/2002|
|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |BRIAN MCDERMOTT      R1      |
|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 TO STATE OF THE CONNECTICUT DEPARTMENT OF
ENVIRONMENTAL |
| PROTECTION                                                                   |
|                                                                              |
| In a Material Engineering Lab storage cabinet  a 250 milliliter container    |
| approximately 25% full was found to contain liquid picric acid.  The         |
| Material Engineering Lab is located in a Warehouse in the Owners Control     |
| Area but is not in the Protected Area.  A contract HAZMAT team, Onyx, was    |
| called to the site to remove the container.  The State of Connecticut        |
| Department of Environmental Protection was notified of this information.     |
|                                                                              |
| The NRC Resident Inspector was notified of this event by the licensee.       |
+------------------------------------------------------------------------------+
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