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Event Notification Report for August 26, 2002

                        
                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           08/23/2002 - 08/26/2002

                              ** EVENT NUMBERS **

39141  39144  39148  39149  39150  39151  39152  

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   39141       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  WA DIVISION OF RADIATION PROTECTION  |NOTIFICATION DATE: 08/21/2002|
|LICENSEE:  PROVIDENCE EVERETT MEDICAL CENTER    |NOTIFICATION TIME: 15:02[EDT]|
|    CITY:  EVERETT                  REGION:  4  |EVENT DATE:        08/19/2002|
|  COUNTY:                            STATE:  WA |EVENT TIME:             [PDT]|
|LICENSE#:  WN-M0135-1            AGREEMENT:  Y  |LAST UPDATE DATE:  08/21/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |WILLIAM JOHNSON      R4      |
|                                                |DOUG BROADDUS        NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  TERRY C. FRAZEE (e-mail)     |                             |
|  HQ OPS OFFICER:  MIKE NORRIS                  |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT INVOLVING MEDICAL MISADMINISTRATION                   |
|                                                                              |
| "The licensee reported that a patient received 2640 cGy (rad) during a       |
| cardiac intravascular brachytherapy treatment instead of the intended 2000   |
| cGy (rad), a 32% overexposure.  The patient was being treated with the       |
| Guidant Corporation Galileo intravascular brachytherapy high dose rate       |
| remote afterloader device (serial #27958502) with a model GDT-P32-2 source   |
| wire (serial #020807016) containing 4.44 GBq (119.9 [millicuries]) of P-32   |
| at time of treatment.  The patient's vessel size was larger than the         |
| automatically calculated maximum diameter treatment.  A manual calculation   |
| of dwell time was required, based on the dose rate tables available in the   |
| Guidant Manual (section 6.13 table 5).  However, the dose rate for a 4.6 mm  |
| diameter (3.30 mm treatment depth) was inadvertently used instead of 4.05 mm |
| diameter (3.03 mm treatment depth). This resulted in a delivered dose of     |
| 2640 cGy (rad) at 3.03 mm.  The cause of the event is human error.  The      |
| licensee's corrective action is to have a second independent calculation     |
| performed by Physics and Dosimetry staff prior to treatment whenever a       |
| manual calculation using the dose rate tables is necessary.  No adverse      |
| consequences are expected. The referring physician and the patient were      |
| notified of the overexposure."                                               |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   39144       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: MILLSTONE                REGION:  1  |NOTIFICATION DATE: 08/22/2002|
|    UNIT:  [] [] [3]                 STATE:  CT |NOTIFICATION TIME: 17:06[EDT]|
|   RXTYPE: [1] GE-3,[2] CE,[3] W-4-LP           |EVENT DATE:        08/22/2002|
+------------------------------------------------+EVENT TIME:        16:33[EDT]|
| NRC NOTIFIED BY:  MICHAEL MARTELL              |LAST UPDATE DATE:  08/23/2002|
|  HQ OPS OFFICER:  FANGIE JONES                 +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |CLIFFORD ANDERSON    R1      |
|10 CFR SECTION:                                 |                             |
|AUNA 50.72(b)(3)(ii)(B)  UNANALYZED CONDITION   |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|                                                   |                          |
|                                                   |                          |
|3     N          Y       95       Power Operation  |95       Power Operation  |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| UNANALYZED CONDITION CONCERNING STEAM GENERATOR ATMOSPHERIC RELIEF VALVE     |
| BYPASS VALVES                                                                |
|                                                                              |
| Historical analysis deficiencies associated with the steam generator         |
| atmospheric dump bypass valves, a condition that during a fire could cause   |
| seriously degrade the safety of the plant.                                   |
|                                                                              |
| "The system affected is main steam, there are no actuation signals.  The     |
| cause is historical analysis deficiencies.  There are no affects on the      |
| plant.  There are no actions taken or planned at this time and there is no   |
| additional information.  The NRC Resident Inspector was notified.  The State |
| and Local Authorities have been notified."                                   |
|                                                                              |
| * * * UPDATE 1605EDT ON 8/23/02 FROM MICHAEL MARTELL TO S. SANDIN * * *      |
|                                                                              |
| The following information from Millstone Condition Report CR-02-08666 was    |
| provided by the licensee as an update:                                       |
|                                                                              |
| "On August 22, 2002, with Millstone Unit 3 in Mode 1, and as a result of     |
| transient analysis of the fire shutdown scenarios, the potential for         |
| spurious operation associated with the Main Steam atmospheric dump valve     |
| bypass motor operated valves (3MS*MOV74A thru D) from a hot short was found  |
| to result in non-compliance with the BTP 9.5-1 performance criteria. The     |
| Millstone Unit 3 licensing basis regarding BTP 9.5-1 performance criteria    |
| provides that a fire in an alternate shutdown area shall pose a transient no |
| more severe than a reactor trip due to loss of normal power and that         |
| pressurizer level remain in the indicating range. Spurious operation of      |
| plant components due to credible hot shorts must be postulated and have      |
| methods for mitigation that do not require the use of any other component    |
| potentially affected by the fire. The current BTP 9.5-1 compliance report    |
| and shutdown methods address the spurious opening of the Main Steam          |
| atmospheric dump valve bypass motor operated valves. Fire safe shutdown      |
| procedures provide methods for mitigating this spurious actuation.           |
|                                                                              |
| "On-going effort to validate assumptions used in the fire safe shutdown      |
| analysis concluded that insufficient operator response time was available to |
| support mitigation of this transient. It has been determined that spurious   |
| opening of one of the dump valves could cause pressurizer level to go below  |
| the indicating range in a time frame shorter than originally assumed. This   |
| condition is being reported as an unanalyzed condition that significantly    |
| degrades plant safety, pursuant to 50.72 (b)(3)(ii)(B).                      |
|                                                                              |
| "It should be noted that, consistent with the Licensing Basis, this analysis |
| assumes a fire of sufficient magnitude to result in an instantaneous hot     |
| short. Such fires are viewed to be very low probability events. The fire     |
| areas of concern are the control room and cable spreading area. The control  |
| room is continuously manned, and currently a continuous compensatory fire    |
| watch is required in the cable spreading room for other conditions. No       |
| additional compensatory actions are judged to be necessary at this time.     |
| Corrective actions are under evaluation in accordance with the Millstone     |
| corrective action program."                                                  |
|                                                                              |
| The licensee informed the NRC Resident Inspector.  Notified R1DO(Noggle).    |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   39148       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  GENERAL ELECTRIC COMPANY             |NOTIFICATION DATE: 08/23/2002|
|LICENSEE:  GE NUCLEAR ENERGY                    |NOTIFICATION TIME: 15:45[EDT]|
|    CITY:  SAN JOSE                 REGION:  4  |EVENT DATE:        08/23/2002|
|  COUNTY:                            STATE:  CA |EVENT TIME:             [PDT]|
|LICENSE#:                        AGREEMENT:  Y  |LAST UPDATE DATE:  08/23/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |WILLIAM JOHNSON      R4      |
|                                                |KEN BARR             R2      |
+------------------------------------------------+VERN HODGE - FAX     NRR     |
| NRC NOTIFIED BY:  JASON POST                   |                             |
|  HQ OPS OFFICER:  FANGIE JONES                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|CCCC 21.21               UNSPECIFIED PARAGRAPH  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| 10 CFR 21 REPORT:  MAIN STEAM LINE OUT-OF-SERVICE                            |
|                                                                              |
| The following is taken from a facsimile report:                              |
|                                                                              |
| "This letter provides notification of a Reportable Condition under 10CFR     |
| 21.21(d) and as an interim report per 21.21.(a)(2) for other plants that    |
| may be determined to be affected. The basis for this conclusion is that a    |
| 1988 GE Nuclear Energy (GE) analysis for Brunswick Units 1 and 2 full power  |
| operation with one Main Steamline Isolation Valve (MSIV) Out of Service      |
| (OOS) provided to Carolina Power and Light (CP&L) did not adequately address |
| the increased flow induced vibratory loads on the MSIVs to assure they would |
| be able to perform their required safety function which could result in      |
| potential offsite exposures in excess of those in 10CFR100.11.               |
|                                                                              |
| "The GE MSIV OOS analysis evaluated plant operation at 100% power with three |
| active steamlines and one set of MSIVs closed (OOS). The GE analysis did not |
| address the increased steam flow hardware effect of potential long-term flow |
| induced vibration degradation on the MSIVs, including the effect on the MSIV |
| air operated controls. During three steamline operation the steam flow in    |
| each line would increase to approximately 133% of normal flow. No vibration  |
| measurements (empirical or experimental data) exist for either Brunswick     |
| Units during operation up to this increased steam flow level.                |
|                                                                              |
| "If it is postulated that the plant operated for an extended period in the   |
| MSIV OOS condition and then a main steam line break is postulated to occur   |
| in one of the three operational steam lines, then there is the potential     |
| that neither MSIV would close to terminate the release from a steamline      |
| break. Because GE has no analytical or experience basis (no available        |
| empirical or experimental data) to support higher main steam line flow rates |
| greater than previously tested, it could be postulated that a common mode    |
| failure of both MSIVs, in the broken line, could occur. Alternatively,       |
| failure of one MSIV due to the high flow induced vibration and the other     |
| MSIV as the design basis single failure, would result in an un-terminated    |
| release, which would exceed the existing 10 CFR 100 radiation release        |
| limits.                                                                      |
|                                                                              |
| "GE has verbally communicated to CP&L the need for the 75% power limitation  |
| when exercising the MSIV OOS flexibility and will follow-up with a written   |
| communication.                                                               |
|                                                                              |
| "GE is reviewing all other MSIV OOS analyses performed by GE for other BWRs  |
| and will communicate to any similarly affected utilities, similar corrective |
| actions. GE will notify all affected utilities that GE recommends operation  |
| at the 75% power level when operating with one MSIV 005, unless there is     |
| sufficient test data to support operation at a higher power level. This      |
| effort will be completed by September 30, 2002."                             |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   39149       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: ROBINSON                 REGION:  2  |NOTIFICATION DATE: 08/24/2002|
|    UNIT:  [2] [] []                 STATE:  SC |NOTIFICATION TIME: 08:50[EDT]|
|   RXTYPE: [2] W-3-LP                           |EVENT DATE:        08/24/2002|
+------------------------------------------------+EVENT TIME:        07:50[EDT]|
| NRC NOTIFIED BY:  DON KNIGHT                   |LAST UPDATE DATE:  08/24/2002|
|  HQ OPS OFFICER:  RICH LAURA                   +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |KEN BARR             R2      |
|10 CFR SECTION:                                 |                             |
|ACOM 50.72(b)(3)(xiii)   LOSS COMM/ASMT/RESPONSE|                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| PLANNED OUTAGE ON ERFIS SYSTEM                                               |
|                                                                              |
| "Emergency Response Data System (ERDS) and Safety Parameter Display System   |
| (SPDS) inoperable due to planned outage of the Emergency Response Facility   |
| Information System (ERFIS).                                                  |
|                                                                              |
| "At 07:50 Hours on August 24, 2002, the H. B. Robinson Steam Electric Plant, |
| Unit No. 2, ERFIS computer system was removed from service for a planned     |
| outage to upgrade this system. The expected duration of the outage is        |
| approximately 5 days. During this time, the ERDS and SPDS will be            |
| unavailable. Alternate means are identified in the HBRSEP, Unit No. 2,       |
| emergency preparedness procedures to collect and distribute data that would  |
| normally be available by the SPDS. The HBRSEP, Unit No. 2, Emergency         |
| Response Organization remains able to respond to an event during the time    |
| the ERFIS is unavailable.                                                    |
|                                                                              |
| "The planned ERFIS changes. when completed, are not expected to change the   |
| ERDS transmission format or data point library. Therefore, additional        |
| reports in accordance with 10 CFR 50, Appendix E, VI. 3. a and b are not     |
| expected.                                                                    |
|                                                                              |
| "The NRC Resident Inspector has been notified."                              |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   39150       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: CALLAWAY                 REGION:  4  |NOTIFICATION DATE: 08/24/2002|
|    UNIT:  [1] [] []                 STATE:  MO |NOTIFICATION TIME: 09:33[EDT]|
|   RXTYPE: [1] W-4-LP                           |EVENT DATE:        08/24/2002|
+------------------------------------------------+EVENT TIME:        08:26[CDT]|
| NRC NOTIFIED BY:  STEVE KOCHERT                |LAST UPDATE DATE:  08/24/2002|
|  HQ OPS OFFICER:  RICH LAURA                   +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |WILLIAM JOHNSON      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 THE EOF FOR 20 HOURS                                         |
|                                                                              |
| "During performance of planned maintenance, the Emergency Operation Facility |
| (EOF) will be without ventilation capabilities. These maintenance            |
| activities, including electrical isolation and restoration are expected to   |
| last approximately 20 hours. Contingency plans for emergency situations have |
| been established.                                                            |
|                                                                              |
| "This event is reportable per 10 CFR50.72(b)(3)(xiii) since this constitutes |
| a loss of an emergency response facility for the duration of the evolution.  |
|                                                                              |
| "The NRC Resident has been notified."                                        |
|                                                                              |
| * * * UPDATE AT 1445EDT ON 8/24/02 FROM STEVE KOCHERT TO S. SANDIN * * *     |
|                                                                              |
| At 1335CDT on 8/24/02 the EOF was declared functional and restored to        |
| operation.                                                                   |
|                                                                              |
| The licensee will inform the NRC Resident Inspector.  Notified               |
| R4DO(Johnson).                                                               |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   39151       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: CALVERT CLIFFS           REGION:  1  |NOTIFICATION DATE: 08/24/2002|
|    UNIT:  [1] [2] []                STATE:  MD |NOTIFICATION TIME: 10:40[EDT]|
|   RXTYPE: [1] CE,[2] CE                        |EVENT DATE:        08/24/2002|
+------------------------------------------------+EVENT TIME:        07:50[EDT]|
| NRC NOTIFIED BY:  LEO GETZ                     |LAST UPDATE DATE:  08/24/2002|
|  HQ OPS OFFICER:  RICH LAURA                   +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |JAMES NOGGLE         R1      |
|10 CFR SECTION:                                 |                             |
|ACOM 50.72(b)(3)(xiii)   LOSS COMM/ASMT/RESPONSE|                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1     N          Y       100      Power Operation  |100      Power Operation  |
|2     N          Y       100      Power Operation  |100      Power Operation  |
|                                                   |                          |
+------------------------------------------------------------------------------+
                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| LOSS OF CALVERT COUNTY EP SIREN ACTIVATION SYSTEM DUE TO LIGHTNING STRIKES   |
|                                                                              |
| "At 07:50 on 8/24/02, notified by system engineer that Calvert County sirens |
| are out of service due to multiple lightning strikes affecting the Calvert   |
| control center siren activation circuit.  The county is using route alerting |
| as a compensatory measure."                                                  |
|                                                                              |
| The NRC resident inspector was notified.                                     |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Power Reactor                                    |Event Number:   39152       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: BEAVER VALLEY            REGION:  1  |NOTIFICATION DATE: 08/25/2002|
|    UNIT:  [] [2] []                 STATE:  PA |NOTIFICATION TIME: 00:45[EDT]|
|   RXTYPE: [1] W-3-LP,[2] W-3-LP                |EVENT DATE:        08/24/2002|
+------------------------------------------------+EVENT TIME:        20:00[EDT]|
| NRC NOTIFIED BY:  PETE SENA                    |LAST UPDATE DATE:  08/25/2002|
|  HQ OPS OFFICER:  RICH LAURA                   +-----------------------------+
+------------------------------------------------+PERSON          ORGANIZATION |
|EMERGENCY CLASS:          NON EMERGENCY         |JAMES NOGGLE         R1      |
|10 CFR SECTION:                                 |                             |
|AUNA 50.72(b)(3)(ii)(B)  UNANALYZED CONDITION   |                             |
|AIND 50.72(b)(3)(v)(D)   ACCIDENT MITIGATION    |                             |
|                                                |                             |
|                                                |                             |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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                                   
+------------------------------------------------------------------------------+
| GAS VOIDING IN ECCS PIPING                                                   |
|                                                                              |
| "At 0425 hrs on 8/24/2002, a gas void was identified in Emergency Core       |
| Cooling System (ECCS) piping at Beaver Valley Power Station (BVPS) Unit No.  |
| 2 that exceeded the gas void volume limit of .872 cubic feet. A gas void     |
| which exceeds .872 cubic feet could potentially disable a single High Head   |
| Safety Injection (HHSI) pump if ingested. The gas void was located in the    |
| 'B' train piping which would be used (only) following the                    |
| transfer-to-recirculation phase of a Loss of Coolant Accident (LOCA).        |
| Technical Specification Action 3.5.2.a and 3.5.2.d was entered for 'B' ECCS  |
| train not being operable. The piping where the void was located leads to a   |
| common HHSI pump suction header which connects to both trains' HHSI pumps.   |
|                                                                              |
| "At 1345 hrs on 8/24/2002, an isolation valve (2SIS-MOV863B) was             |
| de-energized closed. De-energizing this isolation valve prevents the gas     |
| void traveling to the common HHSI suction header during                      |
| transfer-to-recirculation flow. This was done as a general precaution to     |
| strengthen the operable 'A' HHSI train during the ongoing gas void           |
| generation investigation since this gas void generation process was not yet  |
| fully understood.                                                            |
|                                                                              |
| "At 1638 hrs on 8/24/2002 it was calculated that the actual gas void volume  |
| in the 'B' train piping was 1.3 cubic feet. It was also identified that the  |
| previously established gas void volume limit of .872 cubic feet was          |
| incorrect and the applicable gas void volume limit was .319 cubic feet. With |
| an evaluation of the new gas void limit, it was concluded at 2000 hrs that   |
| BVPS Unit No. 2 had been vulnerable to a degradation of both trains' HHSI    |
| pumps between 0425 and 1345. This would be possible since the gas void could |
| potentially have split in half (0.65 cubic feet) and migrated during         |
| post-LOCA transfer-to-recirculation flow through the common HHSI suction     |
| header. Each half-sized void could enter each train's HHSI pump, potentially |
| affecting both trains of HHSI pumps (.65 cubic feet would exceed the limit   |
| of .319 cubic feet for each pump). This is reportable pursuant to            |
| 10CFR50.72(b)(3)(ii)(B) as being in an unanalyzed condition that             |
| significantly degraded plant safety. This is also reportable pursuant to     |
| 10CFR50.72(b)(3)(v)(D) as a condition that at the time of discovery could    |
| have prevented the fulfillment of the safety function of systems needed to   |
| mitigate consequences of an accident.                                        |
|                                                                              |
| "Currently with 2SIS-M0V863B de-energized closed, the gas void can not       |
| travel to the 'A' train HHSI pump. Actions are being initiated to eliminate  |
| this gas void. BVPS Unit No. 2 remains in Tech Specification Action 3.5.2.a  |
| and 3.5.2.d for one ECCS subsystem inoperable. The investigation of the gas  |
| void generation process is continuing."                                      |
|                                                                              |
| The NRC Resident Inspector was notified.                                     |
+------------------------------------------------------------------------------+