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Event Notification Report for November 5, 2003

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/04/2003 - 11/05/2003

** EVENT NUMBERS **


40294 40295 40296 40297 40298

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Hospital Event Number: 40294
Rep Org: COOPER HEALTH SYSTEM
Licensee: COOPER HEALTH SYSTEM
Region: 1
City: CAMDEN State: NJ
County:
License #: 290828501
Agreement: N
Docket:
NRC Notified By: MIKE COOPER
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 11/04/2003
Notification Time: 11:30 [ET]
Event Date: 11/03/2003
Event Time: 13:00 [EST]
Last Update Date: 11/04/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
RICHARD BARKLEY (R1)
ROBERTO TORRES (NMSS)

Event Text

A PATIENT RECEIVED AN UNDERDOSAGE DURING THERAPUTIC TREATMENT OF THE CERVEX

A patient who was receiving her second of six treatments for cervix cancer on 10/31/03 was given a 200 Rad dose when a 600 Rad dose was prescribed. This was due to personnel error and both the patient and physician were notified. Since the treatment was an under dose and only the second treatment of six, the physician will make up for the discrepancy during the other treatments.

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Power Reactor Event Number: 40295
Facility: WATERFORD
Region: 4 State: LA
Unit: [3] [ ] [ ]
RX Type: [3] CE
NRC Notified By: RON WILLIAMS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/04/2003
Notification Time: 12:08 [ET]
Event Date: 11/04/2003
Event Time: [CST]
Last Update Date: 11/04/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
MARK SHAFFER (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Refueling 0 Refueling

Event Text

NUMBER OF STEAM GENERATOR TUBES REQUIRING REPAIR EXCEEDS 1 PERCENT

"At 0400 CDT on November 4, 2003 with Waterford 3 refueled, steam generator inspection was being performed in accordance with Technical Specification (TS) 4.4.4.2, Steam Generator Tube Sample Selection and Inspection. The results of the on-going inspection performed on Steam Generator 31 indicated that greater than 1% of the inspected tubes require repair. The number of inspected tubes for SG 31 is 8906 and to date 98 tubes require repair. Based on TS 4.4.4.2.C, this determination results in the Category C-3. The current inspection results do not meet the criteria specified for steam generator tube degradation in NUREG 1022, Event Reporting Guidelines 10 CFR 50.72 and 10 CFR 50.73. However, for Category C-3, TS Table 4.4-2, Steam Generator Tube Inspection, requires that the results of the inspection be reported under 10 CFR 50.72(b)(2), which was superceded by an 8 hr notification in accordance with 50.72(b)(3)(ii).

"Per TS 4.4.4.5, the final results of the SG tube inspection, which fall into Category C-3, shall be reported in a special report within 30 days and prior to resumption of plant operation."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 40296
Facility: THREE MILE ISLAND
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP
NRC Notified By: ADAM MILLER
HQ OPS Officer: GERRY WAIG
Notification Date: 11/04/2003
Notification Time: 15:50 [ET]
Event Date: 11/04/2003
Event Time: 14:30 [EST]
Last Update Date: 11/04/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
RICHARD BARKLEY (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

PRESSURIZER HEATER BUNDLE DIAPHRAGM PLATE DEGRADED CONDITION

"On November 4, 2003, during the TMI Unit 1 15th (T1R15) refueling outage, an inspection of the Pressurizer Heater Bundle (PHB) Diaphragm Plate was completed. This Inspection identified a leak path emanating from the lower Pressurizer Heater Bundle.

"The initial indication of a potential Reactor Coolant System (RCS) leak was boric acid residue located between the PHB Diaphragm Plate and the PHB Cover Plate. Initially the leak was believed to be from a seal weld, which is considered comparable to a gasket leak. Following disassembly of the PHB Cover Plate and performance of NDE, it was determined that the pathway was through the edge of the PHB Diaphragm Plate. This degraded condition of the PHB Diaphragm Plate is indicative of a RCS pressure boundary leak. This notification is being made in accordance with 10 CFR 50.72(b)(3)(ii)(A)."

The licensee provided the following pre-refuel outage information:
RCS Leak Rate = less than 0.1 gallons per minute
Activity = 0.45 microcuries/milliliter
TS [Technical Specifications] Limits: No leakage (3.1.6.4)
Secondary System Activity = less than 1E-10 microcuries/milliliter

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 40297
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DANIEL HARDIN
HQ OPS Officer: GERRY WAIG
Notification Date: 11/04/2003
Notification Time: 21:20 [ET]
Event Date: 11/04/2003
Event Time: 17:32 [EST]
Last Update Date: 11/04/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(A) - ECCS INJECTION
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
STEPHEN CAHILL (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R N 0 0

Event Text

BRUNSWICK UNIT 2 SCRAM DUE TO GENERATOR/TURBINE TRIP

"On November 4, 2003, at approximately 1732 hours, Unit 2 received a generator/turbine trip due to loss of excitation, which resulted in a Reactor Protection System (RPS) trip. Plant response to the reactor shutdown resulted in High Pressure Coolant Injection and Reactor Core Isolation Cooling [RCIC] system actuations on low reactor coolant level. Additionally, primary containment isolation system actuation signals for valve groups 1, 2, 3 , 6, 8, and 10 were received and the valves closed as required. All four emergency diesel generators automatically started, but did not load because power was never lost to the emergency buses. The loss of power from the generator trip resulted in reactor building ventilation isolation and automatic start of both trains of the Standby Gas Treatment (SBGT) system. SBGT Train A immediately tripped, but was successfully placed in service. All control rods fully inserted into the core. At approximately 1857 hours, another RPS trip was received due to low reactor coolant level while cycling Safety Relief Valves; however, all control rods were already inserted.

"The safety significance of this event is considered to be minimal. The plant responded as designed to the transient with the exception of the SBGT Train A initial starting issue.

"An event investigation team has been assembled to determine the cause of the event. Plant response to the event
is being evaluated and identified issues will be addressed prior to plant restart."

The licensee reported that the station electrical grid is normal and the emergency diesel generators have been shutdown and returned to standby status. The current plant conditions are 550 psi, 496 degrees F with RCIC operating to maintain reactor water level. The main condenser is available and being used to dump steam from the reactor. Two safety relief valves opened during the transient and reclosed as expected. The reactor water level decreased to minimum of approximately 90 inches during the transient. The cause of main steam isolation valve (MSIV) closure is under investigation.

The licensee also reported that this event caused a Group 6 Isolation, reactor building ventilation isolation, and standby gas treatment actuation signal on Brunswick Unit 1. These Unit 1 systems have been returned to a normal configuration.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 40298
Facility: BRAIDWOOD
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JAMES SMIT
HQ OPS Officer: RICH LAURA
Notification Date: 11/05/2003
Notification Time: 03:45 [ET]
Event Date: 11/04/2003
Event Time: 21:32 [CST]
Last Update Date: 11/05/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
DAVID HILLS (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

BRAIDWOOD 2 AFW SUPPORT SYSTEM ACTUATION DURING OUTAGE

"Unit 2 auxiliary feedwater support systems actuated during scheduled ATAWS testing when an unrelated clearance order placement de-energized two 6.9 kv busses (256 and 258). The 2 of 4 6.9 kv bus undervoltage coincidence initiated a valid auto-start signal causing lube oil pumps 2AF01PA-A, 2AF01PB-A and 2AF01PB-C to start. Auxiliary Feedwater Pump AOV discharge valves 2AF004A and 2AF004B auto opened. 2AF01PA 4kv breaker, which was in the equipment test position. Neither auxiliary feedwater pump started and no water transferred to the steam generators."

The licensee notified the NRC resident inspector.

Page Last Reviewed/Updated Friday, March 30, 2012
Friday, March 30, 2012