U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
05/19/2000 - 05/22/2000
** EVENT NUMBERS **
36945 36984 37009 37012 37013 37014 37015
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
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|Power Reactor |Event Number: 36945 |
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| FACILITY: MILLSTONE REGION: 1 |NOTIFICATION DATE: 04/29/2000|
| UNIT: [] [2] [] STATE: CT |NOTIFICATION TIME: 23:38[EDT]|
| RXTYPE: [1] GE-3,[2] CE,[3] W-4-LP |EVENT DATE: 04/29/2000|
+------------------------------------------------+EVENT TIME: 22:34[EDT]|
| NRC NOTIFIED BY: STEPHEN BAKER |LAST UPDATE DATE: 05/19/2000|
| HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |JAMES NOGGLE R1 |
|10 CFR SECTION: | |
|AESF 50.72(b)(2)(ii) ESF ACTUATION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 N N 0 Refueling |0 Refueling |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| UNEXPECTED ISOLATION OF CONTAINMENT PURGE |
| |
| A containment purge valve closed due to a loss of power to a radiation |
| monitor. The licensee stated that the cause was deenergization of the power |
| panel per procedures for that radiation monitor. |
| |
| Apparently, this was the first time this procedure had been performed since |
| it had been revised, and there was no caution in the procedure indicating |
| that if a purge is in effect, it would be secured. The licensee plans to |
| change the procedures to reflect the possibility of isolation so that it can |
| be isolated before the radiation monitor is deenergized. |
| |
| The licensee notified the NRC resident inspector as well as state and local |
| authorities. |
| |
| * * * RETRACTION 1336 5/19/2000 FROM MYER TAKEN BY STRANSKY * * * |
| |
| "On 4/29/00 a Containment Purge Valve Isolation signal (CPVIS) was generated |
| due to a loss of power to a radiation monitor. The CPVIS automatically |
| closed the Containment Purge system supply and exhaust valves. This |
| condition was conservatively reported as an event that resulted in an |
| automatic actuation of an Engineered Safety Feature (ESF). |
| |
| "Subsequent investigation determined that the Containment Gaseous Radiation |
| Monitor, RM-8123B, had been properly removed from service at 0801 on April |
| 28, 2000 in accordance [with] the applicable Operating Procedure. The |
| actuation signal from RM-8123B was the direct result of a planned loss of |
| power to VA-30 and was not the result of a valid high radiation condition |
| with the Containment. Therefore, the actuation signal was invalid. |
| |
| "The actuation only involved the automatic closure of the supply and exhaust |
| valves within the Containment Purge system. The Containment Purge system is |
| equivalent to 'Reactor Building Ventilation System' as defined in IEEE Std |
| 805-1984. Therefore, the Containment Purge system is equivalent to 'Reactor |
| Building Ventilation System' identified in 10CFR50.72(b)(2)(ii). |
| |
| "Section 10CFR50.72(b)(2)(ii) states that the licensee shall report any |
| event or condition that resulted in a manual or automatic actuation of an |
| Engineered Safety Feature (ESF) including the Reactor Protection System |
| (RPS), except when: |
| |
| "(B) The actuation was invalid and |
| |
| " (1) Occurred while the system was properly removed from service (or), |
| |
| " (2) Occurred after the safety function had been already completed or |
| |
| " (3) Involved only the following specific ESFs or their equivalent |
| systems |
| iii Reactor Building Ventilation system. |
| |
| "Since the actuation was invalid and since the event occurred after the |
| applicable sensor had been properly removed from service in accordance with |
| approved plant procedures and the actuation involved only the Containment |
| Purge system, a system which can be shown to be equivalent to the Engineered |
| Safety Feature provided by the Reactor Building Ventilation system, this |
| event is not reportable pursuant to either 10CFR50.72(b)(2)(ii)(B) or |
| 10CFR50.73(a)(2)(iv)(B) and the Immediate Notification for this condition is |
| retracted." |
| |
| The NRC resident inspector has been informed of this retraction. Notified |
| R1DO (Lew). |
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!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
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|Fuel Cycle Facility |Event Number: 36984 |
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| FACILITY: PADUCAH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 05/08/2000|
| RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 17:22[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 05/05/2000|
| 6903 ROCKLEDGE DRIVE |EVENT TIME: 21:30[CDT]|
| BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 05/19/2000|
| CITY: PADUCAH REGION: 3 +-----------------------------+
| COUNTY: McCRACKEN STATE: KY |PERSON ORGANIZATION |
|LICENSE#: GDP-1 AGREEMENT: Y |BRENT CLAYTON R3 |
| DOCKET: 0707001 |JOSEPHINE PICCONE NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: ERIC WALKER | |
| HQ OPS OFFICER: DOUG WEAVER | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|OCBA 76.120(c)(2)(i) ACCID MT EQUIP FAILS | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| SAFETY EQUIPMENT FAILURE (CELL 2) |
| |
| At 2130 CDT on 5/05/2000, the C-337 Unit 3 Cell 2 Freezer/Sublimer A-valve |
| failed to open while in TSR mode F/S 3 which requires operability of the |
| A-valve in order for the valve to open if required to do so upon actuation |
| of the Freezer/Sublimer High-High Weight Trip System. An operator was |
| attempting to place the Freezer/Sublimer into mode F/S 2 which does not |
| require operability of the High-High Weight Trip System. The |
| Freezer/Sublimer was unable to enter Mode F/S 2 due to inability to open |
| A-valve because of mechanical failure. Actuation of High- High Weight Trip |
| system did not occur. However, had it been required to do so while in mode |
| F/S 3, there is potential that the A-valve would not have opened as required |
| if actuation of system occurred. Upon discovery of valve failure, |
| Freezer/Sublimer was placed in mode F/S 4 which does not require operability |
| of the High-High Weight Trip system. The valve failure was caused by a |
| failure of the motor operator in this six inch valve. |
| |
| The NRC Senior Resident Inspector has been notified of this event. See |
| related event 36985. |
| |
| * * * RETRACTION 1718 5/19/2000 FROM MIKE UNDERWOOD TAKEN BY BOB STRANSKY * |
| * * |
| |
| "On May 18, 2000, troubleshooting and functional testing of the F/S in the |
| failed condition determined that the valve was opening in response to DPCS |
| demands, but the limit switches were not correctly communicating the valve |
| position to the DPCS. This caused the DPCS to indicate a mode equipment |
| state failure on May 5, 2000. In addition the F/S was subjected to the |
| high-high weight trip safety system functional test while in cold standby |
| and with the system engineer visually monitoring the A-valve. The valve |
| operated as designed, but due to the failed limit switches, the DPCS tripped |
| the unit into hot standby, recreating the events of May 5, 2000. Thus, the |
| A-valve was capable of performing its intended function if required, and the |
| reporting requirements of 10CFR76.120(c) (2) were not met. |
| |
| "Based on this evaluation, this event has been retracted." |
| |
| The NRC resident inspector has been informed of this retraction. Notified |
| R3DO (Madera). |
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!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
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|Hospital |Event Number: 37009 |
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| REP ORG: INDIANA UNIVERSITY MEDICAL CENTER |NOTIFICATION DATE: 05/17/2000|
|LICENSEE: INDIANA UNIVERSITY MEDICAL CENTER |NOTIFICATION TIME: 15:41[EDT]|
| CITY: INDIANAPOLIS REGION: 3 |EVENT DATE: 04/18/2000|
| COUNTY: STATE: IN |EVENT TIME: [CST]|
|LICENSE#: 13-02752-03 AGREEMENT: N |LAST UPDATE DATE: 05/19/2000|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |JOHN MADERA R3 |
| |BILL REAMER NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: MACK RICHARD | |
| HQ OPS OFFICER: FANGIE JONES | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|BAB2 20.2201(a)(1)(ii) LOST/STOLEN LNM>10X | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| LOST ONE SEED CONTAINING 0.5 MILLICURIE OF IRIDIUM-192 |
| |
| After applicator removal and the seeds were inventoried, it was determined |
| that one seed out of sixty four seeds was missing. Each of the seeds |
| contained 0.5 mCi of Ir-192. A survey of the patient and room did not find |
| the missing seed. An investigation is ongoing to find the lost seed. It is |
| possible that the right number of seeds were not implanted. The applicator |
| was removed with the seed intact, the seeds are contained in ribbons and the |
| ribbons are retained in the applicator, making it unlikely that the seed |
| would have been lost during the treatment. |
| |
| The patient has been discharged and there is no problem with dose |
| administered with one seed missing at the beginning. Also, there is little |
| safety implications to the public. |
| |
| * * * RETRACTION 1533 5/19/2000 FROM MARK RICHARD TAKEN BY BOB STRANSKY * * |
| * |
| |
| The licensee reported that the seed was not missing. The initial count of |
| seeds was erroneous. When the seeds were independently recounted, all seeds |
| were present. Notified R3DO (Madera). |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 37012 |
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| FACILITY: OYSTER CREEK REGION: 1 |NOTIFICATION DATE: 05/19/2000|
| UNIT: [1] [] [] STATE: NJ |NOTIFICATION TIME: 12:23[EDT]|
| RXTYPE: [1] GE-2 |EVENT DATE: 05/19/2000|
+------------------------------------------------+EVENT TIME: 11:38[EDT]|
| NRC NOTIFIED BY: JERRY FREEMAN |LAST UPDATE DATE: 05/19/2000|
| HQ OPS OFFICER: BOB STRANSKY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |DAVID LEW R1 |
|10 CFR SECTION: | |
|APRE 50.72(b)(2)(vi) OFFSITE NOTIFICATION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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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| OFFSITE NOTIFICATION REGARDING SPURIOUS SIREN ACTIVATION |
| |
| At 1138, the licensee was notified that prompt notification siren #4 in |
| Barnegat Township had spuriously activated. The siren was deactivated at |
| 1210, and a faulty circuit board was identified in the siren. The licensee |
| contacted the Barnegat Township Police Department, the Ocean County |
| Sheriff's office and the New Jersey State Police of the siren activation. |
| The NRC resident inspector has been informed of this event by the licensee. |
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|Power Reactor |Event Number: 37013 |
+------------------------------------------------------------------------------+
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| FACILITY: QUAD CITIES REGION: 3 |NOTIFICATION DATE: 05/19/2000|
| UNIT: [1] [2] [] STATE: IL |NOTIFICATION TIME: 14:34[EDT]|
| RXTYPE: [1] GE-3,[2] GE-3 |EVENT DATE: 05/19/2000|
+------------------------------------------------+EVENT TIME: 10:45[CDT]|
| NRC NOTIFIED BY: DARYL CLARK |LAST UPDATE DATE: 05/19/2000|
| HQ OPS OFFICER: BOB STRANSKY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |JOHN MADERA R3 |
|10 CFR SECTION: | |
|AIND 50.72(b)(2)(iii)(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 |
|2 N Y 100 Power Operation |100 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| CONTROL ROOM EMERGENCY VENTILATION SYSTEM REFRIGERATION CONTROL UNIT |
| INOPERABLE |
| |
| "On May 19, 2000, at 1045 hours, while performing the Control Room Emergency |
| Ventilation System monthly operability test. the refrigeration control unit |
| failed to start. The cause of the failure is unknown, and troubleshooting is |
| in progress. Technical Specification 3.8.D, Action 1.b was entered, placing |
| both units in a 30 day LCO. |
| |
| "This is being reported per 10 CFR 50.72(b)(2)(iii)(D), loss of a safety |
| function needed to mitigate the consequences of art accident." |
| |
| The NRC resident inspector will be informed of this event by the licensee. |
+------------------------------------------------------------------------------+
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|Other Nuclear Material |Event Number: 37014 |
+------------------------------------------------------------------------------+
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| REP ORG: CROW BUTTE RESOURCES |NOTIFICATION DATE: 05/19/2000|
|LICENSEE: CROW BUTTE RESOURCES |NOTIFICATION TIME: 16:55[EDT]|
| CITY: CRAWFORD REGION: 4 |EVENT DATE: 05/19/2000|
| COUNTY: STATE: NE |EVENT TIME: [CDT]|
|LICENSE#: SUA-1534 AGREEMENT: Y |LAST UPDATE DATE: 05/19/2000|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |BILL JONES R4 |
| |TOM ESSIG NMSS |
+------------------------------------------------+BILL REAMER NMSS |
| NRC NOTIFIED BY: MIKE GRIFFIN | |
| HQ OPS OFFICER: BOB STRANSKY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|NLTR LICENSEE 24 HR REPORT | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| EVAPORATION POND LINER LEAKING |
| |
| The licensee reported that the inner liner of evaporation pond #4 appears to |
| be leaking. Increased conductivity has been detected in the underdrain |
| system. The pond contains a brine solution with trace amounts of Ra-226 and |
| uranium. |
| |
| The licensee believes that the leakage is through a poor weld on a six inch |
| patch of the inner liner located just above the waterline. High winds in the |
| area have been pushing the water level above the patch. Samples taken from a |
| standpipe located near the patch indicate conductivity approaching that of |
| the brine solution. The licensee is pumping down the pond for a liner |
| inspection. No leakage into the soil has occurred. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 37015 |
+------------------------------------------------------------------------------+
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| FACILITY: PERRY REGION: 3 |NOTIFICATION DATE: 05/22/2000|
| UNIT: [1] [] [] STATE: OH |NOTIFICATION TIME: 04:48[EDT]|
| RXTYPE: [1] GE-6 |EVENT DATE: 05/22/2000|
+------------------------------------------------+EVENT TIME: 02:53[EDT]|
| NRC NOTIFIED BY: BOB KIDDER |LAST UPDATE DATE: 05/22/2000|
| HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |JOHN MADERA R3 |
|10 CFR SECTION: | |
|AESF 50.72(b)(2)(ii) ESF ACTUATION | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 100 Power Operation |100 Power Operation |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| - ESF ACTUATION OF REACTOR WATER CLEANUP SYSTEM FOR UNKNOWN REASONS - |
| |
| At 0253 on 05/22/00, the plant experienced an isolation of the Reactor Water |
| Cleanup System on a Division 2 isolation signal when the Residual Heat |
| Removal heat exchanger vent valve closed unexpectedly. An apparent |
| electrical power supply spike to the Division 2 isolation instrumentation |
| occurred. No testing or maintenance activities or electrical storms were |
| occurring at the time of the isolation. The licensee is investigating the |
| cause of the isolation. |
| |
| The licensee notified the NRC Resident Inspector. |
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