Event Notification Report for February 27, 2007

FIRE INSIDE THE UNIT 3 TURBINE AREA LOAD CENTER

At 0941 the licensee declared an unusual event at the site due to a fire in the protected area not extinguished in less than 15 minutes (EAL HU-6). The fire is located in the Unit 3 Turbine Area Load Center cubicle. The fire has affected Unit 3 bus duct cooling so the licensee is currently reducing power. The fire is currently out but the licensee is assessing conditions in the area. The licensee will do a thorough analysis of the affected load center to determine the extent of damage before officially exiting the unusual event.

All emergency diesel generators and emergency core cooling systems are fully-operable and available if needed.

The licensee has notified the NRC Resident Inspector.


* * * UPDATE ON 02/27/07 AT 1147 EST BY ADAM FRAIN TO MACKINNON * * *

Unusual Event exited at 1137 EST. R1DO (Rogge), NRR EO (M.J. Ross-Lee), IRD Manager (T. Blount), FEMA (Fuller) and DHS SWO (Haselton) notified.

CHILLER COPPER SLEEVE CRACKS LEADING TO SLOW REFRIGERENT DISCHARGE

Manufacturer provided the following information via facsimile:

Carrier Corporation provided the following information of a potentially reportable condition regarding a Compressor and Bearing Discharge Temperature Sensor, Carrier Part #17FA999-1200-381 supplied by Carrier Corporation's Replacement Components Division to PSE&G Nuclear, LLC for use at Hope Creek Nuclear Station.

"Nature of the defect or failure to comply and the safety hazard which is created or could be created by such defect or failure to comply.

"The operative portion of the Sensor is encased in a copper sleeve 1 1/2 inch in length and 1/4 inch in diameter which is soldered to a brass fitting, which fitting couples the Sensor to the chiller to be monitored. PSE&G notified Carrier of four (4) separate instances where a crack occurred in the Sensor's copper sleeve. This crack did not affect the Sensor's ability to function and the Sensors did not cease to function. However, the crack in the Sensor's copper sleeve did result in a leak of refrigerant from the compressor of the chiller to which the Sensor was coupled. Three (3) of these four (4) instances were noted on chillers with safety-related applications, while the fourth was noted on a chiller dedicated to a non-safety application.

"PSE&G noticed the fast refrigerant leak during a routine, visual equipment inspection. As a result of this discovery, the Sensor was replaced, but a similar refrigerant leak was noticed approximately three (3) months thereafter. At approximately the same time, during pressure testing of another safety-related chiller, PSE&G noticed a similar refrigerant leak.

"Safety Hazard which could be created by such a defect: While the refrigerant leak appeared to have been a slow process occurring over some period of time, had that refrigerant leak continued uncorrected, the result would have been a loss of enough refrigerant such that the chiller would be automatically shut down by a separate safety feature.

Since mid- 2001 Carrier has sold the sensor to the following facilities:

NRC Region 1: Limerick Generating Station, PSE&G (Hope Creek Generating Station, Salem Generating Station)

NRC Region 2: Catawba Nuclear Station, McGuire Nuclear Station

NRC Region 3: Braidwood Station, Perry Nuclear Power Plant

NRC Region 4: San Onofre Nuclear Generating Station, Waterford 3 Steam Electric Station

* * * UPDATE ON 8/23/07 AT 1424 FROM IWACHIW TO SNYDER * * *

Manufacturer provided the following information via facsimile:

"In response to the notice of a potential defect or failure to comply received from PSE&G, along with a report of various analysis conducted by PSE&G, Carrier convened its 'Nuclear Defect Review Board' (NDRB) to review and respond to PSE&G's notice and report.

"As part of its review, Carrier's NDRB requested various additional information from PSE&G regarding the Sensor's alleged defect or failure to comply experienced by PSE&G, as well as its use and operation of the Sensor and the chillers utilizing the Sensor. The chiller use and operation data provided by FSE&O showed that the chiller was run under such an extremely light cooling capacity that Carrier has no reference test data or experience available. As a result, Carrier cannot accurately predict the effects of this low cooling capacity on the operation of the Sensor.

"Carrier's NDRB also reviewed Carrier's current process of brazing the Sensor's copper sleeve, as compared to the brazing process utilized when the Sensor was first offered for sale approximately 30 years ago. Carrier's NDRB commissioned testing by a third party firm to determine if changes in the brazing process had any impact on the hardness or grain size of the Sensor's copper sleeve. This testing determined that there was no significant difference in the hardness of the Sensor's copper sleeve between a sample using the original brazing method, another sample using the current brazing method and a third sample using an alternate brazing method not previously or currently in use in connection with the Sensor. In addition, the firm indicated that it is typical that a lack of significant difference in hardness will also be an indicator of a lack of significant difference in grain size.

"Carrier's third party test results showing no change in hardness or grain size, PSE&G's operation of the associated chiller at an extremely light cooling capacity and the fact that the PSE&G failures were very isolated occurrences have convinced Carrier's NDRB that the cause of the potential defect or failure to comply was other than a defect inherent in the Sensor. Rather, Carrier's NDRB believes that the potential defect or failure to comply resulted from a cause or causes external to the Sensor.

"Carrier plans to work with PSE&G over the next sixty (60) days to explore these possible external causes and to take corrective actions, as may be necessary, to limit the effects of these external causes on the Sensor and/or to modify the Sensor to better operate in the presence of these external causes.

"In addition to the above actions, on June 8, 2007, Carrier personnel made a visit to PSE&G to collect vibration data at the point of failure. The data collected and analyzed showed no abnormalities that would cause cracking of the sensor at the copper sleeve braze joint location.

"Conclusion:

"Carrier is unable, at this time, to determine the root cause of the defect.

"Post Evaluation Actions

"Upon completion of Carrier's evaluation, analysis and conclusions, Carrier's Nuclear Defect Review Board (NDRB) was reconvened. The NDRB determined that the supplier of the sensor would be asked to provide a modified design of the sensor to eliminate any future potential failures/defects that could result in sensor cracking and subsequent refrigerant leakage. The supplier has complied and provided a modified design of the sensor which has been approved by the NDRB.

"At the present time, the modified sensor is in production. Essentially, the modification involved complete elimination of the sensor's brazed joint. This improved design consists of a probe body manufactured from a single, solid piece of brass, thus eliminating the copper sleeve portion of the probe and the braze joint, from which there could be a possible leak path thru the sensor body. Additionally, the wall thickness of the body has been increased by approximately four times its original thickness. These changes will not impact the fit or function of the sensor. In addition, prior to production for sale, the modified sensor was tested, to determine if the heavier wall would have an impact on the sensors response time. There was little if any change in the sensor's response time. The modified sensor's body is made from the same brass material as the threaded portion of the previous two piece design. The form changes slightly due to the increased wall thickness.

"Any advice related to the defect or failure to comply about the facility activity, or basic component that has been, is being or will be given to purchasers or licensees.

"Effective July 30, 2007, any purchase orders (PO's) or requests for quotation (RFQ's) received by Carrier for the 17FAS99-1200-381 sensors will be of the modified design described above. Carrier will notify all utilities that may have inventory of the previous design that these sensors may still be used, but only in the Bearing Temperature application, not in the Compressor Discharge Temperature application. Carriers notice will also request the utilities to segregate all previous sensor designs and clearly label them 'For Bearing Temperature Sensor Use Only. Do Not Use As Replacement for Compressor Discharge Temperature Sensor'."

Notified R1DO (Dwyer), R2DO (Payne), R3DO (Lara), R4DO (Clark) and NRR (Hodge and Thorp).

PLANNED MAINTENANCE ON SPDS

"On February 28, 2007, the Safety Parameter Display System (SPDS) will be removed from service to perform planned maintenance to the system. The maintenance will improve the overall reliability of the system. The removal of SPDS from service for Hope Creek also affects the transmission of data via the Emergency Response Data System (ERDS). Appropriate compensatory measures will be in place while SPDS is out of service. The SPDS is expected to be returned to service in approximately 2 days."

The licensee notified the NRC Resident Inspector and will be notifying local officials.

* * * UPDATE AT 0330 ON 03/03/07 FROM T. FOWLER TO W. GOTT * * *

SPDS maintenance has been completed. The ERDS system has been returned to service, tested, and considered operational at 2100 on 03/02/07.

The licensee will notify the NRC Resident Inspector.

Notified R1DO (J. Rogge)

MEDICAL EVENT - TREATMENT TO WRONG PATIENT

Patient "A" was suppose to receive a non-nuclear stress treatment by a technologist. Patient "B" was suppose to receive a nuclear treatment by a technologist. Patient "B" did not show up for the scheduled appointment. The technologist mistakenly gave patient "A" an injection (0.67 ml) of Tc-99m Cardolite (15 millicuries), which was suppose to go to patient "B". The attending physician notified patient "A" of this error, and deemed no corrective action to the patient was necessary. The error was determined to be that the technologist did not follow procedures, which is to verify patient name. As a corrective measure, the technologist was provided additional instruction in this matter.

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 FROM HASSIEN TO KNOKE AT 11:50 ON 03/05/07 ***

The RSO called to retract this event stating that patient "A" did not reach the threshold of effective dose equivalent.

Notified R3DO (Orth) and FSME (G. Morell).

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO FAILED SURVEILLANCE TESTING

"Both Trains of Emergency Core Cooling System (ECCS) Pump Room Exhaust Air Cleanup System (PREACS) were declared inoperable at 1620 when dampers 2-HV-AOD-228-1 and -2, Safeguards Area Exhaust Bypass Dampers, failed surveillance testing. A ramp down was initiated at 1947 as required by Technical Specification 3.0.3.

"Temporary repairs to the dampers were completed at approximately 2125 and the ramp down was terminated."

Temporary repair was made to the bypass damper seating surface.

The licensee notified the NRC Resident Inspector.

REACTOR TRIP DURING THE PERFORMANCE OF A SURVEILLANCE

"On 2/27/2007 at 2333 CST a Reactor Trip occurred during performance of a surveillance procedure calibrating a Nuclear Power Range instrument. The Reactor trip resulted in an automatic Turbine Trip and actuation of the Auxiliary Feedwater System. No safeguards equipment was out of service at the time of the trip. Following the trip, a steam inlet valve on a Moisture Separator associated with the main turbine failed to close which resulted in RCS temperature decreasing to 537 degF. This valve was manually isolated and RCS temperature returned to normal 547 degF. Normal heat sink to the Main Condenser was available during the event. Investigation is continuing into the exact cause of the Reactor trip.

"This event is being reported under 10CFR50.72(b)(2)(iv)(B) for actuation of the Reactor Protection System and 10CFR50.72(b)(3)(iv)(A) for actuation of the Auxiliary Feedwater System."

All control rods fully inserted on the reactor trip. Decay heat is being removed by Auxiliary Feedwater feeding the steam generators, steaming to the main condenser.

The licensee notified the NRC Resident Inspector.

HIGH PRESSURE COOLANT INJECTION (HPCI) INOPERABILITY

"On February 27, 2007, at approximately 2200 hours, testing of the Unit 2 High Pressure Coolant Injection (HPCI) system was in progress in accordance with 0PT-09.2, HPCI System Operability Test following system maintenance. Soon after the HPCI turbine was started a high level alarm condition in the HPCI barometric condenser was experienced. Evidence suggests the most probable cause was due to failure of the 2-E41-F048, Condensate Pump Discharge Check Valve, to open. The adverse consequence of this check valve failing to open is inadequate cooling flow to the HPCI lube oil cooler. The HPCI turbine was removed from service per applicable plant procedures.

"At the time of discovery, the HPCI system was inoperable for scheduled maintenance. However, this equipment failure would have prevented the HPCI system from fulfilling its safety function. Limiting Condition for Operation (LCO) per Technical Specifications (TS) 3.5.1. 'ECCS - Operating' Condition D had been previously entered on 2/25/07 at 1500, which required maintaining the Reactor Core Isolation Cooling (RCIC) system operable and restoration of HPCI operability in 14 days.

All other ECCS systems are operable including RCIC. The LCO allowed outage time is due to expire on 3/11/07 at approximately 1500 hours.

The licensee notified the NRC Resident Inspector.


** UPDATE FROM TURKAL TO KNOKE AT 11:33 EDT ON 04/26/07 ***

"On February 28, 2007, at 0540 hours, the Control Room Supervisor made a notification (Event Number 43197) to the NRC Operations Center in accordance with 10 CFR 50.72(b)(3)(v)(D) (i.e., any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident). The notification was made as a result of an unexpected high level alarm condition for the High Pressure Coolant Injection (HPCI) system barometric condenser, which was received during the post-maintenance operability testing of the HPCI system. At the time of discovery, the HPCI system was inoperable; having been properly removed from service for planned maintenance. It was believed that check valve 2-E41-F048, which is in the discharge piping of the HPCI barometric condenser condensate pump, downstream of a connection from the HPCI lube oil cooler cooling water discharge line, did not open, as required, during the HPCI post maintenance operability run. With valve 2-E41-F048 closed, there is a potential for inadequate cooling flow for the HPCI lube oil and, as such, a potential that the HPCI system could be inoperable as a result.

"Basis for Retraction
Upon further review, it has been determined that the 2-E41-F048 functioned properly during the post-maintenance HPCI system operability testing. The valve was disassembled and inspected during the recent Unit 2 refueling outage and confirmed to be operating properly. As such, adequate HPCI lube oil cooling existed and HPCI could have fulfilled its intended safety function.

"Physical inspection of the HPCI lube oil cooler piping, during the Unit 2 refueling outage, revealed that the lube oil cooler outlet orifice was missing. The missing orifice can result in higher than design flows through the lube oil cooler and higher backpressure at the barometric condenser condensate pump discharge. The higher backpressure can affect the ability to pump down the barometric condenser vacuum tank. Additionally, during troubleshooting activities performed prior to the refueling outage, valve 2-E41-F058, which is in the discharge piping of the HPCl barometric condenser condensate pump, upstream of the connection from the HPCI lube oil cooler cooling water discharge line, showed evidence of sticking. Either of these conditions could have caused the barometric condenser high level alarm without affecting HPCI lube oil cooling. If the barometric condenser becomes completely full, a relief valve on the tank will lift and relieve water to the HPCI room sump. The room sump pump has adequate capacity to keep up with the maximum expected flow. Operability of the HPCI system will not be affected by this condition.

"The higher than design cooling water flow rate does not adversely affect the capability of the lube oil cooler to remove heat from HPCI system lube oil and, as such, does not affect HPCI operability. Additionally, physical inspection of the cooler during the refueling outage found no damage or erosion of the cooler internals, and the cooler was successfully pressure tested.

"The barometric condenser condensate pump, barometric condenser vacuum pump, and barometric condenser water level instrumentation are not required to support operability of the HPCI system.

"Investigation of this condition is documented in the corrective action program in Nuclear Condition Report (NCR) 223820.

"On this basis, the HPCI system was capable of performing its function to mitigate the consequences of an accident and the issue is not reportable under 10 CFR 50.72(b)(3)(v)(D).

"The NRC resident was notified of this retraction." Notified R2DO(Payne).


*** UPDATE FROM TURKAL TO KNOKE AT 09:30 EDT ON 06/04/09 ***

"On February 28, 2007, at 0540 hours, the Control Room Supervisor made a notification (EN 43197) to the NRC Operations Center in accordance with 10 CFR 50.72(b)(3)(v)(D), 'any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident'. The notification was made as a result of an unexpected high level alarm condition for the High Pressure Coolant Injection (HPCI) system barometric condenser, which was received during the post-maintenance operability testing of the HPCI system.

"Revised Basis for Retraction

"On April 26, 2007, EN 43197 was retracted. The basis for the retraction stated that the 2-E41-F048 functioned properly and adequate HPCI lube oil cooling existed. It also attributed the high level in the HPCI barometric condenser to either a missing lube oil cooler outlet orifice or potential sticking of valve 2-E41-F058 versus the originally believed malfunction of the 2-E41-F048 valve. In either case, the retraction stated that if the barometric condenser becomes completely full, a relief valve (2-E41-F018) on the tank will lift and relieve water to the HPCI room sump. The room sump pump has adequate capacity to keep up with the maximum expected flow. As such, operability of the HPCI system would not be affected by either a missing lube oil cooler outlet orifice or potential sticking of valve 2 -E41-F058.

"During the Unit 2 refueling outage, which began on February 28, 2009, it was discovered that the HPCI barometric condenser relief valve (2-E41-F018) had been assembled incorrectly and would not have functioned as described in the April 26, 2007 retraction of EN 43197. However, EN 43197 can be retracted without relying on proper operation of the relief valve. At the time of the event, the HPCI barometric condenser condensate pump, the HPCI barometric condenser vacuum pump, and the HPCI barometric condenser water level instrumentation were functioning properly and would have prevented condensate from reaching the HPCI turbine casing. On this basis, the HPCI system was capable of performing its function to mitigate the consequences of an accident and the issue is not reportable under 10 CFR 50.72(b)(3)(v)(D).

"The NRC Resident Inspector was notified of this revised retraction."

Notified R2DO (Mark Lesser)