Event Notification Report for August 7, 2003
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
08/06/2003 - 08/07/2003
** EVENT NUMBERS **
39631 39941 40033 40049
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|Power Reactor |Event Number: 39631 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SAINT LUCIE REGION: 2 |NOTIFICATION DATE: 03/02/2003|
| UNIT: [1] [2] [] STATE: FL |NOTIFICATION TIME: 16:00[EST]|
| RXTYPE: [1] CE,[2] CE |EVENT DATE: 03/02/2003|
+------------------------------------------------+EVENT TIME: 14:30[EST]|
| NRC NOTIFIED BY: CHARLES PIKE |LAST UPDATE DATE: 08/06/2003|
| HQ OPS OFFICER: GERRY WAIG +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |WALTER RODGERS R2 |
|10 CFR SECTION: |DAVID AYRES R2 |
|APRE 50.72(b)(2)(xi) OFFSITE NOTIFICATION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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
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| OFFSITE NOTIFICATION TO STATE AGENCY OF EXPIRED GREEN SEA TURTLE FOUND AT |
| BARRIER NET |
| |
| "NRC notification [is] being made due to state notification to [the] Florida |
| Wildlife Commission regarding a Green Sea Turtle found dead at barrier net |
| pursuant to 10 CFR 50.72(b)(2)(xi)." |
| |
| The turtle was found on the surface at the barrier net with no injuries or |
| abnormalities except for fresh cuts common for turtles coming through pipes. |
| The cause of death is unknown at this time. A necropsy is planned. |
| |
| The NRC Resident Inspector will be notified by the licensee. |
| |
| * * * UPDATE ON 3/15/03 @ 1033 EST FROM TEREZAKIS TO CROUCH * * * |
| |
| "On 3-15-03, a green sea turtle was retrieved from the plant's intake canal. |
| The turtle was determined to be in need of rehabilitation. The injuries to |
| the turtle are not causal to plant operation. Per the plant's turtle permit, |
| the Florida Fish and Wildlife Conservation Commission (FWCC) was notified at |
| 0920 EST. This non-emergency notification is being made pursuant to 10 CFR |
| 50.72(b)(2)(xi) due to the notification of FWCC." |
| |
| The NRC Resident Inspector will be notified by the licensee. |
| |
| * * * UPDATE ON 3/19/03 AT 1222 EST FROM E. SUMNER TO RIPLEY * * * |
| |
| "On 03/19/03 @ 1105 hrs., one loggerhead turtle was retrieved from the |
| plant's intake canal. The turtle was determined to be in need of |
| rehabilitation. The injury to the turtle is not causal to plant operation. |
| Per the plant's turtle permit, the Florida Fish and Wildlife Conservation |
| Commission (FWCC) was notified at 1115 EST." |
| |
| The NRC Resident Inspector was notified. |
| |
| * * * UPDATED ON 3/31/03 AT 1159 EST FROM W.L. PARK TO A. COSTA * * * |
| |
| "On 3-31-03 [1105 EST], a loggerhead sea turtle was retrieved from the |
| plant's intake canal. The turtle was determined to be in need of |
| rehabilitation. The injuries to the turtle are not causal to plant |
| operation. Per the plant's turtle permit, the Florida Fish and Wildlife |
| Conservation Commission (FWCC) was notified at 1105 EST. This non-emergency |
| notification is being made pursuant to 10 CFR 50.72(b)(2)(xi) due to the |
| notification of FWCC." |
| |
| The NRC Resident Inspector will be notified. |
| |
| * * * UPDATE 1235EST ON 4/9/03 FROM ANDY TEREZAKIS TO S.SANDIN * * * |
| |
| "On 4-9-03, a loggerhead sea turtle was retrieved from the plant's Intake |
| canal. The turtle was determined to be in need of rehabilitation. The |
| injuries to the turtle are not causal to plant operation. Per the plant's |
| turtle permit, the Florida Fish and Wildlife Conservation Commission (FWCC) |
| was notified at 1100 EST. This non-emergency notification is being made |
| pursuant to 10CFR50.72(b)(2)(xi) due to the notification of FWCC." |
| |
| The licensee informed the NRC resident inspector. Notified R2DO(Landis). |
| |
| *** UPDATE ON 5/2/03 AT 1826 FROM S. OEHRLE TO A. COSTA *** |
| |
| "On 5/2/03, a green sea turtle was retrieved from the intake canal. The |
| turtle required rehabilitation. The injuries were not causal to plant |
| operation. Per the plant's turtle permit, the Florida Fish and Wildlife |
| Conservation Commission was notified at 1445 EDT. This non-emergency |
| notification is being made pursuant to 10 CFR 50.72 (b)(2)(xi) due to |
| offsite notification." |
| |
| The Licensee will notify the NRC Resident Inspector. Notified R2DO |
| (Munday). |
| |
| **** update on 05/24/03 at 1417 EDT FROM JOE HESSLING TO JOHN MACKINNON |
| **** |
| |
| "On 5-24-03, a loggerhead sea turtle was retrieved from the plant's intake |
| canal. The turtle was determined to be in need of rehabilitation. The |
| turtle was very underweight and lethargic, no injuries or anomalies noted. |
| Turtle's condition is not causal to plant operation. Per the plant's turtle |
| permit the Florida Fish and Wildlife Conservation Commission (FWCC) was |
| notified at 1345 EDT. This non-emergency notification is being made |
| pursuant to 10 CFR 50.72(b)(2)(xi) due to the notification of FWCC. NRC R2DO |
| (TOM DECKER) notified. |
| |
| The NRC Resident Inspector was by notified of this event by the licensee. |
| |
| ****UPDATE ON 5/27/03 AT 10:49 FROM HESSLING TO LAURA**** |
| |
| "On 5-27-03, a loggerhead sea turtle was retrieved from the plant's intake |
| canal. The turtle was determined to be in need of rehabilitation. The turtle |
| was underweight, and missing lower posterior marginals on left side. |
| Turtle's injuries are not causal to plant operation. Per the plant's turtle |
| permit, the Florida Fish and Wildlife Conservation Commission (FWCC) was |
| notified at 0850 EDT. This non-emergency notification is being made pursuant |
| to 10 CFR 50.72(b)(2)(xi) due to the notification of FWCC." |
| |
| Notified R2DO (T. Decker) |
| |
| * * * UPDATE ON 06/17/03 AT 12:45 EDT FROM CALVIN WARD TO ARLON COSTA * * * |
| |
| "At approximately 12:45 p.m. on 6/17/03 a loggerhead turtle was rescued from |
| the St. Lucie Plant intake canal. The turtle was injured and will be |
| transported to the State authorized sea turtle rehabilitation facility. The |
| Florida Dept. of Environmental Protection (FDEP) was notified at 1:09 p.m. |
| as required by the St. Lucie Plant Sea Turtle Permit - see the attached sea |
| turtle stranding report (1 page). |
| |
| "Notification to the state government agency requires a four (4) Hr. |
| Non-Emergency Notification to the NRC per 10 CFR 50.72(b)(2)(xi). There were |
| no unusual plant evolutions in progress which may have contributed to this |
| event." |
| |
| The licensee notified the NRC Resident Inspector. |
| |
| Notified R2DO (L. Wert). |
| |
| * * * UPDATE 0605 EDT ON 6/26/03 FROM STEVE MERRILL TO S. SANDIN * * * |
| |
| The licensee was informed by the FWCC that the green sea turtle requiring |
| rehabilitation which was retrieved from the plant's intake canal on 3/15/03 |
| had expired within 10 days of removal. Consequently, the licensee is |
| updating their 3/15/03 report to include this additional information. The |
| licensee will inform the NRC Resident Inspector. Notified R2DO(C. Ogle). |
| |
| * * * UPDATE 1506 EDT ON 07/01/03 FROM CALVIN WARD TO GOTT * * * |
| |
| On 04/02/03, a green sea turtle was retrieved from the intake canal. The |
| turtle required rehabilitation. The injuries were not causal to plant |
| operation. Per the plant's turtle permit, the Florida Fish and Wildlife |
| Conservation Commission was notified. This non-emergency notification is |
| being made pursuant to 10 CFR 50.72 (b)(2)(xi) due to offsite notification. |
| On 07/01/03 licensee QA discovered that the injury had occurred and that the |
| NRC had not been notified within the 4 hours. The failure to report the |
| event within the regulatory time is being investigated and has been entered |
| into the stations corrective action program. |
| |
| The licensee notified the NRC Resident Inspector. |
| |
| Notified R2DO (Munday) |
| |
| * * * UPDATE 1750 EDT ON 07/07/03 FROM JOE HESSLING TO MACKINNON * * * |
| |
| On 07/07/03, a Loggerhead sea turtle was retrieved from the plants' intake |
| canal. The turtle was determined to be in need of rehabilitation. The |
| injuries to the turtle are not causal to plant operation. Per the plant's |
| Turtle permit, the Florida Fish and Wildlife Conversation Commission (FWCC) |
| was notified at 1715 EDT. This non-emergency is being made pursuant to 10 |
| CFR 50.72(b)(2)(xi) due to the notification of FWCC. |
| |
| The licensee notified the NRC Resident Inspector. |
| |
| Notified R2DO (Munday). |
| |
| |
| * * * UPDATE ON 07/25/03 @ 1510 BY CALVIN WORD TO STEVE SANDIN * * * |
| |
| On 7/25/03, a sea turtle was retrieved from the plant's intake canal. The |
| turtle was determined to be in need of rehabilitation. The injuries to the |
| turtle are not causal to plant operation. Per the plant's turtle permit, |
| the Florida Fish and Wildlife Conservation Commission (FWCC) was notified. |
| This non-emergency notification is being made pursuant to 10 CFR |
| 50.72(b)(2)(xi) due to the notification of FWCC. |
| |
| The licensee notified the NRC Resident Inspector and other Government |
| Agencies |
| |
| Reg 2 RDO(Anne Boland) was informed |
| |
| * * * UPDATE ON 08/06/03 AT 1611 BY ALAN HALL TO ARLON COSTA * * * |
| |
| "On 08/06/03 [at 1410], a sea turtle was retrieved from the plant's intake |
| canal. The turtle was determined to be in need of rehabilitation. The |
| injuries to the turtle are not causal to plant operation. Per the plant's |
| turtle permit, the Florida Fish and Wildlife Conservation Commission (FWCC) |
| was notified. This non-emergency notification is being made pursuant to 10 |
| CFR 50.72(b)(2)(xi) due to the notification of FWCC. Stranding Report copy |
| attached." |
| |
| The licensee will notify the NRC Resident Inspector. |
| |
| Notified R2DO (Stephen Cahill). |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Hospital |Event Number: 39941 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: GUTHRIE HEALTH CARE |NOTIFICATION DATE: 06/16/2003|
|LICENSEE: GUTHRIE HEALTH CARE |NOTIFICATION TIME: 09:20[EDT]|
| CITY: SAYRE REGION: 1 |EVENT DATE: 06/12/2003|
| COUNTY: STATE: PA |EVENT TIME: [EDT]|
|LICENSE#: 37-01893-01 AGREEMENT: N |LAST UPDATE DATE: 08/06/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |RAYMOND LORSON R1 |
| |DOUG BROADDUS NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: JOON PARK | |
| HQ OPS OFFICER: FANGIE JONES | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LDIF 35.3045(a)(1) DOSE <> PRESCRIBED DOSA| |
|LOTH 35.3045(a)(3) DOSE TO OTHER SITE > SP| |
| | |
| | |
| | |
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EVENT TEXT
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| DISCOVERY THAT PART OF THE IMPLANTED SEEDS WERE NOT IN THE PROPER SITE |
| |
| A patient was referred for treatment, due to reoccurring prostate cancer, to |
| the hospital where he had previously had treatment. Seeds were implanted |
| around May 2001. A scan of the previous treatment of implanted seeds |
| determined that many of the seeds were not located in the prostate, but in |
| adjacent tissue where they would have been ineffective in treatment. Also, |
| a review of the records indicated a scan was performed in early 2002, but |
| was not followed up on. The patient and referring physician have been |
| informed. The hospital is conducting an investigation into the event and |
| also developing a plan to provide appropriate treatment for the patient. |
| |
| * * * UPDATE ON 07/18/03 AT 1638 FROM JOON PARK TO ARLON COSTA * * * |
| |
| Post-op dosimetry on one patient was determined to be a misadministration. |
| The dose that covered the prostate was more than 20 percent different from |
| the prescription as well as the penile bulb dose being close to 50 percent |
| of the prescription dose. Efforts are being made to contact the affected |
| patient. The licensee will continue efforts to obtain post-op dosimetry on |
| the rest of the patients related to this incident so that evaluations for |
| misadministration can be performed. |
| |
| Notified R1DO (Della Greca) and NMSS EO (Pierson). |
| |
| * * * UPDATE ON 07/25/03 AT 0921 EDT FROM JOON PARK TO JOHN MACKINNON * * * |
| |
| Post-op dosimetry for two patients were determined to be a |
| misadministration. The patients had their prostates treated some time in |
| the year 2001. The iodine-125 seeds were placed 2 to 3 centimeters below |
| the area where they were supposed to be located. The improper location of |
| the iodine-125 seeds caused more than 50% of the prescribed dose to be |
| delivered to an un-intended organ. The patients will be notified. |
| |
| Notified R1DO (Dan Holody) and NMSS EO (Trish Holahan). |
| |
| * * * UPDATE ON 07/30/03 AT 0911 EDT FROM JOON PARK TO ARLON COSTA * * * |
| |
| Two additional patients of a group of seven were identified as having |
| received a misadministration of iodine-125 to an unintended organ. The |
| patients will be notified of this misadministration. The licensee is in the |
| process of clarifying and document the issues related to this incident. |
| |
| Notified R1DO (James Moorman) and NMSS EO (Tom Essig). |
| |
| * * * UPDATE ON 08/07/03 AT 1535 EDT FROM CHARLES LEE TO NATHAN SANFILIPPO * |
| * * |
| |
| Another patient has been identified who received a misadministration of |
| iodine-125 to the prostate. The prescribed dose was 144 Gy, and it was |
| delivered using 76 seeds and 27 needles as planned prior to the implant |
| date. After reviewing the CT, which was done on Feb. 27, 2001, the V100 of |
| the prostate received 29% of the prescribed dose. The penile bulb at 72 Gy |
| received 44.8%. The licensee indicated that they have looked into 8 |
| patients who may have been misadministered, of which, one was not declared a |
| misadministration. The other seven appear in this notification. There are |
| 23 total patients that the licensee intends to review. |
| |
| Notified R1DO (Clifford Anderson) and NMSS EO (Fred Brown). |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 40033 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PALO VERDE REGION: 4 |NOTIFICATION DATE: 07/29/2003|
| UNIT: [] [2] [] STATE: AZ |NOTIFICATION TIME: 21:13[EDT]|
| RXTYPE: [1] CE,[2] CE,[3] CE |EVENT DATE: 07/29/2003|
+------------------------------------------------+EVENT TIME: 15:16[MST]|
| NRC NOTIFIED BY: DUANE KANITZ |LAST UPDATE DATE: 08/06/2003|
| HQ OPS OFFICER: STEVE SANDIN +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |CHUCK CAIN R4 |
|10 CFR SECTION: |PAT GWYNN RA |
|ARPS 50.72(b)(2)(iv)(B) RPS ACTUATION - CRITICA|WILLIAM BECKNER NRR |
|AESF 50.72(b)(3)(iv)(A) VALID SPECIF SYS ACTUAT| |
|ACCS 50.72(b)(2)(iv)(A) ECCS INJECTION | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 M/R Y 98 Power Operation |0 Hot Standby |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| UNIT 2 WAS MANUALLY TRIPPED AFTER A STUCK OPEN SPRAY VALVE FAILED TO CLOSE |
| |
| "On July 29, 2003, at approximately 1518 Mountain Standard Time (MST) Palo |
| Verde Unit 2 plant operators manually tripped the reactor from approximately |
| 98% rated thermal power due to reduced reactor coolant system pressure when |
| a pressurizer spray valve opened and failed to close on operator demand. |
| Unit 2 was at normal temperature and pressure prior to the trip. All CEAs |
| inserted fully into the reactor core. This was an uncomplicated reactor |
| trip. No emergency classification was required per the Emergency Plan. |
| Containment Isolation and Safety Injection Actuation Signals were received |
| following the manual reactor trip per design. Safety related buses remained |
| energized during and following the reactor trip. No significant LCOs have |
| been entered as a result of this event. The pressurizer spray valve that |
| initiated the event was being placed in service following maintenance. |
| |
| "Unit 2 is stabilized in Mode 3 at approximately 564 degrees F and 2200 |
| psia. The reactor coolant system remains in natural circulation with heat |
| removal via Steam Bypass Control to the main condenser. The event did not |
| result in any challenges to fission product barriers and there were no |
| adverse safety consequences as a result of this event. The event did not |
| adversely affect the safe operation of the plant or the health and safety of |
| the public. |
| |
| "The Resident Inspector was informed of the Unit 2 reactor trip and this |
| notification. The Resident Inspector is onsite to observe response to the |
| reactor trip. |
| |
| "The reactor coolant pumps were secured after the trip to stop continued |
| spray flow and depressurization per the alarm response procedure. The |
| offsite electrical power grid is stable." |
| |
| * * * UPDATE ON 8/6/03 AT 2325 EDT FROM D. GRAFF TO E. THOMAS * * * |
| |
| "At the time of the initial notification it was not believed that an ECCS |
| discharge to the RCS occurred. Subsequent review of post-trip data |
| determined that injection did occur. The total accumulated actuation cycles |
| to date for Palo Verde Unit 2 is 8. The thermal fatigue limit is 160 |
| cycles, thus the unit is well within the 0.70 (70%) usage threshold of 112 |
| cycles. |
| |
| "Unit 2 is in Mode 1 at approximately 98% power, normal operating |
| temperature and pressure. |
| |
| "The NRC Resident Inspector has been notified of this followup |
| notification." |
| |
| The ECCS actuation occurred on a low pressurizer pressure signal. |
| |
| Notified R4DO (J. Whitten) |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 40049 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: BEAVER VALLEY REGION: 1 |NOTIFICATION DATE: 08/06/2003|
| UNIT: [] [2] [] STATE: PA |NOTIFICATION TIME: 19:12[EDT]|
| RXTYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 08/06/2003|
+------------------------------------------------+EVENT TIME: 16:30[EDT]|
| NRC NOTIFIED BY: GEORGE STOROLIS |LAST UPDATE DATE: 08/06/2003|
| HQ OPS OFFICER: BILL GOTT +-----------------------------+
+------------------------------------------------+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 |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 N Y 100 Power Operation |100 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| UNANALYZED CONDITION |
| |
| "On 8/06/2003 at 1630 hours, the Beaver Valley Power Station (BVPS) Unit 2 |
| control room was notified by Engineering that the manual operator actions |
| specified in Unit 2 post-fire procedures are not adequate for defeating a |
| potential fire-induced spurious operation of the Power Operated Relief |
| Valves (PORVs). The procedure step de-energizes the PORVs by opening |
| breakers at the d-c distribution panel. This action alone would not be |
| sufficient to prevent a cable-to-cable hot short from re-energizing the |
| circuit since the de-energized circuit is routed in cable trays with other |
| energized circuits in the affected fire areas. Preliminary reviews have |
| identified the following potentially affected fire areas: |
| |
| CB-1 Control Building Instrumentation and Relay Area |
| CB-2 Control Building Cable Spreading Room |
| CB-3 Control Building Main Control Room |
| CB-6 Control Building West Communication Room |
| CT-1 Cable Tunnel |
| CV-1 Cable Vault and Rod Control Area |
| SB-1 Emergency Switchgear Room (Orange) |
| RC-1 Reactor Containment |
| |
| "An hourly roving fire watch patrol has been established for the affected |
| fire areas as compensatory measures, with the exception of the Main Control |
| Room and the Reactor Containment area, until the condition is fully |
| evaluated and resolved. The Main Control Room is continuously manned and |
| does not require an hourly fire watch patrol. The Reactor Containment area |
| is not accessible during normal power operations and, as such, compensatory |
| measures for this area will include a once-per-shift verification of remote |
| instrumentation by operations personnel to confirm that there are no |
| abnormal conditions or indications for this area. |
| |
| "This condition was discovered during the review of manual operator actions |
| for fire-induced spurious operations to confirm the safe shutdown circuit |
| analysis is consistent with the manual actions identified in the |
| procedures. |
| |
| "This condition is being reported pursuant to 10 CFR 50.72(b)(3)(ii) as an |
| unanalyzed condition that significantly degraded plant safety since the |
| failure to assure the PORVs remain in the closed position could result in |
| the failure to meet the fire protection safe shutdown criteria. BVPS Unit 2 |
| was licensed to the NUREG 0800 Standard Review Plan 9.5.1 "Fire Protection |
| Program", and License Condition 2.F requires compliance to the provisions of |
| the approved fire protection program as described in the Final Safety |
| Analysis Report. UFSAR Section 9.5A.1.2.1.6 states that the safe shutdown |
| capability should not be adversely affected by a fire in any plant area |
| which results in spurious actuation of the redundant valves in any one |
| high-low pressure interface line. Even though there is a very low |
| likelihood of multiple shorts causing a spurious PORV actuation in an |
| ungrounded DC circuit, the existing actions to prevent re-energizing the |
| circuit and causing a spurious actuation of the PORVs is not consistent with |
| the NRC guidance for high-low pressure interface valves. |
| |
| "The NRC resident inspector has been notified." |
+------------------------------------------------------------------------------+
Page Last Reviewed/Updated Thursday, March 25, 2021