Event Notification Report for March 8, 2002
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
03/07/2002 - 03/08/2002
** EVENT NUMBERS **
38602 38648 38751 38752 38753 38754 38755
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|Power Reactor |Event Number: 38602 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: CRYSTAL RIVER REGION: 2 |NOTIFICATION DATE: 01/01/2002|
| UNIT: [3] [] [] STATE: FL |NOTIFICATION TIME: 10:08[EST]|
| RXTYPE: [3] B&W-L-LP |EVENT DATE: 01/01/2002|
+------------------------------------------------+EVENT TIME: 09:19[EST]|
| NRC NOTIFIED BY: BILL BANDHAUER |LAST UPDATE DATE: 03/07/2002|
| HQ OPS OFFICER: FANGIE JONES +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |ANNE BOLAND R2 |
|10 CFR SECTION: | |
|APRE 50.72(b)(2)(xi) OFFSITE NOTIFICATION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|3 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| OFFSITE NOTIFICATION DUE RESCUED SEA TURTLE |
| |
| EN #37902 started the biennial report period. |
| |
| On January 1, 2002 at 0919, a rescued sea turtle was identified as a green |
| sea turtle. This is the 62nd rescue of a live sea turtle at Crystal River |
| Unit 3 (CR-3) in this biennial period. Notification to the National Marine |
| Fisheries Service and the Florida Fish and Wildlife Conservation Commission. |
| |
| |
| The licensee intends to notify the NRC Resident Inspector. |
| |
| * * * UPDATE ON 1/05/02 @ 1002 BY RAWLS TO GOULD * * * |
| |
| On January 5, 2002, at 0720, a rescued sea turtle was identified as a |
| Loggerhead Sea Turtle. This is the 63rd rescue of a live sea turtle at |
| Crystal River Unit 3 (CR3) in this biennial period. This is reportable as a |
| 4-hour report under 10 CFR 50.72(b)(2)(xi) as this event is related to the |
| protection of the environment for which a notification to other government |
| agencies (National Marine Fisheries Service and Florida Fish and Wildlife |
| Conservation Commission) has been or will be made. |
| |
| The NRC Resident Inspector was notified. |
| |
| Reg 2 RDO (Decker) was notified. |
| |
| * * * UPDATE ON 01/09/02 @ 1107 EST BY ANDY BARNES TAKEN BY MACKINNON * * * |
| |
| On January 9, 2002, at 0838, a rescued sea turtle was identified as a Kemp's |
| Ridley Sea Turtle. This is the 64th rescue of a live turtle at Crystal River |
| Unit 3 (CR-3) in this biennial period. This is reportable as a 4-hour 10 CFR |
| 50.72 (b)(2)(xi) as this event is related to the protection of the |
| environment for which a notification to other government agencies (National |
| Marine Fisheries Service and Florida Fish and Wildlife Conservation |
| Commission) has been or will be made. |
| |
| The NRC Resident Inspector was notified. |
| |
| Reg 2 (Brian Bonser) was notified. |
| |
| * * * UPDATE ON 02/17/02 at 0940 EST BY RICKY RAWLS TO FANGIE JONES * * * |
| |
| "On February 17, 2002 at 0820, a rescued injured sea turtle was identified |
| as a Kemp's Ridley Sea Turtle. The injury will require transportation to |
| Clearwater Marine Science Center or Florida Fish and Wildlife Conservation |
| Refuge. The Injury appears to be from a boat propeller. This is the 65th |
| rescue of a live sea turtle at Crystal River Unit 3 (CR-3) in this biennial |
| period. This is Reportable as a 4-Hour Report under 10 CFR 50.72(b) (2) (xi) |
| as this event is related to the protection of the environment for which a |
| notification to other government agencies (National Marine Fisheries Service |
| and Florida Fish and Wildlife Conservation Commission) has been or will be |
| made. This Is an update to event 38602." |
| |
| The NRC Resident Inspector will be notified. R2DO (Stephen Cahill) has been |
| notified. |
| |
| * * * UPDATE ON 03/01/02 AT 1122 EST BY RICKY RAWLS TO GERRY WAIG * * * |
| |
| "On March 1, 2002 at 0952, a healthy rescued sea turtle was identified as a |
| Green Sea Turtle. This is the 66th rescue of a live sea turtle at Crystal |
| River Unit 3 (CR-3) in this biennial period. This is Reportable as a 4-Hour |
| Report under 10 CFR 50.72 (b) (2) (xi) as this event is related to the |
| protection of the environment for which a notification to other government |
| agencies (National Marine Fisheries Service and Florida Fish and Wildlife |
| Conservation Commission) has been or will be made. This is an update to |
| event 38602." |
| |
| The NRC Resident Inspector was notified. R2DO (Julian) was notified. |
| |
| * * * UPDATE ON 03/07/02 AT 1114 EST BY CHUCK MORRIS TO MIKE NORRIS * * * |
| |
| "On March 7, 2002 at 0835, two healthy sea turtles rescued at CR#3 were |
| identified as Green Sea Turtles. These are the 67th and 68th live sea turtle |
| rescues at the Crystal River Energy Complex in this biennial period. This is |
| Reportable as a 4-Hour Report under 10 CFR 50.72(b) (2) (xi) as this event |
| is related to the protection of the environment for which a notification to |
| other government agencies (National Marine Fisheries Service and Florida |
| Fish and Wildlife Conservation Commission) has been or will be made. This is |
| an update to event 38602." |
| |
| The NRC Resident Inspector was notified. R2DO (Henson) was notified. |
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!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 38648 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
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| FACILITY: SUSQUEHANNA REGION: 1 |NOTIFICATION DATE: 01/24/2002|
| UNIT: [1] [2] [] STATE: PA |NOTIFICATION TIME: 18:20[EST]|
| RXTYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 01/24/2002|
+------------------------------------------------+EVENT TIME: 11:00[EST]|
| NRC NOTIFIED BY: GORDON ROBINSON |LAST UPDATE DATE: 03/07/2002|
| HQ OPS OFFICER: BOB STRANSKY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |PETE ESELGROTH R1 |
|10 CFR SECTION: | |
|AINA 50.72(b)(3)(v)(A) POT UNABLE TO SAFE SD | |
|AINB 50.72(b)(3)(v)(B) POT RHR INOP | |
|AIND 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 93 Power Operation |93 Power Operation |
|2 N Y 100 Power Operation |100 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| FAILURE OF REACTOR VESSEL WATER LEVEL SWITCH |
| |
| "At 11:00 EST, during performance of the 24 Month Calibration of Reactor |
| Vessel Water Level Channels on Unit 2, Level Indicating Switch |
| LIS-B21-2N031C would not properly relock following calibration. As a result |
| of this, the switch was declared inoperable. A review of the design drawings |
| revealed that this switch provides inputs (through relays) that affect the |
| reset logic for the 'A' and 'C' ESW pumps and the trips for the 'A' Reactor |
| and Turbine Building Chillers on a Low Reactor Water Level signal. Without |
| this switch functioning properly, the listed ESW pump start timers would not |
| reset as required and the listed chillers would not trip as required on the |
| Low Reactor Water signal. The Tech Spec Basis for this instrumentation |
| indicates that without these features, both offsite circuits and the |
| associated Diesel Generators would be inoperable. Given this, both offsite |
| sources and two (2) Diesel Generators were declared inoperable. SSES safety |
| analysis requires three Operable Diesel Generators to safely shutdown the |
| plant. Given this, this condition requires an 8 hour ENS notification in |
| accordance with 10CFR50.72(b)(3)(v). |
| |
| "As a result of this condition, LCO 3.0.3 was entered on both Unit 1 and |
| Unit 2 (in addition to other applicable LCO's). As of 13:00 on 01/24/02, the |
| switch was repaired and declared operable (and the associated LCO's were |
| cleared). |
| |
| "There were no Diesel Generators, ECCS, or Tech Spec Electrical Distribution |
| systems out of service at the time of the event." |
| |
| The NRC resident inspector has been informed of this notification by the |
| licensee. |
| |
| * * * EVENT RETRACTED AT 1743 EST 3/7/02 BY GRANT FERNSLER TO GERRY WAIG * *
|
| * |
| |
| "A subsequent evaluation of the inoperable level switch determined that the |
| impact, under worst case conditions, would have resulted in only one |
| inoperable Emergency Diesel Generator. Both offsite power sources and the |
| remaining three aligned Emergency Diesel Generators would remain operable. |
| This is within the design basis of the plant and therefore the condition |
| would not have resulted in a complete loss of a safety function. Based on |
| that evaluation, ENS notification EN#38648 is retracted." The NRC Resident |
| has been notified of the retraction by the licensee. |
| |
| Notified the R1DO (Mohamed Shanbaky). |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 38751 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: CALLAWAY REGION: 4 |NOTIFICATION DATE: 03/07/2002|
| UNIT: [1] [] [] STATE: MO |NOTIFICATION TIME: 06:41[EST]|
| RXTYPE: [1] W-4-LP |EVENT DATE: 03/07/2002|
+------------------------------------------------+EVENT TIME: 05:41[CST]|
| NRC NOTIFIED BY: J. R. WEEKLY |LAST UPDATE DATE: 03/07/2002|
| HQ OPS OFFICER: MIKE NORRIS +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |DAVE LOVELESS R4 |
|10 CFR SECTION: | |
|ACOM 50.72(b)(3)(xiii) LOSS COMM/ASMT/RESPONSE| |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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
+------------------------------------------------------------------------------+
| PLANNED LOSS OF POWER TO EOF DUE TO MAINTENANCE |
| |
| "During performance of planned maintenance, the Emergency Operation Facility |
| (EOF) will be de-energized. These maintenance activities, including |
| electrical isolation and restoration are expected to last approximately 8 |
| hours. Contingency plans for emergency situations have been established. |
| |
| "This event is reportable per 10CFR50.72(b)(3)(xiii) since this constitutes |
| a loss of an emergency response facility for the duration of the evolution. |
| |
| "The NRC Resident was previously notified that this activity was scheduled |
| to occur and will be informed of this ENS notification." |
| |
| * * * UPDATE ON 3/7/02 @ 2231 BY WEEKLEY TO GOULD * * * |
| |
| Power restored at 20:34 CT. Notified RDO(Loveless). |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 38752 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: WATTS BAR REGION: 2 |NOTIFICATION DATE: 03/07/2002|
| UNIT: [1] [] [] STATE: TN |NOTIFICATION TIME: 13:42[EST]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 03/07/2002|
+------------------------------------------------+EVENT TIME: 07:00[EST]|
| NRC NOTIFIED BY: RICHARD KIMBROUGH |LAST UPDATE DATE: 03/07/2002|
| HQ OPS OFFICER: GERRY WAIG +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |JAY HENSON R2 |
|10 CFR SECTION: | |
|NONR OTHER UNSPEC REQMNT | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N N 0 Refueling |0 Refueling |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| C-3 STEAM GENERATOR CLASSIFICATION BECAUSE GREATER THAN 1% OF THE
INSPECTED |
| TUBES WERE DISCOVERED TO BE DEFECTIVE |
| |
| "At 0700 EST on March 7, 2002, with Watts Bar Unit 1 in Mode 6, steam |
| generator inspections were being performed in accordance with Technical |
| Specification (TS) 5.7.2.12, 'Steam Generator (SG) Tube Surveillance |
| Program.' The results of the inspections performed on SG Number 4 indicated |
| that greater than 1% of the inspected tubes were defective. Based on TS |
| 5.7.2,12, this determination results in the classification of C-3. The |
| current inspection results do not meet the criteria specified for steam |
| generator tube degradation in Revision 2 of NUREG 1022, Event Reporting |
| Guidelines 10 CFR 50.72 and 50.73. However, for classification C-3, WBN TS |
| 5.9.9, 'SG Tube Inspection Report', requires that the results of the |
| inspection be reported under 10 CFR 50.72. At this time, the submittal of a |
| Licensee Event Report in accordance with 10 CFR 50.73 is not planned." |
| |
| The NRC Resident has been notified. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|General Information or Other |Event Number: 38753 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: ARKANSAS DEPARTMENT OF HEALTH |NOTIFICATION DATE:
03/07/2002|
|LICENSEE: ST BERNARDS REGIONAL HEALTH CTR |NOTIFICATION TIME: 14:57[EST]|
| CITY: JONESBORO REGION: 4 |EVENT DATE: 02/26/2002|
| COUNTY: STATE: AR |EVENT TIME: [CST]|
|LICENSE#: 365-BP-07-97 AGREEMENT: Y |LAST UPDATE DATE: 03/07/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |DAVE LOVELESS R4 |
| |JANET SCHLUETER NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: KIM WIEBECK | |
| HQ OPS OFFICER: GERRY WAIG | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| ST BERNARD'S REGIONAL MEDICAL CENTER MEDICAL MISADMINISTRATION |
| |
| The following event description is taken from a faxed report. |
| |
| "Description of Event: |
| |
| Following initial source send, the proximal gold marker could not be |
| discerned under fluoroscopy due to wire suture in the patients sternum. |
| Twenty-four seconds elapsed between the arrival of the distal marker at the |
| treatment site to source return to the delivery device. Two additional |
| source sends were attempted with immediate return of the sources due to the |
| inability to discern the proximal marker. Upon return of the sources to the |
| delivery device, all sources were visible in the source chamber but the |
| distal marker was not visualized. The treatment catheter was removed from |
| the patient while still attached to the delivery device. The catheter and |
| delivery device were placed into the bail-out box. The sources and distal |
| cold marker were successfully returned to the delivery device following |
| conclusion of the case." |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 38754 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: OCONEE REGION: 2 |NOTIFICATION DATE: 03/07/2002|
| UNIT: [1] [2] [3] STATE: SC |NOTIFICATION TIME: 20:03[EST]|
| RXTYPE: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-L|EVENT DATE: 03/07/2002|
+------------------------------------------------+EVENT TIME: 14:00[EST]|
| NRC NOTIFIED BY: RANDY TODD |LAST UPDATE DATE: 03/07/2002|
| HQ OPS OFFICER: GERRY WAIG +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |JAY HENSON R2 |
|10 CFR SECTION: | |
|AINA 50.72(b)(3)(v)(A) POT UNABLE TO SAFE SD | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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 |
|3 N Y 100 Power Operation |100 Power Operation |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| POTENTIAL LOSS OF SAFE SHUTDOWN CAPABILITY |
| |
| |
| "At Oconee, TS 3.4.9 requires a minimum of 126 kW of Pressurizer heaters to |
| be operable and capable of being powered from an emergency power supply. |
| These heaters are needed to compensate for ambient heat loss from the |
| Pressurizer in order to maintain single phase RCS natural circulation flow |
| during various design basis events. |
| |
| In addition, TS 3.10.1 requires that the Standby Shutdown Facility (SSF) be |
| operable for certain emergency conditions. One subsystem of the SSF is the |
| Auxiliary Service Water (ASW) system. This system supplies a back-up |
| emergency feedwater supply to any or all of the three Oconee Units. |
| |
| The Bases for TS 3.10.1 document that, in order to maintain single phase RCS |
| natural circulation flow, an adequate number of Pressurizer heaters must be |
| OPERABLE and capable of being powered from the SSF power supply. |
| |
| On March 7, 2002, Oconee Nuclear Site Engineering personnel concluded that |
| heat transfer losses from the Reactor Coolant System Pressurizer to the |
| reactor building environment exceeded the value previously used in system |
| calculations and analyses. This conclusion was based on recent analysis of |
| operational data on all three Oconee Units. There are two results of this |
| conclusion: |
| |
| 1.Engineering concluded that the TS 3.4.9 requirement for a |
| minimum of 126 kW of heater capacity is nonconservative. |
| Operations personnel were notified. The operable capacity |
| greatly exceeds the minimum so current compliance with the |
| intent of TS 3.4.9 is not considered an issue. |
| |
| 2.Engineering recommended to Operations that the SSF-ASW system be |
| declared inoperable because the existing heater capacity powered |
| from the SSF is less than the minimum needed to fully |
| compensate for the ambient heat losses as calculated from the |
| recent analysis. |
| |
| Event: |
| |
| At 1400 hours on March 7, 2002, Oconee Operations accepted the Engineering |
| recommendation and conservatively declared the Standby Shutdown Facility |
| (SSF) ASW system inoperable and entered TS 3.10.1, Condition A, which has a |
| 7 day completion time. The SSF-ASW was declared inoperable due to the |
| discovery by site Engineering that heat transfer losses from the Pressurizer |
| to the reactor building environment exceeded the capacity of Pressurizer |
| heaters powered from the SSF power source. |
| |
| At the time of the discovery, there was no analysis to justify that single |
| phase natural circulation could be maintained during all SSF design |
| scenarios using the new loss values as inputs. Therefore Engineering |
| concluded that there was a potential that two phase cooling might occur. At |
| this time, the judgment of Engineering personnel is that two phase cooling |
| would be adequate to protect the affected unit from any core damage, but two |
| phase cooling is outside the TS basis documented for TS 3.10.1. |
| |
| Analyses are in progress to support a revision of applicable Abnormal |
| Procedure to provide interim compensatory guidance to Operators. It is |
| expected that this guidance will allow the Operator to avoid two phase |
| flow. |
| |
| Oconee personnel will evaluate more permanent corrective actions after |
| additional analyses are completed. |
| |
| This event is conservatively being reported under 10 CFR 50.72(b)(3)(v) as a |
| condition that, at time of discovery, could have prevented the fulfillment |
| of the safety function of the SSF ASW system to maintain a safe shutdown |
| condition. |
| |
| The NRC Resident was notified at 1900 hours." |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Research Reactor |Event Number: 38755 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: UNIV OF MICHIGAN |NOTIFICATION DATE: 03/07/2002|
| RXTYPE: 2000 KW POOL |NOTIFICATION TIME: 20:08[EST]|
| COMMENTS: |EVENT DATE: 03/05/2002|
| |EVENT TIME: [EST]|
| |LAST UPDATE DATE: 03/07/2002|
| CITY: ANN ARBOR REGION: 3 +-----------------------------+
| COUNTY: WASHTENAW STATE: MI |PERSON ORGANIZATION |
|LICENSE#: R-28 AGREEMENT: N |JOHN MADERA R3 |
| DOCKET: 05000002 |AL ADAMS NRR |
+------------------------------------------------+ |
| NRC NOTIFIED BY: BECKER | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NPOW NON-POWER REACTOR EVENT| |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| 24-HOUR REPORT DUE TO TS VIOLATION INVOLVING A FUEL ELEMENT NOT
INSERTED IN |
| ITS PROPER LOCATION DURING REFUELING |
| |
| "This is a 24-hour Notification regarding a violation of Technical |
| Specification 3.4.3. Following a major refueling |
| and rod calibrations, the reactor was started up in accordance with |
| Operating Procedure 101, Reactor Startup. The |
| reactor reached 2 MW on 6 March 2002 at 19:22 hours. The following morning 7 |
| March 2002 at 08:16 hours, the |
| reactor was promptly shut down when the Day shift operating staff noted that |
| core location 77 was open, and did |
| not contain a fuel element, reflector, sample holder or experimental |
| facility as required by Technical Specification |
| 3.4.3." |
| |
| "The licensee identified safety concerns with respect to Technical |
| Specifications 2.1.1 (safety' Limits in the Forced |
| Convection Mode), 2.1.1 (Safety Limits in the natural Convection Mode), and |
| 3.1.4 (Reactivity Limits). This |
| occurrence may also involve unanalyzed conditions with respect to their |
| Safety Analysis Report. The safety concerns and unanalyzed conditions |
| include: reactor operation in forced convection at 2MW with an open grid |
| location |
| providing bypass flow: a fuel element being in natural convection cooling |
| mode with the reactor operating above |
| 100 KW; and a fuel element outside the normal configuration while the |
| reactor is critical." |
| |
| "Description of Occurrence" |
| |
| "4-5 March - Refueling during dayshift |
| 5 March 18:15 - Commence reactor startup in forced convection mode for Rod |
| Calibrations between 5 and 59 KW. |
| 6 March 16:05 - Complete Rod Calibrations, shut down reactor |
| 17: 10 - Reactor Startup |
| 17:29 - 500 KW Checks |
| 17:32 - 1 MW, Calorimeter commenced |
| 18:50 - Calorimeter completed |
| 19:22 - Raise reactor power to 2 MW" |
| |
| "7 March 08:1 6 - Reactor Shutdown" |
| |
| "During this time indicated primary coolant flow was between 1053 to 1073 |
| gallons per minute. A review of all nuclear instrument channel recorders |
| showed no unusual indications. The core excess reactivity and measured |
| core worth were all normal." |
| |
| "Core inspections were performed by many members of the operating staff as |
| required by procedures during this |
| time. During refueling, all fuel handling was done with at least two |
| persons observing. A core inspection was |
| performed immediately after refueling was completed. In addition, three |
| core inspections were performed during |
| building checks while rod calibrations were in progress, a core inspection |
| was made during the Reactor Startup's |
| 500 KW checks, and core inspections were made by the Swing and Mid shifts |
| during building checks while operating at 2 MW. No abnormalities were noted |
| on any of these inspections. Shortly after 08:00 on March 7, the Day shift |
| operating staff inspected the core and noted that location 77 was open. The |
| shift supervisor promptly shut down the reactor and informed both the |
| On-Call Supervisor and the Reactor Manager." |
| |
| "A review of this occurrence has concluded that when grid location 77 was |
| refueled, fuel element #304 ended up with its bottom nose cone outside the |
| grid plate, while the bottom edge of the fuel element came to rest on the |
| outside edge of the grid plate. The top of the slightly tilted fuel element |
| was directly over location 77. Thus the element appeared, when inspected |
| from above, to be correctly seated. Eventually, the element shifted to a |
| vertical orientation caught between the edge of the grid plate and the |
| nearby pneumatic tube bundle. Once the element shifted, the open location |
| 77 became apparent and the reactor was shut down." |
| |
| "Safety Implications" |
| |
| "Two main issues have been identified: (1) The effect of an open grid |
| location on forced convection operation at 2 MW; and (2) the effect on the |
| fuel element #304 of operating it in natural convection mode. Analyses are |
| being performed on both issues. A pool water sample was taken and |
| analyzed. The pool water analysis was compared to past analyses of fuel |
| element cladding failures. No fission products were noted. Fuel element |
| #304 has been temporarily secured with a line to prevent failing off the |
| grid plate. Procedures are being developed to remove the fuel element and |
| will receive approval of the Safety Review Committee prior to |
| implementation. The reactor remains in operation as required by Technical |
| Specifications, but is shutdown (zero power). Analyses are being performed |
| on these conditions to determine their full impact." |
| |
| "Root Causes" |
| |
| "The Reactor Manager and Operations staff reviewed the occurrence. The root |
| cause investigation is ongoing." |
| |
| "Immediate Corrective Actions" |
| |
| "The reactor was shut down and will not be restarted for sustained operation |
| until an operational review of this reportable occurrence is made and |
| presented to the Safety Review Committee. An initial outside review of |
| this occurrence has been made by the Dow Chemical Company, Midland, |
| Michigan. A closed-mouth hook (carabiner) has been lowered on a line with |
| a stainless steel leader and attached to the handling bail of element #304 |
| to ensure it does not fall off the grid plate." |
+------------------------------------------------------------------------------+
Page Last Reviewed/Updated Wednesday, March 24, 2021