Event Notification Report for April 15, 2024
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/14/2024 - 04/15/2024
Part 21
Event Number: 57072
Rep Org: Engine Systems, Inc
Licensee: Fitzpatrick NPS
Region: 1
City: Oswego State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Dan Roberts
HQ OPS Officer: Ernest West
Licensee: Fitzpatrick NPS
Region: 1
City: Oswego State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Dan Roberts
HQ OPS Officer: Ernest West
Notification Date: 04/12/2024
Notification Time: 11:49 [ET]
Event Date: 02/22/2024
Event Time: 00:00 [EDT]
Last Update Date: 04/12/2024
Notification Time: 11:49 [ET]
Event Date: 02/22/2024
Event Time: 00:00 [EDT]
Last Update Date: 04/12/2024
Emergency Class: Non Emergency
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
Person (Organization):
Defrancisco, Anne (R1DO)
Part 21/50.55 Reactors, - (EMAIL)
Defrancisco, Anne (R1DO)
Part 21/50.55 Reactors, - (EMAIL)
EN Revision Imported Date: 4/15/2024
EN Revision Text: PART 21 - LEAKING CYLINDER LINER IN EMERGENCY DIESEL GENERATOR
The following is a summary of the information provided by Engine Systems Inc. (ESI) via facsimile:
An EMD (Brand Name: Electro-Motive Diesel) cylinder liner developed a jacket water leak following installation on an emergency diesel generator set at the James A. Fitzpatrick Nuclear Power Plant. The leak occurred at a brazed joint and was detected after post-installation engine testing. Had the leak gone undetected, jacket water may have accumulated in the combustion chamber, airbox, and/or lubricating oil which could have eventually led to failure of the emergency diesel generator set.
ESI was the supplier of the EMD cylinder liner (part number: 9318833, serial number: 20D6294). The EMD cylinder was a component of a Blade Power Pack Assembly, part number: 40124898, serial number: 20L0603
Corrective Actions:
ESI will revise the dedication package to include additional verifications to prevent reoccurrence. The revision will be implemented within 30 days. Fitzpatrick returned the power assembly to ESI for replacement and no further action is required from Fitzpatrick.
Affected Plants:
Fitzpatrick. No other sites known to be affected.
The name and address of the individuals reporting this information is:
John Kriesel
Engineering Manager
Engine Systems, Inc.;
175 Freight Rd.
Rocky Mount, NC 27804
Dan Roberts
Quality Manager
Engine Systems, Inc.;
175 Freight Rd.
Rocky Mount, NC 27804
EN Revision Text: PART 21 - LEAKING CYLINDER LINER IN EMERGENCY DIESEL GENERATOR
The following is a summary of the information provided by Engine Systems Inc. (ESI) via facsimile:
An EMD (Brand Name: Electro-Motive Diesel) cylinder liner developed a jacket water leak following installation on an emergency diesel generator set at the James A. Fitzpatrick Nuclear Power Plant. The leak occurred at a brazed joint and was detected after post-installation engine testing. Had the leak gone undetected, jacket water may have accumulated in the combustion chamber, airbox, and/or lubricating oil which could have eventually led to failure of the emergency diesel generator set.
ESI was the supplier of the EMD cylinder liner (part number: 9318833, serial number: 20D6294). The EMD cylinder was a component of a Blade Power Pack Assembly, part number: 40124898, serial number: 20L0603
Corrective Actions:
ESI will revise the dedication package to include additional verifications to prevent reoccurrence. The revision will be implemented within 30 days. Fitzpatrick returned the power assembly to ESI for replacement and no further action is required from Fitzpatrick.
Affected Plants:
Fitzpatrick. No other sites known to be affected.
The name and address of the individuals reporting this information is:
John Kriesel
Engineering Manager
Engine Systems, Inc.;
175 Freight Rd.
Rocky Mount, NC 27804
Dan Roberts
Quality Manager
Engine Systems, Inc.;
175 Freight Rd.
Rocky Mount, NC 27804
Power Reactor
Event Number: 57075
Facility: Beaver Valley
Region: 1 State: PA
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: James (Jake) Davis
HQ OPS Officer: Thomas Herrity
Region: 1 State: PA
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: James (Jake) Davis
HQ OPS Officer: Thomas Herrity
Notification Date: 04/13/2024
Notification Time: 03:55 [ET]
Event Date: 04/13/2024
Event Time: 00:35 [EDT]
Last Update Date: 04/13/2024
Notification Time: 03:55 [ET]
Event Date: 04/13/2024
Event Time: 00:35 [EDT]
Last Update Date: 04/13/2024
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
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical 50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
Defrancisco, Anne (R1DO)
Defrancisco, Anne (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | A/R | Y | 97 | Power Operation | 0 | Hot Standby |
EN Revision Imported Date: 4/15/2024
EN Revision Text: AUTOMATIC REACTOR TRIP
The following information was provided by the licensee via phone and email:
"At 0035 EDT on April 13, 2024, with Unit 1 at 97 percent power, the reactor automatically tripped due to 1 of 3 reactor coolant pump (RCP) low flow reactor trip [signal] associated with a loss of the 'A' and 'B' 4160 volt normal buses. Auxiliary feedwater and the 1-1 emergency diesel generator (EDG) automatically started on valid actuation signals. The 1-1 EDG sequenced on to supply all required loads per plant design. All control rods fully inserted and the trip was not complex with all systems responding normally post-trip. Operators have responded and stabilized the unit in Mode 3 [Hot Standby]. Decay heat is being removed by discharging steam to the main condenser via the condenser steam dump system with steam generators being supplied by the main feedwater system.
"Unit 2 is not affected by the event.
"Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B).
"Due to the valid actuations of auxiliary feedwater and the 1-1 EDG, this event is reportable in accordance with 10 CFR 50.72(b)(3)(iv)(A).
"There was no impact to the health and safety of the public or plant personnel. The NRC senior resident inspector has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
Power for the A-E Bus is on the 1-1 EDG. The D-F Bus is on offsite power. One electrical train of offsite power is down.
EN Revision Text: AUTOMATIC REACTOR TRIP
The following information was provided by the licensee via phone and email:
"At 0035 EDT on April 13, 2024, with Unit 1 at 97 percent power, the reactor automatically tripped due to 1 of 3 reactor coolant pump (RCP) low flow reactor trip [signal] associated with a loss of the 'A' and 'B' 4160 volt normal buses. Auxiliary feedwater and the 1-1 emergency diesel generator (EDG) automatically started on valid actuation signals. The 1-1 EDG sequenced on to supply all required loads per plant design. All control rods fully inserted and the trip was not complex with all systems responding normally post-trip. Operators have responded and stabilized the unit in Mode 3 [Hot Standby]. Decay heat is being removed by discharging steam to the main condenser via the condenser steam dump system with steam generators being supplied by the main feedwater system.
"Unit 2 is not affected by the event.
"Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B).
"Due to the valid actuations of auxiliary feedwater and the 1-1 EDG, this event is reportable in accordance with 10 CFR 50.72(b)(3)(iv)(A).
"There was no impact to the health and safety of the public or plant personnel. The NRC senior resident inspector has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
Power for the A-E Bus is on the 1-1 EDG. The D-F Bus is on offsite power. One electrical train of offsite power is down.
Non-Agreement State
Event Number: 57069
Rep Org: Vartanian Medical, PLLC
Licensee: Vartanian Medical, PLLC
Region: 3
City: Farmington Hills State: MI
County:
License #: 21-356-97-01
Agreement: N
Docket:
NRC Notified By: Jonathan Olsen
HQ OPS Officer: Karen Cotton-Gross
Licensee: Vartanian Medical, PLLC
Region: 3
City: Farmington Hills State: MI
County:
License #: 21-356-97-01
Agreement: N
Docket:
NRC Notified By: Jonathan Olsen
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 04/09/2024
Notification Time: 16:12 [ET]
Event Date: 04/09/2024
Event Time: 12:40 [EDT]
Last Update Date: 04/09/2024
Notification Time: 16:12 [ET]
Event Date: 04/09/2024
Event Time: 12:40 [EDT]
Last Update Date: 04/09/2024
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
Person (Organization):
Edwards, Rhex (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Edwards, Rhex (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MEDICAL EVENT - UNDERDOSE
The following information is an event summary via phone call from Vartanian Medical, PLLC:
On April 9, 2024, at 1240 EDT, a patient received only 73 percent of the intended dose of Y-90 TheraSpheres during a radioembolization. The prescribed dose was 3000 Gy and the dose received was approximately 2200 Gy. The physician described the cause of the event to be due to a smaller catheter needle used for treatment, which impeded the requisite flow.
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 is an event summary via phone call from Vartanian Medical, PLLC:
On April 9, 2024, at 1240 EDT, a patient received only 73 percent of the intended dose of Y-90 TheraSpheres during a radioembolization. The prescribed dose was 3000 Gy and the dose received was approximately 2200 Gy. The physician described the cause of the event to be due to a smaller catheter needle used for treatment, which impeded the requisite flow.
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.
Power Reactor
Event Number: 57077
Facility: Watts Bar
Region: 2 State: TN
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Tony Pate
HQ OPS Officer: Sam Colvard
Region: 2 State: TN
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Tony Pate
HQ OPS Officer: Sam Colvard
Notification Date: 04/15/2024
Notification Time: 14:38 [ET]
Event Date: 02/15/2024
Event Time: 22:24 [EDT]
Last Update Date: 04/15/2024
Notification Time: 14:38 [ET]
Event Date: 02/15/2024
Event Time: 22:24 [EDT]
Last Update Date: 04/15/2024
Emergency Class: Non Emergency
10 CFR Section:
50.73(a)(1) - Invalid Specif System Actuation
10 CFR Section:
50.73(a)(1) - Invalid Specif System Actuation
Person (Organization):
Miller, Mark (R2DO)
Miller, Mark (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 | Y | 100 | Power Operation | 100 | Power Operation |
INVALID ACTUATION OF EMERGENCY DIESEL GENERATORS
The following information was provided by the licensee via email:
"At 2224 EST on February 15, 2024, with both units 1 and 2 in Mode 1 at 100 percent power, an invalid start of the emergency diesel generator (EDG) system on 1A-A, 1B-B, and 2B-B EDGs occurred while removing clearances. The 2A-A EDG did not start because it was still under a clearance. The 1A-A, 1B-B, and 2B-B EDGs started and functioned successfully.
"The start signal for the 1A-A, 1B-B, and 2B-B EDGs was generated from the common emergency start of the 2A-A EDG. The signal was not from a loss of offsite power (LOOP) to any shutdown board or from any parameters that would initiate a safety injection (SI) signal, for which the EDG is designed to provide a design basis safety function. Also, the starts were not from intentional manual actuation. Starting the EDGs did not make them inoperable and each EDG was able to perform its design [basis] safety function.
"The common emergency start relay for each diesel is not safety related. It is an anticipatory and redundant circuit to start other EDGs in the event of a LOOP or SI related to the specific EDG. With the 2A-A EDG out of service, the associated common emergency circuit would not be required to perform any function. The starts were not initiated in response to actual plant conditions or parameters satisfying the requirements for initiation of the system.
"This event was originally reported under EN 56970 on February 16, 2024, at 0205 EST in accordance with 10 CFR 50.72(b)(3) (iv)(A) as an event that results in a valid actuation of the emergency diesel generator system. This EN was retracted on February 21, 2024, at 1549 EST.
"This event is being reported in accordance with 10 CFR 50.73(a)(1) and 10 CFR 50.73(a)(2)(iv)(A) as an event that results in an invalid actuation of the emergency diesel generator system.
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
The following information was provided by the licensee via email:
"At 2224 EST on February 15, 2024, with both units 1 and 2 in Mode 1 at 100 percent power, an invalid start of the emergency diesel generator (EDG) system on 1A-A, 1B-B, and 2B-B EDGs occurred while removing clearances. The 2A-A EDG did not start because it was still under a clearance. The 1A-A, 1B-B, and 2B-B EDGs started and functioned successfully.
"The start signal for the 1A-A, 1B-B, and 2B-B EDGs was generated from the common emergency start of the 2A-A EDG. The signal was not from a loss of offsite power (LOOP) to any shutdown board or from any parameters that would initiate a safety injection (SI) signal, for which the EDG is designed to provide a design basis safety function. Also, the starts were not from intentional manual actuation. Starting the EDGs did not make them inoperable and each EDG was able to perform its design [basis] safety function.
"The common emergency start relay for each diesel is not safety related. It is an anticipatory and redundant circuit to start other EDGs in the event of a LOOP or SI related to the specific EDG. With the 2A-A EDG out of service, the associated common emergency circuit would not be required to perform any function. The starts were not initiated in response to actual plant conditions or parameters satisfying the requirements for initiation of the system.
"This event was originally reported under EN 56970 on February 16, 2024, at 0205 EST in accordance with 10 CFR 50.72(b)(3) (iv)(A) as an event that results in a valid actuation of the emergency diesel generator system. This EN was retracted on February 21, 2024, at 1549 EST.
"This event is being reported in accordance with 10 CFR 50.73(a)(1) and 10 CFR 50.73(a)(2)(iv)(A) as an event that results in an invalid actuation of the emergency diesel generator system.
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."