Event Notification Report for February 15, 2001
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
02/14/2001 - 02/15/2001
** EVENT NUMBERS **
37743 37744 37745 37746 37747 37748 37749 37750
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|Power Reactor |Event Number: 37743 |
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| FACILITY: INDIAN POINT REGION: 1 |NOTIFICATION DATE: 02/14/2001|
| UNIT: [2] [] [] STATE: NY |NOTIFICATION TIME: 02:51[EST]|
| RXTYPE: [2] W-4-LP,[3] W-4-LP |EVENT DATE: 02/14/2001|
+------------------------------------------------+EVENT TIME: 01:50[EST]|
| NRC NOTIFIED BY: MARK LEONE |LAST UPDATE DATE: 02/14/2001|
| HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |CLIFFORD ANDERSON R1 |
|10 CFR SECTION: |JOHN ZWOLINSKI NRR |
|*ESF 50.72(b)(3)(iv)(A) VALID SPECIF SYS ACTUAT| |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|2 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
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EVENT TEXT
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| THE LOSS OF A 480-VOLT BUS DUE TO A PERSONNEL ERROR DURING SURVEILLANCE |
| TESTING RESULTED IN THE AUTOMATIC START OF THREE EMERGENCY DIESEL |
| GENERATORS. |
| |
| At 0150 on 02/14/01, 480-volt bus 3A was lost due to incorrect operation of |
| a switch during performance of a surveillance test. An individual |
| performing the test needed to simultaneously hold a switch in the bypass |
| position while a test button was pressed, and the switch was not held in the |
| correct position. As a result, an undervoltage signal was inserted on the |
| bus when the test button was pushed, and all three emergency diesel |
| generators automatically started as designed. |
| |
| The licensee stated that the emergency diesel generators do not |
| automatically load on the loss of an internal bus and that all automatic |
| functions operated properly. The licensee also stated that the loss of any |
| 480-volt bus places the unit in a shutdown action statement in accordance |
| with Technical Specification 3.0.1. However, power (via an emergency diesel |
| generator) was restored to the bus in accordance with procedures at 0215, |
| and restoration of power satisfied the action statement requirements in |
| Technical Specification 3.0.1 within 25 minutes. The licensee is currently |
| in the process of restoring normal bus power supply. |
| |
| The licensee stated that bus 3A is one of the power supplies for the 22 |
| safety injection pump. This bus also supplies power to the 21 residual heat |
| removal pump, 22 and 25 service water pumps, 24 fan cooler unit, 21 |
| auxiliary boiler feed pump, 22 charging pump, 21 backup heater for the |
| pressurizer, and 23 instrument bus (via the 23 battery charger). |
| |
| The licensee plans to notify the NRC resident inspector and applicable |
| government agencies. The licensee may also issue a press release. |
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|Fuel Cycle Facility |Event Number: 37744 |
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| FACILITY: HONEYWELL INTERNATIONAL, INC. |NOTIFICATION DATE: 02/14/2001|
| RXTYPE: URANIUM HEXAFLUORIDE PRODUCTION |NOTIFICATION TIME: 07:44[EST]|
| COMMENTS: UF6 CONVERSION (DRY PROCESS) |EVENT DATE: 02/14/2001|
| |EVENT TIME: 02:30[CST]|
| |LAST UPDATE DATE: 02/14/2001|
| CITY: METROPOLIS REGION: 3 +-----------------------------+
| COUNTY: MASSAC STATE: IL |PERSON ORGANIZATION |
|LICENSE#: SUB-526 AGREEMENT: Y |MONTE PHILLIPS R3 |
| DOCKET: 04003392 |FRED BROWN NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: HUGH ROBERTS | |
| HQ OPS OFFICER: LEIGH TROCINE | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|JBBE 40.60(b)(2) SAFETY EQUIPMENT FAILUR| |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| SANITARY WELL WATER FAILURE DUE TO A LINE RUPTURE (24-Hour Report involving |
| the potential inability to mitigate the circumstances of an accident) |
| |
| Honeywell Metropolis Works is a fuel cycle facility that performs UF6 |
| conversion. |
| |
| At approximately 0230 CST, a 6-inch diameter sanitary process line ruptured. |
| As a result, the licensee secured (shut down) both the safety showers and |
| the process. The ruptured line has been isolated, and process water has |
| been valved into the safety showers. However, the licensee has not yet |
| brought up the process. Repair planning is underway. |
| |
| The licensee plans to notify the NRC Region 3 office, an onsite NRC |
| inspector (Mary Thomas), and the NRC resident inspector at Paducah (Courtney |
| Blanchard). (The USEC Paducah facility is located across the river.) |
| |
| Call the NRC operations officer for a licensee contact telephone number. |
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|Hospital |Event Number: 37745 |
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| REP ORG: MERCY HOSPITAL |NOTIFICATION DATE: 02/14/2001|
|LICENSEE: MERCY HOSPITAL |NOTIFICATION TIME: 09:37[EST]|
| CITY: PORT HURON REGION: 3 |EVENT DATE: 02/13/2001|
| COUNTY: STATE: MI |EVENT TIME: 23:30[EST]|
|LICENSE#: 211563801 AGREEMENT: N |LAST UPDATE DATE: 02/14/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |MONTE PHILLIPS R3 |
| |BRIAN SMITH NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: CHUCK SMITH | |
| HQ OPS OFFICER: LEIGH TROCINE | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| POSSIBLE MISADMINISTRATION AT MERCY HOSPITAL IN PORT HURON, MICHIGAN |
| |
| A patient was receiving a treatment with a gynecological implant containing |
| two cesium-137 sources (with 13.74 milligrams radium equivalent each). The |
| patient was reportedly restless and moving around quite a bit, and the |
| applicator was in its proper position at 2100. However, when nurses checked |
| on positioning of applicator at 2330 on 02/13/01, it was discovered that |
| the applicator had gotten past the sutures and come out completely. The |
| implant treatment procedure was terminated at that time. |
| |
| Based on the minimum and maximum amount of time that the applicator may have |
| been in the proper position, the patient received between 66% and 71% of the |
| intended dose. Conservative calculations (assuming that the applicator came |
| out at 2100) revealed doses to unintended areas were not anticipated to |
| cause adverse health complications as a result of this exposure. The |
| patient has been informed. |
| |
| (Call the NRC operations officer for a licensee contact telephone number.) |
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|General Information or Other |Event Number: 37746 |
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| REP ORG: TEXAS DEPARTMENT OF HEALTH |NOTIFICATION DATE: 02/14/2001|
|LICENSEE: RONE ENGINEERS |NOTIFICATION TIME: 10:00[EST]|
| CITY: DALLAS REGION: 4 |EVENT DATE: 02/03/2001|
| COUNTY: STATE: TX |EVENT TIME: [CST]|
|LICENSE#: L02356 AGREEMENT: Y |LAST UPDATE DATE: 02/14/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |GREG PICK R4 |
| |BRIAN SMITH NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: JAMES H. OGDEN, JR. (fax) | |
| HQ OPS OFFICER: LEIGH TROCINE | |
+------------------------------------------------+ |
|EMERGENCY CLASS: | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| AGREEMENT STATE REPORT INVOLVING A STOLEN TROXLER NUCLEAR DENSITY GAUGE |
| |
| The following text is a portion of a facsimile received from the Texas |
| Department of Health, Bureau of Radiation Control: |
| |
| "This is an initial notification of a stolen nuclear gauge. The gauge was |
| stolen on Saturday February 3, 2001, from the parking lot of the Midway |
| Point Restaurant, [...], Dallas, Texas, while the [driver] ate lunch between |
| jobs. The Licensee's initial report indicates that the gauge was secured in |
| it's transport case and chained to the company pickup with chain and lock. |
| The driver noted that the gauge, the lock, and chain were all missing. The |
| stolen gauge was a Troxler Model 3430, Serial Number 31580. The gauge |
| contained two sources: 8 millicuries of Cs-137, Source Serial No. 750-6419, |
| and 40 millicuries of Am-241:Be, Source Serial No. 47-28229. A Police |
| Report was filed with the Dallas Police Department (Report Service |
| #0083748-K - [...]). The operator reported the loss to his supervisor and a |
| report was telephoned to this Agency on February 5, 2001. Two written |
| reports were faxed to the Agency [...]. The gauge has not been recovered to |
| date. An Agency investigation is ongoing. The Texas Licensee (L02356) is |
| Rone Engineers [located in] Dallas, Texas [...]." |
| |
| (Call the NRC operations officer for contact information.) |
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|Power Reactor |Event Number: 37747 |
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| FACILITY: INDIAN POINT REGION: 1 |NOTIFICATION DATE: 02/14/2001|
| UNIT: [2] [] [] STATE: NY |NOTIFICATION TIME: 10:49[EST]|
| RXTYPE: [2] W-4-LP,[3] W-4-LP |EVENT DATE: 02/14/2001|
+------------------------------------------------+EVENT TIME: 04:08[EST]|
| NRC NOTIFIED BY: PHIL SANTINI |LAST UPDATE DATE: 02/14/2001|
| HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |CLIFFORD ANDERSON R1 |
|10 CFR SECTION: |TAD MARSH NRR |
|NONR OTHER UNSPEC REQMNT | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|2 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| HIGH PRESSURE FIRE HEADER IMPAIRMENT AND SURVEILLANCE PER STATION |
| ADMINISTRATIVE ORDER (SAO) 703 (24-Hour Report in accordance with the |
| license) |
| |
| The following text is a portion of a facsimile received from the licensee: |
| |
| "The high pressure Fire Water Protection System is degraded due to planned |
| maintenance work. The inner and outer high-pressure fire headers are split |
| to provide protection for work on the valves for [the] 12 Fire Main Booster |
| Pump. [The] 12 Fire Main Booster Pump is inoperable during this tag-out. |
| The diesel fire pump is in service as the alternate fire protection for the |
| outside fire header. [The] 11 Fire Main Booster Pump is in service for the |
| inside header. SAO-703 states [that] one fire main booster pump out of |
| service is a 7-day action statement to return it to operable status. The |
| headers being separated or any part of the fire protection piping or valves |
| not being able to perform [their] function other than the specific instances |
| described in SAO-703 [require] an alternate fire protection system shall be |
| established. This was established within 24 hours to ensure compliance with |
| SAO-703 as described above. A special report shall be submitted to the NRC |
| Regional Administrator of the Region 1 Office outlining this issue within 14 |
| days." |
| |
| The licensee notified the NRC resident inspector and plans to notify the NRC |
| Region 1 office (Pete Eselgroth). |
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|General Information or Other |Event Number: 37748 |
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| REP ORG: TEXAS DEPARTMENT OF HEALTH |NOTIFICATION DATE: 02/14/2001|
|LICENSEE: DRASH CONSULTING ENGINEERS, INC. |NOTIFICATION TIME: 12:33[EST]|
| CITY: HARLINGEN REGION: 4 |EVENT DATE: 01/01/2001|
| COUNTY: STATE: TX |EVENT TIME: [CST]|
|LICENSE#: TX L04724 AGREEMENT: Y |LAST UPDATE DATE: 02/14/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |GREG PICK R4 |
| |JOHN HICKEY NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: HELEN WATKINS | |
| HQ OPS OFFICER: FANGIE JONES | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| AGREEMENT STATE REPORT OF STOLEN HUMBOLDT GAUGE |
| |
| The following text is a portion of a facsimile received from the Texas |
| Department of Health, Bureau of Radiation Control: |
| |
| "On Monday January 1, 2001, a moisture/density gauge was stolen from the |
| back of a pickup truck that was parked at an apartment complex in Harlingen, |
| Texas. The technician who had used the gauge went to his apartment from |
| 10:00 am to 1:00 pm after completing work at one job site. When the |
| technician was getting into his truck, he noticed the lid on the gauge |
| transport case was cracked open and the gauge was missing. |
| |
| "The stolen gauge is a Humboldt Model 5001-C, serial number 1467. The gauge |
| contained two sources: |
| 10 millicuries of Cs-137, source serial No. 692GH, and 40 millicuries of |
| Am-241:Be, source serial No. |
| NJO1429. |
| |
| "The Licensee notified the Harlingen Police Department, this Agency, and the |
| manufacturer. The Licensee placed an ad in a local newspaper offering a $500 |
| reward for the return of the gauge." |
| |
| Call the NRC operations officer for contact information. |
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|Power Reactor |Event Number: 37749 |
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| FACILITY: CALLAWAY REGION: 4 |NOTIFICATION DATE: 02/14/2001|
| UNIT: [1] [] [] STATE: MO |NOTIFICATION TIME: 17:05[EST]|
| RXTYPE: [1] W-4-LP |EVENT DATE: 02/14/2001|
+------------------------------------------------+EVENT TIME: 08:51[CST]|
| NRC NOTIFIED BY: BRUCE SCHOENBACH |LAST UPDATE DATE: 02/14/2001|
| HQ OPS OFFICER: FANGIE JONES +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |GREG PICK R4 |
|10 CFR SECTION: | |
|*IND 50.72(b)(3)(v)(D) ACCIDENT MITIGATION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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
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| BOTH TRAINS OF CONTAINMENT COOLERS AND ONE TRAIN OF CONTAINMENT SPRAY |
| INOPERABLE |
| |
| The following text is a portion of a facsimile received from the licensee: |
| |
| "On 2/14/01, the 'A' train containment cooling train was removed from |
| service at 0507 CST for associated circuit breaker work. At 0851 CST the 'B' |
| Train Essential Service Water pump was started to support performance of the |
| 'A' Train SIS/CIS Slave Relay Test. |
| |
| "The 'B' Essential Service Water pump failed to achieve rated flow and |
| pressure and was declared inoperable at 0851 CST. This resulted in entry |
| into Technical Specification LCO 3.6.6, Required Action F.1 for both trains |
| of containment coolers inoperable and one train ('B') of Containment Spray |
| inoperable. LCO 3.6.6 Required Action F.1 also requires entry into LCO |
| 3.0.3. Technical Specification 3.0.3 was entered at 0851 CST and exited at |
| 1123 CST when the 'A' train of Containment Cooling was returned to service. |
| The plant remains in Technical Specification LCO 3.7.8 Required Action A.1 |
| (72-Hour Action Statement) for one train ('B') of Essential Service Water |
| inoperable. |
| |
| "This condition at the time of discovery could have prevented the |
| fulfillment of the safety function of structures or systems that are needed |
| to control the release of radioactive material or mitigate the consequences |
| for an accident. It was concluded that this event was reportable per |
| 10CFR50.72(b) (3) (v) since: |
| |
| (1) Both trains of containment cooling were lost as a result of the |
| unanticipated failure of the 'B' train Essential Service Water pump in |
| conjunction with the 'A' train containment coolers being removed from |
| service. |
| (2) Cascading through technical specification resulted in the loss of 'B' |
| train containment spray system. |
| |
| "The failure of the 'B' train Essential Service Water pump is under |
| evaluation." |
| |
| The licensee notified the NRC Resident Inspector. |
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|Power Reactor |Event Number: 37750 |
+------------------------------------------------------------------------------+
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| FACILITY: KEWAUNEE REGION: 3 |NOTIFICATION DATE: 02/14/2001|
| UNIT: [1] [] [] STATE: WI |NOTIFICATION TIME: 20:00[EST]|
| RXTYPE: [1] W-2-LP |EVENT DATE: 02/14/2001|
+------------------------------------------------+EVENT TIME: 16:00[CST]|
| NRC NOTIFIED BY: GARY HARRINGTON |LAST UPDATE DATE: 02/14/2001|
| HQ OPS OFFICER: FANGIE JONES +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |MONTE PHILLIPS R3 |
|10 CFR SECTION: | |
|*UNA 50.72(b)(3)(ii)(B) UNANALYZED COND OP | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 96 Power Operation |96 Power Operation |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| ANALYSES OF AN ELECTRICAL BOX DOES NOT MEET THE FIRE RESISTANCE OF APPENDIX |
| R |
| |
| The Kewaunee Engineering staff, while conducting a review, recognized that |
| they could provide no analyses to support compliance to 10CFR50, Appendix R, |
| for an electrical wiring pull box. The box provides an enclosure for |
| dedicated safe shutdown equipment wiring, 'A' train equipment. The box is |
| located in an alternate safe shutdown equipment room, 'B' train, where the |
| box provides protection against fire. However, though the analyses of the |
| box provides assurance that the design will protect the 'A' train equipment |
| wiring from a fire, it does not provide a three hour barrier consistent with |
| Appendix R requirements. Therefore, this places the plant in an unanalyzed |
| condition. The box was designed and installed in the early to mid 1980s. |
| Compensatory measures have been taken to ensure continued safe plant |
| operation. |
| |
| The licensee notified the NRC Resident Inspector. |
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