Event Notification Report for July 9, 1999
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
07/08/1999 - 07/09/1999
** EVENT NUMBERS **
35871 35902 35903 35904
!!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!!
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|Fuel Cycle Facility |Event Number: 35871 |
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| FACILITY: PORTSMOUTH GASEOUS DIFFUSION PLANT |NOTIFICATION DATE: 06/26/1999|
| RXTYPE: URANIUM ENRICHMENT FACILITY |NOTIFICATION TIME: 19:04[EDT]|
| COMMENTS: 2 DEMOCRACY CENTER |EVENT DATE: 06/26/1999|
| 6903 ROCKLEDGE DRIVE |EVENT TIME: 05:33[EDT]|
| BETHESDA, MD 20817 (301)564-3200 |LAST UPDATE DATE: 07/08/1999|
| CITY: PIKETON REGION: 3 +-----------------------------+
| COUNTY: PIKE STATE: OH |PERSON ORGANIZATION |
|LICENSE#: GDP-2 AGREEMENT: N |MIKE JORDAN R3 |
| DOCKET: 0707002 |ROBERT PIERSON NMSS |
+------------------------------------------------+ |
| NRC NOTIFIED BY: DALE NOEL | |
| HQ OPS OFFICER: BOB STRANSKY | |
+------------------------------------------------+ |
|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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| MOTOR STOP BUTTON FAILED TO FUNCTION AS DESIGNED |
| |
| "ON 6/26/99 AT 0533 HOURS, THE X-333 PROCESS BUILDING AREA CONTROL ROOM |
| (ACR) #1 MOTOR STOP BUTTON FAILED TO FUNCTION AS DESIGNED WHEN CALLED UPON |
| TO SHUTDOWN MOTORS ON CELL 33-5-10 (CASCADE OPERATIONAL MODE Ill). THIS |
| REPRESENTS THE FAILURE OF TECHNICAL SAFETY REQUIREMENT (TSR) SURVEILLANCE |
| 2.2.3.14.3 FOR CASCADE D.C. CONTROL POWER WHICH STATES: 'UTILIZE THE ACR |
| MOTOR STOP BUTTON FOR EACH SCHEDULED CELL TRIP. MONITOR EXPECTED CELL BLOCK |
| VALVE CLOSURE AND ANY RECYCLE VALVE ACTUATION.' OPERATIONS PERSONNEL |
| IMMEDIATELY UTILIZED AN ALTERNATE MEANS LOCATED AT THE CELLS LOCAL CONTROL |
| CENTER (LCC) TO TRIP CELL 33-5-10 MOTORS. |
| |
| "THIS EVENT IS REPORTABLE DUE TO A SAFETY SYSTEM COMPONENT (SSC) REQUIRED BY |
| THE TSR NOT BEING AVAILABLE OR OPERABLE AND NO REDUNDANT EQUIPMENT WAS |
| AVAILABLE TO PERFORM THE REQUIRED SAFETY FUNCTION. |
| |
| "THERE WAS NO LOSS OF HAZARDOUS/RADIOACTIVE MATERIAL OR |
| RADIOACTIVE/RADIOLOGICAL CONTAMINATION EXPOSURE AS A RESULT OF THIS EVENT." |
| |
| The NRC resident inspector has been informed of this event by the licensee. |
| |
| * * * UPDATE AT 1820 ON 7/8/99 BY SISLER, RECEIVED BY WEAVER * * * |
| |
| "THIS EVENT RETRACTION IS BEING SUBMITTED BASED ON FURTHER REVIEW OF THE |
| PROCESS CELL DC CONTROL AND TRIP CIRCUITRY. TSR 2.2.3.14.3 SPECIFIES THAT |
| DC CONTROL (CELL TRIP) POWER FOR UF6 STAGE MOTORS SHALL BE OPERABLE. AS |
| PART OF THE CELL TRIP CIRCUIT THERE ARE FOUR REMOTE LOCATIONS FROM WHICH THE |
| X-333 CELLS COULD BE TRIPPED (i.e., THE ACR, LCC, X-533 SWITCHYARD AND |
| X-300). THE PURPOSE OF THE TSR SURVEILLANCE 2.2.3.14.3, WHICH REQUIRES THE |
| USE OF THE ACR MOTOR STOP BUTTON DURING SCHEDULED CELL SHUTDOWNS, IS TO |
| DEMONSTRATE THE RELIABILITY OF THE ACR CELL TRIP FUNCTION. |
| |
| "HOWEVER, IN A TRANSIENT CONDITION, ANY OF THE CELL TRIP LOCATIONS MAY BE |
| USED TO INITIATE CELL SHUTDOWN. IN THIS EVENT, THE CELL WAS BEING SHUTDOWN |
| DUE TO A TRANSIENT CONDITION (SURGING) AND THE SURVEILLANCE REQUIREMENT DID |
| NOT APPLY. THE CELL WAS SUCCESSFULLY SHUTDOWN UTILIZING THE LCC WHICH |
| DEMONSTRATED THAT THE CELL TRIP CIRCUIT WAS OPERABLE. |
| |
| "THIS EVENT IS BEING RETRACTED BASED UPON DC CONTROL AND CELL TRIP POWER WAS |
| OPERABLE, LIMITING CONDITIONS FOR OPERATIONS (LCO) WAS MAINTAINED AND A |
| SAFETY FAILURE DID NOT OCCUR." |
| |
| The licensee notified the NRC resident Inspector. The operations center |
| notified the R3DO (Vegel). |
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|Power Reactor |Event Number: 35902 |
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| FACILITY: BYRON REGION: 3 |NOTIFICATION DATE: 07/08/1999|
| UNIT: [1] [2] [] STATE: IL |NOTIFICATION TIME: 13:51[EDT]|
| RXTYPE: [1] W-4-LP,[2] W-4-LP |EVENT DATE: 07/08/1999|
+------------------------------------------------+EVENT TIME: 11:55[CDT]|
| NRC NOTIFIED BY: L. RUPPERT |LAST UPDATE DATE: 07/08/1999|
| HQ OPS OFFICER: WILLIAM POERTNER +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |TONY VEGEL R3 |
|10 CFR SECTION: | |
|AENS 50.72(b)(1)(v) ENS INOPERABLE | |
| | |
| | |
| | |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|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 |
| | |
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EVENT TEXT
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| LOSS OF EMERGENCY NOTIFICATION SYSTEM (ENS) AND COMMERCIAL TELEPHONE LINES. |
| |
| At 11:55 CDT on 07/08/99, the main communication lines to Byron were cut at |
| Byron Prairie View Golf Course. This resulted in the ENS, Nuclear Accident |
| Reporting System, and normal offsite communication lines being lost. The |
| licensee presently has 4 cellular telephones available (1 in the main |
| control room, 1 in the plant managers office, and 2 in the TSC) and the |
| company tie lines are available (load dispatcher). |
| |
| The licensee estimate for repair is 24 hours (Refer to HOO Log for cellular |
| telephone number). |
| |
| The licensee has notified the NRC resident inspector and the State. |
| |
| ***UPDATE ON 07/08/99 @ 1521 BY ALLEN TO POERTNER *** |
| |
| ENS and commercial telephone lines have been returned to service. |
| |
| The NRC operations officer notified the R3DO (Tony Vegel). |
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|Hospital |Event Number: 35903 |
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| REP ORG: SW INDIANA RAD ONCOLOGY CENTER |NOTIFICATION DATE: 07/08/1999|
|LICENSEE: SW INDIANA RAD ONCOLOGY CENTER |NOTIFICATION TIME: 16:33[EDT]|
| CITY: EVANSVILLE REGION: 3 |EVENT DATE: 05/18/1999|
| COUNTY: STATE: IN |EVENT TIME: 12:00[CST]|
|LICENSE#: 13-25945-01 AGREEMENT: N |LAST UPDATE DATE: 07/08/1999|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |TONY VEGEL R3 |
| | |
+------------------------------------------------+ |
| NRC NOTIFIED BY: SAIYID SHAH | |
| HQ OPS OFFICER: DOUG WEAVER | |
+------------------------------------------------+ |
|EMERGENCY CLASS: N/A | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
| | |
| | |
| | |
| | |
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EVENT TEXT
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| MEDICAL MISADMINISTRATION - UNDER DOSE |
| |
| A patient was prescribed a treatment plan consisting of two doses, 5040 cGy |
| and 2000 cGy using Co-60 therapy. The first dose was given as prescribed on |
| 5/18/99, but the second dose was never given. The prescribing doctor was |
| out of town and his substitute did not notice the second half of the |
| treatment which was written on a second piece of paper. This error was |
| discovered when the original doctor returned to work. The patient was |
| immediately notified of the mistake and requested to come in to finish the |
| treatment. The patient has refused further therapy. |
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|Power Reactor |Event Number: 35904 |
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| FACILITY: SAN ONOFRE REGION: 4 |NOTIFICATION DATE: 07/09/1999|
| UNIT: [] [2] [3] STATE: CA |NOTIFICATION TIME: 02:10[EDT]|
| RXTYPE: [1] W-3-LP,[2] CE,[3] CE |EVENT DATE: 07/08/1999|
+------------------------------------------------+EVENT TIME: 20:35[PDT]|
| NRC NOTIFIED BY: MATT THURBERN |LAST UPDATE DATE: 07/09/1999|
| HQ OPS OFFICER: BOB STRANSKY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: N/A |CHARLES MARSCHALL R4 |
|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 Y 100 Power Operation |100 Power Operation |
|3 N Y 100 Power Operation |100 Power Operation |
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EVENT TEXT
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| TRAIN 'A' TOXIC GAS ISOLATION SIGNAL ACTUATION |
| |
| A train 'A' toxic gas isolation signal (TGIS) occurred, causing the control |
| room ventilation system to isolate and the train 'A' emergency chill water |
| system to start. The TGIS was caused when the ammonia channel went into |
| alarm. The licensee is investigating the cause of the ammonia alarm, but |
| reported that maintenance workers were venting freon at the time of the |
| actuation. The NRC resident inspector has been informed of this event by the |
| licensee. |
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Page Last Reviewed/Updated Thursday, March 25, 2021
Page Last Reviewed/Updated Thursday, March 25, 2021