Event Notification Report for March 07, 2013
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/06/2013 - 03/07/2013
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 48811
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DAVE BORGER
HQ OPS Officer: BILL HUFFMAN
Region: 1 State: PA
Unit: [] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DAVE BORGER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/07/2013
Notification Time: 03:36 [ET]
Event Date: 03/07/2013
Event Time: 01:35 [EST]
Last Update Date: 05/03/2013
Notification Time: 03:36 [ET]
Event Date: 03/07/2013
Event Time: 01:35 [EST]
Last Update Date: 05/03/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
BLAKE WELLING (R1DO)
BLAKE WELLING (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 99 | Power Operation | 99 | Power Operation |
HIGH PRESSURE COOLANT INJECTION DECLARED INOPERABLE
"At 0135 EST, Unit 2 High Pressure Coolant Injection (HPCI) system was declared inoperable, and LCO 3.5.1 entered, due to its turbine steam exhaust valve failing in the closed position during the quarterly valve exercising surveillance. The supply breaker tripped when the opening stroke was attempted. The valve was verified to have remained fully closed via the manual operator. HPCI will not automatically start with this valve closed.
"HPCI is a single train Emergency Core Cooling Safety [ECCS] system. This event results in the loss of an entire safety function which requires an 8 hour ENS notification in accordance with 10CFR50.72(b)(3)(v) and the guidance provided under NUREG-1022, rev. 2.
"There are no other ECCS systems presently out of service."
The licensee has notified the NRC Resident Inspector.
* * * RETRACTION FROM TODD CREASY TO PETE SNYDER ON 5/3/13 AT 1401 EDT * * *
"The reported condition, described above, was further evaluated by PPL Susquehanna, LLC (PPL). The following is additional information concerning the condition:
"The HPCI Turbine Exhaust valve (HV255F066): 1) is a DC motor operated valve with no design features which cause automatic valve actuation, 2) is manipulated by remote Operator action to open or close the valve, 3) is designed as a normally open valve to support the HPCI function, and 4) is manually closed for long-term containment isolation.
"When the HPCI turbine exhaust valve was stroked, the valve successfully closed; however, position indication was lost when attempting to re-open the valve. Troubleshooting identified a faulty relay contact that in conjunction with the operator repositioning the key lock switch from CLOSE to OPEN caused a direct short in the circuit.
"NUREG-1022, Revision 2, Section 3.2.7, provides the following example of a condition that is not reportable under 10 CFR 50.72(b)(3)(v): 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).
"When the failure of the HV255F066 occurred, HPCI was properly removed from service for planned quarterly valve exercising in accordance with an approved surveillance procedure and LCO 3.5.1.
"Since HV255F066 is a normally open valve, a failure to open does not impact the safety function to provide a flow path for HPCI exhaust since routine valve stroking or maintenance that might close the valve would not be conducted in an accident scenario where HPCI would be required to start and closure associated with long-term containment isolation would only occur after the HPCI function is complete (i.e., the failure to open was introduced by the testing activity and would not occur in a scenario in which the valve is required to perform its safety function to open). With regard to the long-term containment isolation function, the faulty relay contact failed in a manner that prevented the valve from opening but did not prevent the valve from closing. Based on closure of the valve during the test, there was no pre-existing operability issue associated with its safety function to close. Furthermore, even without credit for HV255F066, the containment isolation safety function would be maintained by Check Valve 255F049 and Drain Isolation Valve 255F013.
"Based on the above additional information, PPL is retracting this report. Susquehanna was in a planned evolution and did not discover a condition that could have prevented performing a safety function."
The licensee will notify the NRC Resident Inspector. Notified R1DO (Hunegs).
"At 0135 EST, Unit 2 High Pressure Coolant Injection (HPCI) system was declared inoperable, and LCO 3.5.1 entered, due to its turbine steam exhaust valve failing in the closed position during the quarterly valve exercising surveillance. The supply breaker tripped when the opening stroke was attempted. The valve was verified to have remained fully closed via the manual operator. HPCI will not automatically start with this valve closed.
"HPCI is a single train Emergency Core Cooling Safety [ECCS] system. This event results in the loss of an entire safety function which requires an 8 hour ENS notification in accordance with 10CFR50.72(b)(3)(v) and the guidance provided under NUREG-1022, rev. 2.
"There are no other ECCS systems presently out of service."
The licensee has notified the NRC Resident Inspector.
* * * RETRACTION FROM TODD CREASY TO PETE SNYDER ON 5/3/13 AT 1401 EDT * * *
"The reported condition, described above, was further evaluated by PPL Susquehanna, LLC (PPL). The following is additional information concerning the condition:
"The HPCI Turbine Exhaust valve (HV255F066): 1) is a DC motor operated valve with no design features which cause automatic valve actuation, 2) is manipulated by remote Operator action to open or close the valve, 3) is designed as a normally open valve to support the HPCI function, and 4) is manually closed for long-term containment isolation.
"When the HPCI turbine exhaust valve was stroked, the valve successfully closed; however, position indication was lost when attempting to re-open the valve. Troubleshooting identified a faulty relay contact that in conjunction with the operator repositioning the key lock switch from CLOSE to OPEN caused a direct short in the circuit.
"NUREG-1022, Revision 2, Section 3.2.7, provides the following example of a condition that is not reportable under 10 CFR 50.72(b)(3)(v): 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).
"When the failure of the HV255F066 occurred, HPCI was properly removed from service for planned quarterly valve exercising in accordance with an approved surveillance procedure and LCO 3.5.1.
"Since HV255F066 is a normally open valve, a failure to open does not impact the safety function to provide a flow path for HPCI exhaust since routine valve stroking or maintenance that might close the valve would not be conducted in an accident scenario where HPCI would be required to start and closure associated with long-term containment isolation would only occur after the HPCI function is complete (i.e., the failure to open was introduced by the testing activity and would not occur in a scenario in which the valve is required to perform its safety function to open). With regard to the long-term containment isolation function, the faulty relay contact failed in a manner that prevented the valve from opening but did not prevent the valve from closing. Based on closure of the valve during the test, there was no pre-existing operability issue associated with its safety function to close. Furthermore, even without credit for HV255F066, the containment isolation safety function would be maintained by Check Valve 255F049 and Drain Isolation Valve 255F013.
"Based on the above additional information, PPL is retracting this report. Susquehanna was in a planned evolution and did not discover a condition that could have prevented performing a safety function."
The licensee will notify the NRC Resident Inspector. Notified R1DO (Hunegs).
Power Reactor
Event Number: 48812
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: DAN HUNT
HQ OPS Officer: PETE SNYDER
Region: 3 State: IL
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: DAN HUNT
HQ OPS Officer: PETE SNYDER
Notification Date: 03/07/2013
Notification Time: 11:52 [ET]
Event Date: 03/07/2013
Event Time: 07:56 [CST]
Last Update Date: 03/07/2013
Notification Time: 11:52 [ET]
Event Date: 03/07/2013
Event Time: 07:56 [CST]
Last Update Date: 03/07/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
NICK VALOS (R3DO)
NICK VALOS (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | A/R | Y | 97 | Power Operation | 0 | Hot Shutdown |
AUTOMATIC REACTOR SCRAM ON GENERATOR TRIP/TURBINE TRIP
"While operating at rated electrical power, a main generator trip and subsequent turbine trip resulted in a reactor scram. The cause of the generator trip is under investigation. All systems operated as expected with no complications. The plant is stable in Mode 3."
The licensee notified the NRC Resident Inspector and the State of Illinois.
"While operating at rated electrical power, a main generator trip and subsequent turbine trip resulted in a reactor scram. The cause of the generator trip is under investigation. All systems operated as expected with no complications. The plant is stable in Mode 3."
The licensee notified the NRC Resident Inspector and the State of Illinois.
Agreement State
Event Number: 48813
Rep Org: NJ DEQ RADIOACTIVE MATERIALS PRGM
Licensee: UNIVERSITY OF MEDICINE AND DENTISTRY
Region: 1
City: NEWARK State: NJ
County:
License #: NJ PI ID #450
Agreement: Y
Docket:
NRC Notified By: RICHARD PEROS
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: UNIVERSITY OF MEDICINE AND DENTISTRY
Region: 1
City: NEWARK State: NJ
County:
License #: NJ PI ID #450
Agreement: Y
Docket:
NRC Notified By: RICHARD PEROS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/08/2013
Notification Time: 12:54 [ET]
Event Date: 03/07/2013
Event Time: 00:00 [EST]
Last Update Date: 03/08/2013
Notification Time: 12:54 [ET]
Event Date: 03/07/2013
Event Time: 00:00 [EST]
Last Update Date: 03/08/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
BLAKE WELLING (R1DO)
FSME RESOURCES
BLAKE WELLING (R1DO)
FSME RESOURCES
AGREEMENT STATE REPORT - MEDICAL UNDERDOSE DUE TO EQUIPMENT FAILURE
"A patient was treated with a Varian GammaMed plus iX HDR unit on March 7, 2013. The prescription dose was 700 cGy per fraction for 2 fractions, with a prescription dose of 800 cGy for a third fraction. The first two fractions were delivered to the patient as planned, the first fraction on February 26, 2013 and the second on February 28, 2013. The third fraction was to be delivered via tandem and ovoid. The planned tandem dose of 613 cGy was successfully delivered, and the source returned to its shielded position. However, prior to delivery of the ovoid dose of 187 cGy, the HDR unit displayed an error message of 'Electronics Defective error.'
"The staff could not correct the error. The manufacturer was notified and a service technician arrived later in the day to correct the problem. The remaining portion of the fraction was cancelled for the day and re-scheduled. The fractionated dose delivered differed from the prescribed fraction by 23.37%.
"The Varian service technician arrived later in the day and replaced the unit's indexer board, cleaned the indexer belt, tested a spring for tightness and re-set the wheel on the belt. The unit then functioned properly."
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.
"A patient was treated with a Varian GammaMed plus iX HDR unit on March 7, 2013. The prescription dose was 700 cGy per fraction for 2 fractions, with a prescription dose of 800 cGy for a third fraction. The first two fractions were delivered to the patient as planned, the first fraction on February 26, 2013 and the second on February 28, 2013. The third fraction was to be delivered via tandem and ovoid. The planned tandem dose of 613 cGy was successfully delivered, and the source returned to its shielded position. However, prior to delivery of the ovoid dose of 187 cGy, the HDR unit displayed an error message of 'Electronics Defective error.'
"The staff could not correct the error. The manufacturer was notified and a service technician arrived later in the day to correct the problem. The remaining portion of the fraction was cancelled for the day and re-scheduled. The fractionated dose delivered differed from the prescribed fraction by 23.37%.
"The Varian service technician arrived later in the day and replaced the unit's indexer board, cleaned the indexer belt, tested a spring for tightness and re-set the wheel on the belt. The unit then functioned properly."
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.