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Event Notification Report for May 24, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/21/2004 - 05/24/2004

** EVENT NUMBERS **


40758 40762 40764 40766 40767 40768 40769 40770 40771 40772

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General Information or Other Event Number: 40758
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: MT. SINAI MEDICAL CENTER OF GREATER MIAMI, INC.
Region: 1
City: MIAMI BEACH State: FL
County: MIAMI-DADE
License #: 64-12
Agreement: Y
Docket:
NRC Notified By: CHARLES ADAMS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/18/2004
Notification Time: 16:31 [ET]
Event Date: 05/14/2004
Event Time: [EDT]
Last Update Date: 05/18/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN CARUSO (R1)
CHARLES MILLER (NMSS)

Event Text

FLORIDA AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was received from the State of Florida Bureau of Radiation Control via e-mail:

"Patient was scheduled to receive a 2 fraction treatment to the breast over a five day period - for a total ten fractions. Prior to the last two fractions the doctor went out of town. The new doctor discovered that the calculated center of the balloon was off by 4 mm. The doctor chose to cancel the ninth & tenth fractions. Subsequent calculations showed the dose received was approximately 19 [to] 35% less than prescribed, depending on axis used relative to the catheter. The patient has been notified. This office was notified the day the last two fractions were canceled on May 14. However, review of events and the dose calculations were not complete until May 18. Licensee will send a written report on this event. Examination of this report will determine future Florida actions."

The fraction treatments were delivered using a Mammosite with an Ir-192, 6 Curie source. The maximum dose the patient received was calculated to be 2720 centiGray.

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Power Reactor Event Number: 40762
Facility: BRAIDWOOD
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: PATRICK SIMPSON
HQ OPS Officer: ARLON COSTA
Notification Date: 05/21/2004
Notification Time: 08:47 [ET]
Event Date: 05/20/2004
Event Time: 14:35 [CDT]
Last Update Date: 05/21/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
26.73 - FITNESS FOR DUTY
Person (Organization):
ERIC DUNCAN (R3)

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

CORPORATE HEADQUARTERS NON-LICENSED EMPLOYEE TESTED POSITIVE DURING URINALYSIS

A non-licensed supervisory employee with normal work location at corporate headquarters tested positive during a random urinalysis test. The employee's access to Braidwood, Byron, Clinton, Dresden, LaSalle and Quad Cities nuclear power stations has been suspended. Contact the Headquarters Operations Officer for additional details.

The licensee will notify the NRC Resident Inspectors for the above sites.

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Power Reactor Event Number: 40764
Facility: SALEM
Region: 1 State: NJ
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: STEVE SAUER
HQ OPS Officer: JOHN MacKINNON
Notification Date: 05/21/2004
Notification Time: 14:50 [ET]
Event Date: 05/21/2004
Event Time: 13:15 [EDT]
Last Update Date: 05/21/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
JOHN CARUSO (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 90 Power Operation 60 Power Operation

Event Text

TECHNICAL SPECIFICATION SHUTDOWN

A unit shutdown was commenced to comply with the technical specification for containment integrity. A service water isolation valve supplying the turbine generator area lost power when the 2B vital bus 230v transformer failed at 1147 on 5/21/04. This results in entry into a restore in 1 hour or hot shutdown in 6 hours LCO (3.6.1.1) since the valve cannot be isolated and maintain the unit in service. The failure of the transformer is currently under investigation. A power reduction of 20% per hour is currently in progress.

Other equipment affected by the transformer loss, various containment isolation valves, 2B emergency diesel generator, 22 chiller, 22 and 24 containment fan coil units, and 23 and 24 service water pumps. Prior to the event the only safety related equipment out of service was the service 23 service water pump that was out for planned maintenance. There were no personnel injuries as a result of this event.

The NRC Resident Inspector was notified of this event by the licensee.

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Power Reactor Event Number: 40766
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DON ROLAND
HQ OPS Officer: JOHN MacKINNON
Notification Date: 05/21/2004
Notification Time: 15:58 [ET]
Event Date: 04/04/2004
Event Time: 14:57 [EDT]
Last Update Date: 05/21/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
JOHN CARUSO (R1)

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

Event Text

60 -DAY REPORT: INVALID ACTUATION OF THE "E" EMERGENCY DIESEL GENERATOR

On 04/04/04 at 14:57 hours, the "E" Emergency Diesel Generator unexpectedly started in the emergency mode of operation during performance of Unit 1 LOCA/LOOP surveillance testing. The diesel generator started in response to a false loss of offsite power signal that occurred after an electrical test jumper was incorrectly installed in panel 1A201. While the procedure directed installation of the jumper across the field side of states links T5-10 and T5-12, the jumper was instead installed across the panel side of the links. When link T5-10 was opened per procedural direction, a false LOOP signal was sent to the "E" diesel generator start circuit. The "E" emergency diesel generator successfully started and properly responded to the complete train actuation signal. The diesel was shutdown following the incident. No other plant equipment was affected by this jumper use error. At the time of this event, Unit 1 was in Mode 5 and Unit 2 was in Mode 1. Both Units continued in Modes 5 and 1, respectively. Surveillance testing was successfully completed on 04/05/04.

The consequences of this event were limited to the unplanned start of the "E" emergency diesel generator. The diesel generator started and functioned in accordance with its design. This event comprises an invalid actuation of an emergency AC electrical power system and is therefore being reported in accordance with 10 CFR 50.73(a)(2)(iv)(A) as a 60- day telephone notification per the provision of 10 CFR 50.73 (a)(1).

The NRC Resident Inspector was notified of the 60- day report notification by the licensee.

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Power Reactor Event Number: 40767
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: JIM CASE
HQ OPS Officer: JOHN MacKINNON
Notification Date: 05/21/2004
Notification Time: 16:11 [ET]
Event Date: 05/21/2004
Event Time: 16:00 [EDT]
Last Update Date: 05/21/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
ANTON VEGEL (R3)

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

TECHNICAL SPECIFICATION SHUTDOWN

Emergency Service Water "A" (ESW) Pump failure results in inoperability of all Div 1 ECCS systems. The plant entered the Limiting Condition for Operation for the ESW inoperability at 0150 on 05/21/04. The action times for Tech Spec 3.7.1 are as follows: restore ESW to operable status within 72 hours, if this cannot be accomplished be in Mode 3 (Hot Shutdown) in the following 12 hours and Mode 4 (Cold Shutdown) in 36 hours. Reactor power was reduced at 1600 to begin the shutdown process. Division 2 and 3 ECCS are fully operable.

The NRC Resident Inspector was notified of this event by the licensee.

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Power Reactor Event Number: 40768
Facility: SURRY
Region: 2 State: VA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: TERRY HUFF
HQ OPS Officer: JOHN MacKINNON
Notification Date: 05/21/2004
Notification Time: 21:36 [ET]
Event Date: 05/21/2004
Event Time: 21:16 [EDT]
Last Update Date: 05/21/2004
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
JAY HENSON (R2)
EDWIN HACKETT (NRR)
DICK WESSMAN (DIRO)
M. A. DOYLE (DHS)
DAVID BARDEN (FEMA)

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

Event Text

UNUSUAL EVENT DECLARED

At 2108 hours a main generator lead failed (exploded) causing a generator lead differential lockout/turbine trip/reactor trip. All rods fully inserted into the core. Both Motor Driven and the Turbine Driven Auxiliary Feedwater Pumps started as expected and are supplying water to the steam generators. Electrical power is being supplied from offsite and all systems are operating as expected. The reactor tripped at 2108 hours and a report of a fire in the switchyard was reported to Control Room at 2109 hours. Fire Brigade was dispatched and the fire was reported out at 2142 hours. Reflash fire watch has been set. All Emergency Core Cooling Systems and the Emergency Diesel Generators are fully operable if needed. Surry Unit 1 remains at 100% power. Licensee notified State and Local officials of their declaration of an Unusual Event.

The NRC Resident Inspector was notified of the event by the licensee.

* * * UPDATE ON 5/21/04 AT 2310 EDT FROM CHARLES YOUNG TO G. WAIG * * *

The licensee terminated the NOUE at 2256 EDT. Damage appears to be confined to the main generator leads with one lead missing and some damage to other leads. The plant is stable with RCS temperature at 547 degrees Fahrenheit, 2235 psia. The NRC Resident Inspector will be notified of the NOUE termination by the licensee.

Notified R2DO (Jay Henson), NRR EO (Edwin Hackett), DIRO (Tom Andrews), FEMA (David Barden), DHS (Robert Bozzo).

See EN 40769 , 40770 & 40771 for related Non Emergency notifications.

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Power Reactor Event Number: 40769
Facility: SURRY
Region: 2 State: VA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: GROVER M. WOODZELL
HQ OPS Officer: JEFF ROTTON
Notification Date: 05/22/2004
Notification Time: 00:28 [ET]
Event Date: 05/21/2004
Event Time: 21:08 [EDT]
Last Update Date: 05/22/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JAY HENSON (R2)

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

Event Text

AUTOMATIC REACTOR TRIP DUE TO GENERATOR LEADS FAILURE

"Unit 2 Reactor tripped at 2108, first out is F-E-2, 500KV leads differential lockout relay trip.

"This notification is being made pursuant to 10 CFR 50.72(b)(2)(iv)(B) for 4-hour notification of RPS Activation and 10 CFR 50.72(b)(3)(iv)(A) for 8-hour notification of automatic actuation of AFW. Plant responded as expected with the exception of 'C' SG AFW flow indication. The 'C' SG level responded normally to Unit conditions. The NRC resident has been notified of this event and is on site. Notification was made to NRC duty officer upon declaration on NOUE[See EN#40768], which was declared based on EAL Tab K-6 for 'Confirmed report of unplanned explosion within Protected Area or Switchyard.' An electrical fault was observed in the 500 KV switchyard and is currently being investigated. No further damage has been detected in the switchyard. The NOUE, which was declared at 2116, has been terminated as of 2256."

Reactor shutdown with all control rods fully inserted. Electric plant is in a normal shutdown mode lineup. The other operating unit was unaffected by this event. Decay heat is being removed to the main condenser using the condenser steam dump valves.

See Surry Unit 2 event # 40770 & 40771.

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Power Reactor Event Number: 40770
Facility: SURRY
Region: 2 State: VA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: LARRY WHEELER
HQ OPS Officer: JOHN MacKINNON
Notification Date: 05/22/2004
Notification Time: 15:06 [ET]
Event Date: 05/21/2004
Event Time: 21:46 [EDT]
Last Update Date: 05/22/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
JAY HENSON (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Hot Standby 0 Hot Standby

Event Text

UNANALYZED CONDITION DUE TO AUXILIARY FEEDWATER NOT BEING IN COMPLIANCE WITH JUSTIFICATION FOR CONTINUED OPERATION (JCO).

"At 2146 hours on 05/21/04, Unit 2 entered a 30 Hr. clock to Cold Shutdown (CSD) in accordance with T.S.3.0.1 due to Auxiliary Feedwater (AFW) not being in compliance for Continued Operation (JCO) SC 03-002 configuration. Auxiliary Feedwater was declared inoperable at 2146 hours. During post trip recovery, Emergency Procedure, 2-ES-0.1, directed that the six (6) AFW motor operated valves (MOVs) be checked opened after securing the AFW Pumps. This is contrary to the AFW JCO, which requires four (4) MOVs out of six (6) to be closed for AFW to remain Operable. At 0040 hours on 5/22/04 the correct valve alignment in accordance with the JCO was established and the 30 hour TS 3.0.1 clock was exited.

"This event is reportable in accordance with 10CFR50.72(b)(3)(ii)(B); any event or condition that results in the Station being in an unanalyzed condition that significantly degrades plant safety.

"The NRC resident has been notified."

The licensee found out about this event today during event investigation. See Surry Unit 2 events 40769, 40768 and 40771.

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Power Reactor Event Number: 40771
Facility: SURRY
Region: 2 State: VA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: JAMES SHELL
HQ OPS Officer: JOHN MacKINNON
Notification Date: 05/22/2004
Notification Time: 22:29 [ET]
Event Date: 05/22/2004
Event Time: 21:30 [EDT]
Last Update Date: 05/22/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JAY HENSON (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Hot Standby 0 Hot Standby

Event Text

AUXILIARY FEEDWATER SYSTEM DECLARED INOPERABLE DUE TO UNDERGROUND LEAK

"There is sufficient reason to believe that the buried auxiliary feedwater piping associated with Unit 2 is degraded and leaking and thus as a conservative measure it is declared inoperable. This operability determination is based on not having a reasonable assurance that the auxiliary feedwater piping can continue to perform its intended function under all design basis events including seismic events. Approximate leakrate is 8 gpm. Makeup is sufficient at this time to maintain desired level in the affected tank. Further efforts to determine the exact leak location are ongoing. This notification is being made pursuant to 10 CFR 50.72(b)(3)(v)(D) for the 8-hour notification of a condition that could have prevented the fulfillment of the safety function of systems or structures that are needed to mitigate the consequences of an accident."

Emergency Condensate Storage Tank level was decreasing and water has been detected coming from a conduit in the Safeguard Building. Licensee is in Tech Spec 3.0.1 (30 hours to get below 350 degrees F and 450 psig).

The NRC Resident Inspector was notified of this event by the licensee.

See EN #'s 40770, 40769 & 40768 for Surry Unit 2 related problems.

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Power Reactor Event Number: 40772
Facility: SURRY
Region: 2 State: VA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: GROVER WOODZELL
HQ OPS Officer: JEFF ROTTON
Notification Date: 05/23/2004
Notification Time: 06:21 [ET]
Event Date: 05/23/2004
Event Time: 05:26 [EDT]
Last Update Date: 05/23/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
JAY HENSON (R2)

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

Event Text

TECHNICAL SPECIFICATIONS REQUIRED COOLDOWN

"Based on the inoperability of Unit 2 Auxiliary Feedwater (reference EN # 40771) due to an underground leak, Unit 2 has initiated a plant cooldown from Hot Shutdown (547F) to Cold Shutdown (<200F). This notification is being made pursuant to 10 CFR 50.72(b)(2)(i) for the 4-hour notification of a Technical Specification Required Shutdown."

This event notification is required per licensee's Administrative procedures.

The licensee has notified the NRC Resident Inspector.

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