Morning Report for May 25, 1999
Headquarters Daily Report
MAY 25, 1999
REPORT NEGATIVE NO INPUT
ATTACHED INPUT RECEIVED RECEIVED
REGION I X
REGION II X
REGION III X
REGION IV X
PRIORITY ATTENTION REQUIRED MORNING REPORT - HEADQUARTERS MAY 25, 1999
Part 21 Database MR Number: H-99-0046
Foxboro Date: 05/25/99
Subject: Part 21 - Lack of inspection documentation for spare parts
VENDOR: Foxboro PT21 FILE NO: 99-17-0
DATE OF DOCUMENT: 03/03/99 ACCESSION NUMBER:
SOURCE DOCUMENT: EN 35473 REVIEWER: REXB, V. Hodge
NEW ISSUE. The vendor, Foxboro, reports that it cannot provide detailed
documentation of the inspection criteria for spare parts that have been
released to customers in support of Foxboro nuclear qualified parts. The
vendor knows of no failures or defects in these parts and is notifying
all utilities who have purchased commercial spare parts since April 1998.
HEADQUARTERS MORNING REPORT PAGE 2 MAY 25, 1999
Part 21 Database MR Number: H-99-0047
Abb Date: 05/25/99
Subject: Part 21 - Incorrectly mounted shutter roller pin on
circuit breaker chassis
VENDOR: ABB PT21 FILE NO: 99-20-0
DATE OF DOCUMENT: 03/03/99 ACCESSION NUMBER: 9903110295
SOURCE DOCUMENT: LER 50-361/99-001 REVIEWER: REXB, D. Skeen
NEW ISSUE. Southern California Edison, the San Onofre Unit 2 licensee,
reported an inadvertent emergency diesel generator start that was caused
by loss of a 4.16 kV Class 1E bus (see Event Notification 35336 and
Morning Report 4-99-0003). This happened on February 1, 1999, while a
worker was removing an ABB model 5HK-350 circuit breaker from its
cubicle. While trying to rack the breaker out, the breaker became stuck.
Plant personnel decided that discharging the closing springs would be
prudent to prevent personnel injury while trying to remove the breaker.
They mistakenly believed that the closing springs could be discharged
without closing the breaker. When they discharged the breaker's closing
springs, the breaker closed, and since the supply transformer was already
grounded in preparation for transformer maintenance, a ground fault
occurred, causing the alternate feeder breaker to open, and the bus was
The breaker is mounted on a rolling chassis (truck) for ease of racking
it in and out of the switchgear. The difficulty in racking out the
breaker was caused by an incorrectly placed shutter roller pin (called a
shutter kick pin by the vendor) mounted on the truck. The licensee
submitted a 10 CFR Part 21 report because the pin had been incorrectly
installed by the vendor. The breaker was one of three that had been
recently overhauled by the vendor, ABB Service Inc. of The Woodlands,
Texas. The vendor incorrectly re-installed the pin into a spare hole on
the side of the chassis, where it caused mechanical interference with the
movement of the roller.
The vendor evaluated this condition in accordance with 10 CFR Part 21.
The vendor evaluation determined that three breakers refurbished for San
Onofre had the trucks replaced and all three breakers had the shutter
kick pin installed in the wrong hole. The vendor stated that the truck is
not normally replaced during refurbishment, but in this case replacement
was necessary. The vendor technicians performing the work did not realize
that the kick pins on the new trucks were installed in a different hole
in the chassis than for the original trucks on the San Onofre breakers.
They were aware of the vendor design drawing showing the location of the
shutter kick pin in the closest hole to the rear of the truck, but did
not realize that two footnotes on the drawing stated that the correct
location of the pin for the 5HK350-3000 amp breaker is the third hole
from the rear of the breaker truck. With the pin in the wrong location,
HEADQUARTERS MORNING REPORT PAGE 3 MAY 25, 1999
MR Number: H-99-0047 (cont.)
the breaker will rack in properly and operate normally. However, the pin
gets behind the shutter lifting arm linkage during the racking in process
and causes the breaker to get stuck in the cubicle when being racked out.
The vendor has taken the following corrective actions: (1) revised the
breaker refurbishment procedure to include steps to inspect the pin for
proper location, and (2) trained their breaker technicians at all four
ABB Service shops on the procedure revisions.
In a letter to the licensee dated May 6, 1999, the vendor stated that
this issue is not reportable under the provisions of 10 CFR Part 21
because the normal closing, opening, and trip functions are not affected
by the shutter kick pin being installed in the wrong location. No other
reports of pins being installed in the wrong location have been received.
However, the NRC staff believes that licensees with Model HK circuit
breakers should be aware of the event at San Onofre. The staff has
discussed this issue with a representative of the Electric Power Research
Institute's Nuclear Maintenance Applications Center (EPRI/NMAC) ABB
Circuit Breaker Users Group. The users group is aware of the issue and it
will be discussed at their upcoming meeting in June.
Technical Contact: Dave Skeen, NRR
REGION I MORNING REPORT PAGE 3 MAY 25, 1999
MR Number: 1-99-0018
Mercy Hospital Date: 05/20/99
Dockets: 03002983 License No: 37-01374-03
Subject: FAILURE OF NUCLETRON CONSOLE
During a safety inspection from May 17-20, 1999, the inspector determined
that on December 21, 1998, the licensee terminated a brachytherapy
procedure when it was noted that the Nucletron HDR treatment console had
"frozen". The console indicated that 88 seconds of the planned treatment
of 343.8 seconds had transpired when the console "froze". However, the
licensee noted, by observing the patient with the closed circuit
television monitor that the treatment was still underway. Licensee
personnel stopped the procedure by pressing the emergency stop button.
Upon opening the treatment door, the sealed source retracted into the
shielded position. Nucletron, on December 22, 1998, determined that the
procedure had continued for 42 seconds after the console froze for a
total of 130 seconds by retrieving and reviewing the HDR Central
Processing Unit (CPU) treatment data. Nucletron replaced the CPU of the
console and committed to sending a report to the licensee concerning the
cause of the failure. As of the date of the NRC inspection, the licensee
has not yet received a report.
Although no misadministration occurred, the unit failure contributed to a
recordable event. The patient received a total dose of 1750 centiGray
(cGy) instead of a planned dose of 2100 cGy. The causes and root causes
of the console failure were not identified.
The State of Maryland was notified of the failure of the Nucletron
console on May 21, 1999, and stated that they were aware of the problem.
Nucletron is still investigating this and similar incidents.
Contact: S. Courtemanche (610)337-5075
M. Shanbaky (610)337-5209
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