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Event Notification Report for December 26, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/21/2017 - 12/26/2017

** EVENT NUMBERS **


53120 53134 53135 53137

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Agreement State Event Number: 53120
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 D. GORETZKI
HQ OPS Officer: JEFF HERRERA
Notification Date: 12/15/2017
Notification Time: 15:40 [ET]
Event Date: 12/14/2017
Event Time: 14:00 [MST]
Last Update Date: 12/15/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - PATIENT UNDERDOSE

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

"On December 13, 2017, at approximately [1345 CST], the Agency [Arizona Radiation Regulatory Agency] received notification from the licensee of a possible medical event involving Yttrium-90. The patient received approximately 60 percent of the prescribed dose. The Agency has requested additional information and continues to investigate the event."

Arizona First Notice: 17-017

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: 53134
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [ ] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: ALEX THORNBURG
HQ OPS Officer: STEVEN VITTO
Notification Date: 12/22/2017
Notification Time: 11:09 [ET]
Event Date: 10/23/2017
Event Time: 08:56 [CDT]
Last Update Date: 12/22/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
BILLY DICKSON (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Defueled 0 Defueled

Event Text

INVALID ACTUATION OF EMERGENCY DIESEL GENERATOR

"At 0856 [CDT] on October 23, 2017, during the Unit 2 refueling outage, with no fuel in the Reactor Vessel, an unexpected auto start of the Unit 2 Train B Emergency Diesel Generator (D6) occurred when construction electricians inadvertently bumped the plunger for relay 2Sl-20X while working in the relay rack. Relay 2Sl-20X is a slave relay that actuates a light on the control board, starts D6, and starts 22 Residual Heat Removal (RHR) pump on a Safety Injection signal. In this instance, the RHR pump did not start as its control switch was in pull-out. It is expected that the control board light lit for the brief time the relay plunger was depressed, but this could not be confirmed. The D6 actuation resulted in an unexpected annunciator for D6 EMERGENCY GENERATOR SI SIGNAL EMERGENCY START. Operators responded per the alarm response procedure, performed a walk down of running D6 and then performed a shutdown of D6. D6 started and functioned as expected.

"There was no impact on public health and safety.

"This event is being reported as a 60-day telephone notification in accordance with 10 CFR 50.73(a)(2)(iv)(A) as an invalid actuation of an emergency diesel generator."

The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 53135
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: ALEX THORNBURG
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 12/22/2017
Notification Time: 11:09 [ET]
Event Date: 10/25/2017
Event Time: 20:50 [CDT]
Last Update Date: 12/22/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
BILLY DICKSON (R3DO)

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 Defueled 0 Defueled

Event Text

INVALID ACTUATION OF COOLING WATER SYSTEM

"At 2050 [CDT] on October 25, 2017, during the Unit 2 refueling outage, with no fuel in the Reactor Vessel, control room operators found that Unit 1 Train B Containment Fan Coil Units (FCUs) had swapped from chilled water to cooling water (CL). Construction Electricians were installing a new relay 2Sl-22X when the plunger on adjacent relay 2Sl-23X was bumped, which caused the swap of the Unit 1 Containment Fan Coil Units (CFCUs) from chilled water to cooling water. Relay 2SI-23X is a slave relay that starts 22 Turbine Driven Auxiliary Feed Water Pump, illuminates blue lights on various control switches, closes MV-32159 Loop A/B CLG WTR HDR XOVR MV B, closes chilled water Isolation Valves to Unit 1 Train B, and closes chilled water Isolation Valves to Unit 2 Train B.

"This actuation was as expected. CL is a shared system and, upon a Safety Injection (SI) signal on either unit, the CL header splits into two trains and, as a result, the CL supply is isolated to the chillers that supply chilled water to both units' CFCUs. By design, CL is the safety related source of cooling to the CFCUs.

"22 Turbine Driven Auxiliary Feed Water Pump did not start as the unit was in 'No Mode' with the control switch for the pump in manual. MV-32159 did automatically close per design. Unit 2 Chilled Water was already isolated due to work in progress with the unit in 'No Mode.'

"There was no impact on public health and safety.

"This event is being reported as a 60-day telephone notification in accordance with 10 CFR 50.73(a)(2)(iv)(A) as an invalid actuation of a containment heat removal system (the FCUs were running, but were swapped to their safeguards source due to an invalid actuation of a relay)."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 53137
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: DANIEL HARTIGAN
HQ OPS Officer: DAVID AIRD
Notification Date: 12/23/2017
Notification Time: 05:00 [ET]
Event Date: 12/22/2017
Event Time: 23:48 [EST]
Last Update Date: 12/23/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
BILLY DICKSON (R3DO)

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 CORE SPRAY SYSTEM DECLARED INOPERABLE

"High Pressure Core Spray System was declared inoperable due to the discovery of a through-wall leak on the Minimum Flow line. Leak rate is 60 drops per minute from ASME Class 2 Piping. The leak has been isolated and the High Pressure [Core Spray] System has been placed in Secured Status.

"High Pressure Core Spray is considered a single train safety system. Inoperability of [the] High Pressure Core Spray System is considered an 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.

"This event is being reported in accordance with 10 CFR 50.72(b)(3)(v)(D).

"The NRC Senior Resident Inspector was notified."

Technical Specifications Limiting Condition for Operation 3.5.1 Condition B was entered, requiring restoration of the High Pressure Core Spray System in 14 days.

The licensee plans to notify State and Local Governments (Lake, Geauga, and Ashtabula Counties).

Page Last Reviewed/Updated Tuesday, December 26, 2017
Tuesday, December 26, 2017