United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for December 21, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/20/2012 - 12/21/2012

** EVENT NUMBERS **


48058 48463 48582 48589 48603 48610 48611 48612 48615 48616

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Agreement State Event Number: 48058
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: SAINT JOSEPH HOSPITAL
Region: 4
City: EUREKA State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KENT PRENDERGAST
HQ OPS Officer: JOE O'HARA
Notification Date: 06/29/2012
Notification Time: 15:59 [ET]
Event Date: 05/02/2012
Event Time: [PDT]
Last Update Date: 12/20/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEFF CLARK (R4DO)
FSME RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - POTENTIAL MEDICAL EVENT DUE TO LEAKING I-125 SEEDS

The following was received via e-mail:

"On 6/28/12 Saint Joseph Hospital personnel were surveying a packing materials used to ship I-125 seeds, for a procedure conducted earlier that day, when they noted elevated readings. Further surveys revealed that the elevated readings were not coming from the packing material associated with the 6/28/12 procedure but from packing material that was used to ship I-125 seeds for a previous procedure, which was in the area of the survey. Surveys of the packing material revealed no loose contamination on the exterior or interior of the box but elevated readings of 2500-350000 cpm and .2 mrem/hr. Receipt and post procedure surveys of the procedure associated with contaminated box did not reveal any abnormal readings. The Saint Joseph RSO assumes the material is I-125 but they do not have the capability to verify this. No loose seeds were found in any of the packing material. The I-125 seeds were accompanied by the manufacturers leak test report which indicated no contamination.

"The patient, whose procedure was associated with the contaminated packing material, will be evaluated on Monday 7/2/12 to determine if there was any uptake in his urine or thyroid of I-125 as a result of leaking seeds."

CA Report Number: 062912

A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

* * * UPDATE ON 7/2/12 AT 1806 EDT FROM EUGENE FORRER TO DONG PARK VIA EMAIL * * *

"This is a follow up of an incident, as information only, on Friday, June 29, 2012. Radiologic Health Branch reference would be 5010 #062912. The notification was about contaminated packaging that had contained Best Medical I-125 seeds. A thyroid count was performed on the patient who had the seeds implanted in May. The thyroid count verified that there had been an uptake of iodine by the thyroid. Below is the write up and preliminary dose estimate from the licensee regarding.

"Based upon this morning's patient measurements, instrument-manufacturer supplied efficiency data, and reference data for dose conversion, we estimate the patient involved received a thyroid uptake of 0.1 mCi of I-125 and a dose to the thyroid of 300 cGy.

"1) Conversion of counts per minute (cpm) to activity

Two[Pi] counting efficiency for I-125 (per manufacturer) is 133.5%
fraction of 2[Pi] solid angle subtended by a 2 inch diameter detector at a distance of 30 cm from the thyroid is 10.13 squared cm / 5654.9 squared cm = 0.00179
overall efficiency = 1.335 x 0.00179 = 0.00239

(190493 - 30) net cpm / 0.00239 x 4.505x10-10 mCi/dpm = 0.0359 mCi present thyroid burden.
Back-correcting 60 days to time of implantation (conservatively assuming that all uptake occurred at that time) with 42-day effective half-life, initial uptake given by 0.0359 / 0.3715 = 0.0967 approximately 0.1 mCi

"2) Taking the value quoted by Chen et.al. (attached) from NUREG/CR-6345, we assume the dose to thyroid is 780 cGy per mCi of I-125 administered, and this value assumes 25% uptake into the thyroid. Our calculated estimated thyroid burden of 0.1 mCi then gives an estimated absorbed dose of 0.0967 mCi x 780 cGy/mCi / 0.25 (since we measured actual thyroid burden v. amount administered) = 302 cGy approximately 300 cGy (rad) to thyroid.

"3) Whole body committed effective dose equivalent (CEDE) from a 300 rad dose to the thyroid (using a thyroid weighting factor of 0.04) would be 12 rem."

Notified R4DO (Allen) and FSME (Einberg).

* * * UPDATE FROM GENE FORRER TO CHARLES TEAL ON 12/19/12 AT 1650 EST * * *

"EVENT SUMMARY: While surveying an empty brachytherapy seeds package for return to Best Medical hospital personnel discovered contamination on the interior of the package. Follow up thyroid scans of the patient who was implanted with the seeds associated with the package verified an uptake of I-125 by the patient's thyroid. The initial report to RHB was intended, by the licensee, to be a notification of a Medical Event.

"REPORTING: This event was reported to the NRC, by phone, on 4/13/12, at 8:50 am via email.

"HEALTH AND SAFETY: Based on surveys of the packing material all contamination was contained within the package and did not pose a threat to hospital personnel. The estimated dose to the patient's thyroid was calculated to be approximately 330 rad with a CEDE of 12 rem.

"ADDITIONAL DETAILS: The RSO conducted an investigation of the incident and could not find any indication that there were any irregularities with the implantation procedures. Hospital personnel associated with the procedure indicated to the RHB inspector that there were no irregularities with the procedure. In addition receipt surveys of the package did not reveal any contamination of any of the packaging material. The RSO concluded that the cause of the contamination was due to a manufacturing error.

"The RSO of Best Medical conducted an investigation of the production of the seeds implanted in the patient. All records at Best Medical indicate that all QC tests of the seeds were done satisfactorily. The RSO concluded that the seeds had been damaged in transit or that Saint Joseph personnel must have damaged the seeds either during the initial surveys or during the implantation. The Best Medical RSO was unable to explain how the seeds could have been damaged and still be implantable. The Virginia Department of Health inspected the Best Medical facility and concluded that all QC testing on the seeds had been completed satisfactorily with no abnormalities noted.

"After interviewing Saint Joseph and Best Medical personnel RHB personnel concluded that the most logical explanation for the leaking seeds was a manufacturing error, however, without samples from the same lot of seeds implanted available for analysis this can not be proven conclusively.

"The hospital has changed suppliers for the brachytherapy seeds. In addition they have initiated a procedure where the needles containing the seeds are wiped after they have been removed from the shipping container.

"ENFORCEMENT ACTIONS: The hospital was not cited for this incident.

"INVESTIGATION STATUS: This investigation is closed."

Notified R4DO (Spitzberg) and FSME Event Resource via email.

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Power Reactor Event Number: 48463
Facility: COMANCHE PEAK
Region: 4 State: TX
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MICHAEL STAKES
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/31/2012
Notification Time: 14:09 [ET]
Event Date: 10/31/2012
Event Time: 06:15 [CDT]
Last Update Date: 12/20/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
RICK DEESE (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 97 Power Operation

Event Text

SEQUENCER FAULT RESULTING IN SYSTEM ACTUATIONS

"On October 31, 2012 at 0615 hours CDT, Unit 1 Train 'B' Safety Injection/Blackout Sequencer faulted resulting in a start of the Turbine Driven Auxiliary Feed Water (TDAFW) Pump and Train 'B' Emergency Diesel Generator (EDG). Reactor power was reduced to 97% rated thermal power (RTP) by an immediate load reduction of 50 MWe due to the resulting cooler Auxiliary Feed Water being injected into the Steam Generators; reactor power did not exceed 100% RTP. Train 'A' equipment was not affected by the event.

"The TDAFW Pump was secured at 0628 hours by closing the Train 'B' steam supply valve from the main control board and the steam supply valve was declared operable at 0916 hours when the hand switch was returned to 'Auto' and the control switch lineup surveillance was completed. The Train 'B' EDG was loaded to 100% capacity in accordance with the operating procedure and secured at 1032 hours. The EDG is available but remains inoperable until the Sequencer is declared operable.

"Efforts continue to restore the Sequencer at this time. A faulted 15 Volt power supply was identified and further investigation/calibration will determine if other conditions contributed to the fault. A final surveillance test will determine Sequencer operability. The most limiting Shutdown Technical Specification action statement is 24 hours in accordance with Safety Injection Sequencer TS 3.8.1 F. Current projections for Sequencer operability, and thus Train 'B' EDG operability, are 1800 hours.

"This action appears to be an invalid actuation. However, this will be confirmed after a cause analysis and an update to this event will be provided at that time."

The licensee has notified the NRC Resident Inspector.

* * * UPDATE FROM ROBERT CLARK TO VINCE KLCO ON 12/20/12 AT 1130 EST * * *

"This is an update to Event Notification #48463. This event was initially reported on October 31, 2012 as a valid actuation per 50.72(b)(3)(iv)(A). However, further evaluation of this event has confirmed that the cause was isolated to a failed 15VDC power supply and the ESF bus voltage sensed by the Blackout Sequencer did not dip. Therefore, a valid blackout condition did not occur and the starts of the Unit 1 Turbine Driven Auxiliary Feed Water Pump (TDAFWP) and the Unit 1 Train B Emergency Diesel Generator (EDG) were both determined to be invalid.

"For the EDG start, the associated electrical bus was never de-energized and the EDG output breaker did not close. Therefore, the EDG start is not reportable per 10CFR50.73(a)(2)(iv)(A) since it was an invalid actuation and the safety function (i.e. provide power to the safety related electrical bus) had already been completed at the time of the EDG actuation.

"For the TDAFWP start, the AFW system safety function had not already been completed. Therefore, the TDAFWP start is reportable as an invalid actuation per 10CFR50.73(a)(2)(iv)(A) with the option to provide a telephone notification within 60 days instead of an LER per 10CFR50.73(a)(1). The following required information is being submitted per NUREG-1022, Rev. 2 for the TDAFWP start:

"(a) The specific train(s) and system(s) that were actuated - Unit 1 Turbine Driven Auxiliary Feed Water Pump.

"(b) Whether each train actuation was complete or partial - The train actuation was complete.

"(c) Whether or not the system started and functioned successfully - The system started and functioned successfully.

"The NRC Resident Inspector has been informed."

Notified R4DO (Spitzberg).

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Agreement State Event Number: 48582
Rep Org: NORTH DAKOTA DEPARTMENT OF HEALTH
Licensee: BRAUN INTERTEC CORPORATION
Region: 4
City: EPPING State: ND
County:
License #: 33-48303-01
Agreement: Y
Docket:
NRC Notified By: LEWIS VIGEN
HQ OPS Officer: CHARLES TEAL
Notification Date: 12/12/2012
Notification Time: 12:38 [ET]
Event Date: 12/10/2012
Event Time: 09:43 [MST]
Last Update Date: 12/12/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK HAIRE (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE - SOURCE DISCONNECTED FROM RADIOGRAPHY CAMERA

While conducting radiography operations with a Sentinel Model 880D camera, the radiographer noticed that the connection to the source was not holding. The radiographer was qualified in source retrieval. He was able to retrieve the source into its secured position. After securing the source he inspected the camera to determine if there was a mechanical problem. No problems were found. It is believed that the problem was due to ice buildup. There were no significant exposures during this event.

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Agreement State Event Number: 48589
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: THERMO SCIENTIFIC PORTABLE ANALYTICAL INSTRUMENTS
Region: 1
City: TEWKSBURY State: MA
County:
License #: 55-0238
Agreement: Y
Docket:
NRC Notified By: i
HQ OPS Officer: CHARLES TEAL
Notification Date: 12/13/2012
Notification Time: 17:05 [ET]
Event Date: 12/12/2012
Event Time: [EST]
Last Update Date: 12/13/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DANIEL HOLODY (R1DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE - POTENTIAL CONTAMINATED SEALED SOURCE

The following was received from the Commonwealth of Massachusetts via email:

"On 12/13/12, licensee notified this Agency of the 12/12/12 determination of a potential leaking or contaminated sealed source that had been received from an out-of-state vendor. The source being returned to vendor for further analysis. There was no evidence of contamination beyond the source itself."

"The Agency considers this matter to be OPEN pending receipt of written report."

The sealed source contained 0.040 Ci of Cd-109. The manufacturer is Eckert and Zeigler, model XFB-3, with serial number TR2463. 45

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Power Reactor Event Number: 48603
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [1] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: BRIAN HAYDEN
HQ OPS Officer: CHARLES TEAL
Notification Date: 12/18/2012
Notification Time: 14:36 [ET]
Event Date: 12/18/2012
Event Time: 14:36 [EST]
Last Update Date: 12/20/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
GORDON HUNEGS (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

PARTIAL LOSS OF EMERGENCY ASSESSMENT DURING PLANNED MODIFICATIONS

"Calvert Cliffs Nuclear Power Plant will begin a planned modification of the Unit 1 and Unit 2 Plant Process Computers (PPC's) and associated network infrastructure on December 18, 2012. This includes the Emergency Response Data System (ERDS) communication with the NRC Operations Center. This work will require the TSC, OSC and subsequently EOF to lose data flow from the plant data network for a period of approximately 36 hours. During this time, the following systems will be impacted for the duration of maintenance:

1. ERDS will be out of service.
2. Plant Data will not reach the TSC and OSC from the plant data network.
3. TSC Computer data transfer to the EOF only will be out of service.
4. Chemistry DAS remote monitoring capability will be lost.
5. Plant parameter data will not be available on the site's LAN network.

"Once the schedule maintenance starts, the systems (listed above) can be returned to service within 1 hour. Should an emergency be declared during this period, the Control Room will continue to have the capability to retrieve plant data inputs to assess plant conditions and perform core damage assessment. Control Room Emergency response personnel will use emergency response procedures (ERPIP 106) to disseminate plant parameter data to the effected Emergency Response Facilities. MIDAS (Meteorological Data) will continue to be operational at the site. Compensatory measures exist within the Calvert Cliffs Emergency Response procedures to provide plant data in the event of an actual Emergency to the NRC Operations Center until the ERDS can be returned to service."

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM BRIAN HAYDEN TO S. SANDIN ON 12/20/2012 AT 1035 EST * * *

On 12/20/2012 at 0200 EST, the plant process computer and associated network infrastructure was restored to service. The licensee will notify the NRC Resident Inspector.

Notified the R1DO (Hunegs).

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Power Reactor Event Number: 48610
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: ED CONDO
HQ OPS Officer: STEVE SANDIN
Notification Date: 12/20/2012
Notification Time: 07:51 [ET]
Event Date: 12/20/2012
Event Time: 07:51 [EST]
Last Update Date: 12/20/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JAMNES CAMERON (R3DO)
ERDS GROUP (EMAI)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

EMERGENCY RESPONSE DATA SYSTEM (ERDS) OUT-OF-SERVICE

"Computer engineering personnel will be taking the plant integrated computer system (ICS) out-of-service for planned maintenance. During the time ICS is out-of-service, the Safety Parameter Display System (SPDS) and the Emergency Response Data System (ERDS) will be unavailable. The computer outage is scheduled for six hours.

"Contingency plans have been established to transmit plant parameter data and perform the dose assessment function in the event of an emergency while ERDS is unavailable.

"This event is being reported in accordance with 10 CFR 50.72(b)(3)(xiii). A follow-up notification will be made when the maintenance activities are complete and the equipment is restored."

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM JIM CASE TO HOWIE CROUCH AT 1309 EST ON 12/20/12 * * *

At 1300 EST, the plant integrated computer system was restored and SPDS and ERDS was returned to service.

Notified R3DO (Cameron) and ERDS Group email.

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Power Reactor Event Number: 48611
Facility: HARRIS
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: CHRIS HAYES
HQ OPS Officer: VINCE KLCO
Notification Date: 12/20/2012
Notification Time: 09:22 [ET]
Event Date: 12/20/2012
Event Time: 07:35 [EST]
Last Update Date: 12/20/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
BRIAN BONSER (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

LOSS OF ASSESSMENT CAPABILITY - RADIATION MONITORS INOPERABLE FOR PRE- PLANNED MAINTENANCE

"This is a non-emergency notification. At 0735 [EST] on December 20, 2012, radiation monitors RM-1CR-3561A, RM-1CR-3561B, RM-1CR-3561C and RM-1CR-3561D, Containment Ventilation Isolation Radiation Monitors, were declared inoperable for preplanned maintenance. These monitors are the only monitors credited in the EALs for monitoring elevated radiation levels inside containment for irradiated fuel.

"These radiation monitors are necessary for accident assessment and are credited for Emergency Action Level (EAL) classification in the Harris Nuclear Plant Emergency Plan. Inability to classify an EAL due to these monitors being out of service is considered a loss of accident assessment capability and is reportable per 10 CFR 50.72(b)(3)(xiii) as described in NUREG-1022, Rev. 2. This condition does not affect the health or safety of the public or the operation of the facility.

"The NRC Resident Inspector has been notified."

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Part 21 Event Number: 48612
Rep Org: EMERSON PROCESS MANAGEMENT
Licensee: FISHER DIVISION
Region: 3
City: MARSHALLTOWN State: IA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DENNIS SWANSON
HQ OPS Officer: STEVE SANDIN
Notification Date: 12/20/2012
Notification Time: 10:17 [ET]
Event Date: 11/27/2012
Event Time: [CST]
Last Update Date: 12/20/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
JAMNES CAMERON (R3DO)
BRIAN BONSER (R2DO)
PART 21 GROUP (EMAI)

Event Text

PART 21 REPORT INVOLVING PERFORMANCE OF NPT STAMPED CAVITROL III PLUGS AT CATAWBA NUCLEAR STATION

The following report was received via fax:

"Fisher Information Notice: FIN 2012-05
19 December, 2012

"Subject: Instrument & Valve Services Company (Columbia, South Carolina location), Job 400000838 for Duke Energy Carolinas, LLC Catawba Nuclear Station

"From:

Chad Engle
Nuclear Business Unit Director
Fisher Controls International LLC
205 South Center Street
Marshalltown, IA 50158
Fax: (641) 754-2854

"Equipment Affected By This Information Notice:

Items provided solely to Duke Energy Carolinas, LLC Catawba Nuclear Station per Instrument & Valve Services Company (Columbia; South Carolina location) Job 400000838 (Duke Energy Carolinas, LLC Catawba Nuclear Station PO 00161159). Specifically, the affected parts are two hard faced NPT stamped Cavitrol III plugs, piece serial numbers 400838-1-2A and 400838-1-3A (part number 24A3784X152).

"Purpose:

The purpose of this Fisher Information Notice (FIN) is to alert Duke Energy Carolinas, LLC Catawba Nuclear Station (Duke) that as of 27 November 2012, Fisher Controls International LLC (Fisher) became aware of the possibility of a situation which may affect the performance of the aforementioned equipment.

Out of an abundance of caution, Fisher is informing you of this situation in accordance with Section 21.21 (b) of 10CFR21.

"Applicability:

This FIN applies only to the subject equipment supplied by Fisher, as identified above, provided to Duke pursuant to PO 00161159 and affects no other materials provided to Duke or any other utility.

"Discussion:

It was determined by Fisher that two hard faced NPT stamped Cavitrol III Plugs, piece serial numbers 400838-1-2A and 400838-1-3A, were delivered to Duke after being repaired by a welder that, at the time of shipment, was not qualified in accordance with ASME B&PVC Section IX for the base metal thickness welded to affect the repair.

Upon discovery, Duke was notified and segregated the affected parts for return to the Instrument & Valve Services Company's Columbia, South Carolina location.

"Action Required:

Duke has returned the parts to Instrument & Valve Services Company's Columbia, South Carolina location. The parts have been labeled as nonconforming and have been segregated.

The welder involved has subsequently successfully completed a welding qualification test meeting the requirements of ASME B&PVC Section IX (such testing included the base metal thickness applicable to the affected equipment).

The welder qualifications and the nonconformance report will be submitted to the ANI and to Duke for review and approval. Fisher is completing a Corrective Action Report to prevent a similar situation from reoccurring in the future.

"10CFR21 Implications:

Fisher requests that the recipient of this notice review it and take appropriate action in accordance with 10CFR21.

If there are any technical questions or concerns, please contact:

Guy Scaggs
Quality Manager
Instrument & Valve Services Company
757 Old Clemson Road
Columbia, SC 29229
Fax: (803) 736-3105
Phone: (803) 736-3101
Guy.Scaggs@emerson.com"

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Power Reactor Event Number: 48615
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [ ] [2] [ ]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: FARA ORESHACK
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/20/2012
Notification Time: 14:07 [ET]
Event Date: 10/25/2012
Event Time: 21:08 [MST]
Last Update Date: 12/20/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
BLAIR SPITZBERG (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling

Event Text

60-DAY OPTIONAL TELEPHONIC NOTIFICATION FOR AN INVALID ACTUATION OF THE ESSENTIAL SPRAY POND SYSTEM

"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.

"This telephone notification is being made pursuant to the reporting requirements of 10 CFR 50.73(a)(2)(iv)(A) and 50.73(a)(1) to describe an invalid actuation of the Palo Verde Nuclear Generating Station (PVNGS) Unit 2 essential spray pond system (SP) which serves as the ultimate heat sink as described in 10 CFR 50.73(a)(2)(iv)(B)(9).

"On October 25, 2012, at approximately 2108, Mountain Standard Time, during refueling outage 2R17, Unit 2 experienced an invalid actuation of the train B essential spray pond system. Testing of the train B engineered safeguards features actuation system (ESFAS) was in progress. During the test, following activities to reset the train B containment spray actuation signal (CSAS), the procedure required a check of contact status on a relay contact which provides input to the train B Load Sequencer. The guidance required the use of a digital multi-meter to perform the contact status check. When the digital multi-meter test leads were landed and removed from the circuit, the train B Load Sequencer changed output modes which resulted in automatic starting of the train B essential chilled water system, essential cooling water system, essential fuel building air filtration unit and essential spray pond system.

"This was a partial actuation of the train B ESF equipment and all the affected equipment responded as designed. No equipment failures resulted from the event. The event was entered into the PVNGS corrective action program. The invalid actuation was caused by an incorrect testing methodology in the procedure instructions which resulted in the unintended interaction of the digital multi-meter and the digital train B Load Sequencer. The inadequate procedures will be revised to modify the testing methodology for verification of relay contact status."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 48616
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: RICK DAVIDSON
HQ OPS Officer: VINCE KLCO
Notification Date: 12/21/2012
Notification Time: 00:06 [ET]
Event Date: 12/20/2012
Event Time: 16:00 [CST]
Last Update Date: 12/21/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
KENNETH RIEMER (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

UNANALYZED CONDITION DUE TO AN IDENTIFIED DEGRADED FIRE BARRIER

"During a walkdown on December 20, 2012 at 1600 CST, two degraded Appendix R fire barriers (walls) were identified. These barriers separate the Torus Room (Fire Area IV)/ 'A' RHR Room (Fire Area I) and the Torus Room (Fire Area IV)/ 'B' RHR Room (Fire Area II). The walls separate Appendix R fire safe shutdown divisional equipment.

"A fire watch was established as a compensatory measure immediately following identification of the issue on December 20, 2012. The barrier affecting the 'B' RHR Room has been repaired on both sides. The barrier affecting the 'A' RHR Room has been repaired on the Torus Room side. The discovery of this non-compliance is being reported as an unanalyzed condition as defined by 10CFR50.72(b)(3)(ii)(B).

"The fire watch remains in place until verification of the completed repair is performed."

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Friday, December 21, 2012
Friday, December 21, 2012