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Event Notification Report for April 6, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/05/2004 - 04/06/2004

** EVENT NUMBERS **


40641 40642 40643 40644 40646 40647 40648

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Fuel Cycle Facility Event Number: 40641
Facility: PADUCAH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
                   6903 ROCKLEDGE DRIVE
                   BETHESDA, MD 20817 (301)564-3200
Region: 2
City: PADUCAH State: KY
County: McCRACKEN
License #: GDP-1
Agreement: Y
Docket: 0707001
NRC Notified By: KEVIN BEASLEY
HQ OPS Officer: MIKE RIPLEY
Notification Date: 04/05/2004
Notification Time: 01:40 [ET]
Event Date: 04/04/2004
Event Time: 14:30 [CDT]
Last Update Date: 04/05/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
RESPONSE-BULLETIN
Person (Organization):
JOEL MUNDAY (R2)
SCOTT MOORE (NMSS)

Event Text

24-HOUR NRC BULLETIN 91-01 LOSS OF CRITICALITY CONTROL NOTIFICATION

"At 1430, on 04-04-04 the Plant Shift Superintendent was notified of a violation of Nuclear Criticality Safety (NCS) control in the C-333 process building. While preparing for start up of the C-333 #1 High Speed Purge and Evacuation (P & E) pump, operations discovered that the delta pressure (DP) alarm instrument line to the RCW supply was unattached and the isolation valve was closed. With the RCW instrument line not attached, both DP alarms for this pump were not functional and therefore not able to perform their safety function, violating a safety related item (SRI) in NCSE 039. The SRI requires that both DP alarms be functional while the P & E is isolated from the cascade. The purpose of the SRI Is to alert the operator to take actions within a 28-hour timeframe to prevent wet R-114 from leaking into the process gas system. The DP alarms had been nonfunctional for more than 28 hours when discovered. Both DP alarms were put back in service and the R-114 sampled and found dry within 4 hours of discovery, therefore, re-establishing double contingency.

"The Senior NRC Resident Inspector has been notified of this event."

"PGDP Problem Report No, ATR-04-1342; PGDP Event Report No. PAD-2004-09; Event Worksheet #40641 Responsible Division: Operations

"SAFETY SIGNIFICANCE OF EVENTS: While the R-114 was demonstrated to be dry, both DP alarms relied on for double contingency were disabled without the knowledge of the operators.

"POTENTIAL CRITICALITY PATHWAYS INVOLVED: In order for a criticality to occur, an unsafe mass uranium deposit would have to be present in the process gas system, an R-114 leak to the process gas system would have to occur, the R-114 would have to contain an unacceptable amount of moisture ( i.e., greater than 10 kg of water) and moderate the deposit.

"CONTROLLED PARAMETERS (MASS, MODERATION, G5OMETRY, CONCENTRATION, ETC): Double contingency is maintained by implementing two controls on moderation.

"ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL: No known mass of licensed material exists in the #1 High Speed Purge and Evacuation pump.

"NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION OF THE FAILURES OR DEFICIENCIES: The first leg of double contingency is based on the DP switch alarming to alert the operator to take action to either verify the R-114 is dry or to isolate the RCW and remove the R-114 from the system in order to prevent water from leaking into the process gas system. This DP alarm was not maintained as functional. The DP alarm was put back in service and the R-114 was sampled and found to be dry. The SRI was not maintained and the control was violated but the process condition was maintained.

"The second leg of double contingency is based on the independent DP switch alarming to alert the operator to take action to either verify the R-114 is dry or to isolate the RCW and remove the R-114 from the system in order to prevent water from leaking into the process gas system. The independent DP alarm was not maintained as functional. The independent DP alarm was put back in service and the R-114 was sampled and found to be dry. The SRI was not maintained and the control was violated but the process condition was maintained. This re-established double contingency.

"CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED: Both DP switches were returned to service and the R-114 was sampled and found to be dry on 04-04-04 at 1655."

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Power Reactor Event Number: 40642
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: JIM HUFFORD
HQ OPS Officer: MIKE RIPLEY
Notification Date: 04/05/2004
Notification Time: 04:02 [ET]
Event Date: 04/05/2004
Event Time: 01:30 [EDT]
Last Update Date: 04/05/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
Person (Organization):
KENNETH JENISON (R1)

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

Event Text

LOSS OF SAFETY FUNCTION FOR EMERGENCY DIESEL GENERATORS DURING SURVEILLANCE TESTING

"At 0030 [ET] during setup for Unit 1 Division 1 LOCA/LOOP Surveillance testing, the controlling procedure required making the Loss of Power instrumentation for the 1A and 1C ESS buses inoperable. The specification has a 1 hour time limit for restoration, or the associated Diesel Generators must be declared inoperable. Due to delays during the setup of equipment the time requirements were not met, and the associated Diesel Generators were declared inoperable at 0130. The Susquehanna Safety Analysis requires three operable Diesel Generators to safely shutdown. Therefore, this condition is reportable for Unit 2 under 10CFR50.72(b)(3)(v). Unit 1 is in Mode 5 and therefore not impacted. The Loss of Power instruments were restored, and the Diesel Generators declared operable at 0223."

The licensee notified the NRC Resident Inspector.

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Hospital Event Number: 40643
Rep Org: ST. VINCENT HOSPITAL
Licensee: ST. VINCENT HOSPITAL
Region: 3
City: INDIANPOLIS State: IN
County:
License #: 13-00133-02
Agreement: N
Docket:
NRC Notified By: ED WROBLEWSKI
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/05/2004
Notification Time: 16:33 [ET]
Event Date: 04/05/2004
Event Time: 11:00 [CST]
Last Update Date: 04/05/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
BRENT CLAYTON (R3)
SCOTT MOORE (NMSS)

Event Text

MEDICAL EVENT INVOLVING FRACTIONATED DOSE DELIVERY HIGHER THAN PRESCRIBED

A patient was prescribed five (5) fractional treatments of 500 centigray each to the surface using a 6.7 curie Ir-192 brachytherapy source. On 3/15, 3/22 and 3/29/04 the patient received 500 centigray/fraction at a depth of 5 mm. This resulted in a delivered dose of 818 centigray/fraction at the surface. The error was discovered prior to delivering the fourth (4th) fraction and is attributed to a miscalculation. The prescribing physician has been informed and concluded that there would be no adverse effects to the patient. The licensee is implementing additional reviews to preclude this type of event from reoccurring.

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Power Reactor Event Number: 40644
Facility: MAINE YANKEE
Region: 1 State: ME
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: LARRY JEWETT
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/05/2004
Notification Time: 16:45 [ET]
Event Date: 03/31/2004
Event Time: [EDT]
Last Update Date: 04/05/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
LAWRENCE DOERFLEIN (R1)

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

Event Text

OFFSITE NOTIFICATION TO THE STATE OF MAINE CONCERNING AN UNSCHEDULED RAD RELEASE

"Notification made to government agencies (State of Maine Dept. of Human Services and Maine Emergency Management Agency) for unscheduled release of radioactive materials. On Wednesday 3/31 Maine Yankee had a minor release of 0.0000000470 curies of particulate material, which resulted in an exposure value of about 0.00000426 millirem. The cause of the release resulted from a minor fire during thermal cutting of structural material during the demolition process."

The licensee will inform their designated NRC Inspectors.

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Power Reactor Event Number: 40646
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: RONALD FRY
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/05/2004
Notification Time: 18:19 [ET]
Event Date: 04/05/2004
Event Time: 11:40 [EDT]
Last Update Date: 04/05/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(B) - POT RHR INOP
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
LAWRENCE DOERFLEIN (R1)

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

Event Text

LOSS OF SAFETY FUNCTION FOR EMERGENCY DIESEL GENERATORS DURING SURVEILLANCE TESTING

"At 1040 hrs during setup for Unit 1 Division 1 LOCA/LOOP Surveillance testing, the controlling procedure required making the Loss of Power instrumentation for the 1A and 1C ESS buses inoperable. The specification has a 1 hour time limit for restoration, or the associated Diesel Generators must be declared inoperable. Due to delays during the setup of equipment the time requirements were not met, and the 'E' (Substituting for 'A') and 'C' Diesel Generators were declared inoperable at 1140 hrs. The Loss of Power instruments were restored, and the Diesel Generators declared operable at 1206 hrs. Unit 1 is in Mode 5 requiring only 2 diesel generators operable, therefore not impacted by the Loss of Power instrumentation inoperability.

"Also during the surveillance, two pump start timers failed to meet the required acceptance criteria. The 'A' ESW Pump timer actuated at 47.86 seconds (criteria; 36 sec. to 44 sec) and the 'C' ESW Pump timer actuated at 50.38 seconds (criteria: 39.6 sec. to 48.4 sec). With failure of the timers, proper loading on the Diesel Generators is not assured, and they were declared inoperable until the associated pump control breakers were opened. The 'E' Diesel Generator was declared inoperable at 1448 hrs, when the data analysis identified that the A ESW pump timer did not meet acceptance criteria. The 'E' Diesel Generator was returned to operable at 1453 hrs when the DC Knife switches for the A ESW pump were open. The 'C' Diesel Generator was declared inoperable at 1524 hrs, when the data analysis identified that the 'C' ESW pump timer did not meet acceptance criteria. The 'C' Diesel Generator was restored to operable at 1706 hrs after supported systems were realigned to prevent further loss of safety function and the DC Knife switches for the 'C' ESW pump were open.

"The Susquehanna safety analysis requires three operable Diesel Generators to safely shutdown the plant. Therefore with only two operable Diesel Generators, the condition requires an 8 hr ENS notification in accordance with 10CFR50.72(b)(3)(v)and (vi)."

All times referenced above are EDT. The licensee informed the NRC Resident Inspector.

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Power Reactor Event Number: 40647
Facility: HATCH
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: GARY R. BRINSON
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/05/2004
Notification Time: 20:46 [ET]
Event Date: 04/05/2004
Event Time: 19:16 [EDT]
Last Update Date: 04/05/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JOEL MUNDAY (R2)

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

Event Text

BRIEF LOSS OF NOAA WEATHER RADIO CAPABILITY

"Site experienced a momentary loss of the NOAA Weather Radio System from 1916 to 1918 EST. During the time that this system was out of service, a major loss of offsite communication capability is considered. Site emergency planning personnel were notified and will investigate this momentary loss. The system is in service and functioning properly."

The licensee notified both state/local agencies and will inform the NRC Resident Inspector.

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Power Reactor Event Number: 40648
Facility: HOPE CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: ART BREADY
HQ OPS Officer: MIKE RIPLEY
Notification Date: 04/06/2004
Notification Time: 02:17 [ET]
Event Date: 04/05/2004
Event Time: 20:30 [EDT]
Last Update Date: 04/06/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
LAWRENCE DOERFLEIN (R1)

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

Event Text

OFFSITE ELECTRICAL POWER SOURCES AND 1E 4KV DISTRIBUTION BUSES INOPERABLE

"On 04/05/04 at 2030 hours, Engineering personnel informed Operations personnel of an issue affecting the ability of the offsite power sources to provide adequate 1E bus voltage consistent with the design basis. Operating procedures currently contain non-conservative values for minimum voltage on 1E 4 kV buses. In addition, the transformer auto load tap changer (LTC) is currently set to regulate at approximately 4200 VAC, a value that is below the required 1E 4 kV bus lower voltage design limit. Adequate voltage from the offsite power sources is required IAW General Design Criteria 17 to ensure that vital buses remain connected to their preferred power source and adequate terminal voltage exists at the load end device during accident conditions. The ability of the Emergency Diesel Generators to perform their design function is not affected by this condition. This event is being reported in accordance with 10CFR50.72(b)(3)(v)(D) as a condition that could have prevented the fulfillment of a safety function because it affects the ability of both offsite power sources to provide adequate voltage to all 1E buses to properly mitigate the consequences of an accident.

"Both offsite electrical power sources and all four 4 kV distribution buses have been declared inoperable and the appropriate Technical Specification Actions have been entered. The current voltage readings for all 1E 4 kV buses are between 4204 and 4263 VAC. The plant will remain in Operational Condition 4 until this condition is corrected. Engineering and Operations personnel are evaluating this condition to determine required corrective actions. All other plant systems are available to support Operational Condition change and reactor startup."

The licensee notified the NRC Resident Inspector and will notify the local township.

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