U.S. Nuclear Regulatory Commission Operations Center Event Reports For 08/04/95 - 08/07/95 ** EVENT NUMBERS ** 29144 29160 29161 29162 29163 29164 !!!!!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!!! +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29144 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: WOLF CREEK REGION: 4 |NOTIFICATION DATE: 08/01/95 | |UNIT: [1] [ ] [ ] STATE: KS |NOTIFICATION TIME: 14:08 [ET]| |RX TYPE: [1] W-4-LP |EVENT DATE: 08/01/95 | +------------------------------------------------+EVENT TIME: 12:35[CDT]| |NRC NOTIFIED BY: LUTZE |LAST UPDATE DATE: 08/04/95 | |HQ OPS OFFICER: TIM McGINTY +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JOHN PELLET RDO | |DDDD 73.71 UNSPECIFIED PARAGRAPH | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | DISCOVERY OF A FALSIFIED APPLICATION REGARDING CRIMINAL HISTORY INVOLVING A | | CONTRACTOR WHO HAD RECENTLY BEEN GRANTED ACCESS. | | | | THE LICENSEE TOOK IMMEDIATE COMPENSATORY ACTIONS UPON DISCOVERY. THE | | LICENSEE WILL NOTIFY THE RESIDENT INSPECTOR. (SEE HOO LOG FOR DETAILS.) | | | | *** UPDATE RECEIVED AT 1514 ON AUGUST 4, 1995, FROM JOHNSON BY TROCINE *** | | | | THE LICENSEE IS RETRACTING THIS EVENT BASE ON ITS REVIEW OF THE GUIDANCE | | PROVIDED IN AN NRC MEMORANDUM FROM NRR TO THE REGIONAL OFFICES. THE | | GUIDANCE STATED THAT IF THE EVENT INVOLVED A PROGRAM BREAKDOWN, IT WOULD BE | | A ONE-HOUR REPORTABLE EVENT. IF THE EVENT INVOLVED THE FAILURE OF AN | | INDIVIDUAL TO PROVIDE THE INFORMATION, THEN IT WOULD ONLY BE A LOGGABLE | | EVENT. IN ADDITION, THE LICENSEE PERFORMED A FIVE-YEAR BACKGROUND | | INVESTIGATION. THE OMISSION OCCURRED SEVEN YEARS PRIOR TO THE | | INVESTIGATION AND WAS, THEREFORE, OUTSIDE OF THE BACKGROUND INVESTIGATION'S | | SCOPE. THE OMISSION WAS ALSO CONSIDERED TO BE MINOR IN NATURE. | | | | THE LICENSEE WILL NOTIFY THE NRC RESIDENT INSPECTOR. THE NRC OPERATIONS | | CENTER NOTIFIED THE R4DO (PELLET). | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29160 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: MILLSTONE REGION: 1 |NOTIFICATION DATE: 08/04/95 | |UNIT: [1] [ ] [ ] STATE: CT |NOTIFICATION TIME: 13:24 [ET]| |RX TYPE: [1] GE-3,[2] CE,[3] W-4-LP |EVENT DATE: 08/04/95 | +------------------------------------------------+EVENT TIME: 06:30[EDT]| |NRC NOTIFIED BY: WILLIAM NOLL |LAST UPDATE DATE: 08/04/95 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JACK DURR RDO | |ASHU 50.72(b)(1)(i)(A) PLANT S/D REQD BY TS | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | 1 | N Y 100 POWER OPERATION | 60 POWER OPERATION | | | | | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | THE LOSS OF A 480-VOLT BUS RESULTED IN A UNIT SHUTDOWN REQUIRED BY | | TECHNICAL SPECIFICATIONS. | | | | AT 0630, THE UNIT EXPERIENCED THE LOSS OF A 480-VOLT FEEDER BREAKER TO ONE | | OF TWO EMERGENCY BUSSES. THIS LOSS IS BELIEVED TO BE RELATED TO A RELAYING | | PROBLEM ON THE FEEDER BREAKER ITSELF. AS A RESULT, SOME SUPPORT EQUIPMENT | | WAS LOST, AND A NUMBER OF TECHNICAL SPECIFICATION LIMITING CONDITIONS FOR | | OPERATION WERE ENTERED WITH RESPECT TO CORE SPRAY, LOW PRESSURE COOLANT | | INJECTION, AND FEEDWATER COOLANT INJECTION. THE AFFECTED BUS IS NOW | | CROSS-TIED WITH ANOTHER POWER SUPPLY AS ALLOWED BY TECHNICAL | | SPECIFICATIONS; BUT THE ASSOCIATED CORE SPRAY, LOW PRESSURE COOLANT | | INJECTION, AND FEEDWATER COOLANT INJECTION TRAINS ARE CONSIDERED TO BE | | INOPERABLE BECAUSE THEY ARE NOT BEING POWERED BY AN INDEPENDENT POWER | | SUPPLY. THE UNIT ENTERED A 24-HOUR TO COLD SHUTDOWN LIMITING CONDITION FOR | | OPERATION AT 0630, AND THE UNIT SHUTDOWN WAS COMMENCED AT 1302. | | | | THE LICENSEE NOTIFIED THE NRC RESIDENT INSPECTOR AND THE STATE AND LOCAL | | OFFICIALS. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |HOSPITAL | |EVENT NUMBER: 29161 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |LICENSEE: ST. VINCENT HOSPITAL |NOTIFICATION DATE: 08/04/95 | | CITY: WORCESTER REGION: 1 |NOTIFICATION TIME: 13:26 [ET]| | COUNTY: STATE: MA |EVENT DATE: 05/02/94 | |LICENSE#: 20-12869-01 AGREEMENT: N |EVENT TIME: 15:35[EDT]| | DOCKET: |LAST UPDATE DATE: 08/04/95 | | +-----------------------------+ | |PERSON ORGANIZATION| | |JACK DURR RDO | | | | +------------------------------------------------+ | |NRC NOTIFIED BY: PAUL IMBERGAMO | | |HQ OPS OFFICER: LEIGH TROCINE | | +------------------------------------------------+ | |EMERGENCY CLASS: NOT APPLICABLE | | |10 CFR SECTION: | | |LADM 35.33(a) MED MISADMINISTRATION | | | | | | | | | | | | | | +------------------------------------------------+-----------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | ST. VINCENT HOSPITAL WHICH IS LOCATED IN WORCESTER, MASSACHUSETTS, | | IDENTIFIED THE POSSIBILITY OF USING A 5-MILLIGRAM, CESIUM-137, | | BRACHYTHERAPY SOURCE IN LIEU OF A 10-MILLIGRAM SOURCE. | | | | DURING THE PERFORMANCE OF A QUARTERLY INVENTORY AND SURVEY ON MAY 27, 1995, | | ST. VINCENT HOSPITAL DISCOVERED THAT TWO SOURCES HAD BEEN STORED IN THE | | WRONG SLOTS SINCE APRIL 24, 1994. A NOMINAL, 5-MILLIGRAM, CESIUM-137, | | STAINLESS STEEL, ENCAPSULATED, MICROSPHERE, BRACHYTHERAPY SOURCE WAS FOUND | | TO BE LOCATED IN THE SLOT FOR A SIMILAR 10-MILLIGRAM SOURCE; AND THE | | 10-MILLIGRAM SOURCE WAS FOUND TO BE LOCATED IN THE SLOT FOR THE 5-MILLIGRAM | | SOURCE. THESE SOURCES ARE CATEGORIZED BY BOTH COLOR CODING (RED AND | | PURPLE) AND STORAGE POSITION IN A SAFE. THE LICENSEE ALSO UTILIZED A | | DOUBLE CHECKING SYSTEM IN WHICH ONE INDIVIDUAL LOADED THE SOURCES IN THE | | SAFE AND ANOTHER INDIVIDUAL VERIFIED THEM. IN THIS CASE, THE COLORS HAD | | FADED AND WERE HARD TO DISTINGUISH INDIVIDUALLY. THE LICENSEE CURRENTLY | | PLANS TO REPAINT THE SOURCES AND POSSIBLY TO COME UP WITH A SOURCE MAP | | DIAGRAM TO IDENTIFY WHICH SOURCE IS TO BE PULLED PER CASE. | | | | THE LICENSEE'S INVESTIGATION REVEALED THAT THE 10-MILLIGRAM SOURCE HAD NOT | | BEEN USED FOR ANY APPLICATIONS INTENDED FOR A 5-MILLIGRAM SOURCE. HOWEVER, | | THERE WAS A POSSIBILITY THAT THE 5-MILLIGRAM SOURCE COULD HAVE POTENTIALLY | | BEEN USED IN LIEU OF THE 10-MILLIGRAM SOURCE. THERE WERE FIVE CASES WHERE | | THERE WAS A ONE IN SIX CHANCE THAT THE POTENTIAL DOSE DIFFERENCES BETWEEN | | THE PRESCRIBED AND DELIVERED DOSES WERE NOT ENOUGH TO CLASSIFY THEM AS | | EITHER RECORDABLE EVENTS OR MISADMINISTRATIONS. THERE WERE SIX CASES WHERE | | THERE WAS A ONE IN SIX CHANCE THAT THE POTENTIAL DOSE DIFFERENCES WOULD | | HAVE BEEN ENOUGH TO CLASSIFY THEM AS RECORDABLE EVENTS, BUT IT IS VERY | | UNLIKELY THAT THE WRONG SOURCE WAS USED IN THESE APPLICATIONS BECAUSE THE | | SOURCE WAS USED FOR A SEPARATE APPLICATOR AND STORED IN A SEPARATE LOCATION | | AND BECAUSE OF THE INDIVIDUAL'S WORK PRACTICES FOR LOADING SOURCES. THE | | LICENSEE DID, HOWEVER, IDENTIFY ONE CASE WHERE THERE WAS A ONE IN FIVE | | CHANCE THAT ONE HALF OF THE DIAGNOSED DOSAGE MAY HAVE BEEN ADMINISTERED BY | | ANOTHER INDIVIDUAL. | | | | THIS POTENTIAL MISADMINISTRATION INVOLVED A 2,000-CENTIGRAY PRESCRIPTION TO | | THE SURFACE OF A BURNETT APPLICATOR WITH A 20% CHANCE OF A 1,098-CENTIGRAY | | ADMINISTRATION. THIS EQUATES TO A POTENTIAL 45% UNDER DOSE FOR TREATING | | RECURRENT DISEASE ON AN ELDERLY PATIENT WITH MULTIPLE ILLNESSES. THIS | | IMPLANT WAS PUT INTO THE PATIENT AT 1535 ON MAY 2, 1994, AND IT WAS REMOVED | | AT 0815 ON MAY 4, 1994. | | | | THE LICENSEE NOTIFIED THE MEDICAL STAFF, AND THE APPROPRIATE PHYSICIANS | | DETERMINED THAT THERE WAS NO CLINICAL SIGNIFICANCE TO THE POTENTIAL UNDER | | DOSAGE TREATMENTS FOR ANY OF THESE EVENTS. THE LICENSEE OPTED NOT TO | | NOTIFY THE PATIENT INVOLVED IN THE POTENTIAL MISADMINISTRATION. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29162 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: DRESDEN REGION: 3 |NOTIFICATION DATE: 08/04/95 | |UNIT: [ ] [2] [3] STATE: IL |NOTIFICATION TIME: 17:13 [ET]| |RX TYPE: [1] GE-1,[2] GE-3,[3] GE-3 |EVENT DATE: 08/04/95 | +------------------------------------------------+EVENT TIME: 14:08[CDT]| |NRC NOTIFIED BY: KEITH POLSON |LAST UPDATE DATE: 08/04/95 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JIM MCCORMICKBARGER RDO | |APRE 50.72(b)(2)(vi) OFFSITE NOTIFICATION | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE | +-----+----------+-------+--------+-----------------+--------+-----------------+ | | | | | 2 | N N 0 REFUELING | 0 REFUELING | | 3 | N N 0 COLD SHUTDOWN | 0 COLD SHUTDOWN | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | NOTIFICATION OF OFFSITE AGENCIES DUE TO THE DISCOVERY OF SLIGHT | | CONTAMINATION ON FIVE CIRCUIT BREAKERS THAT HAD BEEN SHIPPED OFFSITE. | | | | FIVE CIRCUIT BREAKERS WHICH WERE SHIPPED OFFSITE TO THE GENERAL ELECTRIC | | FACILITY IN HAMMOND, INDIANA, WERE DISCOVERED TO BE SLIGHTLY CONTAMINATED | | AFTER DISASSEMBLY. THE CONTAMINATION WAS DISCOVERED AFTER THE BREAKERS HAD | | BEEN SHIPPED TO ANOTHER GENERAL ELECTRIC FACILITY IN CHICAGO, ILLINOIS, | | BECAUSE THE HAMMOND FACILITY WAS CLOSED DOWN WHILE THE BREAKERS WERE | | LOCATED THERE. THREE OF THE FIVE BREAKERS WERE FOUND TO HAVE 3,000 TO | | 5,000 DPM FIXED CONTAMINATION AND 2,000 DPM SMEARABLE CONTAMINATION WHILE | | THE OTHER TWO BREAKERS WERE FOUND TO HAVE 1,000 DPM FIXED CONTAMINATION AND | | 1,000 DPM SMEARABLE CONTAMINATION. THESE RADIATION LEVELS ARE NOT | | REPORTABLE. HOWEVER, THE LICENSEE NOTIFIED THE INDIANA STATE DEPARTMENT OF | | HEALTH, THE INDIANA EMERGENCY MANAGEMENT AGENCY, AND THE ILLINOIS | | DEPARTMENT OF NUCLEAR SAFETY. | | | | THE BREAKERS ARE CURRENTLY LOCATED AT THE GENERAL ELECTRIC FACILITY IN | | CHICAGO, AND THE LICENSEE IS PLANNING TO SEND REPRESENTATIVES TO THIS | | LOCATION TO CLEAN THEM. THE LICENSEE IS ALSO PLANNING TO SEND | | REPRESENTATIVES TO THE GENERAL ELECTRIC FACILITY IN HAMMOND TO DETERMINE | | WHETHER OR NOT THERE IS ANY SMEARABLE CONTAMINATION ON TOOLS, ETC. AT THAT | | LOCATION. | | | | THE LICENSEE NOTIFIED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29163 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: COOPER REGION: 4 |NOTIFICATION DATE: 08/05/95 | |UNIT: [1] [ ] [ ] STATE: NE |NOTIFICATION TIME: 03:56 [ET]| |RX TYPE: [1] GE-4 |EVENT DATE: 08/05/95 | +------------------------------------------------+EVENT TIME: 02:18[CDT]| |NRC NOTIFIED BY: STEVE SMALLFOOT |LAST UPDATE DATE: 08/05/95 | |HQ OPS OFFICER: RUDY KARSCH +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |JOHN PELLET RDO | |AUNA 50.72(b)(1)(ii)(A) UNANALYZED COND OP | | | | | | | | | | | | | | +-----+----------+-------+--------+--------------+--+--------+-----------------+ |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 +------------------------------------------------------------------------------+ | HPCI DECLARED INOPERABLE DUE TO WATER HAMMER STRESSES WHICH MAY RESULT FROM | | THE ACCUMULATION OF WATER IN THE EXHAUST LINE. | | | | THE FOLLOWING IS THE TEXT OF A FAX RECEIVED FROM THE LICENSEE: "ON 8-3-95 | | HPCI WAS DECLARED INOPERABLE DUE TO ANALYSIS OF WATER ACCUMULATION IN THE | | EXHAUST LINE. THIS WAS REPORTED AS A 4 HOUR NOTIFICATION AT 0540 ON | | 8-3-95." (REFER TO EVENT NUMBER 29154.) "AS PART OF THE CONTINUING | | ANALYSIS OF THIS CONDITION GENERAL ELECTRIC AND VECTRA HAVE PERFORMED A | | CONSERVATIVE HYDRODYNAMIC AND PIPE STRESS EVALUATION OF THE POTENTIAL WATER | | HAMMER EFFECTS TO THE HPCI EXHAUST LINE. THIS EVALUATION INCLUDED A | | CONDITION WHICH OCCURRED ON JULY 5, 1995 AND JULY 6, 1995 DURING WHICH A | | SIGNIFICANT AMOUNT OF WATER ACCUMULATED IN THE EXHAUST LINE WHICH WAS | | UNDETECTED DUE TO A FAILED EXHAUST LINE LEVEL SWITCH (MINOR WATER | | ACCUMULATION AFTER TURBINE OPERATION IS NORMAL AND SHOULD BE REMOVED BY THE | | DRAIN SYSTEM). THIS ANALYSIS DETERMINED THAT, ON THESE DATES, A TURBINE | | START COULD HAVE RESULTED IN THE PIPE, SUPPORT, AND CONTAINMENT PENETRATION | | STRESSES EXCEEDING DESIGN CRITERIA BY A SUBSTANTIAL MARGIN." | | | | "THE INTERIM ACTION PERFORMED WAS THE OPERATIONS STAFF PERFORMED MANUAL | | DRAINING OF THE HPCI EXHAUST LINE TO PREVENT SIGNIFICANT WATER | | ACCUMULATION." | | | | "CURRENTLY COOPER IS IN THE PROCESS OF PERFORMING TWO MODIFICATIONS WHICH | | WILL ALLEVIATE THIS CONCERN." | | | | THE LICENSEE WILL MODIFY THE GOVERNOR TO RAMP UP TURBINE SPEED AND WILL | | INSTALL A BIGGER SNUBBER ON THE EXHAUST LINE. THE LICENSEE WILL ALSO | | INFORM THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+ +----------------------------------+ +-----------------------+ |POWER REACTOR | |EVENT NUMBER: 29164 | +----------------------------------+ +-----------------------+ +------------------------------------------------+-----------------------------+ |FACILITY: BRUNSWICK REGION: 2 |NOTIFICATION DATE: 08/05/95 | |UNIT: [1] [2] [ ] STATE: NC |NOTIFICATION TIME: 17:17 [ET]| |RX TYPE: [1] GE-4,[2] GE-4 |EVENT DATE: 08/05/95 | +------------------------------------------------+EVENT TIME: 13:46[EDT]| |NRC NOTIFIED BY: MARK SHALL |LAST UPDATE DATE: 08/05/95 | |HQ OPS OFFICER: LEIGH TROCINE +-----------------------------+ +------------------------------------------------+ NOTIFICATIONS | |EMERGENCY CLASS: NOT APPLICABLE +-----------------------------+ |10 CFR SECTION: |CHARLES CASTO RDO | |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 | | 2 | N Y 100 POWER OPERATION | 100 POWER OPERATION | | | | | +-----+---------------------------------------------+--------------------------+ EVENT TEXT +------------------------------------------------------------------------------+ | CONTAINMENT ATMOSPHERE CONTROL SYSTEM ISOLATION, SECONDARY CONTAINMENT | | ISOLATION, AND STANDBY GAS TREATMENT SYSTEM START ON BOTH UNITS DUE TO AN | | INVALID OFF-GAS VENT STACK HIGH-HIGH RADIATION SIGNAL. | | | | AT 1346 ON AUGUST 5, 1995, BOTH UNITS RECEIVED A CONTAINMENT ATMOSPHERE | | CONTROL SYSTEM ISOLATION (GROUP 6), SECONDARY CONTAINMENT ISOLATION, AND | | STANDBY GAS TREATMENT SYSTEM START. ALL SYSTEMS RESPONDED AS DESIGNED. THE | | ISOLATION SIGNAL RESULTED FROM AN INVALID OFF-GAS VENT STACK HIGH-HIGH | | RADIATION SIGNAL. THE LICENSEE WAS NOT SURE OF THE ROOT CAUSE OF THIS | | SIGNAL, BUT IT APPEARED TO BE RELATED TO THE PERFORMANCE OF A PROCEDURE FOR | | OBTAINING A STACK GAS SAMPLE. (THE LICENSEE STATED THAT THE PROCEDURE USED | | FOR THIS TASK WAS NOT A NEW PROCEDURE BUT WAS ONE THAT WAS ROUTINELY | | PERFORMED AND THAT IT APPEARED THAT THE PROCEDURE HAD BEEN PERFORMED | | CORRECTLY.) THE ISOLATION SIGNAL WAS ONLY MOMENTARY, AND THE READING | | RETURNED TO NORMAL WITHIN A FEW SECONDS. THE LICENSEE BELIEVES THAT THE | | SIGNAL WAS INVALID AND THAT THE INITIAL SAFETY SIGNIFICANCE WAS MINIMAL. | | | | FOLLOWING THE EVENT, THE ISOLATION SIGNAL WAS RESET. BOTH UNITS RESTORED | | REACTOR BUILDING HEATING VENTILATION AND AIR CONDITIONING, SHUT DOWN THE | | STANDBY GAS TREATMENT SYSTEM, AND RESTORED THE CONTAINMENT ATMOSPHERE | | CONTROL SYSTEM TO ITS NORMAL LINEUP. THE LICENSEE'S INVESTIGATION TO | | DETERMINE THE ROOT CAUSE OF THE EVENT IN CURRENTLY ONGOING. | | | | THE LICENSEE NOTIFIED THE NRC RESIDENT INSPECTOR. | +------------------------------------------------------------------------------+