U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
07/29/1999 - 07/30/1999
** EVENT NUMBERS **
35889 35958 35971 35972 35973
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
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|Power Reactor |Event Number: 35889 |
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| FACILITY: NINE MILE POINT REGION: 1 |NOTIFICATION DATE: 07/02/1999|
| UNIT: [] [2] [] STATE: NY |NOTIFICATION TIME: 16:41[EDT]|
| RXTYPE: [1] GE-2,[2] GE-5 |EVENT DATE: 07/02/1999|
+------------------------------------------------+EVENT TIME: 13:30[EDT]|
| NRC NOTIFIED BY: HANK STRAHLEY |LAST UPDATE DATE: 07/29/1999|
| HQ OPS OFFICER: DICK JOLLIFFE +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |LAWRENCE DOERFLEIN R1 |
|10 CFR SECTION: | |
|AIND 50.72(b)(2)(iii)(D) ACCIDENT MITIGATION | |
|NLCO TECH SPEC LCO A/S | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
| | |
|2 N Y 15 Power Operation |15 Power Operation |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| - RCIC SYSTEM DECLARED INOPERABLE - |
| |
| While performing Reactor Core Isolation Cooling (RCIC) System injection |
| testing, the licensee declared the RCIC System inoperable due to problems |
| with the system injection testable check valves. Valve #2ICS*AOV157 did not |
| indicate open with full flow to the reactor vessel and valve #2ICS*AOV156 |
| continued to indicate open following injection. The licensee declared these |
| containment isolation valves inoperable and is taking actions to isolate the |
| containment penetration. The RCIC System injected properly with the |
| exception of the above noted problem. Otherwise, the RCIC System operated |
| properly. Tech Spec 3.7.4 requires the licensee to restore the RCIC System |
| to operable status within 14 days. The High Pressure Core Spray System is |
| operable. The licensee will be troubleshooting these valves. |
| |
| The licensee informed the NRC Resident Inspector. |
| |
| * * * UPDATE AT 1028 ON 7/29/99, BY PITTS RECEIVED BY WEAVER * * * |
| |
| At 1330 on 7/2/99, report was made associated with the Reactor Core |
| Isolation Cooling (RCIC) inoperability in accordance with |
| 10CFR50.72(b)(2)(iii)(D). RCIC was declared inoperable due to problems with |
| the injection testable check valves which are Primary Containment Isolation |
| valves. 2ICS*AOV 156 continued to indicate open following injection and |
| 2ICS*AOV 157 did not indicate open with full flow to the Reactor Vessel. |
| These containment isolation valves were declared inoperable and actions were |
| taken to isolate the containment penetration. RCIC injected properly when |
| tested and injection capabilities were only effected by virtue of the |
| necessity to comply with isolation requirements. |
| |
| RCIC testable check valves 21CS*AOV156 and 2ICS*AOV157 failing to properly |
| close or indicate position are independent of the ability of RCIC to operate |
| and perform its function. |
| |
| Based on the above, RCIC would have operated under all design conditions and |
| was only incapacitated as a result of satisfying Primary Containment |
| isolation functions. Therefore this is a retraction of notification made |
| under 10CFR50.72(b)(2)(iii)(D) (See event notification # 35889). |
| |
| The licensee notified the NRC resident inspector and the Operations Center |
| notified the R1DO (Kinneman). |
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!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
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|Power Reactor |Event Number: 35958 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: LASALLE REGION: 3 |NOTIFICATION DATE: 07/25/1999|
| UNIT: [1] [] [] STATE: IL |NOTIFICATION TIME: 22:32[EDT]|
| RXTYPE: [1] GE-5,[2] GE-5 |EVENT DATE: 07/25/1999|
+------------------------------------------------+EVENT TIME: 20:21[CDT]|
| NRC NOTIFIED BY: WILLIAMS |LAST UPDATE DATE: 07/30/1999|
| HQ OPS OFFICER: CHAUNCEY GOULD +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |PATRICK HILAND R3 |
|10 CFR SECTION: | |
|AUNA 50.72(b)(1)(ii)(A) UNANALYZED COND OP | |
|NLCO TECH SPEC LCO A/S | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N Y 87 Power Operation |87 Power Operation |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| PLANT ENTERED TECH SPEC 3.2.3 LCO ACTION STATEMENT |
| |
| AT 2021 CDT ON 07/25/99, THE "1B21-N500" PRESSURE TRANSMITTER INDICATION |
| DROPPED FROM 1000 PSIG TO INDICATED 600 PSIG REACTOR PRESSURE. THIS |
| TRANSMITTER IS THE PRIMARY PRESSURE TRANSMITTER TO THE ELECTROHYDRAULIC |
| SYSTEM (EHC). DUE TO THIS CHANGE IN PRESSURE INDICATION, THE BACKUP |
| TRANSMITTER TOOK CONTROL. IN THIS LINEUP (BACKUP TRANSMITTER IN CONTROL OF |
| THE EHC), THERE IS NO OTHER BACKUP TRANSMITTER AVAILABLE AND PROCEDURE |
| "LOA-EH-101" STATES THAT THIS CONDITION IS AN UNANALYZED CONDITION AND THE |
| PLANT IS TO ENTER TS 3.2.3. TS 3.2.3 REQUIRES THE REACTOR TO BE <25% POWER |
| WITHIN 4 HOURS. THIS CONDITION WAS NOT DETERMINED TO BE AN UNANALYZED |
| CONDITION UNTIL 2045 CDT ON 07/25/99 UTILIZING THE ABOVE PROCEDURE AND THE |
| UFSAR. THE PROBLEM WITH THE TRANSMITTER IS BEING INVESTIGATED TO DETERMINE |
| WHY IT DOES NOT INDICATE 1000 PSIG. |
| |
| THE RESIDENT INSPECTOR WILL BE INFORMED. |
| |
| * * *RETRACTION 2253 7/29/99, FROM GRANWALD TAKEN BY STRANSKY * * * |
| "It was subsequently determined from a detailed evaluation that was |
| performed in May of 1999, which clearly shows that operation with a pressure |
| regulator out of service at LaSalle is bounded by the thermal limits |
| calculated for the slow closure of one or more turbine control valves |
| (TCVs). The use of the thermal limits reported in the LaSalle Unit 1 Cycle |
| 8 Core Operating Limits Report for the slow closure of one or more TCVs for |
| operations with a pressure regulator out of service does not result in |
| operation of the plant in an unanalyzed condition. The thermal limits were |
| adjusted to be in line with the TCV slow closure analysis and plant thermal |
| limits were declared OPERABLE and Tech Spec 3.2.3 exited within 4 hours. |
| Therefore, LaSalle Unit 1 was not in an unanalyzed condition as reported in |
| Event No.35958." |
| |
| The NRC resident inspector will be informed of this retraction by the |
| licensee. |
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+------------------------------------------------------------------------------+
|Hospital |Event Number: 35971 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: VA COMMONWEALTH UNIVERSITY |NOTIFICATION DATE: 07/29/1999|
|LICENSEE: VA COMMONWEALTH UNIVERSITY |NOTIFICATION TIME: 13:51[EDT]|
| CITY: RICHMOND REGION: 2 |EVENT DATE: 07/23/1999|
| COUNTY: STATE: VA |EVENT TIME: [EDT]|
|LICENSE#: 45-00048-17 AGREEMENT: N |LAST UPDATE DATE: 07/29/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |ROBERT HAAG R2 |
| | |
+------------------------------------------------+ |
| NRC NOTIFIED BY: MARY BETH TAORMINAL | |
| HQ OPS OFFICER: BOB STRANSKY | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
+------------------------------------------------------------------------------+
EVENT TEXT
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| MEDICAL MISADMINISTRATION |
| |
| On 7/23/99, a medical misadministration occurred during a procedure |
| involving a "Betacath" brachytherapy device with a strontium-90 source. Due |
| to a problem with the catheter, a patient received only 2.26 Gy (226 rads) |
| of the prescribed 14 Gy (1,400 rad) dose. The Betacath device is used during |
| cardiac catherization to prevent restenosis of blood vessels. |
| |
| This event was reported to the licensee's radiation safety office on |
| 7/29/99. The licensee has contacted the NRC Region II office regarding this |
| event. |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 35972 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: PRAIRIE ISLAND REGION: 3 |NOTIFICATION DATE: 07/29/1999|
| UNIT: [1] [2] [] STATE: MN |NOTIFICATION TIME: 17:59[EDT]|
| RXTYPE: [1] W-2-LP,[2] W-2-LP |EVENT DATE: 07/29/1999|
+------------------------------------------------+EVENT TIME: 16:40[CDT]|
| NRC NOTIFIED BY: PAT RYAN |LAST UPDATE DATE: 07/29/1999|
| HQ OPS OFFICER: BOB STRANSKY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |GEOFFREY WRIGHT 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
+------------------------------------------------------------------------------+
| CONTROL ROOM SPECIAL VENTILATION SYSTEM DECLARED INOPERABLE |
| |
| "At approximately 1640 on July 29, 1999, Plant Engineering discovered that a |
| condition existed with door 158 (entry door to 122 Control Room Chiller |
| Room) on 7/27/99 similar to a condition that existed on 6/25/99 that |
| resulted in a LER. Further investigation concluded that the condition of |
| door 158 on 7/27/99 was almost exactly the same as that on 6/25/99. Door 158 |
| was identified as having a broken latch mechanism. The broken latch results |
| in a breach of the Control Room Special Ventilation System, such that both |
| trains are to be considered inoperable. |
| |
| "Interviews with duty people present during the 7/27/99 breach confirmed |
| that the door latch was repaired well within an hour from its discovery and |
| returned to service." |
| |
| The NRC resident inspector has been informed of this event by the licensee. |
| |
| [HOO note: see related EN 35860] |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
|Power Reactor |Event Number: 35973 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| FACILITY: NINE MILE POINT REGION: 1 |NOTIFICATION DATE: 07/30/1999|
| UNIT: [] [2] [] STATE: NY |NOTIFICATION TIME: 00:02[EDT]|
| RXTYPE: [1] GE-2,[2] GE-5 |EVENT DATE: 07/29/1999|
+------------------------------------------------+EVENT TIME: 23:16[EDT]|
| NRC NOTIFIED BY: ANTHONY PETRELLI |LAST UPDATE DATE: 07/30/1999|
| HQ OPS OFFICER: DOUG WEAVER +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |JOHN KINNEMAN R1 |
|10 CFR SECTION: | |
|AINA 50.72(b)(2)(iii)(A) POT UNABLE TO SAFE SD | |
|NLCO TECH SPEC LCO A/S | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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
+------------------------------------------------------------------------------+
| HIGH PRESSURE CORE SPRAY INOPERABLE |
| |
| Check valve 2CSH*V16 on the High Pressure Core Spray pump suction from the |
| suppression pool is not in the IST program plan for reverse flow testing. A |
| preliminary review indicates that this check valve should be reverse flow |
| tested. The HPCS was declared inoperable and the plant entered a 14 day |
| LCO. Steps are being taken to retest the valve. |
| |
| The licensee notified the NRC resident inspector. |
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