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Event Notification Report for February 20, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/16/2018 - 02/20/2018

** EVENT NUMBERS **


53200 53215 53216 53217 53219

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Non-Agreement State Event Number: 53200
Rep Org: CENTRO DE RADIOTERAPIA
Licensee: CENTRO DE RADIOTERAPIA
Region: 1
City: HATO REY State: PR
County:
License #: 52-30937-01
Agreement: N
Docket:
NRC Notified By: LUIS RIVERA
HQ OPS Officer: ANDREW WAUGH
Notification Date: 02/08/2018
Notification Time: 14:47 [ET]
Event Date: 02/06/2018
Event Time: [EST]
Last Update Date: 02/08/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(b) - PATIENT INTERVENTION DAMAGE
Person (Organization):
RAY POWELL (R1DO)
DOUGLAS BOLLOCK (NMSS)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

SKIN REACTION RESULTING FROM RADIATION THERAPY

The following event was received from Auxilio Mutuo Radiation Therapy Center via phone:

A patient who had undergone three gynecological intracavitary brachytherapy procedures was noticed to have a skin reaction. The skin reaction was noticed on the third of the three treatments occurring on 1/24/2018. At this point, it was unclear if the skin reaction was related to the treatments. On 2/6/2018, the attending physician saw the patient and declared that the skin reaction was caused by the radiation treatments, because it had progressed to moist desquamation.

The prescribed dose was 400 cGy per fraction for 3 fractions for a total of 1,200 cGy to a depth of 5 cm.

This event is under further investigation.

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: 53215
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [ ] [ ]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: JORGE LESTER
HQ OPS Officer: JEFF HERRERA
Notification Date: 02/16/2018
Notification Time: 02:50 [ET]
Event Date: 02/15/2018
Event Time: 21:53 [MST]
Last Update Date: 02/16/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
GREG WERNER (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP DUE TO LOW DEPARTURE FROM NUCLEATE BOILING SIGNAL

"The following event description is based on information currently available. If through subsequent reviews of this event additional information is identified that is pertinent to this event or alters the information being provided at this time a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73.

"On February 15, 2018, at approximately 2153 Mountain Standard Time (MST), the Palo Verde Generating Station (PVGS) Unit 1 Control Room received Reactor Protection System alarms for Low Departure from Nucleate Boiling Ratio and an automatic reactor trip occurred. Prior to the reactor trip, Unit 1 was operating normally at 100 percent power. Plant operators entered the emergency operations procedures and diagnosed an uncomplicated reactor trip but noted that Reactor Coolant Pumps 1B and 2B were not running due to a loss of power. All CEAs [Control Element Assemblies] fully inserted into the core. Following the reactor trip, all nuclear instruments responded normally. No emergency classification was required per the PVGS Emergency Plan.

"The PVGS Unit 1 safety related electrical busses remained energized from normal offsite power during the event. The Unit 1 'B' Diesel Generator is currently removed from service for maintenance. Due to ongoing planned maintenance on NAN-X02, Startup Transformer 2, fast bus transfer for NAN-S02 (from NAN-S04) was blocked. This resulted in a loss of offsite power to NAN-S02 and NBN-S02. The offsite power grid is stable. Unit 1 is currently stable in Mode 3 with the reactor coolant system at normal operating temperature and pressure.

"The event did not result in any challenges to fission product barriers and there were no adverse safety consequences as a result of this event. The event did not adversely affect the safe operation of the plant or the health and safety of the public.

"The NRC Resident Inspector has been informed of the Unit 1 reactor trip."

* * * UPDATE ON 2/16/18 AT 1640 EST FROM DAVID HECKMAN TO DONG PARK * * *

"Unit 1 is stable in Mode 3 following an uncomplicated trip. Offsite power has been restored to non-safety related electrical busses. Troubleshooting continues to determine the cause of the event.

"During performance of the alarm response procedure, it was identified that the seismic monitoring (SM) system had been in alarm since the reactor trip and was incapable of performing its emergency plan function. Pursuant to 10 CFR 50.72(b)(3)(xiii), this condition constitutes a major loss of emergency assessment capability. Compensatory measures have been implemented in accordance with PVNGS procedures to provide alternative methods for HU2.1 event classification with the SM system out of service. Maintenance is currently in progress to restore SM system functionality."

The licensee notified the NRC Resident Inspector. Notified R4DO (Werner).

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Power Reactor Event Number: 53216
Facility: INDIAN POINT
Region: 1 State: NY
Unit: [ ] [3] [ ]
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: JOHN DIGNAM
HQ OPS Officer: JEFF HERRERA
Notification Date: 02/16/2018
Notification Time: 04:43 [ET]
Event Date: 02/16/2018
Event Time: 02:01 [EST]
Last Update Date: 02/16/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
FRED BOWER (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 A/R Y 100 Power Operation 0 Hot Standby

Event Text

AUTOMATIC TRIP DUE TO LOSS OF EXCITATION ON MAIN GENERATOR

"On February 16, 2018 at 02:01 EST Indian Point Unit 3 automatically tripped on a turbine trip due to a loss of main generator excitation. All control rods fully inserted and all plant equipment responded normally to the unit trip. This is reportable under 10 CFR 50.72(b)(2)(iv)(B).

"The auxiliary feedwater system actuated following the automatic trip as expected. This is reportable under 10 CFR 50.72(b)(3)(iv)(A). During the event offsite power remained available and stable. No primary or secondary reliefs lifted. The plant is stable, in Mode 3, at no load operating temperature and pressure. Decay heat removal is via the steam generators to the main condenser via the condenser steam dumps. No radiation was released.

"Indian Point Unit 2 was unaffected by this event and remains at 100 percent power.

"A post trip investigation is in progress.

"The licensee has notified the NRC Resident Inspector."

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Power Reactor Event Number: 53217
Facility: MCGUIRE
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BRIAN JETTON
HQ OPS Officer: DONG HWA PARK
Notification Date: 02/16/2018
Notification Time: 13:58 [ET]
Event Date: 02/16/2018
Event Time: 10:14 [EST]
Last Update Date: 02/16/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
OMAR LOPEZ (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP DURING SOLID STATE PROTECTION SYSTEM TESTING

"At 1014 [EST] hours on 2/16/18, with Unit 1 in Mode 1 at approximately 100 percent power, the reactor automatically tripped when the Reactor Trip Breakers opened during Train B Solid State Protection System (SSPS) testing. The trip was uncomplicated with all systems responding normally post-trip. Operations manually started the motor driven auxiliary feedwater
pumps. The turbine driven auxiliary feedwater pump (TDCAP) auto-started on low steam generator level. A Feedwater Isolation occurred as designed due to the Reactor Trip and Lo Tave condition. Operations stabilized the plant. Decay heat is being removed by the condenser. Unit 2 is not affected.

"Due to the Reactor Protection System actuation while critical, actuation of the TDCAP and motor driven auxiliary feedwater pumps along with the Feedwater Isolation, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B) and an 8 hour non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A).

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. "

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Power Reactor Event Number: 53219
Facility: LASALLE
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: TERRY MARTIN
HQ OPS Officer: JEFF HERRERA
Notification Date: 02/17/2018
Notification Time: 10:29 [ET]
Event Date: 02/17/2018
Event Time: 02:00 [CST]
Last Update Date: 02/17/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
AARON McCRAW (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 94 Power Operation 94 Power Operation

Event Text

DAMAGED BUS BAR IDENTIFIED POTENTIALLY AFFECTING HIGH PRESSURE CORE SPRAY

"This report is being made in accordance with 10 CFR 50.72(b)(3)(v)(D) for an event or condition that could have prevented fulfillment of a safety function needed to mitigate the consequences of an accident. While troubleshooting an issue with the Unit 1B Diesel Generator Oil Circulating pump, damage of a bus bar was identified at the breaker that supplies the Unit 1B Diesel Generator Auxiliaries. One of the loads fed from this breaker is the Division 3 DC Battery Charger. It has been determined that the degradation of the bus bar may have prevented the Division 3 DC Battery Charger from performing its function which could have prevented the High Pressure Core Spray System (HPCS) from performing its design safety function. Since HPCS is a single train safety system, it has been determined that this failure could potentially affect the safety function of this system, and is reportable as an 8 hour notification."

The NRC Resident Inspector has been notified.

Page Last Reviewed/Updated Tuesday, February 20, 2018
Tuesday, February 20, 2018