United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for March 15, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/14/2012 - 03/15/2012

** EVENT NUMBERS **


47524 47727 47731 47734 47740 47741 47742 47743 47744 47745

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Power Reactor Event Number: 47524
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [ ] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: TIMOTHY MILLER
HQ OPS Officer: JOE O'HARA
Notification Date: 12/15/2011
Notification Time: 07:30 [ET]
Event Date: 12/15/2011
Event Time: 09:00 [EST]
Last Update Date: 03/14/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
SCOTT FREEMAN (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

ERDADS OUT OF SERVICE FOR PLANNED MAINTENANCE

"The St. Lucie Unit 1 Emergency Response Data Acquisition and Display System (ERDADS) will be removed from service for system modification following completion of core offload for the current cycle 24 refueling outage, currently scheduled for 12/15/2011 at 0900. The ERDADS system will be functional prior to core reload (Mode 6) and fully operational prior to the plant startup. This is an informational notification of a planned loss of emergency assessment capability. Control room indications including annunciators are available as alternate means to monitor critical data. An update to this notification will be provided when the system is restored to service."

The NRC Resident Inspector has been notified.

* * * UPDATE FROM PORRO TO CROUCH AT 1703 EDT ON 3/14/12 * * *

"The St. Lucie Unit 1 Emergency Response Data Acquisition and Display System (ERDADS) has been restored to service. Some area rad monitoring functional testing remains in progress; however full assessment capability is functional via the control room indications and alarms. All ERDS link data points provided by the Emergency Response Data Acquisition and Display System have been restored to service and fully operational to support plant start up."

The licensee has notified the NRC Resident Inspector. Notified R2DO (Guthrie).

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Agreement State Event Number: 47727
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL
Region: 1
City: CHAPEL HILL State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DIANA SULAS
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/09/2012
Notification Time: 15:57 [ET]
Event Date: 03/08/2012
Event Time: [EST]
Last Update Date: 03/09/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LAWRENCE DOERFLEIN (R1DO)
BRUCE WATSON (FSME)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE DURING HEPATIC TREATMENT USING YTTRIUM-90 THERASPHERES

The following information was received via e-mail from the State of North Carolina Radiation Protection Section:

"The agency [NC Radiation Protection Section] was notified of a medical event at UNC - Chapel Hill by the RSO. The event occurred yesterday. The patient was administered a Y-90 therasphere dose. Three flushes were done and proper surveys were made to ensure none of the dose was left in the IV lines. As per protocol, dose delivered is calculated via measurement of the administration vial and the waste collection vial. At this point it was noted that the patient only received 78% of the prescribed dose. The surveys indicate that the dose was left in the administration vial.

"Exact prescription dose was not provided at this time. No cause has been determined yet. There was no spilling, but the physician did note that it was harder to push the plunger for the flush to go through than he usually experiences. A second dose was delivered to a different patient using the same lot today, and the administration was successful (95% delivered).

"The patient who received the underdose has not yet been notified due to other health complications not caused by the underdosage. The patient's physician is aware and waiting for an appropriate opportunity to inform the patient. It has been determined that a second dose will not be administered since the physician has deemed the dose received adequate."

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: 47731
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: SAINT THOMAS HOSPITAL
Region: 1
City: NASHVILLE State: TN
County:
License #: R-19190-H14
Agreement: Y
Docket:
NRC Notified By: ROBIN HERIGES
HQ OPS Officer: PETE SNYDER
Notification Date: 03/12/2012
Notification Time: 08:06 [ET]
Event Date: 03/12/2012
Event Time: [EDT]
Last Update Date: 03/12/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAUL KROHN (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - SURFACE CONTAMINATION IDENTIFIED ON LAB FLOOR

The following information was received from the State of Tennessee via e-mail:

"During the routine lab cleanup/surveys, the RSO found 50-70 spots of contamination throughout the lab on the floor. It was determined that the contamination had occurred when a pharmacist working with I-131 capsules under the hood, had removed his glove within the hood. Subsequently, the glove had fallen to the floor depositing an unknown quantity of I-131. The pharmacist then walked through the lab and spread the contamination throughout. The pharmacist failed to survey the area or himself upon exiting the lab. The RSO found no contamination outside the restricted area. The RSO proceeded to cover the floor with cardboard, covering all areas of contamination. Areas were surveyed and the dose rates were very low even at 1 ft. from the I-131 contamination. There were no dose readings at 1 meter. All staff bioassays were below detectable limits."

TN Report ID: TN-10-082

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Agreement State Event Number: 47734
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: CONSOLIDATED ENGINEERING LABORATORIES
Region: 4
City: OAKLAND State: CA
County:
License #: 3250-07
Agreement: Y
Docket:
NRC Notified By: KENT PRENDERGAST
HQ OPS Officer: JOHN KNOKE
Notification Date: 03/12/2012
Notification Time: 20:18 [ET]
Event Date: 03/10/2012
Event Time: [PDT]
Last Update Date: 03/12/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4DO)
BRUCE WATSON (FSME)
ILTAB (EMAI)
MEXICO (EMAI)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - TWO MISSING MOISTURE DENSITY NUCLEAR GAUGES

The following information was provided by the State of California via email:

"On March 12, 2012, the RSO at Consolidated Engineering called the RHB [State of California - Radiological Health Branch] to report two missing moisture density nuclear gauges from their Oakland, CA storage facility, followed by an email (see below) detailing the events:

"On January 4 and January 5, 2012, as part of our bi-annual inventory, personnel performed an audit on a number of our nuclear gauges as required by our license. The inventory report was submitted to the RSO for review. Additional information was requested by the RSO on some of the gauges as is normal and customary. All of the gauges at that time were present and accounted for and were found to be satisfactory.

"On January 26, gauge # 0840 was signed in and out of our Oakland laboratory by one of our senior technicians. He subsequently used a different gauge in the days that followed. As part of my continuing duty to monitor locations and conditions of gauges, it became apparent to me last week that one of our gauges, #0840 was not in its designated storage location. In the course of calling all of our technicians and evaluating all of our storage locations, we called all gauges to be brought into our San Ramon office on Saturday March 10th. A second inventory was performed at that time on all of the gauges on our license. It was noted that gauge #0840 was missing as was gauge #5027, which was also stored in the Oakland location.

"We continued to exhaust all records, including sign-in and sign-out logs, report forms and checking with our license repair personnel and have concluded today that these gauges were more than likely stolen out of our Oakland office in January.

Manufacturer Model # Serial No Last documented use of gauge

Troxler 3411B T341 5027 06 January 2012
CPN MC3 M320400840 26 January 2012

"The [source] quantities are as follows:

CPN, 10 millicuries of Cesium 137 and 50 millicuries of Americium 241
Troxler, 09 millicuries of Cesium 137 and 44 millicuries of Americium 241."

California Incident #5010-031212

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Power Reactor Event Number: 47740
Facility: HARRIS
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: ANTHONY FULTZ
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/14/2012
Notification Time: 08:00 [ET]
Event Date: 03/14/2012
Event Time: 08:00 [EDT]
Last Update Date: 03/14/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
EUGENE GUTHRIE (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

Event Text

TECHNICAL SUPPORT CENTER PLANNED MAINTENANCE

"At approximately 0800 EDT on March 14, 2012, preplanned maintenance will be performed on the Technical Support Center (TSC) ventilation system. This maintenance will be performed for door seal replacement, ventilation shaft seal and belt replacement. This maintenance is planned to be performed and completed within 10 hours. If an emergency condition should occur that would require activation of the TSC, the Harris Nuclear Plant (HNP) emergency plan has procedural guidance for use of an alternate location.

"This event is reportable per 10 CFR 50.72(b)(3)(xiii) as described in NUREG-1022, Rev. 2 since this work activity affects an emergency response facility for the duration of the maintenance."

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM RICHARD VANDENBERG TO JOHN KNOKE AT 1735 EDT ON 03/14/12 * * *

The preplanned maintenance on the Technical Support Center (TSC) ventilation system was completed at 1730 EDT. The TSC is now fully functional.

The licensee has notified the NRC Resident Inspector. Notified the R2DO (Guthrie).

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Part 21 Event Number: 47741
Rep Org: AMETEK SOLIDSTATE CONTROLS
Licensee: AMETEK SOLIDSTATE CONTROLS
Region: 3
City: COLUMBUS State: OH
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT GEORGE
HQ OPS Officer: JOHN KNOKE
Notification Date: 03/14/2012
Notification Time: 15:38 [ET]
Event Date: 03/14/2012
Event Time: [EDT]
Last Update Date: 03/14/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
PAUL KROHN (R1DO)
EUGENE GUTHRIE (R2DO)
MICHAEL KUNOWSKI (R3DO)
CHUCK CAIN (R4DO)
PART 21 GRP (EMAI)

Event Text

PART 21 - POTENTIAL DEFECT ON ARVAN ELECTRICAL TERMINAL BLOCKS

The following information was provided by facsimile:

"COMPONENT DESCRIPTION:
Arvan electrical terminal blocks, part number MS27212-x-xx, Revision P, sizes -3-xx and -5-xx. any length; Ametek Solidstate Controls part number 03-120608-00. Only lots purchased from 2010 to present are of concern.

"PROBLEM YOU COULD SEE:
A mottled or marbled appearance, vertical cracks and/or a slim void/flow line on a cut section of the terminal block,

"CAUSE:
The manufacturer's investigation revealed that an improper application of acetone agent, which ensures proper bonding/blending of materials, was not properly monitored and resulted in intermittent inadequate blending. Not every lot or complete batch run is affected.

"EFFECT ON SYSTEM PERFORMANCE:
Cracks and/or voids in the material could be exploited should a seismic event occur.

"ACTION REQUIRED:
We have no known failures of these terminal block products in our systems. We believe the failure rate has been extremely low and the risk is minimal. Each operating facility will need to evaluate the potential risk to their operation.

"AMETEK SOLIDSTATE CONTROLS CORRECTIVE ACTION:
If you wish to replace the terminal blocks in your systems, Ametek Solidstate Controls will work with you to arrange replacements. Please contact our Client Services group at 1-800-222-9079 or 614-846-7500 ext. 6260."

The nuclear sites identified by the licensee to have these potentially defective parts are: Beaver Valley, Ginna, Harris, Hatch, VC Summer, Watts Bar, Braidwood, Byron, Cook, Davis Besse, Prairie Island, Arkansas Nuclear One, San Onofre Nuclear Generating Station, and South Texas Project.

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Power Reactor Event Number: 47742
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: STEVE DE FILLIPPO
HQ OPS Officer: JOHN KNOKE
Notification Date: 03/14/2012
Notification Time: 16:22 [ET]
Event Date: 03/14/2012
Event Time: 13:05 [EDT]
Last Update Date: 03/14/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
PAUL KROHN (R1DO)

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

TONE ALERT RADIOS OUT OF SERVICE

"At 1430 EDT on March 14, 2012, with the James A. FitzPatrick (JAF) Nuclear Power Plant operating at 100% reactor power, Oswego County Emergency Management notified JAF that the Tone Alert Radios had been out of service since 1305 EDT.

"This impacts the ability to readily notify a portion of the Emergency Planning Zone (EPZ) Population for the Nine Mile Point and JAF Nuclear Power Plants. This failure meets NRC 8 hour reporting criterion 10 CFR 50.72(b)(3)(xiii).

"The County Alert Sirens which also function as part of the Public Prompt Notification System remain operable.

"The loss of the Tone Alert Radios constitutes a significant loss of emergency off-site communications ability. Compensatory measures have been verified to be available should the Prompt Notification System be needed. This consists of utilizing the hyper reach system which is a reverse 911 feature available from the county 911 center. Local Law Enforcement Personnel are also available for 'Route Alerting' of the affected areas of the EPZ.

"This loss is believed to have been caused by a problem on a Verizon trunk line, which is currently being investigated.

"The event has been entered into the corrective action program and the NRC Resident Inspector has been briefed."

Licensee also notified the state and local authorities.

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Power Reactor Event Number: 47743
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [2] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: RYAN HAMILTON
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/14/2012
Notification Time: 17:32 [ET]
Event Date: 03/14/2012
Event Time: 13:05 [EDT]
Last Update Date: 03/14/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
PAUL KROHN (R1DO)

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

Event Text

LOSS OF THE TONE ALERT RADIO SYSTEM

"On Monday, March 12, 2012, at 1435 EDT, Oswego County Warning Point notified Nine Mile Point, and NYS [New York State] Warning Point, via the land line, of a loss of the Tone Alert System for greater than one hour from the National Weather Service as of 1305 hrs. Site Emergency Procedures define a loss of Tone Alert System for greater than one hour, as a significant loss of Emergency Communications (EPIP-EPP-30).

"This impacts the ability to readily notify a portion of the Emergency Planning Zone (EPZ) population for the NMP [Nine Mile Point] and JAF [James A. Fitzpatrick] Nuclear Power Plants. This failure meets NRC 8-Hour reporting criteria 10 CFR 50.72(b)(3)(xiii).

"The County Alert Sirens, which also function as part of the Public Prompt Notification System, remained operable.

"The loss of the Tone Alert System constitutes a significant loss of Emergency Off-Site Communications capability. Compensatory measures were verified to be available should the Prompt Notification System be needed. This consists of utilizing the hyper-reach system, which is a reverse 911 feature available from the county 911 center. Local law enforcement personnel are also available for 'Route Alerting' of the affected areas of the EPZ."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 47744
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [ ] [ ] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: RYAN TREADWAY
HQ OPS Officer: JOHN KNOKE
Notification Date: 03/14/2012
Notification Time: 18:20 [ET]
Event Date: 03/14/2012
Event Time: 11:20 [PDT]
Last Update Date: 03/14/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
CHUCK CAIN (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

UNIT 3 STEAM GENERATOR TUBES FAILED IN-SITU PRESSURE TESTING

"On January 31, 2012, Unit 3 was shut down due to detection of a tube leak in one Steam Generator (SG). The shutdown was previously reported on Event Notification # 47628. Southern California Edison (SCE) has been performing in-situ pressure testing with non-radioactive water on tubes with significant wear indications. On March 14, 2012, at approximately 1120 PDT, Unit 3 Steam Generator (SG) E088 Tube R106 C78 did not meet the target performance criteria because leakage exceeded 0.5 gallons per minute at the maximum pressure achieved during the test (2,884 psig). This was the leaking tube that resulted in the Unit 3 shutdown.

"Subsequently, two additional tubes in Unit 3 SG E088 did not meet the target performance criteria as follows: at 1249 PDT, Tube R102 C78 exceeded 0.5 gallons per minute at 3,268 psig and at 1425 PDT, Tube R104 C78 exceeded 0.5 gallons per minute at 3,180 psig. These occurrences are reportable as an 8-hour notification to the NRC in accordance with 10 CFR 50.72(b)(3)(ii)(A). Testing and inspection of Unit 3 steam generator tubes is ongoing to determine the extent and cause of the observed wear. A follow-up notification will be made for additional in-situ pressure test failures. The extent and cause of the condition will be addressed in the follow-up licensee event report that will be submitted in accordance with 10 CFR 50.73(a)(2)(ii)(A). Defective tubes will be removed from service as required prior to Unit 3 plant startup.

"Unit 2 has been shut down since January 9, 2012 for a scheduled refueling outage. SCE previously performed in-situ pressure testing of the tube with the most wear in Unit 2. Results from this test demonstrated that the tube met the target performance criteria.

"The NRC Resident Inspector has been notified of this event."

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Power Reactor Event Number: 47745
Facility: HOPE CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: KENNETH BRESLIN
HQ OPS Officer: CHARLES TEAL
Notification Date: 03/15/2012
Notification Time: 04:12 [ET]
Event Date: 03/14/2012
Event Time: 20:34 [EDT]
Last Update Date: 03/15/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
PAUL KROHN (R1DO)

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

HPCI INOPERABLE DUE TO FAILURE OF TURBINE GOVERNOR VALVE

"On March 14th, 2012 at 2034 EST the High Pressure Coolant Injection System (HPCI) was declared inoperable due to a failure of the turbine governor valve to respond as expected to demanded position. With the HPCI system flow controller output signal at zero percent demand the governor valve traveled to the mid position and did not remain closed as expected when the oil system auxiliary pump was started. With this unexpected response the speed and flow control system for the turbine is inoperable. The failure was discovered as part of a planned evolution for oil sampling.

"All other Emergency Core Cooling Systems and the Reactor Core Isolation Cooling (RCIC) system remain operable.

"The unit remains at 100% power.

"The station has initiated an Event Response Team to identify and correct the cause of the failure.

"No personnel injuries resulted from the event.

"The NRC Resident Inspector and Lower Alloway Creek Township will be notified."

Page Last Reviewed/Updated Thursday, March 29, 2012
Thursday, March 29, 2012