Event Notification Report for November 09, 2012

RPS ACTUATION RESULTING FROM LOW REACTOR WATER LEVEL

"At approximately 04:20 hours on November 9, 2012, Susquehanna Steam Electric Station Unit Two reactor received a subsequent scram due to low reactor water level during recovery from the scram (EN# 48496) that occurred at approximately 01:18 hours due to a loss of ICS (Integrated Control System; which controls the reactor feed and reactor recirculation systems). Reactor water level was +15 inches at the time of the trip. All isolations and initiations at this level occurred as expected. No steam relief valves opened. Pressure was controlled via turbine bypass valve operation. All safety systems operated as expected.

"The reactor is currently stable in Mode 3. Unit One continued power operation. The NRC Resident Inspectors were notified."

The licensee will notify the Pennsylvania Emergency Management Agency.

AGREEMENT STATE REPORT - PATIENT RECEIVED WRONG TREATMENT PLAN

The following report was received from the State of Florida via facsimile:

"On November 9, 2012, two patients with a different treatment plan (HDR Brachytherapy) were scheduled on the same day, patient 2 received patient 1 treatment plan. [The] error [was] found during mid treatment and stopped. Oncologist and patient informed, treatment continued under original plan, expect no adverse effects to patient Primary care physician has not been informed as of 13 November 2012, 0800 hours. A private company Radio Physics Associates (TRP-73) performs procedures involving HDR at this hospital. Investigation assigned to [State of Florida Bureau of Radiation Control] Tampa Office. No further action will be taken on this incident.

"Isotope involved: Ir-192; Activity: 8.3 Ci"

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.

UNIT 2 MANUAL SCRAM DUE TO LOSS OF THE INTEGRATED CONTROL SYSTEM

"At approximately 0118 hours [EST] on November 9, 2012, Susquehanna Steam Electric Station Unit Two reactor was scrammed by plant operators due to a loss of ICS (Integrated Control System; which controls the reactor feed and reactor recirculation systems). The reactor operator placed the mode switch in shutdown when reactor water level reached +25 inches and lowering. All control rods inserted and both reactor recirculation pumps tripped at -38 inches. Reactor water level lowered to -52 inches causing Level 3 (+13 inches) and level 2 (-38 inches) isolations. HPCI and RCIC both automatically initiated. HPCI was overridden prior to injection and RCIC was utilized to restore reactor water level to the normal band. All isolations and initiations at this level occurred as expected. No steam relief valves opened. Pressure was controlled via turbine bypass valve operation. All safety systems operated as expected.

"The [Unit 2] reactor is currently stable in Mode 3. An investigation into the cause of the loss of ICS is underway.

"Unit One continued power operation [at 78% power].

"The NRC Resident Inspectors were notified. A press release will occur."

The licensee will inform the State of Pennsylvania.

Decay heat removal is being maintained through the main condenser. On-site electrical power is in the normal configuration.

UNANALYZED CONDITION - SYSTEM AS-FOUND CONDITION NOT FULLY DESCRIBED IN ISA

"As part of the ongoing GNF-A review of the Fuel Manufacturing Operation (FMO) Integrated Safety Analysis (ISA), an accident sequence associated with hydrogen piping in the laboratory area was being evaluated. As part of this evaluation, a configuration that had not been properly analyzed was identified. Based on a review of this as-found condition, it was determined at approximately 11 AM [EST] on November 9, 2012 that the system was not fully described in the ISA and resulted in a failure to demonstrate performance requirements were met.

"Hydrogen supply to the affected piping system has been isolated. Additional corrective actions and extent of condition are being evaluated.

"This event is being reported pursuant to the reporting requirements of 10CFR70 Appendix A (b)(1) within 24 hours of discovery."

The licensee determined the as-found condition is of minimal safety significance. The licensee will be notifying NRC Region 2, State, and local authorities.

AGREEMENT STATE REPORT - STUCK SHUTTER ON PROCESS GAUGE

The following information was received from the Louisiana Department of Environment Quality via facsimile:

"On 11/09/2012, the RSO for Phillips 66 called in a preliminary report about [stuck] shutters on fixed level gauges utilized in their processes in the chemical plant. There was no possible exposure to the plant workers because the gauges were still installed on a process [tank in a remote location] and the shutters remaining open was not a problem. . . . The gauges are Omart and Ronan Engineering devices. [A manufacturer service technician] was contacted to evaluate the source holders and determined which devices could be repaired and which ones needed to be replaced. All of the source holders, with the exception of two were able to be freed up for continual use. . . . Two source holders were damaged during the evaluation process. . . .These two sources in their holders will be replaced during the next turn-a-round to reduce down time. . . . The gauges have been in the elements for a prolonged period of time and the shutters malfunctioned due to corrosion in the mechanism of the source holder. All of the sources were evaluated and inspected . . .. The manufacturer's service tech stated that it appears the be from being in the elements. The manufacturer stated that they were looking into finding a modification to shield the shutter mechanism from the elements. The Louisiana Department of Environmental Quality considers this item closed and the records will be reviewed during the next inspection."

The gauges involved are:
1) Omart SHLG2-45
2) Omart SR 2
3) Ronan SA1-F37

Louisiana Incident Number T145023

PART 21 - BRACKETS USED PROXIMITY SWITCHES INSTALLED UPSIDE DOWN

"Equipment Affected By This Fisher Information Notice:

"This Fisher Information Notice (FIN) applies to equipment provided to Arizona Public Service Company-Palo Verde Nuclear Generating Station per Fisher Order Number 019-F10051845, Items 0001, 0002, 0004, and 0005 (Arizona Public Service PO# 500559374).

"The affected equipment Is:
"4 [inch] CL900 Fisher HPD valve assemblies with TopWorx C8-24521-E3 proximity switches.

"The equipment is identified by Fisher serial numbers 20417605, 20428975, 20428977, and 20428978 respectively and Arizona Public Service Company tag numbers 1JSGEUV0169, 2JSGEUV0169, 1JSGEUV0183, and 2JSGEUV0183.

"Purpose:

"The purpose of this FIN is to alert Arizona Public Service Company that as of 9 November, 2012, Fisher Controls International LLC (Fisher) became aware of a situation which may potentially affect the safety-related performance of the aforementioned equipment.

"Fisher is informing you of this circumstance in accordance with Section 21.21 (b) of 10 CFR 21.

"Applicability:

"This FIN applies only to the aforementioned equipment supplied by Fisher to Arizona Public Service Company- Palo Verde Nuclear Generating Station.

"Discussion:

"Arizona Public Service Company has determined that the brackets used to install the TopWorx switches were installed improperly by Fisher.

"Specifically, the mounting brackets for the switches were installed upside down. This orientation makes it impossible for the switches to operate properly and to perform their safety-related function.

"While the design used for these brackets was unique and constituted a first-time installation by Fisher, Fisher is in the process of performing a root cause analysis as well as investigating why the error was not detected prior to shipment. Fisher will implement a corrective action to prevent problems like this from reoccurring in the future.

"Additionally specific arrangements are being made with Arizona Public Service Company to correct the problem on the subject serial numbers, at Fisher's cost.

"Action Required:

"Fisher is currently working with Arizona Public Service Company to resolve the situation, including, the implementation of a bracket redesign and testing program to demonstrate the problem has been satisfactorily corrected.

"10 CFR 21 Implications:

"Fisher requests that the recipient of this notice review it and take appropriate action in accordance with 10 CFR 21.

"If there are any technical questions or concerns, please contact:
"George Baitinger;
Manager, Quality;
Fisher Controls International LLC;
205 South Center Street Marshalltown, IA 50158;
Fax: (641) 754-2854, Phone: (641) 745-2026."

* * * UPDATE AT 1634 EDT ON 4/30/2013 FROM CHAD ENGLE TO MARK ABRAMOVITZ * * *

The following information was received via fax:

"After the switches were properly reinstalled it was discovered that due to potential rotation of the valve stem connector when operating the hand wheel, the target magnets could, in some cases, rotate beyond the gap required for switch functionality. This additional discovery is the reason for the issue of this supplemental FIN.

"Fisher is currently working with TopWorx and APS/PVNGS [Arizona Public Service / Palo Verde Nuclear Generating Station] to develop a bracket redesign with adequate guiding which will constrain the magnet/switch gap to within acceptable criteria."

Notified the R4DO (Haire), R3DO (Duncan) and Part 21 Group (via e-mail).