Event Notification Report for March 12, 2001
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
03/09/2001 - 03/12/2001
** EVENT NUMBERS **
37816 37817 37818 37819 37820 37821 37822 37823 37824 37825
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 37816 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: MONTICELLO REGION: 3 |NOTIFICATION DATE: 03/09/2001|
| UNIT: [1] [] [] STATE: MN |NOTIFICATION TIME: 04:30[EST]|
| RXTYPE: [1] GE-3 |EVENT DATE: 03/09/2001|
+------------------------------------------------+EVENT TIME: 01:30[CST]|
| NRC NOTIFIED BY: TIM ROGERS |LAST UPDATE DATE: 03/09/2001|
| HQ OPS OFFICER: BOB STRANSKY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |JOHN MADERA R3 |
|10 CFR SECTION: | |
|*SHU 50.72(b)(2)(i) PLANT S/D REQD BY TS | |
|*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 |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 A N 0 Refueling |0 Cold Shutdown |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| MODE CHANGE DUE TO LITERAL INTERPRETATION OF REQUIREMENTS |
| |
| "To meet compliance with literal interpretation of Tech Spec 3.7.A.5 and |
| 3.8.B.6, containment venting and purging using SBGT is required above 'Cold |
| Shutdown.' Plant is < 212�, all rods in BUT mode switch was in 'Refuel.' To |
| comply with Tech Specs, a Tech Spec shutdown with mode switch was performed. |
| All rods were already in but it wasn't a preplanned shutdown evolution. |
| Other similar 'Cold Shutdown' Tech Spec compliance issues are being looked |
| at." |
| |
| An automatic scram signal was generated when the mode switch was taken to |
| the 'Shutdown' position. Although all control rods were already inserted, |
| the licensee considers this action to be reportable as a valid safety system |
| actuation. The NRC resident inspector will be informed of this event by the |
| licensee. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 37817 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: INDIAN POINT REGION: 1 |NOTIFICATION DATE: 03/09/2001|
| UNIT: [2] [] [] STATE: NY |NOTIFICATION TIME: 07:18[EST]|
| RXTYPE: [2] W-4-LP,[3] W-4-LP |EVENT DATE: 03/09/2001|
+------------------------------------------------+EVENT TIME: 01:45[EST]|
| NRC NOTIFIED BY: FRANK KICH |LAST UPDATE DATE: 03/09/2001|
| HQ OPS OFFICER: STEVE SANDIN +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |RONALD BELLAMY R1 |
|10 CFR SECTION: |ED GOODWIN 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
+------------------------------------------------------------------------------+
| 24 Hour Notification of High Pressure Fire Water Fire Protection System |
| Impairment per Station Administration Order (SAO) 124 Item 64 and SAO-703 |
| Addendum I Item 2.b.1.b.i. |
| |
| "At 0145 on March 9, 2001, 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 12 |
| Fire Main Booster Pump. 12 Fire Main Booster Pump is inoperable during this |
| tag-out. The Diesel Fire Pump is in service to maintain header pressure for |
| the outside fire header. 11 Fire Main Booster Pump is in operation providing |
| fire header pressure for the inside fire header. Contingency hoses have been |
| staged to provide fire water supply to cross connect the inside and outside |
| headers in the event of a failure on either header. SAO-703 Addendum I Item |
| 2.a.1.a states 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 |
| its function other than the specific instances described in SAO-703 requires |
| an alternate fire protection system shall be established. The alternate fire |
| protection system was established within 24 hours to ensure compliance with |
| SAO-703 as described above. A special report will be submitted to the NRC |
| Regional Administrator of the Region 1 Office outlining this event within 14 |
| Days." |
| |
| The licensee informed the NRC resident inspector. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 37818 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PALISADES REGION: 3 |NOTIFICATION DATE: 03/09/2001|
| UNIT: [1] [] [] STATE: MI |NOTIFICATION TIME: 09:31[EST]|
| RXTYPE: [1] CE |EVENT DATE: 02/08/2001|
+------------------------------------------------+EVENT TIME: 14:37[EST]|
| NRC NOTIFIED BY: R. VINCENT |LAST UPDATE DATE: 03/09/2001|
| HQ OPS OFFICER: BOB STRANSKY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |JOHN MADERA R3 |
|10 CFR SECTION: | |
|BAB2 20.2201(a)(1)(ii) LOST/STOLEN LNM>10X | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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
+------------------------------------------------------------------------------+
| MISSING LOW ACTIVITY SOURCE |
| |
| "During a routine inventory of licensed radioactive sources, one low |
| activity, mixed isotope source could not be accounted for. The source |
| contained a total of approximately 0.992 microcurie, of which approximately |
| 0.154 microcurie was americium-241. Since the quantity of americium-241 in |
| this source was more than ten times greater than the quantity specified in |
| Appendix C of 10CFR20, a telephone report is required in accordance with |
| 10CFR20.2201(a)(1)(ii). None of the other isotopes in the source exceeded |
| reportable quantities specified in Appendix C. The low activity and |
| relatively large physical size of the source are such that it would not be a |
| significant radiological hazard. A search of the site failed to locate the |
| source. It is not likely that a person could have inadvertently carried the |
| source out of the radiologically controlled area (RCA) on his body since the |
| source would have caused the RCA exit monitors to alarm. We have concluded |
| that the source was most likely discarded by mistake inside the RCA into a |
| yellow trash bag with other radioactive waste. The low level radioactive |
| waste from the time period in question was shipped off site to a licensed |
| vendor and has been incinerated." |
| |
| The NRC resident inspector has been informed of this event by the licensee. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Other Nuclear Material |Event Number: 37819 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: AGILENT TECHNOLOGIES |NOTIFICATION DATE: 03/09/2001|
|LICENSEE: AGILENT TECHNOLOGIES |NOTIFICATION TIME: 15:18[EST]|
| CITY: WILMINGTON REGION: 1 |EVENT DATE: 02/16/2001|
| COUNTY: STATE: DE |EVENT TIME: 12:00[EST]|
|LICENSE#: 07-28762-01 AGREEMENT: N |LAST UPDATE DATE: 03/09/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |RONALD BELLAMY R1 |
| |JOSIE PICCONE NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: DAVID BENNET | |
| HQ OPS OFFICER: DOUG WEAVER | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|BAB2 20.2201(a)(1)(ii) LOST/STOLEN LNM>10X | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| Agilent Technologies reported the loss of two electron capture detectors. |
| Each detector contains a 15 mCi Ni-63 source. Because the Ni-63 is plated |
| on the inside of the device and Ni-63 is a low energy Beta emitter, the risk |
| of exposure to the public is low. The detectors were last accounted for in |
| December 1995. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Hospital |Event Number: 37820 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: ILLINOIS DEPT OF NUCLEAR SAFETY |NOTIFICATION DATE: 03/09/2001|
|LICENSEE: LOYOLA UNIVERSITY MEDICAL CENTER |NOTIFICATION TIME: 15:57[EST]|
| CITY: MAYWOOD REGION: 3 |EVENT DATE: 03/08/2001|
| COUNTY: STATE: IL |EVENT TIME: 12:00[CST]|
|LICENSE#: IL-01131-02 AGREEMENT: Y |LAST UPDATE DATE: 03/09/2001|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |JOHN MADERA R3 |
| |JOHN GREEVES NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: JOE KLINGER | |
| HQ OPS OFFICER: DOUG WEAVER | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| MEDICAL MISADMINISTRATION |
| |
| The following text was taken from an email sent to the NRC's Operations |
| Center from the State of Illinois. |
| |
| The RSO at Loyola University Medical Center, IL-01131-02, Maywood, IL, |
| called at approximately 12:30 p.m., 3/9/01, to report a reportable event |
| involving the Cordis Intravascular Brachytherapy (IVB) |
| system. He stated that two patients undergoing cardiac therapy on the |
| previous day, had been treated with the Ir-192 seeds to prevent restenosis |
| in a stent. The prescribed dose was 8 gray (800 rads) to the tunica media |
| layer of the heart. However, the calculated dose to one of the patients |
| was12.5 gray (1250 rads) (56% overdose) and 14.3 gray (1,430 rads) (79% |
| overdose). |
| |
| The cause of the problem appears to be due to a new method for this |
| institution to determine the actual dose to the intended organ. In the |
| past, dwell times were based on 14 gray being delivered at 2 mm distance |
| from the radioactive sources. This new procedure requires an intravascular |
| ultrasound device to be used and measurements from the intended treatment |
| portion of the heart and the sources are determined. These measurements |
| then determine the dwell time for the prescribed dose. This new measurement |
| method and possible communication problems while taking the measurements and |
| using the measurements contributed to the problem. No further use of this |
| system will be conducted until these problems are resolved and the Radiation |
| Safety Committee and the Department are satisfied that there will be no |
| recurrence. |
| |
| . |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 37821 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: CALLAWAY REGION: 4 |NOTIFICATION DATE: 03/09/2001|
| UNIT: [1] [] [] STATE: MO |NOTIFICATION TIME: 20:46[EST]|
| RXTYPE: [1] W-4-LP |EVENT DATE: 03/09/2001|
+------------------------------------------------+EVENT TIME: 12:51[CST]|
| NRC NOTIFIED BY: GARY OLMSTEAD |LAST UPDATE DATE: 03/09/2001|
| HQ OPS OFFICER: DOUG WEAVER +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |WILLIAM JOHNSON R4 |
|10 CFR SECTION: | |
|*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 |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 A/R Y 100 Power Operation |0 Hot Standby |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| LOSS OF BOTH CONTROL ROD DRIVE MOTOR GENERATORS CAUSES REACTOR TRIP |
| |
| During performance of work on the 'B' Rod Drive Motor Generator set, the |
| output breaker for 'A' Rod Drive Motor Generator set opened causing a loss |
| of power to the Rod Control System. The cause of the 'A' Rod Drive Motor |
| Generator set output breaker opening is being investigated. With a loss of |
| power, all rods were de-energized and inserted into the core. Rod K-10 |
| developed an alarm and the problem was determined to be a faulty circuit |
| card. The circuit card was replaced and the problem corrected. |
| |
| This event resulted in a Reactor Protection System (RPS) actuation, when |
| rods were inserted, an Over Temperature delta T (OTdeltaT) trip was |
| generated which generated the RPS actuation. After the RPS system actuated, |
| an Auxiliary Feedwater System actuation was generated. |
| |
| It was concluded this event is reportable per 10CFR50.72(b)(3)(iv)(A) |
| since: |
| (1) The actuation of the Reactor Protection System occurred after the rods |
| were at the bottom of the Reactor core (i.e. shut down) as indicated by |
| computer point alarm printout. |
| |
| The NRC Resident inspector was notified of this event by the licensee |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 37822 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: SUSQUEHANNA REGION: 1 |NOTIFICATION DATE: 03/10/2001|
| UNIT: [] [2] [] STATE: PA |NOTIFICATION TIME: 04:50[EST]|
| RXTYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 03/10/2001|
+------------------------------------------------+EVENT TIME: 04:14[EST]|
| NRC NOTIFIED BY: ARDLE KISSINGER |LAST UPDATE DATE: 03/10/2001|
| HQ OPS OFFICER: FANGIE JONES +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |RONALD BELLAMY R1 |
|10 CFR SECTION: | |
|NINF INFORMATION ONLY | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 M/R Y 21 Power Operation |0 Hot Shutdown |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| COURTESY NOTIFICATION FOR ENTRY INTO 10TH REFUELING |
| |
| "This is a Courtesy Notification and does not fall within 10CFR50.72 |
| Guidelines. |
| |
| "Susquehanna Unit 2 was manually shutdown on 3/10/01 to enter its 10th |
| Refueling and Inspection outage. At 1630 hours on 3/9/01, a controlled |
| shutdown was commenced by reducing recirc flow and then inserting control |
| rods. At 03:45 on 3/10/99, the Main Turbine was manually tripped with power |
| at 17.5%. At 04:14 with power at 21% the reactor mode switch was taken to |
| shutdown placing the unit in condition 3. All control rods fully inserted. |
| Rx Water level dropped to approximately -1 inch as recorded on wide range |
| instrumentation, and was restored using Feedwater. There were no ECCS |
| initiations or Diesel Generator starts. No safety/relief valves lifted. |
| There were no challenges to containment or fuel as a result of the |
| shutdown. |
| |
| "The shutdown is continuing according to schedule and is scheduled to return |
| to service in 35 days." |
| |
| The licensee notified the NRC Resident Inspector. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 37823 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: MONTICELLO REGION: 3 |NOTIFICATION DATE: 03/10/2001|
| UNIT: [1] [] [] STATE: MN |NOTIFICATION TIME: 18:59[EST]|
| RXTYPE: [1] GE-3 |EVENT DATE: 03/10/2001|
+------------------------------------------------+EVENT TIME: 17:05[CST]|
| NRC NOTIFIED BY: P DECKER |LAST UPDATE DATE: 03/10/2001|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |JOHN MADERA 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 N 0 Cold Shutdown |0 Cold Shutdown |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| DIFFERENTIAL PRESSURE TO OPEN THE SUPPRESSION CHAMBER TO DRYWELL VACUUM |
| BREAKERS DISCREPANCIES WERE IDENTIFIED. |
| |
| During review of Inservice Testing requirements, while the plant was in |
| shutdown, discrepancies were identified with acceptance criteria for the |
| torque values used to determine the equivalent differential pressure to open |
| the suppression chamber to drywell vacuum breakers. The measured torque |
| values indicate that the differential pressure required to fully open the |
| suppression chamber to drywell vacuum breakers would be greater than that |
| assumed in containment analyses. The suppression chamber to drywell vacuum |
| breakers insure that the 2 psig external design pressure for the primary |
| containment drywell suppression chamber and vent system is not exceeded and |
| containment integrity is assured. |
| |
| The NRC Resident Inspector will be notified of this event by the licensee. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 37824 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: NORTH ANNA REGION: 2 |NOTIFICATION DATE: 03/10/2001|
| UNIT: [] [2] [] STATE: VA |NOTIFICATION TIME: 22:29[EST]|
| RXTYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 03/10/2001|
+------------------------------------------------+EVENT TIME: 15:15[EST]|
| NRC NOTIFIED BY: JAMES JOHNSTONE |LAST UPDATE DATE: 03/10/2001|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |THOMAS DECKER R2 |
|10 CFR SECTION: | |
|*SHU 50.72(b)(2)(i) PLANT S/D REQD BY TS | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 N Y 72 Power Operation |71 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| TECHNICAL SPECIFICATION (TS) SHUTDOWN |
| |
| "At time 2058 (EST) on 03/10/01, Unit 2 commenced a normal rampdown to cold |
| shutdown for refueling. The unit was in action statement that expires at |
| 1515 on 03/11/01. The action statement of TS 3.6.1.3.b had been entered at |
| 1515 on 03/10/01 when 2-PT-62.1 failed. This test was a routine pre-outage |
| test on the containment equipment hatch personnel access air lock. The unit |
| shutdown was planned for this date and time. Repairs to the failed |
| component will be made with unit in mode 5." |
| |
| The licensee thinks that the equipment hatch inner air lock door equalizing |
| valve is leaking by. |
| |
| The NRC Resident Inspector was notified of this event by the licensee. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 37825 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: NORTH ANNA REGION: 2 |NOTIFICATION DATE: 03/11/2001|
| UNIT: [] [2] [] STATE: VA |NOTIFICATION TIME: 04:28[EST]|
| RXTYPE: [1] W-3-LP,[2] W-3-LP |EVENT DATE: 03/11/2001|
+------------------------------------------------+EVENT TIME: 01:19[EST]|
| NRC NOTIFIED BY: JAMES JOHNSTONE |LAST UPDATE DATE: 03/11/2001|
| HQ OPS OFFICER: FANGIE JONES +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |THOMAS DECKER R2 |
|10 CFR SECTION: | |
|*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 M/R N 0 Hot Standby |0 Hot Standby |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| TECHNICAL SPECIFICATION REQUIRED MANUAL REACTOR TRIP DURING PLANT SHUTDOWN |
| |
| At 0109 EST on 3/11/01 with the reactor already subcritical during the |
| insertion of control bank 'B', the licensee noted that the group 2 step |
| counter stopped moving at 53 steps. Technical specification 3.1.3.3 |
| requires the reactor trip breakers to be opened within 15 minutes and at |
| 0119 EST the licensee performed a manual reactor trip opening the trip |
| breakers. The plant is entering a refueling outage and the problem will be |
| corrected before startup. |
| |
| The licensee intends to notify the NRC Resident Inspector. |
+------------------------------------------------------------------------------+
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