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Event Notification Report for April 4, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/03/2006 - 04/04/2006

** EVENT NUMBERS **


42305 42461 42462 42468 42469

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 42305
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: MICHAEL POTTER
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/03/2006
Notification Time: 04:59 [ET]
Event Date: 02/02/2006
Event Time: 23:36 [EST]
Last Update Date: 04/03/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
RUDOLPH BERNHARD (R2)

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

HIGH PRESSURE COOLANT INJECTION (HPCI) SYSTEM INOPERABLE DUE TO ONE HPCI TURBINE EXHAUST VACUUM BREAKER ISOLATION VALVE FAILURE

"On February 2, 2006 at 23:36 [EST], during testing of the HPCI System per OPT-09.7, HPCI System Valve Operability Test, 1-E41-F079, Turbine Exhaust Vacuum Breaker valve, was given a close signal and failed in the intermediate position. The 1-E41-F079 is one of the two HPCI Turbine Exhaust Line Vacuum Breaker isolation valves. When 1-E41-F079 failed in the intermediate position, the HPCI system was considered inoperable. HPCI is a single-train, safety function system. Approximately two minutes later, the valve was reopened and HPCI was restored to operable status (1-E41-F079 remains inoperable).

"The cause of the 1-E41-F079 failing to stroke is being investigated and will be repaired."

HPCI will be inoperable after 1-E41-F079 is isolated for maintenance.

The licensee notified the NRC Resident Inspector.

****RETRACTION BY MARK TURKAL TO MACKINNON ON 04/03/06 AT 1516 EDT *****

"The purpose of this call is to retract the notification (Event Number 42305) made by the Brunswick Steam Electric Plant, Unit No. 1, Docket No. 50-325/License No. DPR-71. On February 3, 2006, at 0459 hours, the control room Shift Supervisor made a notification (Event Number 42305) 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 event was reported as the HPCI system inoperable due to the HPCI inboard turbine exhaust vacuum breaker isolation valve (1-E41-F079) failure during scheduled testing.

"Valve 1-E41-F079 is a motor-operated valve that is normally open when the HPCI system is in service. When the valve is closed, it prevents the HPCI turbine exhaust vacuum breakers from operating, and the HPCI system is considered to be inoperable. During the testing, performed under 0PT-09.7, "HPCI System Valve Operability Test," on February 2, 2006, operators observed a dual indication when attempting to stroke the valve 1-E41-F079 closed. An auxiliary operator observed that the thermal overloads on the breaker were not tripped and no overload annunciator was received. The valve was then reopened. During the time that 1-E41-F079 had dual indication until the valve was full open (i.e., 2336 to 2338 hours), the operators considered the HPCI system inoperable and the event to be an unplanned inoperability of the HPCI system.

"Further troubleshooting and evaluation of the valve performance indicates that the valve did not close sufficiently to adversely affect the HPCI system's ability to perform its safety function. Subsequent valve disassembly identified pitting corrosion of the stem. This problem results in increased torque requirements through the first approximately 20 percent of the valve travel as the valve strokes from open to closed. When operators attempted to stroke the valve closed on February 2, 2006, the valve closed less than 20 percent of its stroke when the "closed" torque switch stopped the actuator from further closing the valve. A documented engineering evaluation established that, with valve 1-E41-F079 stroked less than 50 percent closed, enough flow is provided through the valve to allow the vacuum breakers to operate and allow the HPCI system to perform its safety function. Therefore, during the stroking of 1-E41-F079 in accordance with 0PT-09.7 on September 2, 2006, it is reasonable to expect that the performance of the valve did not result in the loss of safety function of the HPCI system.

"NUREG-1022, Rev. 2, Section 3.2.7 lists types of events or conditions that are generally not reportable under 10 CFR 50.72(b)(3)(v) and 10 CFR 50.73 (a)(2)(v) criteria. The list of not-reportable conditions includes:

"Removal of a system or part of a system from service as part of a planned evolution for maintenance or surveillance testing when done in accordance with an approved procedure and the plant's TS (unless a condition is discovered that could have prevented the system from performing its function)

"The performance of 1-E41-F079 did result in the valve being declared inoperable for its PCIV isolation function. This condition resulted in the penetration being isolated under an equipment clearance, which closed the HPCI outboard turbine exhaust vacuum breaker isolation valve (1-E41-F075). Closure of 1-E41-F075 under the equipment clearance process did result in the inoperability of the HPCI system; however, this planned inoperability of the system for maintenance is not reportable (as discussed in NUREG-1022, Rev. 2, Section 3.2.7) and no condition was discovered that could have prevented the HPCI system from performing its safety function.


"Investigation of this condition and evaluation of other reportability considerations documented in the corrective action program in Action Request (AR) 183102. Carolina Power & Light Company, doing business as Progress Energy Carolina, Inc., has determined that this event does not meet the 10 CFR 50.72 or 10 CFR 50.73 reporting criteria and the notification for Event Number 42305 is retracted. The resident inspector has been notified. "

NRC R2DO (Tom Decker) notified.

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General Information or Other Event Number: 42461
Rep Org: WHITING CORPORATION
Licensee: WHITING CORPORATION
Region: 3
City: MONEE State: IL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MARK KWASNY
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/31/2006
Notification Time: 17:56 [ET]
Event Date: 03/30/2006
Event Time: [CST]
Last Update Date: 04/03/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
SONIA BURGESS (R3)
WILLIAM COOK (R1)
THOMAS DECKER (R2)
DALE POWERS (R4)
FRANK GILLESPIE (NRR)
OMID TABATABAI (NRR)

Event Text

PART 21 - CRANE OVERSTRESS CONDITIONS

The following is a summary of information provided by the manufacturer via email:

On March 30, 2006, as part of a crane design analyses and study, Whiting Corporation identified two overstress conditions. One is on the Girder End connection of a low head room bridge and one on a single fastener in a main hoist gear case application. It is recommended that the affected cranes at the facilities listed below be restricted to 50% capacity for the over stressed end connection and 50% or 85 % capacity for the suspected over-stressed bolt until such time as the fastener or end connection can be inspected and evaluated or replaced. The following list identifies the facilities where the bridges and trolleys are suspected to be affected by the Whiting Corporation.

Oyster Creek, Three Mile Island, Seabrook

Oconee, McGuire, Shearon Harris, St. Lucie, Catawba

D. C. Cook

Cooper, Waterford, Grand Gulf, San Onofre, Palo Verde, Columbia Generating Station

Whiting Corporation is attempting to contact the customers directly to notify them of this circumstance.


* * * PART 21 UPDATE - CRANE OVERSTRESS CONDITIONS VIA E-MAIL ON 04/03/06 AT 1800 EDT ENTERED BY MACKINNON* * *

The following is a summary update of information provided by the manufacturer via e-mail

Indian Point added.

R1DO (Finney), R2DO (Tom Decker), R3DO (Anne Marie Stone), R4DO (Linda Smith), NRR Part 21 (Omid Tabatabai) & NRR Part 21 (Jack Foster) notified via e-mail.

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Power Reactor Event Number: 42462
Facility: PALISADES
Region: 3 State: MI
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: CHRISTER DAHLGREN
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/31/2006
Notification Time: 20:14 [ET]
Event Date: 03/29/2006
Event Time: 12:15 [EST]
Last Update Date: 04/03/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
SONIA BURGESS (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 99 Power Operation 0 Refueling

Event Text

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO HPSI INOPERABILITY

"On 3/29/06 at 1215, the left train High Pressure Safety Injection [HPSI] Pump P-66B subcooling valve CV-3070 was declared inoperable due to valve failing to stroke. Technical Specification Limiting Condition for Operation 3.5.2 ECCS - Operating, Required Action B.1 requires HPSI train to be restored to operable status within 72 hours. This required action expires on 04/01/06 at 1215. It has been determined that it will not be possible to restore operability prior to the expiration of this action statement.

"A Technical Specification required shutdown to Primary Coolant system temperature < 325 degrees F will be initiated on March 31, 2006 at 2100. The site will then commence a planned refueling outage that was scheduled to begin on April 01, 2006."

The licensee notified the NRC Resident Inspector.

* * * * UPDATE from Dan Malone to MacKinnon on 04/03/06 at 1451 EDT * * * *

Event date changed from 03/28/06 to 03/29/06. NRC Resident Inspector notified by licensee.

R3DO (Anne Marie Stone) notified.

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Power Reactor Event Number: 42468
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [ ] [ ] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: STEVE SMITH
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/03/2006
Notification Time: 03:56 [ET]
Event Date: 04/02/2006
Event Time: 20:54 [MST]
Last Update Date: 04/03/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
DALE POWERS (R4)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

EMERGENCY DIESEL TRIP DURING TESTING

"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.

"On April 2, 2006 at approximately 20:54 Mountain Standard Time, Palo Verde Nuclear Generating Station Unit 3 experienced a valid Loss of Power (LOP) actuation on the Train 'B' 4.16 kV safety bus. The event occurred due to personnel error during performance of surveillance test 73ST-9DG02 (Class 1 E Diesel Generator and Integrated Safeguards Test Train B). EDG 'B' had been started In Emergency Mode per the surveillance test by opening the normal supply breaker to the associated 4.16 kV bus and initiating simulated Safety Injection Actuation System (SIAS) and Containment Isolation Actuation System (CIAS) signals. A subsequent portion of the surveillance test was in progress which demonstrates that the EDG 'test mode' trips are bypassed with the EDG operating in Emergency Mode. The step being performed was intended to simulate an Overcurrent (test mode) trip by installing a jumper at the Overcurrent relay. However the jumper was inadvertently installed at the Differential Current relay, which generated an 'Emergency Mode' trip of EDG 'B'. This resulted in the deenergization of the 4.16 kV bus. The operations staff entered Abnormal Operating Procedure (AOP) 40AO-9ZZ12 (Degraded Electrical) and reset EDG 'B'. Upon reset at approximately 21:26 MST, EDG 'B' automatically started in response to a valid Loss of Power (LOP) signal from the deenergized 4.16 kV bus. The EDG 'B' output breaker automatically closed to restore power to the Train 'B' 4.16 kV and equipment sequenced onto the 4.16 kV bus.

"Due to the loss of power on the Train 'B' 4.16 kV bus, the Train 'B' Control Room Essential Filtration System (CREFS) and Control Room Emergency Air Temperature Control System (CREATCS) were rendered inoperable and LCOs 3.7.11 Condition 'A' and 3.7.12 Condition 'A' were entered. Operability of Train 'B' CREFS and CREATCS was restored when the Train 'B' 4.16 kV bus was reenergized and these LCO Conditions were exited.

"Offsite power remained available to the Train 'A' 4.16 kV bus and EDG 'A' remained operable throughout the event. Shutdown Cooling was unaffected since it was being provided by the Train 'A' safety train, which was supplied by offsite power. The offsite electrical grid is stable.

"Palo Verde Unit 3 Is shutdown and in Mode 5 for its 12th refueling outage. No other ESF actuations occurred and none were required. There were no structures, systems, or components that were inoperable at the time of discovery that contributed to this condition. The event did not result in the release of radioactivity to the environment and did not adversely affect the safe operation of the plant or health and safety of the public.

"The NRC Resident Inspector has been notified of the ESF actuation and this ENS notification."

The site performed a work stand down to discuss this event and prevent recurrence.

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Hospital Event Number: 42469
Rep Org: INDIANA UNIVERSITY MEDICAL CENTER
Licensee: INDIANA UNIVERSITY MEDICAL CENTER
Region: 3
City: INDIANAPOLIS State: IN
County:
License #: 13-02752-03
Agreement: N
Docket:
NRC Notified By: JEFFREY MASON
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/03/2006
Notification Time: 12:56 [ET]
Event Date: 01/17/2005
Event Time: 12:00 [CST]
Last Update Date: 04/03/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
ANNE MARIE STONE (R3)
GREG MORELL (NMSS)

Event Text

MEDICAL EVENT INVOLVING DELIVERED DOSE LESS THAN THE PRESCRIBED DOSE

During a review of patient's records, the licensee identified a patient who received a delivered dose of 6,885 Centigray vice the prescribed dose of 8,196 Centigray using an ovoid applicator. The incident occurred on 1/17/05 and was discovered following a similar incident reported on 03/30/06 (see EN #42453). Both the referring physician and patient have been informed. There is indication or requirement for additional treatment at this time. The licensee discussed this incident with R3 (Gattone).

Page Last Reviewed/Updated Friday, March 30, 2012
Friday, March 30, 2012