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Event Notification Report for December 1, 2003

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/28/2003 - 12/01/2003

** EVENT NUMBERS **


40352 40358 40359 40360 40361 40362

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General Information or Other Event Number: 40352
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee:
Region: 3
City:  State: IL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JOE KLINGER
HQ OPS Officer: GERRY WAIG
Notification Date: 11/25/2003
Notification Time: 11:32 [ET]
Event Date: 11/24/2003
Event Time: 14:15 [CST]
Last Update Date: 11/25/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SONIA BURGESS (R3)
JOHN GREEVES (NMSS)

Event Text

AGREEMENT STATE REPORT - DOSE TO PATIENT OUTSIDE INTENDED TREATMENT SITE

"[Radiation Safety Officer (RSO)] for Advocate Lutheran General Hospital called Illinois Emergency Management Agency on 11/24/03 at approximately 1415 to report an event involving a Novoste Intravascular Brachytherapy [IVB] procedure. Hospital RSO stated that at approximately 1100 on 11/24/2003 during an IVB procedure with a prescribed dose of 18.4 gray, the end of the 40mm source train was not visible at the anticipated location at the end of the catheter. The sources were stuck in an apparent kink in the catheter. The source train was immediately retracted into the safe shielded position in the unit. A second attempt was then made but the sources became stuck in the same area and were again immediately retracted.

" The procedure was then terminated and an analysis of the event and dose estimates were performed. An unintended area of the heart was exposed to radiation from the source train for approximately 47 seconds in the first attempt and 10 seconds in the second. The estimated radiation dose calculated to the wrong area of the heart was estimated to be approximately 5 gray. Essentially none of the prescribed dose of 18.4 gray was delivered to the intended area of the heart as the source train was retracted before reaching the intended area.

"The patient has been notified that there was a problem encountered during the procedure and the physician will notify the patient shortly of the particulars involved with the unintended dose delivered. The physicians do not expect any adverse medical effects from this event. Hospital RSO stated that they will carefully review this event and enhance training for this procedure. Hospital RSO added that he will notify Novoste regarding this event and submit the required written report within 15 days."

Illinois Event Report ID: IL030078, License Number: IL -01152-01

Source Information: NOVOSTE Model #A1767, Serial # 91834, Radionuclide: Sr 90, Activity: .0484 Curies

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Power Reactor Event Number: 40358
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: BRUCE FERGUSON
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 11/27/2003
Notification Time: 06:51 [ET]
Event Date: 11/27/2003
Event Time: 06:29 [EST]
Last Update Date: 11/28/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
ANTHONY DIMITRIADIS (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 20 Power Operation 0 Hot Standby

Event Text

PLANT HAD A MANUAL REACTOR TRIP FROM 23% POWER DUE TO TURBINE VIBRATION

While rolling the turbine when at 20% power they experienced an over speed turbine trip. During a second attempt when at 23% power, the turbine had high vibration so they manually tripped the reactor. Cause for the vibration is being investigated since a new rotor had just been installed in the turbine. All rods fully inserted during the reactor trip and no ECCS injection occurred or primary relief valves lifted.


The licensee notified the NRC Resident, the State of Connecticut and Local agencies

* * * UPDATE AT 1423 EST ON 11/28/03 FROM FRANKS TO GOTT * * *

The following clarifying information was provided by the licensee.

"While at 23% power of a scheduled power ascension following a refueling outage, Millstone Unit 2 performed a required manual reactor trip when main turbine vibration reached a trip set point of 12 MILS. The main turbine vibrations were anticipated during the power ascension due to a newly installed low pressure "Mono-Block" rotor. All control rods fully inserted during the reactor trip and no ECCS injection occurred or primary relief valves lifted."

The overspeed trip discussed in the original report was a test conducted prior to placing the main turbine on the grid.

Notified R1DO (Dimitriadis). The licensee will notify the NRC Residence Inspector.

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Power Reactor Event Number: 40359
Facility: CATAWBA
Region: 2 State: SC
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JAMIE MCCONNELL
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 11/28/2003
Notification Time: 01:55 [ET]
Event Date: 11/27/2003
Event Time: 22:55 [EST]
Last Update Date: 11/28/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(B) - POT RHR INOP
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
STEPHEN CAHILL (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling Shutdown 0 Refueling Shutdown
2 N Y 100 Power Operation 100 Power Operation

Event Text

COMPONENT COOLING SYSTEM SURGE TANK SUPPORTS MAY FAIL DURING A SEISMIC EVENT

During an ISI inspection of the component cooling system, it was discovered that several of the surge tank support stiffener plates were missing due to a design change that was never fully implemented. This condition creates a question as to the adequacy of the tanks to withstand a seismic event. This deficiency affects both trains of component cooling on Units 1 and 2. The problem will be corrected on Unit 1 while it is in its refueling outage. Work on the Unit 2 "A" train is currently ongoing, making that train of the component cooling system inoperable, therefore, putting the plant in a 72 hour LCO. When work on the "A" train is completed, they will exit the LCO, but re-enter it when work begins on the "B" train.


Licensee will notify the NRC Resident Inspector, the State and local agencies

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Power Reactor Event Number: 40360
Facility: GINNA
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: ROBIN NYE
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 11/28/2003
Notification Time: 08:18 [ET]
Event Date: 11/27/2003
Event Time: 23:30 [EST]
Last Update Date: 11/28/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
ANTHONY DIMITRIADIS (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

PLANT HAD AN INADVERTENT SIREN ACTIVATION

"At 2330 11/27/2003 RG&E Energy Operations Center Notified the Control Room that an Emergency Notification Siren on Arbor Road was going off. The Siren System Controller was checked and verified that the siren had inadvertently activated. The Siren System Controller was used to reset and then check that the siren was operable. The siren was reset by 2345 11/27/2003. The 4 hour notification was inadvertently missed by the midnight shift."

The licensee will be investigating the cause of this inadvertent siren activation.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 40361
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: JEFF YOUNG
HQ OPS Officer: BILL GOTT
Notification Date: 11/28/2003
Notification Time: 22:57 [ET]
Event Date: 11/28/2003
Event Time: 22:05 [EST]
Last Update Date: 11/28/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
ANTHONY DIMITRIADIS (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 11 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP FROM 11% POWER DUE TO TURBINE VIBRATION

At 2205 EST on 11/28/03 while at 11% power, Millstone Unit 2 performed a required manual reactor trip when main turbine vibration reached a turbine trip set point of 12 MILS. The turbine vibration did not reduce when the turbine was tripped which required breaking condenser vacuum and ultimately a manual reactor trip. The main turbine vibrations were anticipated during power ascension due to a newly installed low pressure "Mono-Block" rotor. All control rods fully inserted during the reactor trip and no ECCS injection occurred or primary relief valves lifted.

The licensee informed the NRC Resident Inspector.

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Power Reactor Event Number: 40362
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: JOHN MYERS
HQ OPS Officer: MIKE RIPLEY
Notification Date: 11/29/2003
Notification Time: 02:47 [ET]
Event Date: 11/28/2003
Event Time: 22:02 [CST]
Last Update Date: 11/29/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(2)(iv)(A) - ECCS INJECTION
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
BLAIR SPITZBERG (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Shutdown

Event Text

AUTOMATIC SCRAM DUE TO LOW REACTOR WATER LEVEL

"At 2202 CST, a low Reactor Water Level Scram (Level 3) occurred due to lowering feedwater flow. All control rods inserted on the Scram. The Scram resulted in actuation of HPCI and RCIC on low Reactor Water level (Level 2), and the low level ATWS Recirculation Pump Trip (RPT). HPCI and RCIC initiated and both Reactor Recirculation pumps tripped. It is estimated that RCIC injected approximately 500 to 600 gallons, and HPCI injected less than 100 gallons. HPCI was secured early in the transient, and RCIC operated for approximately 2 minutes. Reactor Water level was recovered and maintained with the operating feedwater pump.

"The Reactor Water low level (Level 3) also resulted in Group 2 (Primary Containment), Group 3 (Reactor Water Cleanup), and Group 6 isolations (Secondary Containment Isolation and Control Room Ventilation system start). All isolations functioned as designed.

"Initial indications are that Feedwater Pump B speed lowered unexpectedly, causing Reactor Water level to lower. Reactor Water level reached -44 inches (wide range instruments) [120 inches above top of active fuel]. The setpoints for HPCI, RCIC, and ATWS-RPT are -33 inches.

"Plans are to take the unit to Mode 4."

The licensee notified the NRC Resident Inspector.

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Friday, March 30, 2012