Event Notification Report for August 15, 2013
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/14/2013 - 08/15/2013
EVENT NUMBERS
49285492864928749396
Power Reactor
Event Number: 49285
Facility: HATCH
Region: 2 State: GA
Unit: [] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: KENNY HUNTER
HQ OPS Officer: DONG HWA PARK
Region: 2 State: GA
Unit: [] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: KENNY HUNTER
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/15/2013
Notification Time: 16:47 [ET]
Event Date: 08/15/2013
Event Time: 16:10 [EDT]
Last Update Date: 08/15/2013
Notification Time: 16:47 [ET]
Event Date: 08/15/2013
Event Time: 16:10 [EDT]
Last Update Date: 08/15/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
RANDY MUSSER (R2DO)
RANDY MUSSER (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
A HOT SHORT IN THE RHR SHUTDOWN COOLING CONTROL CABLE COULD RESULT IN AN INTER-SYSTEM LOCA
"A condition was identified that resulted from an inter-cable circuit analysis as part of the safe shutdown analysis that identified a vulnerability associated with two Unit 2 valves with controls in Fire Area 2203. Specifically, during the postulated fire scenario, an inter-cable hot short could occur on the control cables for the RHR shutdown cooling suction valve 2E11-F008 valve and cause the valve to open in the event of a postulated fire in Fire Area 2203F which is in the vicinity of the Unit 2 remote shutdown panel. In addition, a spurious opening of RHR shutdown cooling suction valve 2E11-F009 valve could occur due to a hot short on the control cables. The fire is postulated while in Mode 1 which could cause both valves to open during power operation. This postulated event would expose the low pressure RHR-shutdown cooling suction line to normal operating pressures which would result in an inter-system LOCA.
"Immediate actions were taken to de-energize the valves in the 'closed' position which removed the vulnerability. When this condition was first discovered, the consequences of this postulated condition were evaluated and there was reasonable assurance that the condition did not represent an unanalyzed condition that significantly degrades/degraded plant safety. A review of the FSAR, design documents and regulatory requirements was performed to document the foundational logic for the engineering judgment to support the original conclusion that there was reasonable assurance that the inter-system LOCA did not represent an unanalyzed condition that significantly degraded plant safety and that this would not result in a loss of a safety function. Based on information learned in this review there was not sufficient information to make a conclusive determination. Since a conclusive determination cannot be made at this time and since there is some doubt regarding whether or not the report is needed, this report is being made in accordance with 10CFR50.72(b)(3)(ii)."
The licensee has notified the NRC Resident Inspector.
"A condition was identified that resulted from an inter-cable circuit analysis as part of the safe shutdown analysis that identified a vulnerability associated with two Unit 2 valves with controls in Fire Area 2203. Specifically, during the postulated fire scenario, an inter-cable hot short could occur on the control cables for the RHR shutdown cooling suction valve 2E11-F008 valve and cause the valve to open in the event of a postulated fire in Fire Area 2203F which is in the vicinity of the Unit 2 remote shutdown panel. In addition, a spurious opening of RHR shutdown cooling suction valve 2E11-F009 valve could occur due to a hot short on the control cables. The fire is postulated while in Mode 1 which could cause both valves to open during power operation. This postulated event would expose the low pressure RHR-shutdown cooling suction line to normal operating pressures which would result in an inter-system LOCA.
"Immediate actions were taken to de-energize the valves in the 'closed' position which removed the vulnerability. When this condition was first discovered, the consequences of this postulated condition were evaluated and there was reasonable assurance that the condition did not represent an unanalyzed condition that significantly degrades/degraded plant safety. A review of the FSAR, design documents and regulatory requirements was performed to document the foundational logic for the engineering judgment to support the original conclusion that there was reasonable assurance that the inter-system LOCA did not represent an unanalyzed condition that significantly degraded plant safety and that this would not result in a loss of a safety function. Based on information learned in this review there was not sufficient information to make a conclusive determination. Since a conclusive determination cannot be made at this time and since there is some doubt regarding whether or not the report is needed, this report is being made in accordance with 10CFR50.72(b)(3)(ii)."
The licensee has notified the NRC Resident Inspector.
Power Reactor
Event Number: 49286
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: KEN LEFFEL
HQ OPS Officer: DONG HWA PARK
Region: 3 State: IL
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: KEN LEFFEL
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/15/2013
Notification Time: 17:53 [ET]
Event Date: 08/15/2013
Event Time: 09:15 [CDT]
Last Update Date: 08/15/2013
Notification Time: 17:53 [ET]
Event Date: 08/15/2013
Event Time: 09:15 [CDT]
Last Update Date: 08/15/2013
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):
JOHN GIESSNER (R3DO)
JOHN GIESSNER (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 92 | Power Operation | 92 | Power Operation |
DIESEL GENERATOR DECLARED INOPERABLE DUE TO DAMPER FAILING TO OPEN
"During a run of the Division 3 Diesel Generator room ventilation fan to perform thermograph, it was identified that the damper (1VD01YC) that provides the flow path from the outside area into the ventilation room would not open when the fan was started. This renders the Division 3 Diesel Generator inoperable. High Pressure Core Spray was declared inoperable at 1420 hours [CDT], but remains available. This report is being made pursuant to 10CFR50.72(b)(3)(v)(D) as an event or condition that could have prevented fulfillment of a safety function needed to mitigate the consequences of an accident.
"The cause of the damper failing to open has not yet been determined. Troubleshooting is in progress to determine the cause and actions required to restore operability. The Division 1 and Division 2 Diesel Generators are operable."
The licensee is in a 14-day shutdown TS LCO.
The licensee has notified the NRC Resident Inspector.
"During a run of the Division 3 Diesel Generator room ventilation fan to perform thermograph, it was identified that the damper (1VD01YC) that provides the flow path from the outside area into the ventilation room would not open when the fan was started. This renders the Division 3 Diesel Generator inoperable. High Pressure Core Spray was declared inoperable at 1420 hours [CDT], but remains available. This report is being made pursuant to 10CFR50.72(b)(3)(v)(D) as an event or condition that could have prevented fulfillment of a safety function needed to mitigate the consequences of an accident.
"The cause of the damper failing to open has not yet been determined. Troubleshooting is in progress to determine the cause and actions required to restore operability. The Division 1 and Division 2 Diesel Generators are operable."
The licensee is in a 14-day shutdown TS LCO.
The licensee has notified the NRC Resident Inspector.
Power Reactor
Event Number: 49287
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DARRELL JOHNSON
HQ OPS Officer: HOWIE CROUCH
Region: 4 State: CA
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DARRELL JOHNSON
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/16/2013
Notification Time: 02:36 [ET]
Event Date: 08/15/2013
Event Time: 18:24 [PDT]
Last Update Date: 08/16/2013
Notification Time: 02:36 [ET]
Event Date: 08/15/2013
Event Time: 18:24 [PDT]
Last Update Date: 08/16/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
RAY KELLAR (R4DO)
RAY KELLAR (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
LOSS OF STARTUP POWER RESULTS IN VALID STARTS OF ALL THREE EMERGENCY DIESEL GENERATORS
"At 1824 PDT on August 15, 2013, Unit 1 experienced a loss of startup power due to a failure of Startup Transformer 1-1 load tap changer. This loss caused a valid auto-start signal to all three emergency diesel generators and they all started successfully. At 1921, all EDGs were shutdown and returned to standby per plant procedures."
As a result of the loss of startup power, power was also lost to site service buildings. ERDS was lost but compensatory measures are in place to transmit required data via the ENS line if required.
The plant is in a 72-hr. shutdown LCO action statement under T.S. 3.8.1 for the loss of one of three qualified circuits. The two other qualified circuits (vital power via auxiliary transformers and the EDGs) remain operable.
The licensee has notified the NRC Resident Inspector.
"At 1824 PDT on August 15, 2013, Unit 1 experienced a loss of startup power due to a failure of Startup Transformer 1-1 load tap changer. This loss caused a valid auto-start signal to all three emergency diesel generators and they all started successfully. At 1921, all EDGs were shutdown and returned to standby per plant procedures."
As a result of the loss of startup power, power was also lost to site service buildings. ERDS was lost but compensatory measures are in place to transmit required data via the ENS line if required.
The plant is in a 72-hr. shutdown LCO action statement under T.S. 3.8.1 for the loss of one of three qualified circuits. The two other qualified circuits (vital power via auxiliary transformers and the EDGs) remain operable.
The licensee has notified the NRC Resident Inspector.
Agreement State
Event Number: 49396
Rep Org: NEW YORK CITY BUREAU OF RAD HEALTH
Licensee: MONTEFIORE MEDICAL CENTER
Region: 1
City: NEW YORK State: NY
County:
License #: NOT PROVIDED
Agreement: Y
Docket:
NRC Notified By: TOBIAS LICKERMAN
HQ OPS Officer: HOWIE CROUCH
Licensee: MONTEFIORE MEDICAL CENTER
Region: 1
City: NEW YORK State: NY
County:
License #: NOT PROVIDED
Agreement: Y
Docket:
NRC Notified By: TOBIAS LICKERMAN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/30/2013
Notification Time: 15:37 [ET]
Event Date: 08/15/2013
Event Time: 00:00 [EDT]
Last Update Date: 09/30/2013
Notification Time: 15:37 [ET]
Event Date: 08/15/2013
Event Time: 00:00 [EDT]
Last Update Date: 09/30/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JUDY JOUSTRA (R1DO)
FSME EVENTS RESOURCE (EMAI)
JUDY JOUSTRA (R1DO)
FSME EVENTS RESOURCE (EMAI)
AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION OF Y-90
The following information was received from the City of New York via email:
"Incident: Due to the technical difficulties, physician could not deliver the full prescribed dose of Y-90.
"Radiation Dose evaluation: As per physician's medical judgment, the dose given to the patient was adequate for the treatment of this volume and tumors within the region.
"Health effects: Patient will be followed up to determine if an appropriate therapeutic result is achieved.
"Corrective Actions: Administered radiological agent was Y-90 SIRTex. RSO and administering physician have come to the conclusion to wait until the vial and related accessories reach background [radiation levels] in order to investigate this matter. It is unknown whether this was a human error or manufacturer defect.
"As per facility's report, as a precautionary measure, derma bond will be applied to the v-vial before administration of the dose in order to prevent any possibility of leakage."
The prescribed dose of Y-90 was 30 mCi; the delivered dose was 19.26 mCi. NYC Incident Report Identification Number: 75-2885-01
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.
The following information was received from the City of New York via email:
"Incident: Due to the technical difficulties, physician could not deliver the full prescribed dose of Y-90.
"Radiation Dose evaluation: As per physician's medical judgment, the dose given to the patient was adequate for the treatment of this volume and tumors within the region.
"Health effects: Patient will be followed up to determine if an appropriate therapeutic result is achieved.
"Corrective Actions: Administered radiological agent was Y-90 SIRTex. RSO and administering physician have come to the conclusion to wait until the vial and related accessories reach background [radiation levels] in order to investigate this matter. It is unknown whether this was a human error or manufacturer defect.
"As per facility's report, as a precautionary measure, derma bond will be applied to the v-vial before administration of the dose in order to prevent any possibility of leakage."
The prescribed dose of Y-90 was 30 mCi; the delivered dose was 19.26 mCi. NYC Incident Report Identification Number: 75-2885-01
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.