U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
03/13/2003 - 03/14/2003
** EVENT NUMBERS **
39554 39655 39660 39664 39665 39667 39668 39669
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
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|Power Reactor |Event Number: 39554 |
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| FACILITY: FERMI REGION: 3 |NOTIFICATION DATE: 02/01/2003|
| UNIT: [2] [] [] STATE: MI |NOTIFICATION TIME: 09:41[EST]|
| RXTYPE: [2] GE-4 |EVENT DATE: 02/01/2003|
+------------------------------------------------+EVENT TIME: 01:45[EST]|
| NRC NOTIFIED BY: JEFF GROFF |LAST UPDATE DATE: 03/13/2003|
| HQ OPS OFFICER: HOWIE CROUCH +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |MARK RING R3 |
|10 CFR SECTION: | |
|AIND 50.72(b)(3)(v)(D) ACCIDENT MITIGATION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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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| LOSS OF A SAFETY FUNCTION DUE TO ALL FOUR EMERGENCY DIESEL GENERATORS BEING |
| DECLARED INOPERABLE |
| |
| The following information was received from the Licensee via facsimile: |
| |
| "At 0145 hours [EST] on 2/1/2003, all four Emergency Diesel Generators |
| (EDGs) were declared inoperable following discovery of a Fuel Oil leakage |
| drain path change that was installed to prevent Fuel Oil leakage from |
| reaching the ground water. |
| |
| "This change involved the installation of plastic sleeves on the fuel oil |
| drains for all four EDGs to reroute the fuel oil drains to a catch basin. |
| The normal drain path is through the RHR [Residual Heat Removal] Complex |
| (which houses the EDGs) drain system to the chemical pond. This change was |
| installed after a crack was discovered in a 21 inch concrete line in the |
| drain path from the RHR Complex Drain Sump to the Chemical Pond. This change |
| was installed on 01/17/03. |
| |
| "While running EDG 11 for post maintenance testing following a scheduled |
| maintenance outage, fuel oil in a drain sleeve backed up and spilled out of |
| a vent on the fuel oil drain header. This spillage resulted in a small |
| lagging fire. EDG 11 was immediately shutdown and the fire was extinguished |
| within a few minutes. No significant damage to EDG 11 was caused by the |
| fire. Since all four EDGs had a similar fuel oil drain configuration, they |
| were declared inoperable at 0145 hours and Technical Specification 3.8.1, |
| Condition B was entered, which requires restoration of one division of the |
| EDGs within 2 hours. |
| |
| "At 0329 hours, the normal fuel oil drain configuration was restored for EDG |
| 13 and EDG 14 (Division 2) and Technical Specification 3.8.1, Condition B |
| was exited. At 0345 hours, the normal fuel oil drain configuration was |
| restored for EDG 12 (Division 1). EDG 11 remains inoperable until the |
| completion of post maintenance testing. |
| |
| "This notification is being made in accordance with 10CFR50.72(b)(3)(v)[(D)] |
| due to all four EDGs being inoperable causing the loss of a safety |
| function." |
| |
| The fire was extinguished without offsite assistance and there were no |
| injuries due to the fire. |
| |
| The Licensee has notified the NRC Resident Inspector. |
| |
| *** RETRACTION AT 1118 EST ON 3/13/03 FROM PATRICK FALLON TO ERIC THOMAS |
| *** |
| |
| "While running EDG (Emergency Diesel Generator) 11 for post maintenance |
| testing following a scheduled maintenance outage on February 1, 2003, fuel |
| oil in a drain sleeve backed up and spilled out of a vent on the fuel oil |
| drain header. This spillage resulted in a small fire. The fire caused no |
| damage to EDG 11. Since all four EDGs had a similar temporary fuel oil drain |
| configuration, they were declared inoperable. The normal fuel oil drain |
| configuration was restored within the Completion Time of Technical |
| Specification 3.8.1, Condition B. Notification was made in accordance with |
| 10 CFR 50.72(b)(3)(v) due to all four EDGs being declared inoperable causing |
| the loss of a safety function. |
| |
| "The cause of the fire is believed to be excessive fuel oil leaking from the |
| EDG 11 fuel injector compartment onto the exhaust manifold. (The cause was |
| initially reported as normal fuel injector leakage backing up into the fuel |
| oil drain header due to the temporary drain configuration). The injectors |
| allowed an abnormally high rate of fuel oil leakage into the fuel oil drain |
| header for EDG 11 only. The fuel oil drain rates for EDGs 12, 13, and 14 |
| were observed to be normal during subsequent surveillance testing, and |
| within the capability of the temporary fuel oil drain configuration. |
| |
| "Therefore, EDGs 12, 13, and 14 were capable of performing their safety |
| function and there was no common mode failure, as a result of the temporary |
| drain configuration. This condition is therefore not reportable under 10 CFR |
| 50.72(b)(3)(v). The original notification, Event Number 39554, is |
| retracted." |
| |
| The Licensee has notified the NRC Resident Inspector. |
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|General Information or Other |Event Number: 39655 |
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| REP ORG: TEXAS DEPARTMENT OF HEALTH |NOTIFICATION DATE: 03/10/2003|
|LICENSEE: PROFESSIONAL SERVICES INDUSTRIES, PSI|NOTIFICATION TIME: 14:54[EST]|
| CITY: HOUSTON REGION: 4 |EVENT DATE: 03/08/2003|
| COUNTY: STATE: TX |EVENT TIME: 12:45[CST]|
|LICENSE#: AGREEMENT: Y |LAST UPDATE DATE: 03/10/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |MARK SHAFFER R4 |
| |KEVIN HSUEH NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: GLENN CORBIN | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| AGREEMENT STATE REPORT: STOLEN TROXLER MOISTURE DENSITY GAUGE |
| |
| |
| "A Troxler model #3430 (serial number 27095), portable moisture/density |
| gauge was reported stolen from the Texas Medical Center construction project |
| site located at 2450 Holcomb, Houston, Texas between 12:45 p.m. and 1:30 |
| p.m. CT on Saturday, March 8, 2003. This device is bright yellow, |
| approximately 11" long x 8" wide x 5" tall with two metal posts |
| approximately 18" tall protruding from the top of the device and a locked |
| handle at the top. The device contains two sealed sources (isotopes) |
| double-encapsulated in stainless steel, and is licensed by the Texas |
| Department of Health. When not in use, the device emits low-level energy |
| equivalent to a single chest x-ray, which poses no threat unless the device |
| is tampered with. |
| |
| "A police report has been filed with the Houston Police Department. |
| |
| "The company is offering a $500.00 reward for the return of the device on |
| the 'no-questions-asked' bases. If found, please do not move the device and |
| contact the Houston Police Department and refer to police report no. |
| 032141303E. If anyone has any information regarding the theft of the device |
| please [call PSI]." |
| |
| The State of Texas believes the Troxler moisture density gauge contains 10 |
| millicuries of Cesium-137 and 40 millicuries of Am/Be-241. |
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|General Information or Other |Event Number: 39660 |
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| REP ORG: OR DEPT OF HEALTH RAD PROTECTION |NOTIFICATION DATE: 03/11/2003|
|LICENSEE: ROGUE VALLEY MEDICAL CENTER |NOTIFICATION TIME: 11:59[EST]|
| CITY: MEDFORD REGION: 4 |EVENT DATE: 03/11/2003|
| COUNTY: JACKSON STATE: OR |EVENT TIME: [PST]|
|LICENSE#: ORE-90064 AGREEMENT: Y |LAST UPDATE DATE: 03/11/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |MARK SHAFFER R4 |
| |KEVIN HSUEH NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: EDWIN WRIGHT | |
| HQ OPS OFFICER: JOHN MacKINNON | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| AGREEMENT STATE REPORT: MISSING BRACHEYTHERAPY IRIDIUM-192 SEED. |
| |
| Dr. Sinnott called to report the loss of an Ir-192 bracheytherapy seed with |
| a current activity of 6 millicuries. The source was last visually |
| inventoried in December 2002. The loss was noted yesterday, March 9, 2002, |
| while the physicist was packaging sources for return to the manufacturer. |
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|Power Reactor |Event Number: 39664 |
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| FACILITY: PALO VERDE REGION: 4 |NOTIFICATION DATE: 03/13/2003|
| UNIT: [] [2] [] STATE: AZ |NOTIFICATION TIME: 11:14[EST]|
| RXTYPE: [1] CE,[2] CE,[3] CE |EVENT DATE: 02/27/2003|
+------------------------------------------------+EVENT TIME: 09:28[MST]|
| NRC NOTIFIED BY: DUANE KANITZ |LAST UPDATE DATE: 03/13/2003|
| HQ OPS OFFICER: YAMIR DIAZ +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |MARK SHAFFER R4 |
|10 CFR SECTION: | |
|AINV 50.73(a)(1) INVALID SPECIF SYSTEM A| |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 N Y 98 Power Operation |98 Power Operation |
| | |
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EVENT TEXT
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| INVALID SPECIFIED SYSTEM ACTUATION 60 DAY REPORT |
| |
| "The following event description is based on information currently |
| available. If through subsequent reviews of this event, additional |
| information is identified that is pertinent to this event or alters the |
| information being provided at this time, a follow-up notification will be |
| made via the ENS or under the reporting requirements of 10CFR50.73. |
| |
| "On February 17, 2003, at approximately 0928 Mountain Standard Time, Palo |
| Verde Nuclear Generating Station Unit 2 experienced an invalid actuation |
| (start) of the 'A' Emergency Diesel Generator (EDG). EDG 'A' inadvertently |
| started when an Instrument and Control technician, performing the ESFAS |
| train 'A' subgroup relay functional and response time surveillance test, |
| completed a step in the test procedure out of sequence. The technician |
| verified the status of [actuated] an ESFAS relay contact, which generates an |
| EDG start signal, before the 'A' EDG control mode switch was placed in the |
| OFF position. |
| |
| "This report is not considered an LER. |
| |
| "EDG 'A' was the specific System and train that actuated. |
| |
| "EDG 'A' started in the Emergency Mode. The train actuation was complete. |
| |
| "EDG 'A' started and came up to rated speed and voltage as designed. |
| |
| "This report is being made under 10 CFR 50.73 (a) (2) (iv) (A)." |
| |
| The licensee has notified the NRC Resident Inspector. |
+------------------------------------------------------------------------------+
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|Power Reactor |Event Number: 39665 |
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| FACILITY: OYSTER CREEK REGION: 1 |NOTIFICATION DATE: 03/13/2003|
| UNIT: [1] [] [] STATE: NJ |NOTIFICATION TIME: 13:38[EST]|
| RXTYPE: [1] GE-2 |EVENT DATE: 03/13/2003|
+------------------------------------------------+EVENT TIME: 06:15[EST]|
| NRC NOTIFIED BY: CIGANIK |LAST UPDATE DATE: 03/13/2003|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |MOHAMED SHANBAKY R1 |
|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
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| MAJOR LOSS OF EMERGENCY PREPAREDNESS CAPABILITIES |
| |
| The licensee was notified by Ocean County that their alarm panel indicated |
| the radio power to the prompt notification sirens had failed with unknown |
| affect on the sirens operation. The Licensee Technicians were dispatched |
| and had to reboot a computer to clear the alarm. Sirens would not operate |
| until the computer was rebooted. Sirens tested satisfactory @ 0930 hours. |
| |
| This notification was made because it can not be determined if the Ocean |
| County siren activation technicians possess the knowledge and skills to |
| reboot this computer if siren activation would have been required. If it is |
| later determined that the technicians did possess the required knowledge |
| and skills, this notification may be retracted. |
| |
| The NRC Resident Inspector was notified along with local agencies. |
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|Power Reactor |Event Number: 39667 |
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| FACILITY: CALLAWAY REGION: 4 |NOTIFICATION DATE: 03/13/2003|
| UNIT: [1] [] [] STATE: MO |NOTIFICATION TIME: 16:32[EST]|
| RXTYPE: [1] W-4-LP |EVENT DATE: 03/13/2003|
+------------------------------------------------+EVENT TIME: 08:00[CST]|
| NRC NOTIFIED BY: BREDEMAN |LAST UPDATE DATE: 03/13/2003|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |MARK SHAFFER R4 |
|10 CFR SECTION: | |
|AUNA 50.72(b)(3)(ii)(B) UNANALYZED CONDITION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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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| ERROR IN THE CURRENT SAFETY ANALYSIS FOR A STEAM GENERATOR TUBE RUPTURE |
| |
| "On March 13, 2003 while operating at 100% power, Callaway Plant determined |
| a problem existed in the current safety analysis for a steam generator tube |
| rupture accident accompanied by an overfill condition of the ruptured steam |
| generator. This problem was discovered while reviewing a future plant |
| modification package. The current FSAR analysis concluded that an overfill |
| condition would not occur during a tube rupture accident. |
| |
| "Through investigations instigated during the modification review process, |
| it was determined that for current plant conditions, an overfill condition |
| could result if an auxiliary feedwater control valve supplying the ruptured |
| steam generator were to fail open. In this case, it was concluded that the |
| ruptured steam generator would overfill and water would be released through |
| the steam generator safety valves, resulting in a radioactive release to the |
| environment greater than allowed by regulatory guidance. Since this |
| accident was not adequately incorporated in the FSAR, specific procedural |
| time limits for operator actions had not been developed. This lack of |
| credited operator time limits coupled with past plant modifications result |
| in a potential to exist for the ruptured steam generator overfill scenario. |
| |
| "Current Technical Specifications allow a reactor coolant system Dose |
| Equivalent Iodine (DEI) value of 1.0 microcurie per gram. To assure |
| compliance with existing regulatory guidance, plant procedures have been |
| changed to administratively reduce the steady state DEI limit to 0.3 |
| microcurie per gram, a value that has not been exceeded in the last three |
| years. Current steady state DEI concentration in the reactor coolant system |
| is 0.001769 microcurie per gram. The new lower DEI limit will ensure that |
| if an overfill condition were to occur during a steam generator tube |
| rupture, post accident radiological consequences would not exceed the limits |
| imposed by the FSAR and the Standard Review Plan." |
| |
| The NRC Resident Inspector was notified. |
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|Hospital |Event Number: 39668 |
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| REP ORG: REGIONS HOSPITAL |NOTIFICATION DATE: 03/13/2003|
|LICENSEE: REGIONS HOSPITAL |NOTIFICATION TIME: 17:27[EST]|
| CITY: ST PAUL REGION: 3 |EVENT DATE: 03/07/2003|
| COUNTY: STATE: MN |EVENT TIME: 09:00[CST]|
|LICENSE#: 22-02003-04 AGREEMENT: N |LAST UPDATE DATE: 03/13/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |KENNETH O'BRIEN R3 |
| | |
+------------------------------------------------+ |
| NRC NOTIFIED BY: SOGARD | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
+------------------------------------------------+ |
|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|BSUR 20.1906(d)(1) SURFACE CONTAM LEVELS >| |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| SURFACE CONTAMINATION ON AMMO BOX GREATER THAN ACCEPTABLE LIMITS |
| |
| On March 7 @ 0900 an ammo box was received from Syncor that measured |
| 0.3mr/hr at the surface and had a wipe of approximately 9707 DPM (2200 DPM |
| is acceptable). Syncor was notified of the contamination on the box. The |
| box was put into the hospital's storage area until March 11 when the |
| measurements taken were at background. The box was than returned to Syncor. |
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|Power Reactor |Event Number: 39669 |
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| FACILITY: MONTICELLO REGION: 3 |NOTIFICATION DATE: 03/13/2003|
| UNIT: [1] [] [] STATE: MN |NOTIFICATION TIME: 18:35[EST]|
| RXTYPE: [1] GE-3 |EVENT DATE: 03/13/2003|
+------------------------------------------------+EVENT TIME: 14:30[CST]|
| NRC NOTIFIED BY: JACK EARCLEY |LAST UPDATE DATE: 03/13/2003|
| HQ OPS OFFICER: RICH LAURA +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |KENNETH O'BRIEN R3 |
|10 CFR SECTION: | |
|AUNA 50.72(b)(3)(ii)(B) UNANALYZED CONDITION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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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| DEGRADED APPENDIX "R" BARRIER AT MONTICELLO |
| |
| "During inspection of penetration FZ-4900 in the upper 4KV room it was |
| discovered there was a portion of the penetration seal that was degraded |
| which caused the upper and lower 4KV rooms to communicate with each other. |
| Penetration seal FZ-4900 is a gypsum wall board assembly approximately 18 |
| inches wide 4 foot high and 24 foot long. The degraded part of the |
| penetration is approximately 1 inch by 4 inch hole. The upper and lower 4 KV |
| areas are required to be separated in accordance with 10CFR50 Appendix R |
| requirements." |
| |
| The licensee indicated they established a fire watch as a compensatory |
| measure. |
| |
| The NRC Resident Inspector was notified. |
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