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Event Notification Report for April 27, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/26/2016 - 04/27/2016

** EVENT NUMBERS **


51788 51868 51870 51882 51885 51886

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Part 21 Event Number: 51788
Rep Org: ANVIL ENGINEERING PIPE SUPPORT
Licensee: ANVIL ENGINEERING PIPE SUPPORT
Region: 1
City: NORTH KINGSTOWN State: RI
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MARK R. WARD
HQ OPS Officer: DONG HWA PARK
Notification Date: 03/14/2016
Notification Time: 14:07 [ET]
Event Date: 10/01/2015
Event Time: [EDT]
Last Update Date: 04/26/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
JAMES NOGGLE (R1DO)
PART 21/50.55 REACT (EMAI)

Event Text

PART 21 - HYDRAULIC SNUBBER SEAL MATERIAL DEVIATION INTERIM REPORT

"Anvil Engineered Pipe Supports (EPS) supplied 14 Fig. 200N Configuration 'A' style hydraulic snubbers to the Exelon owned and operated Peach Bottom Atomic Power Station (PBAPS) in 2013. During the course of routine refueling outage activities in October 2015, it was discovered that 9 of these 14 snubbers had no hydraulic fluid in the reservoir. The cause of the hydraulic fluid loss was premature aging of the reservoir piston seal due to vibration induced frictional heat. Subsequent laboratory testing of both replacement and degraded seal material by Exelon Power Labs suggested that a material substitution had been made from the Anvil approved Ethylene Propylene (EP) compound to a different grade of EP rubber.

"On February 17, 2016, Anvil determined that a material substitution was made by the seal vendor. A machined seal that was fabricated by the manufacturer was substituted for a seal molded with the approved Anvil compound. Prior to its installation in Fig. 200N/201N Configuration 'A' hydraulic snubbers, the machined seal compound was not tested to establish a service life for the compound.

"Anvil has bounded the extent of condition to 4 specific seal batches of 4" and 5" Fig. 200N/201N Configuration 'A' reservoir piston seals provided after January 1, 2013. Based on its Part 21 investigation, Anvil has yet to determine that a specific defect exists, based on the demonstrated operability of the snubbers at PBAPS despite severe service conditions beyond their published operational limits, and the compatibility of the EP base polymer with Anvil hydraulic fluids.

"Anvil is conducting a test campaign to approve and establish a service life for the machined seal compound. This testing will either qualify the machined compound for use at currently published Anvil service conditions (157 degrees F for 25 years with a total lifetime dose not to exceed 2e8 rads), or establish a reduced service life for the snubbers in which a material substitution was made. This testing is being conducted on an assembled reservoir with the substitute machined compound. It will include irradiation of the reservoir to 6.4e7 rads, accelerated temperature aging, and a final radiation exposure to bring the cumulative dose to 2e8 rads. As of 3/14/16, the reservoir specimen had been irradiated to 6.4e7 rads with no effect on the seal.

"Anvil expects to have this testing complete by May 1, 2016, with a formal evaluation to follow. PBAPS has been notified of the material substitution, and a full accounting of the affected snubbers by serial number, PO number, site, and utility is being assembled. Anvil will notify affected sites when the testing and equivalency evaluation is complete.

"Please feel free to contact me if you have any questions or require any additional information.

"Sincerely,
Mark R Ward
Operations Manager
Anvil Engineered Pipe Supports
160 Frenchtown Road
North Kingstown, Rl, 02852"

* * * UPDATE ON 4/26/2016 AT 12:25 EDT FROM MARK WARD (VIA FAX) TO BETHANY CECERE * * *

The following is a summary of information received from Anvil EPS:

Anvil performed qualification testing of the machined compound with satisfactory results. The machined compound is now qualified for a service life equivalent to the published service life of the molded compound when used as a reservoir piston seal for the Fig. 200N/201N Configuration "A". Anvil has determined that a specific defect does not exist and no action by licensees is needed. Fifty-nine (59) total snubbers were shipped to NRC licensees (Farley, Peach Bottom, Oconee, ANO, and Diablo Canyon); Anvil will advise sites.

Notified R1DO (Dwyer), R2DO (Ehrhardt), R4DO (Groom) and NRR Part 21 Group.

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Agreement State Event Number: 51868
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: UNIVERSITY MEDICAL CENTER CORPORATION
Region: 4
City: TUCSON State: AZ
County:
License #: AZ 10-044
Agreement: Y
Docket:
NRC Notified By: BRIAN GORETZKI
HQ OPS Officer: JEFF HERRERA
Notification Date: 04/18/2016
Notification Time: 18:02 [ET]
Event Date: 04/18/2016
Event Time: 14:00 [MST]
Last Update Date: 04/18/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE - POSSIBLE PATIENT UNDERDOSAGE OF YTTRIUM-90

The following report was received from the Arizona Radiation Regulatory Agency via email:

"On April 12, 2016, at approximately [1630 MST], the Agency [Arizona Radiation Regulatory Agency] received notification from the licensee of a possible medical event involving Yttrium-90. The patient received approximately 3 [percent] of the prescribed dose. The Agency [Arizona Radiation Regulatory Agency] has requested additional information and continues to investigate the event.

"The U.S. NRC and Governor's office are being notified of this event."

Arizona incident #: 16-004

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.

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Agreement State Event Number: 51870
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: DIGNITY HEALTH / ST JOSEPH'S MEDICAL CENTER
Region: 4
City: PHOENIX State: AZ
County:
License #: AZ 07-024
Agreement: Y
Docket:
NRC Notified By: BRIAN GORETZKI
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/19/2016
Notification Time: 17:48 [ET]
Event Date: 04/13/2016
Event Time: [MST]
Last Update Date: 04/19/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HEATHER GEPFORD (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following report was received via e-mail:

"On April 15, 2016, at approximately 1930 [MST], the [Arizona Radiation Regulatory] Agency received notification from the licensee of a possible medical event involving Sir-Spheres (Yttrium-90) that occurred on April 13, 2016. The prescribed dose was 0.95 GBq and the administered dose was 0.74 GBq, which is 77.8 percent of the prescribed dose. The [Arizona Radiation Regulatory] Agency has requested additional information and continues to investigate the event.

"The U.S. NRC and Governor's office are being notified of this event."

First Notice: 16-005

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.

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Power Reactor Event Number: 51882
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: ARIC HARRIS
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/26/2016
Notification Time: 01:54 [ET]
Event Date: 04/25/2016
Event Time: 21:17 [CDT]
Last Update Date: 04/26/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JEREMY GROOM (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

Event Text

HIGH PRESSURE COOLANT INJECTION SYSTEM DECLARED INOPERABLE

"8-hour report due to HPCI inoperability.

"At approximately 2109 [CDT] on 04/25/16, a licensed operator performing a control room panel walkdown noted the green light for HPCI Auxiliary Oil Pump (AOP) was not illuminated. The bulb was replaced and the replacement bulb did not illuminate. A non-licensed operator was dispatched to the local 250VDC starter rack. Both the green and red power indicating lights on the starter rack were found extinguished. An attempt was made to start the AOP with the control switch. The pump did not start. The AOP is required to start in order to open the steam admission valves for the HPCI turbine.

"HPCI was declared inoperable at time 2117 [CDT], resulting in entry into Tech Spec LCO 3.5.1 Condition C - HPCI System Inoperable. Required Actions for Condition C are to verify by administrative means RCIC System is operable within 1 hour and restore HPCI System to operable status within 14 days. RCIC was verified operable by administrative means concurrent with HPCl declaration.

"Troubleshooting activities for HPCI are being planned.

"HPCI is a single train system. This report is submitted as a condition that at time of discovery could prevent the fulfillment of the safety function of an SSC [Structures, Systems, and Components] needed to mitigate the consequences of an accident."

The licensee informed the NRC Resident Inspector.

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Power Reactor Event Number: 51885
Facility: WATTS BAR
Region: 2 State: TN
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN TUITE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 04/27/2016
Notification Time: 00:01 [ET]
Event Date: 04/26/2016
Event Time: 22:13 [EDT]
Last Update Date: 04/27/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
FRANK EHRHARDT (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N N 0 Hot Shutdown 0 Hot Shutdown

Event Text

ALERT AND NOTIFICATION SYSTEM FEEDBACK SYSTEM INOPERABLE

"On April 26, 2016 at 2213 EDT, Watts Bar Nuclear Plant authorized notification of State agencies for the partial loss of the WBN Alert and Notification System (ANS) feedback system. The ANS feedback system provides monitoring capability of the off-site sirens surrounding the facility in the event of a plant Emergency. Without the feedback system in service, sirens may be activated remotely from State and local facilities but verification of successful activation is impaired. State agencies were notified to evaluate if other methods of alerting the public were warranted.

"No compensatory methods are required for this failure, as the ANS activation feedback systems remain fully functional at the State and local facilities.

"The cause for the loss of the ANS feedback system is under investigation.

"This is being reported under 10 CFR 50.72(b)(2)(xi) and 10 CFR 50.72(b)(3)(xiii).

"The NRC Senior Resident has been notified."

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Power Reactor Event Number: 51886
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: ARIC HARRIS
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 04/27/2016
Notification Time: 01:17 [ET]
Event Date: 04/26/2016
Event Time: 17:54 [CDT]
Last Update Date: 04/27/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JEREMY GROOM (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

Event Text

HIGH PRESSURE COOLANT INJECTION SYSTEM DECLARED INOPERABLE

"At 1736 [CDT] on 26 April 2016, a licensed operator performing a control room panel walkdown noted the green standby light for the HPCI [High Pressure Coolant Injection] Auxiliary Oil Pump (AOP) was not illuminated. The bulb was replaced and the replacement bulb did not illuminate. A non-licensed operator (NLO) was dispatched to the local 250VDC starter rack. The NLO discovered the green standby light on the 250VDC starter rack had failed. An attempt was made to start the AOP with the control switch. The pump did not start. The AOP is required to start in order to open the steam admission valves for the HPCI turbine.

"HPCI was declared inoperable at time 1754 [CDT] on 26 April 2016. Tech Spec LCO Conditions were entered and required actions completed.

"HPCI is a single train system. This report is submitted as a condition that at time of discovery could prevent the fulfillment of the safety function of an SSC [Structure, System, and Component] needed to mitigate the consequences of an accident.

"A similar condition was discovered on 25 April 2016 [see NRC Event #51882]. Corrective maintenance was performed and HPCI was declared operable following satisfactory completion of post work testing of the AOP.

"Initial investigation indicates that the fault which occurred on 26 April is not the same as that which occurred 25 April.

"Investigation is on going."

The licensee has notified the NRC Resident Inspector.

Page Last Reviewed/Updated Wednesday, April 27, 2016
Wednesday, April 27, 2016