United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for October 9, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/05/2012 - 10/09/2012

** EVENT NUMBERS **


48293 48300 48331 48338 48349 48352 48355 48356 48358 48365 48379 48380
48381 48382 48383 48385 48386 48387 48388

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 48293
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DAVID WALSH
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/10/2012
Notification Time: 17:15 [ET]
Event Date: 09/10/2012
Event Time: 10:25 [EDT]
Last Update Date: 10/08/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
CHRISTOPHER NEWPORT (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

BOTH UNITS ENTERED TECHNICAL SPECIFICATION 3.0.3 DUE TO INOPERABLE CONTROL STRUCTURE CHILLERS

"Unit 1 and Unit 2 entered LCO 3.0.3 due to both Control Structure (CS) chillers 'A & B' concurrently inoperable.

"At 1025 [EDT], the control room was notified that the 'B' CS Chiller was not running. There were no control room alarms due to this condition. Review of indications on control room panel 0C681 noted that the loop circ pump and all three CS fans remained in service. Indication of CS loop flow and loop temperature remained normal, approximately 600 gpm and 44 degrees.

"The 'B' CS Chiller restarted at 1027 [EDT] and normal system parameters were observed.

"Work on the 'A' CS Chiller was released at 0928 [EDT] on 9/10/2012 for scheduled maintenance, LCO's 3.7.3 and 3.7.4 were entered, however no work had actually commenced or was performed. The 'A' CS Chiller remained available and in standby during the entire evolution.

"Since the cause of the 'B' CS Chiller to shutdown has not been determined, the 'B' CS Chiller was declared inoperable. Inoperability of both CS chillers 'A & B' required immediate entry into LCO 3.0.3 per TS 3.7.4 Condition D. Both chillers were inoperable from 1025 [EDT] until 1042 [EDT] (17 minutes), when the 'A' CS Chiller was restored to operable status.

"This condition is being reported as an event or condition that could have prevented fulfillment of a safety function per 10CFR 50.72(b)(3)(v)(D)."

The licensee informed the NRC Resident Inspector.

* * * RETRACTION FROM LICHTNER TO CROUCH AT 2008 EDT ON 10/08/12 * * *

"This event was reported as a condition that could have prevented fulfillment of a safety function per 10 CFR 50.72(b)(3)(v)(D) because the 'A' Control Structure (CS) chiller was released for scheduled maintenance (LCO's 3.7.3 and 3.7.4 were entered), although no physical work had begun on the 'A' CS chiller. Concurrent with the 'A' chiller being in the aforementioned status, the 'B' CS chiller shutdown for approximately 2.5 minutes before automatically restarting.

"Following the ENS report, Susquehanna determined that although it had shutdown, the 'B' CS chiller remained operable and capable of fulfilling all its design functions. The chiller shutdown was not due to operation of a safety trip. Under safety trip conditions, automatic restart of the chiller would have been prevented and alarms would have been received in the control room. Rather, the event was due to chiller load recycle operation during which the chiller is designed to shutdown at approximately 5 degrees F below the normal operating chilled water temperature and automatically restart. Troubleshooting did not detect any faulty components and the chiller has remained in operation for greater than 48 hours since the shutdown, without a repeat event.

"Additionally, although the 'A' CS chiller was declared inoperable due to entry into LCO's 3.7.3 and 3.7.4 to perform routine maintenance, no physical action had been taken to disable the 'A' chiller. Therefore, the 'A' CS chiller was capable of auto-starting and performing its safety function for all design conditions while in the LCO's.

"Based on the above information, Susquehanna has determined that since both the 'A' and the 'B' CS chillers were available and capable of performing their design safety functions, there was no loss of safety function therefore this ENS report is retracted."

The licensee has notified the NRC Resident Inspector. Notified R1DO (Trapp).

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Agreement State Event Number: 48300
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: HALLIBURTON
Region: 4
City: HOUSTON State: TX
County:
License #: 02113
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 09/12/2012
Notification Time: 08:37 [ET]
Event Date: 09/11/2012
Event Time: 21:00 [CDT]
Last Update Date: 10/05/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN LANTZ (R4DO)
BRIAN MCDERMOTT (FSME)
JANE MARSHALL (IRD)
MEXICO (E-MA)
JIM WHITNEY (ILTA)
DEBORAH HASSEL (DHS)
FSME EVENTS RESOURCE (E-MA)

This material event contains a "Category 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST AM-241/BE WELL LOGGING SOURCE

The following information was obtained from the Texas Department of State Health Services Radiation Branch via e-mail:

"On September 11, 2012, the Agency [Texas Department of State Health Services] was notified by the licensee that an Americium-241/ Beryllium [well logging] source could not be located. The source had been used earlier that day at a well site near Pecos, Texas. The well logging crew left the Pecos site and went about 130 miles to a well site south of Odessa, Texas. When the crew went to remove the Am-241 source they discovered the source transport container lock and plug were not in place and that the source was missing. The crew returned to the well site near Pecos and searched for the source, but did not find it. The Radiation Safety Officer (RSO) stated that the lock was found in the storage compartment in the back of the truck. The transport container plug was not in the container. The RSO stated they were putting together a group to look for the source along the roadway between the two locations.

"The RSO stated that the crew stated that they did not stop anywhere along the route between the two locations. The RSO stated they were verifying that using the vehicles black box. The RSO agreed to contact the appropriate local law enforcement. The RSO stated he would send a copy of the latest dose rate readings for the source to the Agency.

"The Agency has notified their local inspectors of the event. Additional information will be provided as it is received in accordance with SA-300 [Reporting Material Events]."

The source was described as approximately 7 inches long by 1 inch in diameter stainless steel cylinder. The State has not requested any assistance in locating the source at this time.

Texas Report I-8988

* * * UPDATE AT 1744 EDT ON 09/12/12 FROM ART TUCKER TO S. SANDIN * * *

The following update was received from the State of Texas via fax:

"[At] 1430 hours [CDT] the Agency [Texas Department of State Health Services] was contacted by the licensee and provided the following information.

"The licensee has completed a press release which provides a description of the source, actions to take if found, and stated that they would offer a reward. The press release will be issued by their Public Information Group. The licensee has completed logging of the well near Pecos and the source was not located.

"The licensee stated that the well site had been searched and surveyed twice. The licensee stated that the road between Pecos and Odessa had been surveyed using well logging tools extended from pickup trucks and driven between 5 and 10 miles per hour and the source was not found. The licensee stated they have had people on the ground searching, but did not know how much area away from the well site in Pecos had been searched.

"The licensee has sent a Radiation Safety Officer and a second supervisor to the Pecos well site. The RSO is bringing scintillation survey instruments to the well site for additional surveys. An Agency inspector will meet the RSO at the well site.

"The licensee has reviewed the well logging data and confirmed that the source was installed on the tool during logging operations. The licensee has performed preliminary interviews with the operator involved. The licensee indicated that additional interviews are required. They have not been able to determine how the source could have been lost during transport. The licensee stated that they completed a review of the truck's black box and confirmed that the truck did not stop while traveling between the two well sites.

"The license stated that the local sheriff has responded to the Pecos location and was interviewing the tool operators. The licensee stated they believe that the group supervisor involved had been evaluated under the IC's [Increased Controls] as trust worthy and reliable.

"The licensee stated that other entities at the well site as well as the lease holder have been notified of the event. The licensee stated that they will continue to search for the source until it can be located. The Agency has offered their assistance to the licensee. Additional information will be provided as it is received in accordance with SA - 300 [Reporting Material Events]."

Notified R4DO (Lantz) and FSME (McDermott), IRD (Marshall), ILTAB (Whitney) and Mexico via email/fax.

* * * UPDATE ON 9/13/12 AT 1015 EDT FROM ART TUCKER TO HUFFMAN * * *

The following update was received from the State of Texas via e-mail:

"A third search of the well site was completed on September 12, 2012 at 2030 hours. The source was not found. The licensee will resume the search early today. The licensee stated that surveys will be conducted on the road between Odessa and Pecos today. The licensee stated that a mud pit at the Pecos site will be logged today. The logging truck is at their shop in Odessa now and they are literally stripping it down, removing every piece of equipment looking for the source. The licensee stated that the three individuals who were conducting the well logging operations when the source was lost were interviewed by individuals from the Federal Bureau of Investigation working with the Department of Transportation. The licensee stated that the FBI would only say that they believed there was no criminal activity involved with the missing source. Additional information will be provided as it is received in accordance with SA - 300."

Notified R4DO (Lantz) and FSME (McDermott), IRD (Marshall), ILTAB (Whitney) and Mexico via email.

* * * UPDATE ON 10/05/12 AT 0915 EDT FROM ART TUCKER TO DONG PARK * * *

The following update was received from the State of Texas via e-mail:

"On October 5, 2012, the Agency [Texas Department of State Health Services] was notified by the licensee that the missing Americium - 241/Beryllium source had been recovered. No additional information was available at the time of the report. Additional information will be provided as it is received in accordance with SA-300.

Notified R4DO (Powers). ILTAB (Hahn), FSME Events Resource and Mexico informed via email.

THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL

Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Agreement State Event Number: 48331
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: NON-LICENSEE: NITARDY FUNERAL HOME
Region: 3
City: WHITEWATER State: WI
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KRISTA KUHLMAN
HQ OPS Officer: DONALD NORWOOD
Notification Date: 09/21/2012
Notification Time: 16:37 [ET]
Event Date: 09/20/2012
Event Time: [CDT]
Last Update Date: 10/08/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK RING (R3DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

CREMATORY CONTAMINATED DUE TO MEDICAL IMPLANT

The following information was provided via facsimile transmission:

"The Wisconsin Department of Health Services (DHS) received a phone call from the Radiation Safety Officer (RSO) at the University of Wisconsin-Madison informing them that the university had received a phone call from a funeral home that had just cremated remains of a person who had received an I-125 lung mesh implant. The implant was put in the patient on September 13, 2012 at the University of Wisconsin-Madison hospital. The patient was implanted with a lung mesh with 40 seeds totaling 23 mCi. The funeral home received a phone call during the cremation, from a family member notifying them that the person had received a radiation treatment a few weeks prior to the cremation. The cremation took place on September 20, 2012. After the cremation was completed, the crematory remained closed until DHS inspectors arrived. DHS conducted an investigation on September 21, 2012. Radiation readings inside the crematorium were 0.75 mR/hr with a Victoreen, Model 451 (#199588, calibrated on 1/20/2012). The cremains read 3.8 mR/hr on contact with a plastic bag. They have placed the cremains in a concrete container and radiation levels were at background on the outside of the container. No other areas of the facility were contaminated. The facility has agreed to suspend the operations until clean-up."

* * * UPDATE FROM KUHLMAN TO KLCO ON 10/8/2012 AT 1012 EDT* * *

The following corrected information was received by email:

The State of Wisconsin made the clarification that the funeral home received notification from an authorized medical physicist from the University of Wisconsin-Madison.

Notified the R3DO(Valos) and FSME via email.

Wisconsin Event Report ID No.: WI120013

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Power Reactor Event Number: 48338
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: BRETT JEBBIA
HQ OPS Officer: BILL HUFFMAN
Notification Date: 09/24/2012
Notification Time: 11:23 [ET]
Event Date: 09/24/2012
Event Time: 04:07 [EDT]
Last Update Date: 10/06/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MARK RING (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 68 Power Operation 68 Power Operation

Event Text

EMERGENCY RESPONSE DATA SYSTEM PROCESS COMPUTER DATA SERVER FAILURE

"At 04:07 EDT on September 24, 2012, Fermi 2 experienced a failure of a data server within the Process Computer system. The failure of the data server does affect data input to the server providing information to the Emergency Response Data System (ERDS). ERDS is currently not receiving updated information from Fermi data systems. This loss in capability is being reported as a loss of assessment capability in accordance with 10 CFR 50.72(b)(3)(xiii).

"Indications of related plant variables are available in the Main Control Room. The Visual Annunciator System (VAS) and other portions of the Process Computer system remain functional. Meteorological and process effluent radiological monitor indications are available and dose assessment capability is available. Fermi 2 personnel will use normal phone communications to update NRC Operations Center in the case of an event declaration. Information normally provided by ERDS can be transmitted via the notification system as described in the Radiological Emergency Response Preparedness Plan."

The licensee has notified the NRC Resident Inspector.

* * * UPDATE FROM MARK EGHIGIAN TO CHARLES TEAL AT 1435 EDT ON 10/6/12 * * *

"On September 24, 2012, Fermi experienced a failure of a data server within the process computer system which feeds data to Emergency Response Data System (ERDS), and report #48338 was made to the NRC.

"On October 6, 2012, corrective maintenance is complete, which repaired the data server and ERDS functionality is restored."

The licensee has notified the NRC Resident Inspector. Notified R3DO (Valos).

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Agreement State Event Number: 48349
Rep Org: NEW YORK CITY BUREAU OF RAD HEALTH
Licensee: MOUNT SINAI MEDICAL CENTER
Region: 1
City: NEW YORK CITY State: NY
County: NEW YORK
License #: 75-2909-01
Agreement: Y
Docket:
NRC Notified By: TOBIAS LICKERMAN
HQ OPS Officer: VINCE KLCO
Notification Date: 09/27/2012
Notification Time: 07:17 [ET]
Event Date: 09/20/2012
Event Time: 12:00 [EDT]
Last Update Date: 09/27/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RONALD BELLAMY (R1DO)
FSME RESOURCES (FSME)

Event Text

AGREEMENT STATE REPORT- PATIENT UNDEREXPOSURE USING YTTRIUM-90 THERASPHERES TREATMENT

New York City was notified by the licensee Radiation Safety Officer of a patient receiving an underdose of Yttrium-90 TheraSpheres for liver treatment. The prescribed dose was 120 gray, but only 11.4 gray was delivered to the patient. A review of the licensee's patient delivery system indicates that about 90% of the prescribed dosage remained in the catheter.

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: 48352
Facility: COMANCHE PEAK
Region: 4 State: TX
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RAUL MARTINEZ
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 09/27/2012
Notification Time: 14:08 [ET]
Event Date: 09/27/2012
Event Time: 12:54 [CDT]
Last Update Date: 10/06/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
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 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

PARTIAL LOSS OF EMERGENCY ASSESSMENT DURING PLANNED MODIFICATIONS

"On September 27, 2012, Comanche Peak Nuclear Power Plant began a cyber security related modification to the Unit 1 and 2 Plant Computer Systems (PCS) and associated network infrastructure. The entire PCS for each unit will be out of service for approximately 6 hours. During that time, the PCS satellite display systems (SDSs) in the TSC and EOF will be inoperable. After approximately 8 hours, the PCS will be restored to service along with the SDSs in the TSC. The SDSs in the EOF will remain out of service until the modification and related site acceptance testing is complete, currently scheduled for October 5, 2012. During this period. the remote display of Radiation Monitoring System (RMS) information in the EOF and OSC will be unavailable.

"The loss of EOF SDS terminals will be compensated by use of an alternate plant parameter display system, and loss of EOF/OSC RMS remote display will be compensated by means of the status board recorder telephone loop. Therefore, it is expected that appropriate assessment of plant conditions. notifications, dose projections, and communications could still be made, if required, during the time that the SDSs and RMS remote displays are inoperable.

"The extended loss of the EOF SDSs and EOF/OSC remote RMS data is being reported in accordance with 10.CFR.50.72(b)(3)(xiii). which is any event that results in a major loss of emergency assessment capability, offsite response capability, or off site communications capability. The NRC Resident Inspector has been notified. A follow-up ENS communication will be made when the EOF SDSs and EOF/OSC remote RMS remote displays are fully restored to service."

* * * UPDATE FROM RAUL MARTINEZ TO JOHN SHOEMAKER AT 0224 EDT ON 10/06/12 * * *

Maintenance has been completed on the Unit 1 and Unit 2 Plant Computer System. The system has been tested and returned to service.

The licensee will notify the NRC Resident Inspector. Notified R4DO (Powers).

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Agreement State Event Number: 48355
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: GUNDERSON CLINIC, LTD
Region: 3
City: LACROSSE State: WI
County:
License #: 063-1121-01
Agreement: Y
Docket:
NRC Notified By: EMILY EGGERS
HQ OPS Officer: PETE SNYDER
Notification Date: 09/28/2012
Notification Time: 14:21 [ET]
Event Date: 09/27/2012
Event Time: [CDT]
Last Update Date: 09/28/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTINE LIPA (R3DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - THERASEED MODEL 200 SEED CARTRIDGES FAILED TO FUNCTION

The State of Wisconsin submitted the following information via email:

"On September 27, 2012 the Wisconsin Radiation Protection Section received a notification that Pd-103 Theraseed model 200 seed cartridges from Theragenics failed to function as designed while preparing for a prostate seed implant procedure.

"The procedure was scheduled and pre-planned as a 'linked' procedure, with 145 Pd-103 seeds ordered from Theragenics. The order was received timely and the seed calibration was verified. Upon arriving in the Operating Room, the pre-implant testing routinely performed on the linker device worked appropriately, the procedure is performed with blank seed and spacer cartridges. The intraoperative pre-plan was performed from the ultrasound images as normal.

"While attempting to make the linked seeds + spacers the licensee ran into immediate jams. They initially thought it was the link making device, retrieved a spare and encountered the same issue. Shortly after they discovered the seed cartridges had a flaw, the hole on the entrance side of the cartridge was not completely open, thus the link wire could not enter the cartridge to push a seed through. A second cartridge was found with the same problem. On a third cartridge they were able to make a linked needle but the operation was not smooth.

"The Authorized User then decided to change the implant to a MICK applicator technique. All seeds were transferred to sterilized MICK cartridges. The implant proceeded with the MICK applicator. Upon completion of the implant it appears to be a satisfactory implant.

"DHS [Wisconsin Department of Health Services] plans to investigate on Wednesday, October 3, 2012 when a Theragenics representative is present."

Event Report ID No.: WI20014

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Non-Agreement State Event Number: 48356
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: PHOENIX RAYTHEON MISSILE SYSTEMS
Region: 4
City: TUCSON State: AZ
County:
License #: 10-167
Agreement: Y
Docket:
NRC Notified By: AUBREY GOODWIN
HQ OPS Officer: PETE SNYDER
Notification Date: 09/28/2012
Notification Time: 17:19 [ET]
Event Date: 09/19/2012
Event Time: [MST]
Last Update Date: 09/28/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL OKEEFE (R4DO)
FSME RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - LEAKING SEALED SOURCE

The State of Arizona reported the following via email:

"The Agency was notified on 9/19/2012 that the licensee had wipe test results which indicated that two of the Americium-241 sealed sources they possessed are leaking or contaminated. Each Am-241 sealed source has 3 solid metal foils of Am-241 with an activity of 2.1 mCi for each foil, for a total activity of 6.3 mCi for each source. Sealed source number 004 was never installed in an instrument and was stored in a canister provided by the manufacturer. The failed leak test, which showed 0.022 microCuries of removable contamination, occurred on April 19, 2012, but was not reported to the Agency until September 19, 2012. The second failed leak test occurred on source number 003 on September 19, 2012. It was previously installed in a positive mode ion mobility spectrometer where an engineer viewed signs of corrosion on the source. A subsequent leak test showed 0.92 microCuries of removable contamination. The Agency laboratory confirmed the results.

"The licensee has already sent one source, serial number 004, back to the vendor and is in the process of returning the second source."

Arizona First Notice 12-023

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Non-Agreement State Event Number: 48358
Rep Org: TRISTATE MATERIALS TESTING LAB, LLC
Licensee: TRISTATE MATERIALS TESTING LAB, LLC
Region: 1
City: WALLNGFORD State: CT
County:
License #: 06-31462-01
Agreement: N
Docket:
NRC Notified By: HABIB CHAUDHARY
HQ OPS Officer: PETE SNYDER
Notification Date: 09/28/2012
Notification Time: 19:35 [ET]
Event Date: 09/27/2012
Event Time: [EDT]
Last Update Date: 09/29/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
RONALD BELLAMY (R1DO)
FSME EVENT RESOURCE (EMAI)

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

Event Text

LOST MOISTURE DENSITY GAUGE

On 9/27/12, at about 1100 EDT, the Radiation Safety Officer of Tri-State Materials Testing was notified that an employee of Tri-State Materials Testing did not show at a jobsite as expected at 0900 EDT. The employee was carrying a Troxler Model 3411 moisture density gauge, S/N 4783. This gauge typically has a 9 milliCurie Cs-137 source and a 44 milliCurie Am:Be source. The RSO reported that the gauge was in the proper container and properly secured to the employee's vehicle when last seen.

The RSO searched for the employee and attempted to contact him numerous times with no result. The gauge is assumed lost and a report has been filed with the Wallingford Police Department.


* * * UPDATE AT 0002 ON 09/29/12 FROM HABIB CHAUDHARY TO PETE SNYDER * * *

The employee contacted the RSO and confirmed that he was in possession of the gauge and would return it on 09/29/12. The RSO notified the Wallington Police Department that the gauge was still in the possession of the Authorized User and secured.

Notified R1DO (Bellamy) and FSME Event Resource via email.


* * * UPDATE FROM HABIB CHAUDHARY TO DONALD NORWOOD AT 0143 EDT ON 9/29/2012 * * *

As of 0115 EDT, the gauge was in the possession of the RSO.

Notified R1DO (Bellamy) and FSME Event Resource via E-mail.

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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Agreement State Event Number: 48365
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: IRIS NDT MATRIX
Region: 4
City: BATON ROUGE State: LA
County:
License #: LA-12236-L01
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: JOHN KNOKE
Notification Date: 10/01/2012
Notification Time: 16:15 [ET]
Event Date: 09/05/2012
Event Time: 10:45 [CDT]
Last Update Date: 10/01/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE UNABLE TO BE RETRACTED

The following information was provided from the State of Louisiana via facsimile:

"IRISNDT dispatched a radiography crew to Marathon Petroleum on September 5, 2012. The crew set up and began work around 6:30 am. The crew worked with a camera, associated equipment, and a collimator for hours before there was a problem. [At 1045 CDT] the source setup was about 15 feet up above the ground in the pipe rack when the source would not return into the shielded position. After several attempts to retrieve the source, the RSO was notified. The crew was instructed to secure the barricade at the 2 mR distance and maintain observing the area until the RSO could arrive. The RSO arrived and secured the source into the exposure device's shielded position.

"The equipment, QSA Global Delta 880, s/n# D6460, the source is s/n# 86363B ...Ir-192, last leak tested on 08/07/2012. The investigation concluded a gear in the crank assembly was damaged and it caused the drive cable to jam. The assembly was red tagged and removed from service. Event exposures were 29 mR [Radiographer Trainer], 6 mR [Radiographer Trainee] and 2.4 mR [RSO]."

Louisiana Event Report ID No. LA1200004.

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Part 21 Event Number: 48379
Rep Org: MITSUBISHI NUCLEAR ENERGY SYSTEMS
Licensee: MITSUBISHI HEAVY INDUSTRIES, LTD.
Region: 1
City: ARLINGTON State: VA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JOSEPH TAPIA
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/05/2012
Notification Time: 07:17 [ET]
Event Date: 02/13/2012
Event Time: [EDT]
Last Update Date: 10/05/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
DALE POWERS (R4DO)
PART 21 GROUP (EMAI)

Event Text

PART 21 - STEAM GENERATOR TUBE WEAR ADJACENT TO RETAINER BARS

The following information was received via email:

"Mitsubishi Heavy Industries, LTD (MHI) has identified steam generator tube wear for San Onofre Nuclear Generating Station.

"The Steam Generator tube wear adjacent to the retainer bars was identified as creating a potential safety hazard. The maximum wear depth is 90% of the tube thickness. The cause of the tube wear has been determined to be the retainer bars' random flow-induced vibration caused by the secondary fluid exiting the tube bundle. Since the retainer bar has a low natural frequency, the bar vibrates with a large amplitude. This type tube wear could have an adverse effect on the structural integrity of the tubes, which are part of the pressure boundary.

"The plugging of the tubes that are adjacent to the retainer bars was performed. MHI has recommended to the purchaser to remove the retainer bars that would have the possibility of vibration with large amplitude or to perform the plugging and stabilizing for the associated tubes."

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Part 21 Event Number: 48380
Rep Org: MITSUBISHI NUCLEAR ENERGY SYSTEMS
Licensee: MITSUBISHI HEAVY INDUSTRIES, LTD.
Region: 1
City: ARLINGTON State: VA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JOSEPH TAPIA
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/05/2012
Notification Time: 07:17 [ET]
Event Date: 02/21/2012
Event Time: [EDT]
Last Update Date: 10/05/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
DALE POWERS (R4DO)
PART 21 GROUP (EMAI)

Event Text

STEAM GENERATOR TUBE TO TUBE WEAR

The following information was received via email:

"Mitsubishi Heavy Industries, LTD (MHI) has identified steam generator tube wear for San Onofre Nuclear Generating Station.

"Steam Generator tube wear has been identified in areas of the U-bend between anti-vibration bars, where the tube is not supported by the anti-vibration bars. This tube wear occurred due to the contact of a tube with an adjacent tube, and resulted in a leak from a Unit 3 tube. The cause of the tube leak was determined to be the in-plane direction fluid elastic instability under high localized thermal-hydraulic conditions (steam quality (void fraction), flow velocity and hydro-dynamic pressure), and insufficient contact force of the tube to anti-vibration bar. This type Mitsubishi Heavy Industries has identified steam generator tube wear for San Onofre Nuclear Generating Station. The Steam Generator tube wear adjacent to the retainer bars was identified as creating a potential safety hazard.

"The plugging of the tubes that have the possibility of the fluid elastic instability and thermal power output reductions were identified as potential corrective actions. SCE [Southern California Edison] will run Unit 2 at 70% power for a short duration as a corrective action. In addition, SCE and MHI will continue a detailed analysis and investigation to this problem. Additional corrective actions may be required as the analysis and investigation continue. MHI has recommended to the purchaser that it perform eddy current inspection of tubes after Unit 2 operation resumes."

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Power Reactor Event Number: 48381
Facility: HARRIS
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: JUSTIN KELLY
HQ OPS Officer: VINCE KLCO
Notification Date: 10/05/2012
Notification Time: 07:37 [ET]
Event Date: 10/05/2012
Event Time: 08:00 [EDT]
Last Update Date: 10/05/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
KATHLEEN O'DONOHUE (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

LOSS OF EMERGENCY RESPONSE FACILITY INFORMATION SYSTEM DUE TO PLANNED MODIFICATION

"At approximately 0800 EDT, on October 5, 2012, the Emergency Response Facility Information System (ERFIS) will be removed from service to perform a planned modification for the improvement of site wide data communications between various plant process computing platforms. The expected duration of ERFIS non-functionality should not exceed 24 hours and during this time would not be able to be restored within one hour. The ERFIS computer system provides monitoring and communications capability for plant data systems including the Emergency Response Data System (ERDS) and the Safety Parameter Display System (SPDS). The loss of ERFIS requires alternate methods, as described in plant procedures, to be used for the above described functions. Therefore, assessment of plant conditions, notifications, and communications could still be made, if required, during the time that the ERFIS computer system is non-functional. The on call Emergency Response Organization has been notified of the ERFIS outage.

"This report is being made in accordance with 10 CFR 50.72(b)(3)(xiii) as described in NUREG-1022, Rev. 2.

"The NRC Resident Inspector has been notified."

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Part 21 Event Number: 48382
Rep Org: ENGINE SYSTEMS, INC
Licensee: DETROIT SWITCH
Region: 1
City: ROCKY MOUNT State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TOM HORNER
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/05/2012
Notification Time: 10:33 [ET]
Event Date: 04/02/2012
Event Time: [EDT]
Last Update Date: 10/05/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
KATHLEEN O'DONOHUE (R2DO)
DAVE PASSEHL (R3DO)
DALE POWERS (R4DO)
PART 21 GROUP (EMAI)

Event Text

PART 21 - TEMPERATURE SWITCH POTENTIALLY SHIPPED WITHOUT SET SCREW

"Engine Systems Inc. (ESI) began a 10CFR21 evaluation on 9/18/2012 after an ESI test technician found a set screw in one of the oil bath stations of the temperature test fixture. After evaluating all components that were tested on the fixture, it was determined that this set screw is the same length, thread size and style as the set screw utilized in the EMD/Detroit temperature switches to lock the differential adjustment screw. The other components tested on the fixture did not contain such a set screw. Either an extra set screw was inside a temperature switch and it fell into the test fixture oil bath when the test technician removed the switch cover; or, the test technician dropped the set screw after removing it from a temperature switch to adjust the differential setting of the switch. If the latter occurred, then the potential exists that a temperature switch was shipped without the differential adjustment screw locked and therefore the switch settings could drift over-time from exposure to vibration on the EDG skid. ESI has identified the time period in which this could have occurred to be 4/2/2012 to 9/18/2012. The suspect temperature switches are EMD parts manufactured by Detroit Switch. These are located in the engine cooling water and lube oil systems for low standby lube oil temperature alarm, high coolant temperature alarm/shutdown and coolant immersion heater control applications.

"The evaluation was concluded on 10/3/2012 and it was determined that this issue is a reportable defect as defined by 10CFR21. If a switch applied in the immersion heater control application experiences significant setpoint drift, it is possible that the standby temperatures of the lube oil and coolant systems may be degraded enough to affect the start time of the diesel generator.

"All affected users should inspect the suspect switches for presence of the set screw at their earliest convenience. If the set screw is missing, the temperature switch should be returned to ESI for rework."

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Power Reactor Event Number: 48383
Facility: SEQUOYAH
Region: 2 State: TN
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MARLIN JOSEPH QUARBERG
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/05/2012
Notification Time: 11:19 [ET]
Event Date: 10/04/2012
Event Time: 19:21 [EDT]
Last Update Date: 10/05/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
KATHLEEN O'DONOHUE (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

Event Text

CONFIRMED POSITIVE FITNESS FOR DUTY TEST

A non-licensed employee supervisor had a confirmed positive for alcohol during a random fitness for duty test. The employee's access to the plant has been terminated. Contact the Headquarters Operations Officer for additional details.

The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 48385
Facility: VOGTLE
Region: 2 State: GA
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: THOMAS BUSSIERE
HQ OPS Officer: CHARLES TEAL
Notification Date: 10/05/2012
Notification Time: 12:18 [ET]
Event Date: 10/05/2012
Event Time: 05:14 [EDT]
Last Update Date: 10/05/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
KATHLEEN O'DONOHUE (R2DO)

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

Event Text

UNPLANNED AUXILIARY FEEDWATER ACTUATION

"On October 5, 2012 at 05:14 EDT, restoration of steam generator narrow range level instrumentation from a bypassed condition was in progress when a valid Auxiliary Feedwater Actuation signal was received due to steam generator levels being below the Lo-Lo Level setpoint. As a result, both motor driven auxiliary feedpumps automatically started and two turbine driven auxiliary feedwater discharge valves automatically opened. The turbine driven auxiliary feedwater pump and the motor driven auxiliary feedwater discharge valves had been previously removed from service under administrative controls. The system was aligned per procedure so that water injection into the steam generators did not occur and the motor driven pumps were operated on mini-flow. Unit 1 is off line for a planned refueling and maintenance outage. There were no adverse impacts on the plant.

"At the time of the event, Unit 1 was in Mode 5 with RHR in service and preparations for Mode 4 entry in progress."

The NRC Resident Inspector has been informed.

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Power Reactor Event Number: 48386
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: MARTY NEWSHAN
HQ OPS Officer: CHARLES TEAL
Notification Date: 10/05/2012
Notification Time: 16:53 [ET]
Event Date: 10/05/2012
Event Time: 13:03 [EDT]
Last Update Date: 10/06/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JAMES TRAPP (R1DO)

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

Event Text

RPS AND PCIV ACTUATION DUE TO LOSS OF OFFSITE POWER

"On October 5, 2012, at 1303 hrs. EDT James A. FitzPatrick Nuclear Power Plant (JAF) experienced a loss of offsite power during its planned refueling outage. This resulted in the Reactor Power System (RPS) receiving a valid actuation of containment isolation valves in more than one system. All control rods were fully inserted when the full scram signal occurred. In addition, the four Emergency Diesel Generators (EDG) started in response loss of power but the EDG 'A' output breaker did not automatically close. Investigations are underway.
"The following systems were automatically isolated:
- Reaction Water Clean-up (RWCU)
- Drywell Floor Drain
- Drywell Equipment Drain

"The following systems were automatically actuated:
- 4 Emergency Diesel Generators (EDG)

"All systems functioned as required except as noted above. JAF remains in Mode 5.

"In addition, a major loss of Emergency Response communication capability has occurred. Some of the systems not available include: Emergency Notification System (ENS), Health Physics Network (HPN), and commercial phone communication."

The licensee has notified the NRC Resident Inspector.

* * * UPDATE FROM MARK HAWES TO CHARLES TEAL AT 1637 EDT ON 10/6/12 * * *

"On October 5, 2012, at 2011 hrs. EDT, James A. FitzPatrick Nuclear Power Plant (JAF) restored 345 kv backfeed qualified offsite power line and restored non-vital power. One of the two newly installed 115 kv Reserve Station Transformers experienced a lockout signal for an unknown reason which caused an isolation signal disconnecting offsite power. The Emergency Diesel Generators (EDG) started in order to provide vital power to plant systems. Both 115 kv Reserve Station Transformers have been removed from service and corrective actions are resolving this issue and the failure of the EDG 'A' output breaker to close. The EDGs are in standby. The current state of JAF is normal, Refueling Outage mode 5.

"In addition, Emergency Notification System (ENS), Health Physics Network (HPN), and commercial phone communication have been restored and verified functional. The Emergency Plan is functional."

The NRC Resident Inspector has been informed. Notified R1DO (Trapp).

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Power Reactor Event Number: 48387
Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: BLASE BARTKO
HQ OPS Officer: CHARLES TEAL
Notification Date: 10/06/2012
Notification Time: 17:07 [ET]
Event Date: 10/06/2012
Event Time: 16:35 [EDT]
Last Update Date: 10/06/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
JAMES TRAPP (R1DO)

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

Event Text

ONE OF SIXTY SIX REACTOR VESSEL PENETRATIONS DID NOT MEET ACCEPTANCE CRITERIA

"On 10/6/2012 during the Beaver Valley Power Station Unit No. 2 (BVPS-2) refueling outage, it was determined that the results of planned ultrasonic (UT) examinations performed on one of the 66 penetrations of the reactor vessel head would not meet the applicable acceptance criteria. This penetration will require repair prior to returning the vessel head to service. The indications are not through wall and there was no evidence of leakage based on inspections performed on the top of the reactor vessel head. The examinations were being performed to meet the requirements of 10CFR50.55a(g)(6)(ii)(D) and ASME Code Case N-729-1, to find potential flaws/indications well before they grow to a size that could potentially jeopardize the structural integrity of the reactor vessel head pressure boundary. Currently 60 of 66 penetrations have been examined, with 59 satisfactory; all of the penetrations will be examined during the current refueling outage.

"The plant is currently shutdown and in Mode 6 and the reactor vessel head is not currently installed. Repairs are currently being planned and will be completed prior to startup.

"This is reportable pursuant to 10CFR50.72(b)(3)(ii)(A) since the as-found indications did not meet the applicable acceptance criteria referenced in ASME Code Case N-729-1 to remain in-service without repair.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 48388
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [ ] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: JACK BREEN
HQ OPS Officer: VINCE KLCO
Notification Date: 10/08/2012
Notification Time: 02:37 [ET]
Event Date: 10/07/2012
Event Time: 21:40 [EDT]
Last Update Date: 10/08/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
KATHLEEN O'DONOHUE (R2DO)

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

Event Text

ESSENTIAL BUS DEENERGIZED WHILE DEFUELED

"On October 7, 2012, with Unit 2 in a defueled condition, a differential current lockout occurred on the 2B3 4.16kV essential bus, causing a deenergization of the 2B3 4.16kV essential bus. At the time of the event, the 2B Emergency Diesel Generator (EDG) was loaded to the essential bus. Due to the differential current lockout, all bus loads were lost and the 2B EDG output breaker feeding the essential bus opened and the 2B EDG transferred to emergency mode. The 2A EDG is operable and in standby. All equipment responded as expected. The plant is currently being maintained in a defueled condition. Decay heat removal is being supplied by the 2A Fuel Pool Cooling train. The cause of the differential current lockout of the 2B3 4.16kv bus is under investigation.

"This event is reportable pursuant to 10CFR 50.72(b)(3)(iv)(A)."

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Tuesday, October 09, 2012
Tuesday, October 09, 2012