Event Notification Report for April 21, 2004

FAIRBANKS MORSE ENGINE HAS DETERMINED A POTENTIAL SAFETY HAZARD WITH THE WOODWARD DIGITAL REFERENCE UNIT (DRU)

On April 21, 2004, Fairbanks Morse Engine evaluation determined a potential safety hazard exists for Woodward DRU's. The FM P/N is 12998236 and the Woodward P/N is 9903-439.

The defect exhibits erratic ramp up of speed and hence the inability to reach rated RPM and inability to apply load to the engine. The cause has been traced to a random contamination problem of an integrated circuit (IC) in DRU's manufactured by Woodward between November 2000, and January 2002.

The rate of occurrence is less than 10 in the US and approx 20 worldwide. There are approx 38,000 Woodward units worldwide that use this IC. Only one US nuclear utility has experienced this failure and the failure occurred during testing prior to declaration of operability. In all cases, the failure occurs within a very few hours of operation. Therefore, if a DRU has been installed and has been operating for many hours/years, it is not at risk for this failure.

The utilities that FM has supplied DRU's to in the timeframe identified that may be affected include the following:

Utility Site Year Shipped
FP&L Seabrook 2001
WCNOC Wolf Creek 2001

The above utilities are also being notified and affected DRU's will have IC's replaced as necessary.

* * * UPDATE FROM STEVENSON TO KNOKE AT 17:52 ON 01/12/06 * * *

"Fairbanks Morse Engine evaluation has determined a potential safety hazard exists for Woodward Digital Reference Units (DRUs). The FM P/N is 12998236, and the Woodward P/N is 9903-439. A list of specific affected S/N's is identified in the letter dated 01/12/06.

"The defect exhibits erratic ramp up of speed and hence the inability to reach rated RPM and inability to apply load to the engine. The cause has been traced to a random interaction between solder flux and integrated circuit (IC) material causing chip delamination. This condition is further described in Woodward Service Bulletin 01363, dated December 2005.

"This same problem had been previously reported on 4/23/04, and at that time was thought to only affect DRU's manufactured between November 2000 thru January 2002. The manufacturer thought they had purged their stock of the specific IC chips that manifested the problem, but additional chips have been found in their system that now extends the affected time period to December 2005.

"DRU's that have had IC chips replaced per the earlier 10 CFR 21 notification are not affected due to the use of a different solder flux that does not introduce the problem.

"The utility that FM has supplied DRU's to in the timeframe identified that are affected Include the following:

Utility Site

Detroit Edison Fermi
First Energy BV-2
SCE&G VC Summer

"The above utilities are also being notified and affected DRU's will have IC's replaced as necessary."

Notified R1DO (Conte), R2DO (Munday), R3DO (O'Brien), NRR EO (Mayfield), and emailed and faxed to Part 21 Coordinator (Tabatabai)

RADIOACTIVE SURFACE CONTAMINATION GREATER THAN LIMITS

A package that exceeded the limits for removable radioactive surface contamination was received April 21, 2004, by VA Chicago Health Care System , a permittee authorized under the master materials license issued to the Department of Veterans Affairs, NRC License 03-23853-01VA.

The basis for reporting the contamination is under 10 CFR 20.1906(d)(1) in that the package, an ammo box being used to deliver radioactive materials, had approximately 80.9 disintegrations per minute per square centimeter removable radioactive contamination on the outside. The contamination was identified as Tc 99M. The Cardinal Health Nuclear Pharmacy Services delivered the package. The status of whether the vendor delivery vehicle was exclusive use was not determined. The ammo box has been decontaminated.

The permittee's Radiation Safety Officer notified the delivery vendor about the package.

PART 21 NOTIFICATION INVOLVING VOLTAGE MONITORING RELAYS

"The following information is provided pursuant to the requirements of 10 CFR Part 21 to report a potential safety concern. A potential safety condition may exist with the Eaton Cutler-Hammer D65 Series B1 Voltage Monitoring Relay that can cause the unit to bypass the Manual Reset feature. This could result in the D65 relay being energized without an operator manually resetting it resulting in possible personal injury or death or property damage. This condition exists with Eaton Cutler-Hammer D65 Series B1 Voltage Monitoring Relays with a manufacturing date between May 12, 2002, and February 20, 2004.

"On March 25, 2004, Framatome/AREVA Electrical Products received the attached Eaton Cutler Hammer Product Safety Warning for D65 Voltage Monitoring Relays, dated March 24, 2004. The Product Safety Warning states that Eaton's Cutler-Hammer D65 Series B1 Voltage Monitoring Relays with a manufacturing date identified above may power up without being manually reset even when a NC [Normally closed] switch is wired to activate manual reset mode. This condition is only present when used in applications operating in the manual reset mode. This condition is not present when the device is used in automatic reset mode. This condition may only result when the D65 Series B1 is used and will not result if the A1 Series is used (as the A1 series did not offer the potential for manual reset).

"The supply of Safety Related D65 Voltage Monitoring Relays by Framatome/AREVA Electrical Products is isolated to only one Nuclear Customer (i.e. First Energy - Davis Besse Nuclear Power Plant). The First Energy Davis Besse Nuclear Power Plant was notified by Framatome/AREVA Electrical Products on April 2, 2004."

AGREEMENT STATE REPORT INVOLVING LOST GENERAL LICENSE SOURCE MATERIAL

"The licensee called to report that a Filtec FT-50 fill level gauge, serial number, 112082, containing 100 millicuries of Am-241 in sealed source, serial number 4473, could not be located during inventory. The unit was removed from a manufacturing line in June, 1995 and stored in a building along with other idle equipment. During a recent project to clean this building and dispose of old equipment, the licensee was unable to locate this unit. An extensive search was conducted throughout the facility and the gauge could not be located. Personnel who may have had knowledge of the unit were interviewed. The last documented time that the gauge was seen in storage was in January 1998. The licensee believes that the unit was discarded with other idle equipment. The manufacturer's records indicate the source was not returned to them. Inspectors [Tennessee Division of Radiological Health] are enroute to the facility to investigate."

IRRADIATOR SOURCE RACK JAMMED IN THE UP POSITION

At 1200 EDT operators were lowering a source rack when it jammed due to a maintenance ladder. The licensee entered their emergency procedure and contacted the manufacturer, i.e., MDS Nordion, for assistance. MDS Nordion is expected onsite at 1040 EDT tomorrow 4/22 to help the licensee develop a recovery plan. The stuck source rack contains approximately 2,030 curies of Co-60. The maze is closed restricting personnel access. There were no personnel exposures associated with this occurrence.

A conference call with the Baxter Plant Manager and NRC staff was established to discuss the details of this report.

* * * UPDATE ON 04/24/04 @ 1424 BY ANGEL ALICEA TO CHAUNCEY GOULD * * *

The licensee reported that at 2000 on 04/23/04 the source was placed in the shielded position submerged in 25 ft of water in the pool. They are terminating this event.

Notified Tom Decker, George Pangburn, Frank Costello, Cathy Modes, and Betsey Ullrich

* * * UPDATE ON 4/27/04 @ 1129 EDT FROM A. ALICEA TO HOWIE CROUCH * * *

The licensee reported that a re-enactment of the event indicates that two plant employees may have been over-exposed during the initial event. The licensee is conservatively reporting this update under 10 CFR 20.2202 (b)(1) since the exposure value is unknown but believed to be less than 5 rem. Personnel dosimetry is being analyzed and the calculations are being verified by the contractor at the site. The licensee will update this event when the exposure data is known. The licensee has informed the on site Regional Materials Inspector (Diaz).

Notified NMSS (Fred Brown) and R1DO (Richard Barkley).

LICENSEE PLANS TO ISSUE NEWS RELEASE REGARDING AN ACCOUNTABILITY DISCREPANCY OF SNM

The following is the text of the planned press release:

"Entergy Vermont Yankee Press Release

"Fuel Rod Segments at Vermont Yankee Unaccounted For

"BRATTLEBORO, VT -- In response to a recent NRC inspection, Entergy Vermont Yankee has determined that two short spent fuel rod segments are not in their documented location in the spent fuel pool. Entergy engineers are reviewing storage records and performing a thorough inspection of the spent fuel pool to determine the location of the rod segments.

"One of the segments is about the length and diameter of a pencil and the other is the same diameter and about 17 inches long. According to station documentation, in 1979, the highly radioactive rods were placed in a special stainless steel container in the spent fuel pool after a fuel inspection to address fuel cladding deficiencies.

"Vermont Yankee has an extensive system of radiation monitors and, due to the radioactive nature of the material, the segments could not have been inadvertently removed from the pool in anything other than a container specifically designed and licensed to contain radioactive material. Therefore, public health and safety is not at risk as a result of this issue. Entergy Vermont Yankee will continue to keep the Nuclear Regulatory Commission and state authorities informed on the progress of the investigation.

"The Vermont Yankee spent fuel pool is 40 feet in depth and contains 2,789 spent uranium fuel assemblies that were used in energy production since 1972. Vermont Yankee is presently shut down for its twenty fourth refueling and maintenance outage."

The licensee informed the NRC Resident Inspector.

MANUAL REACTOR SCRAM IN RESPONSE TO HIGH MAIN TURBINE VIBRATION DURING STARTUP

"At 1635 on 04/21/2004, Susquehanna Unit 1 was returning to service from its 13th Refueling and Inspection Outage which included main turbine replacement. During start-up turbine testing with the generator off line, several main turbine bearings experienced high vibration. In response to these high vibrations, the reactor was manually scrammed from approximately 17% power. The main steam line isolation valves were manually closed and main condenser vacuum was broken in order to more rapidly slow the main turbine speed.

"All control rods fully inserted on the SCRAM, a level 3 containment isolation signal was received as expected. RCIC was manually initiated to control reactor water level. Lowest reactor water level reached was approximately 3" narrow range. There were no radioactive releases.

"This RPS actuation is reportable under 10CFR50.72(b)(2)(iv)(B) as an 'Unplanned RPS Actuation with the Reactor Critical.' The RPS Actuation and the RCIC injection are reportable per 10CFR50.72(b)(3)(iv)(A) 'Unplanned Actuations of Systems that Mitigate the Consequences of Significant Events.'

"Investigation into the high main turbine bearing vibrations is ongoing."

The main turbine was tripped prior to the manual scram and no SRVs have lifted due to low decay heat level. The electric plant is in a normal lineup.

The licensee notified the NRC Resident Inspector and the PEMA representative.

MISSING DEPLETED URANIUM SHIPPING SHIELD

The licensee reported that an empty 45.7 lb. depleted uranium shipping shield could not be located. The shield was last reported as being shipped back to St. Louis from Mallinckrodt's Beltsville, MD facility on 5/10/03. After an investigation as to the possible location of the shield conducted in early 2004, it was declared lost on 4/21/04. The licensee has contacted NRC Region 3.