Event Notification Report for February 4, 2000
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
02/03/2000 - 02/04/2000
** EVENT NUMBERS **
36588 36605 36655 36656 36657 36658
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|Power Reactor |Event Number: 36588 |
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+------------------------------------------------------------------------------+
| FACILITY: PERRY REGION: 3 |NOTIFICATION DATE: 01/13/2000|
| UNIT: [1] [] [] STATE: OH |NOTIFICATION TIME: 17:04[EST]|
| RXTYPE: [1] GE-6 |EVENT DATE: 03/25/1999|
+------------------------------------------------+EVENT TIME: 03:30[EST]|
| NRC NOTIFIED BY: STETSON |LAST UPDATE DATE: 02/03/2000|
| HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |BRENT CLAYTON R3 |
|10 CFR SECTION: | |
|AOUT 50.72(b)(1)(ii)(B) OUTSIDE DESIGN BASIS | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |0 Cold Shutdown |
| | |
| | |
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EVENT TEXT
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| DISCOVERY THAT A SINGLE PASSIVE FAILURE OF THE INCLINED FUEL TRANSFER SYSTEM |
| FLAP VALVE MAY HAVE RESULTED IN A LOSS OF ECCS DURING A DESIGN BASIS LOCA |
| (HISTORICAL EVENT) |
| |
| The following text is a portion of a facsimile received from the licensee: |
| |
| "With the Inclined Fuel Transfer System (IFTS) flange removed at power, a |
| single passive failure of the IFTS flap valve may have resulted in a loss of |
| Emergency Core Cooling System (ECCS) during a design basis Loss of Coolant |
| Accident (LOCA). This was determined during an engineering review examining |
| the effects on containment structural capability with the IFTS Blind Flange |
| removed." |
| |
| "An assumed single passive failure of the IFTS flap valve would have |
| resulted in inventory loss from the upper containment pools with the IFTS |
| gate removed. The postulated water inventory loss would reduce the |
| inventory to less than required for the makeup to the suppression pool |
| during a LOCA. Therefore, ECCS may not have met single failure criteria |
| during the period when the IFTS Flange was removed at power." |
| |
| "The IFTS flange was removed for approximately 3 days prior to the |
| commencement of the seventh refueling outage. Administrative controls are |
| in place to preclude removal of the IFTS flange at power until this issue is |
| fully evaluated." |
| |
| The licensee stated that this event was determined to be reportable |
| approximately 10 minutes prior to the event notification. |
| |
| The licensee notified the NRC resident inspector. |
| |
| * * * UPDATE ON 02/03/00 AT 1312 BY STERLING SANFORD TAKEN BY STEVE SANDIN |
| * * * |
| |
| The licensee made an editorial correction to the event time to show 0330 |
| hours instead of 1530 hours. |
| |
| The licensee notified the NRC Resident Inspector. The NRC Operations |
| Officer notified the R3DO Tony Vegel. |
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!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
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|Fuel Cycle Facility |Event Number: 36605 |
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| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 01/19/2000|
| RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 17:59[EST]|
| COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 01/19/2000|
| 6903 ROCKLEDGE DRIVE |EVENT TIME: 09:00[EST]|
| BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 02/03/2000|
| CITY: PIKETON REGION: 3 +-----------------------------+
| COUNTY: PIKE STATE: OH |PERSON ORGANIZATION |
|LICENSE#: GDP-2 AGREEMENT: N |DAVID HILLS R3 |
| DOCKET: 0707002 |WAYNE HODGES NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: DALE NOEL | |
| HQ OPS OFFICER: LEIGH TROCINE | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|OCBB 76.120(c)(2)(ii) EQUIP DISABLED/FAILS | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| FAILURE OF HIGH PRESSURE FIRE WATER SPRINKLER SYSTEMS TO MEET SYSTEM |
| OPERABILITY REQUIREMENTS (24-Hour Report) - (Refer the event #36018 for a |
| similar event at Portsmouth and refer to event #35790 and event #36552 for |
| related events at Paducah.) |
| |
| The following text is a portion of a facsimile received from Portsmouth: |
| |
| "On 01/19/00 at approximately 0900 hours during the scheduled semi-annual |
| walkdown of the X-330 Process Building high pressure fire water (HPFW) |
| systems, the Plant Shift Superintendent (PSS) was notified that sprinkler |
| systems #284 and #365 were not capable of meeting system operability |
| requirements due to corrosion problems identified on adjacent sprinkler |
| heads." |
| |
| "Two adjacent heads on system #284 and three adjacent heads on system #365 |
| were identified with corrosion around the valve seat. This condition |
| prevents the heads from being able to actuate at normal water pressure. |
| When two adjacent heads are inoperable, the system is considered unable to |
| perform its design function. The PSS declared the affected sprinkler |
| systems inoperable, and [technical safety requirement (TSR)] required |
| actions were initiated and completed." |
| |
| "Further inspections of the Process Building sprinkler systems are planned. |
| This report will be updated if additional sprinkler systems are determined |
| to be inoperable." |
| |
| "There was no loss of hazardous/radioactive material or |
| radioactive/radiological contamination exposure as a result of this event." |
| |
| At the time of this event notification, Portsmouth personnel had completed |
| repairs and were in the process of closing out the paperwork to be able to |
| declare the systems operable again. |
| |
| Portsmouth personnel notified the NRC resident inspector and a Department of |
| Energy site representative. |
| |
| (Call the NRC operations officer for a site contact telephone number.) |
| |
| |
| * * * RETRACTION AT 1800 HOURS ON 02/03/00 BY ERIC SPAETH TAKEN BY MACKINNON |
| * * * |
| |
| The above listed sprinkler heads were replaced and taken to the USEC |
| Laboratory for testing. Of the seven sprinkler heads tested, all operated |
| at the proper temperature, 5 operated at < 7 psi pressure, one operated at |
| 12 psi pressure and one operated at 16 psi pressure. |
| |
| An Engineering Evaluation (EVAL-SS-2000-0038) completed on 01/25/00, |
| calculated that at roof level with 20 or more heads flowing, system pressure |
| would remain at 18.4 psi. The corroded sprinkler heads were found at lower |
| levels which have smaller pressure losses and less friction losses due to |
| shorter piping runs. Since the available system pressure would have been |
| greater than 18.4 psi and the sprinkler heads all operated at 16 psi or |
| less, it was determined that the sprinkler heads would have operated when |
| needed and performed their intended safety function. |
| |
| Since the sprinkler heads were operable, this condition is not reportable in |
| accordance with 10 CFR 76.120[c][2]. Accordingly, this event is being |
| retracted. R3DO (Vegel) & NMSS EO (Holonich) notified. |
| |
| The NRC Resident Inspector was notified of this retraction by the |
| certificate holder. |
+------------------------------------------------------------------------------+
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
+------------------------------------------------------------------------------+
|Hospital |Event Number: 36655 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: ALLEGHENY VALLEY HOPSITAL |NOTIFICATION DATE: 02/03/2000|
|LICENSEE: ALLEGHENY VALLEY HOSPITAL |NOTIFICATION TIME: 14:55[EST]|
| CITY: Natronia Heights REGION: 1 |EVENT DATE: 02/02/2000|
| COUNTY: Allegheny STATE: PA |EVENT TIME: 15:30[EST]|
|LICENSE#: 37-002584-01 AGREEMENT: N |LAST UPDATE DATE: 02/03/2000|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |TONY DIMITRIADIS R1 |
| |JOSIE PICCONE NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: FRANK PTTINON | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| INCORRECT PATIENT GIVEN TECHNETIUM-99M FOR HDP BONE SCAN |
| |
| A medical technician went to room 113 on 1A level and read the patient name |
| plate on the wall outside the room before entering the room. The medical |
| technician entered the room and addressed the elderly patient by the name |
| that was labeled outside her room. The patient responded by saying yes that |
| was her name. The medical technician injected the patient with 22 |
| millicuries of technetium-99m HDP bone scanning agent. When the medical |
| technician reviewed the patient label chart she discovered that she had |
| given the technetium-99m HDP bone scanning agent to the incorrect patient. |
| The correct patient had been taken downstairs for the technetium-99m |
| injection. The patient and her physician were notified of the error. No |
| harm will come to the patient because of the error. |
| |
| * * * RETRACTION ON 02/03/00 AT 1635 HOURS BY FRANK OTTINON TAKEN BY |
| MACKINNON * * * |
| |
| This event is being retracted because the patient did not receive 5 rems |
| effective dose equivalent or 50 rems dose equivalent to any individual organ |
| as a result of receiving the accidental dose of 22 millicuries of |
| technetium-99m as specified in 10 CFR 35.2 item (6) (ii). |
| |
| NRC R1DO (Tony Dimitriadis) and NMSS EO (Joe Holonich) notified. |
+------------------------------------------------------------------------------+
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|Power Reactor |Event Number: 36656 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: QUAD CITIES REGION: 3 |NOTIFICATION DATE: 02/03/2000|
| UNIT: [1] [2] [] STATE: IL |NOTIFICATION TIME: 15:12[EST]|
| RXTYPE: [1] GE-3,[2] GE-3 |EVENT DATE: 02/03/2000|
+------------------------------------------------+EVENT TIME: 10:21[CST]|
| NRC NOTIFIED BY: M MacLENNAN |LAST UPDATE DATE: 02/03/2000|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |TONY VEGEL R3 |
|10 CFR SECTION: | |
|AESF 50.72(b)(2)(ii) ESF ACTUATION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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 N 0 Refueling |0 Refueling |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| INADVERTENT START OF EMERGENCY DIESEL GENERATOR (EDG) DURING SURVEILLANCE |
| TESTING |
| |
| On 02/03/00 at 1021 CST while performing surveillance test QCOS 0203-06 (ADS |
| Logic Test) the Unit-1/2 EDG received an inadvertent autostart signal from |
| Unit 2 Core Spray Logic system. The Unit 1/2 EDG autostart occurred |
| during the installation of relay finger block being placed as part of the |
| surveillance test. The finger block was being placed on the correct relay |
| finger. However, during the installation, and due to the small contact |
| clearances, a momentary relay actuation occurred and caused the EDG start. |
| A Heightened Level of Awareness Briefing was conducted prior to the logic |
| test, and discussed the potential for equipment actuations to occur during |
| performance of the test. In addition, Limitations and Actions step F.7 of |
| QCOS 0203-06 states that inadvertent actuations may occur during the |
| performance of this test, including the EDG autostart, and requires |
| immediate work stoppage and notification of the Unit Supervisor and a Shift |
| Manager review for reportability. The EDG and associated plant systems |
| responded as expected. This report is being made pending further review of |
| the UFSAR and the stated design ESF systems contained in the UFSAR. |
| |
| The NRC Resident Inspector was notified of this event by the licensee. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36657 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: RIVER BEND REGION: 4 |NOTIFICATION DATE: 02/03/2000|
| UNIT: [1] [] [] STATE: LA |NOTIFICATION TIME: 16:08[EST]|
| RXTYPE: [1] GE-6 |EVENT DATE: 02/03/2000|
+------------------------------------------------+EVENT TIME: 11:14[CST]|
| NRC NOTIFIED BY: VERN CARLSON |LAST UPDATE DATE: 02/03/2000|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |CLAUDE JOHNSON R4 |
|10 CFR SECTION: | |
|AESF 50.72(b)(2)(ii) ESF ACTUATION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| BOTH TRAINS OF THE POST ACCIDENT HYDROGEN ANALYZERS DECLARED |
| ADMINISTRATIVELY INOPERABLE. |
| |
| During an ongoing review of calculations for "Normal and Accident Gamma and |
| Beta Doses for Mechanical Equipment Qualifications" it was discovered that |
| an inaccurate assumption was made concerning the operation of the |
| Containment and Drywell post accident hydrogen monitoring system. This |
| inaccurate assumption could lead to the sample isolation valves receiving |
| more radiation exposure than assumed in the calculations curing a design |
| bases accident. This extra radiation exposure could cause deterioration of |
| the valve seats and prevent them from sealing properly. With the valves |
| leaking the indicated hydrogen concentrations could be non-conservatively |
| low leading to improper actions during an accident. This condition affects |
| both safety trains of the post accident hydrogen analyzers. The actual |
| affect is still indeterminate however both trains have been conservatively |
| declared administratively inoperable. The system is still in a standby |
| lineup and is expected to continue to perform its function during the early |
| stages of an accident. Engineering is continuing to evaluate the actual |
| affect of the increased radiation exposure on the equipment. |
| |
| The NRC Resident Inspector will be informed of this event by the licensee. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 36658 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: POINT BEACH REGION: 3 |NOTIFICATION DATE: 02/03/2000|
| UNIT: [1] [2] [] STATE: WI |NOTIFICATION TIME: 17:18[EST]|
| RXTYPE: [1] W-2-LP,[2] W-2-LP |EVENT DATE: 02/03/2000|
+------------------------------------------------+EVENT TIME: 15:45[CST]|
| NRC NOTIFIED BY: ROB HARRSCH |LAST UPDATE DATE: 02/03/2000|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |GARY SHEAR R3 |
|10 CFR SECTION: | |
|AESS 50.72(b)(1)(v) EMERGENCY SIREN INOP | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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
+------------------------------------------------------------------------------+
| ALL ALERT AND NOTIFICATION SYSTEM SIRENS INOPERABLE AFTER INSTALLING A SIREN |
| STATUS FEEDBACK SYSTEM. |
| |
| Loss of all 14 offsite Alert and Notification System after installation of a |
| siren status feedback system. A common failure has resulted in the inability |
| to activate any sirens. The vendor and plant staff are actively |
| troubleshooting. The licensee will notify state and local officials of this |
| event. |
| |
| The NRC Resident Inspector was notified of this event by the licensee. |
| |
| * * * UPDATE ON 02/03/00 AT 1923 HOURS BY HARRSCH TAKEN BY MACKINNON * * * |
| |
| All Alert and Notification System sirens were returned to service at 1745 |
| CT. A software problem caused the loss of the Alert and Notification |
| system. State and Local officials were notified by the licensee of this |
| update. |
| R3DO (Tony Vegel) notified. |
| |
| The NRC Resident Inspector was notified of this update by the licensee. |
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