Event Notification Report for January 10, 2011

BOTH TRAINS OF AUXILIARY BUILDING VENTILATION BECAME INOPERABLE

"On January 10, 2011, at 1321 PST, Diablo Canyon Power Plant, Unit 2, entered Technical Specification Limiting Condition of Operation (TS LCO) 3.0.3, when both trains of Auxiliary Building Ventilation System (ABVS) became inoperable following closure of damper M-4 and the ensuing loss of both exhaust fans E-1 and E-2. TS LCO 3.0.3 was exited on January 10, 2011, at 1342 following a status reset and selection of fan E-2. This provided a ventilation flowpath and use of both exhaust fans in the Safeguards mode. Both trains of Auxiliary Building Ventilation are operable. This 8-hour non-emergency report is made pursuant to 10 CFR 50.72(b)(3)(v)(D)."

The unit is not in a TS LCO. All 3 unit EDG's are operable and offsite power is in the normal lineup.

The NRC Resident Inspector has been notified.


* * * UPDATE FROM WES FIANT TO DONALD NORWOOD AT 0021 EST ON 1/14/2011 * * *

"On January 13, 2011, at 1603 PST, engineering determined that a single failure design vulnerability exists at Diablo Canyon Power Plant Units 1 and 2.

"Engineering review of the control logic of the ABVS determined that while in Buildings Only (non-safeguards) alignment or during system realignment from Safeguards Only to Buildings Only alignment, failure of damper M-4A or M-4B (series dampers) could result in the control logic securing both ABVS exhaust fans. This would prevent ABVS actuation on receipt of a valid safeguards actuation signal. When this occurs, a control room alarm is actuated, which requires the operators to reset the control logic from the control room, thereby re-enabling the capability of the ABVS to respond to a safeguards actuation signal. The Unit 2 event on January 10, 2011, at 1321, occurred due to this single failure vulnerability when the control system attempted to restore the ABVS alignment from Safeguards Only to the Buildings Only alignment. This design vulnerability is currently mitigated by maintaining the ABVS in either of the two safeguards alignments (Safeguards Only or Buildings and Safeguards).

"This single failure design vulnerability is an 8-hour non-emergency report made pursuant to 10CFR50.72(b)(3)(ii)(B) for an event that resulted in the nuclear power plant being in an unanalyzed condition for both Unit 1 and Unit 2."

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

FITNESS FOR DUTY - CONTRACTOR CUSTODIAN FOUND WITH ALCOHOL INSIDE THE PROTECTED AREA

Alcohol was found in the possession of a contractor inside the protected area. The individuals access to the plant has been terminated. Contact the Headquarters Operations Officer for additional information.

LOCKING MECHANISM MALFUNCTION ON RADIOGRAPHY CAMERA

"On January 10th, the radiography crew working the Kuparuk Oil Field on the North Slope of Alaska experienced a malfunctioning locking system on an INC IR-100 exposure device (serial number 6631).

"During the shift the source was cranked in and the camera was surveyed per the proper procedure. There were no abnormal readings observed during the survey and the key was turned to the lock position. When the crank assembly was removed it was noted that the pigtail was not fully seated.

"The 2 mR/Hr boundary was reconfirmed and the night foreman was notified. The camera was surveyed and noted as being safe to transport. The camera was tagged out and placed in the permanent storage facility. A trained radiographer removed and cleaned the locking system. The locking system was successfully reinstalled. The camera has been returned to service.

"Exposure Device: Industrial Nuclear IR-100
Device SIN: 6631
Source SIN: 666928
Source Activity: 95 curies
Source Type: Ir192
Source Model # QSA 87703

"There was no exposure to the crew or the general public during this incident."

AGREEMENT STATE REPORT - SPOOL VALVE FAILURE ON IRRADIATOR

"A pool type irradiator experienced a drive mechanism failure on one of the two racks. This caused the 1.2 M Curie of Co-60 to remain stuck in the retracted position. It remained there for one hour until the operators discovered that a spool valve was stuck. Once the valve was freed the source rack returned to the pool as normal. The licensee is investigating the equipment malfunction and will submit further information when available."

There were no personnel injuries.

TX Incident No: I- 8809

* * * UPDATE FROM BLANCHARD TO KLCO ON 1/14/11 AT 1355 EST * * *

"At approximately 1900 [CST] on January 10, 2011, a licensee operating a pool-type irradiator in El Paso, TX, experienced a drive mechanism failure on one of two source racks. This caused the 1.2MCi of Cobalt-60 (Co-60) to fail to descend into the pool. The source rack remained in the lifted position for approximately one hour until the operators discovered that a spool valve was stuck. A piece of pipe was removed to allow the piston to vent, thus bypassing the valve. The source rack returned to the pool in a controlled, normal descent. The licensee is investigating the equipment malfunction and will submit further information when available.

"The initial report stated that the source rack had remained in the retracted position. Wording has been changed to more clearly describe, and clarify, that the source rack was stuck outside the pool (unshielded) for approximately one hour. There were no problems with the rack or the sources, the only issue was the spool valve malfunction."

Notified R4DO (Hagar) and FSME (Villamar)

UNAVAILABILITY OF TSC AND EOF FUNCTIONS DUE TO SCHEDULED MAINTENANCE

"At 0921 CST on Monday January 10, 2011, the Kewaunee Power Station (KPS) disabled electrical power to the KPS Technical Support Center (TSC) to perform motor control center maintenance. The major TSC components that were disabled include plant process control system (PPCS) workstations, primary lighting, and ventilation. In the Emergency Operations Facility (EOF), PPCS workstations have been disabled. Additionally, the dose projection program (MIDAS) does not have the capability to automatically populate with plant data. The safety parameter display system (SPDS) and emergency response data system (ERDS) remain operational. This activity has been evaluated in accordance with 10 CFR 50.54(q) to ensure that KPS will be able to deal with an accident or emergency should one occur. If required, existing procedural guidance will be utilized to relocate TSC personnel to predetermined alternate locations. A copy of emergency procedures and emergency telephone directories are staged in the alternate locations.

"The maintenance is scheduled to be completed by 1400 CST on January 10, 2011."

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM GARY AHRENS TO PETE SNYDER AT 1701 EST ON 1/10/11 * * *

At 1545 CST all of the functionality that was removed from service per the above notification was restored to service.

Notified R3DO (Kunowski).

AGREEMENT STATE REPORT - NUMEROUS MEDICAL EVENTS FROM PROSTATE BRACHYTHERAPY

The following was received from the state via fax;

"In July 2010, the Wisconsin Department of Health Services (DHS) sent out an Information Notice to all licensees who perform prostate brachytherapy and asked them to perform a comprehensive review of all prostate brachytherapy cases to determine whether any medical events had occurred. On January 10, 2011, the licensee's Radiation Safely Officer reported the identification of five medical events involving permanent implants of I-125 for prostate brachytherapy where the total dose delivered differs from the prescribed dose by 20% or more. The licensee is identifying a medical event of any case where D90<135 Gy or D90>195 Gy for patients who receive seed implants only. [D90 is a recognized value in the regulatory guidelines and means a dose of 90% to the prostate. Anything outside of the D90 value is considered to be a medical event.] The licensee performed a comprehensive review of all 44 prostate implants performed since August 2003. The licensee's five medical events include one overdose to the prostate and four underdoses to the prostate. All were patients who received seed implants only. No medical events were identified involving doses to other organs or tissue above 0.50 Sv and 50% more than the expected dose. The licensee has notified the referring physicians and will not be notifying the affected patients per DHS 157.72(1)(e).

"Overdoses (medical event criteria used: D90>195 Gy): 11/13/2008: 199.15 Gy

"Underdoses (medical event criteria used: D90<135 Gy):
2/9/2007: 100.20 Gy;
11/12/2007: 127.34 Gy;
6/16/2008: 130.12 Gy; and
7/13/2010: 116.16 Gy"


* * * UPDATE FROM CHRIS TIMMERMAN TO JOHN KNOKE AT 1212 EST ON 2/1/11 * * *

"This is an update to Event Notification 46528. The licensee recently performed post-implant dosimetry on seven prostate brachytherapy patients whose post-implant dosimetry had never been performed. Evaluation of these seven implants prompted the licensee to report two additional medical events. The medical events involved permanent implants of l-125 for prostate brachytherapy where the total dose delivered to the prostate differs from the prescribed dose by 20% or more. The licensee is in the process of notifying the affected patients and referring physicians.

"Underdoses (medical event criteria used: D90<135 Gy):
8/22/2005: 102.89 Gy; and
5/8/2006: 126.24 Gy;

"DHS will send a special inspection team to determine the root cause(s) of these medical events."

WI Event Report ID No.: WI 110001 Update

Notified FSME(Angela McIntire) and R3DO (Richard Skokowski)


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.

* RETRACTION FROM MEGAN SHOBER TO JOHN SHOEMAKER VIA FACSIMLE AT 1355 EST ON 3/1/11 *

"This is a second update to Event Notification 46528. The licensee is retracting an overdose previously reported for a patient who received a permanent prostate implant on November 13, 2008. During a reactive inspection conducted on February 18, 2011, DHS inspectors identified that post-implant dosimetry of prostate brachytherapy implants had not been performed appropriately. Specifically, the licensee's former physics consultant generated post-plans that were not based on the number of I-125 seeds actually implanted in the patients. For the patient in question, the original post-plan was based on an implant of 98 seeds; however, only 76 seeds were actually implanted. The licensee's current physicist generated a new post-plan using the correct number of I-125 seeds and observed a corresponding reduction in dose delivered. The new D90 value for this patient does not meet the licensee's medical event criteria."

WI Event Report ID No.: WI 110002, 2nd Update

Notified FSME(McIntosh) and R3DO (Dickson)

AGREEMENT STATE REPORT - PROSTATE BRACHYTHERAPY MISDOSING

The following information was received from the State of Wisconsin via fax:

"On January 10, 2011, the licensee's Radiation Safety Officer reported the identification of ten medical events involving permanent implants of I-125 for prostate brachytherapy where the total dose delivered differs from the prescribed dose by 20% or more.

"During a recent routine inspection, Department of Health Services inspectors determined that the licensee was not reviewing prostate brachytherapy cases against medical event criteria. The licensee is identifying as a medical event any case where D90<135 Gy or D90>195 Gy for patients who receive seed implants only, and D90<100 Gy or D90>145 Gy for patients who receive seed implants in conjunction with external beam therapy (combined therapy). The licensee performed a comprehensive review of all 82 prostate implants performed since August 2003. The licensee's ten medical events include six overdoses to the prostate and four underdoses to the prostate. No medical events were identified involving doses to other organs or tissue above 0.50 Sv and 50% more than the expected dose. The licensee has notified the referring physicians and will not be notifying the affected patients per DHS 157.72(1).

"Overdoses (medical event criteria used - D90>195 Gy): 12/23/2003: 204.95 Gy; 10/27/2004: 160.49 Gy {combined therapy, medical event criteria used - D90>145 Gy}; 1/20/2006: 211.23 Gy; 6/14/2006: 207.03 Gy; 9/5/2007: 205.7 Gy; and 10/17/2007: 210.47 Gy.

"Underdoses (medical event criteria used - D90<135 Gy): 9/26/2003: 123.03 Gy; 10/31/2003: 116.78 Gy; 1/14/2004: 126.73 Gy; and 3/31/2009: 123.74 Gy.

"DHS will send a special inspection team to determine the root cause(s) of these medical events on February 2, 2011."

* * * UPDATE FROM CHRIS TIMMERMAN TO JOHN KNOKE AT 1212 EST ON 2/1/11 * * *

"This is an update to Event Notification 46529. On January 31, 2011, the licensee retracted one medical event for a prostate brachytherapy patient treated on 3/31/2009 based on refined post-implant dosimetry. Further updates will be made through NMED.

"DHS will send a special inspection team on February 3 2011. "

WI Event Report ID No.: WI 110001 Update

Notified FSME (Angela McIntosh) and R3DO (Richard Skokowski)


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.

DAMAGED FIXED GAUGE SAMPLE WHEEL

The following report was received via fax.

"Licensee's RSO contacted DRH [Mississippi Department of Radiological Health] by letter to report a malfunction of the sample wheel mechanism in their basis weight fixed gauge (Model No. BWM-H Beta Gauge, Gauge Serial No. 25630138, Source Model No. Amersham Corporation Model SIC.L5, Source Serial No. HW338). The device manufacturer was contacted and a representative removed the original faulty basis weight source head and replaced it with a refurbished unit. The replacement did not function, so the original source head was repaired and reattached. A leak test, survey and inspection were all conducted. As a precaution, the licensee ordered a refurbished source head and the manufacturer's representative came out to replace the original faulty source head. A leak test, survey and inspection were conducted. Leak tests revealed no contamination and surveys were normal."

Source: Sr-90, 15 mCi

Mississippi Tracking Number: MS-11002

PART 21 NOTIFICATION OF POTENTIAL DEFECT FOR OVERCURRENT RELAYS

The following information was received by facsimile:

"This letter is submitted in accordance with 10 C.F.R º 21.21(d)(3)(ii) with respect to a failure to comply with the specifications associated with the COM 5, COM 9, and COM 11 Overcurrent Relays. The style numbers for the COM 5 relay are 1326D81A07A. 1326D81A05A, 1326D81A01, 1326D81A02, 1329D12A02, 1329D12A01, 1329D12A06, 1326D81A08, 1329D12A07, 1329D12A05, 1329D12A06, 1329D12A08, 1329D12A09, 1326D81A08A, and 1326D81A09A. The style numbers for the COM 9 relay are 1326D81A10A and 1326D81A10. The style numbers for the COM 11 relay are 1329D12A03, 1326D81A03, and 1326D81A03A.

"The notifying individual is Mr. Pat Wilkinson, General Manager, ABB Inc. (Distribution Automation), 4300 Coral Ridge Rd, Coral Springs FL, 33065.

"Notification regarding the subject relays is as follows: The failure to comply centers around the seismic specification of the COM 5, COM 9, and COM 11 relays. The Zero Period Acceleration (ZPA) rating for the COM 5, COM 9 and COM 11 relays were incorrectly being certified to meet a ZPA rating of 5.6g. The relays only meet a ZPA rating of 3.6g.

"On December 14th, 2010, ABB's Engineering Group, while performing a document review of the ABB's CTR-COM-5 Qualification Conclusion Report, discovered the incorrectly reported ZPA rating. The deviation was identified as a potential defect on January 10, 2011.

"The COM family relays were originally seismically qualified by Westinghouse on July 11, 1977 with a ZPA rating of 5.7g. A second seismic qualification test was performed by an outside vendor on September 12, 2001 with a reported ZPA rating of 3.6g. ABB then transferred the vendor information to its own conclusion report: CTR-COM-5 signed December 14, 2001. The CTR-COM-5 conclusion report incorrectly transcribed the ZPA rating of 3.6g from the outside vendor. The CTR-COM-5 conclusion report is the basis for ABB's Relay Selection disk, used by ABB Marketing, and ABB's quality Certificate of Conformance.

"The root cause of this issue was determined to be inadequate review and transfer of the outside vendor's seismic test data.

"ABB is taking, or has taken, the following corrective actions:

- Correct CTR-COM-5 conclusion report to 3.6g ZPA (Engineering completed request on January 11, 2011 )
- Contact all customers with potentially affected open Purchase Orders to ensure acceptance of the 3.6g ZPA rating. Orders on hold until acceptance. (Sales to complete by January 21, 2011)
- Update Certificate of Conformance template for the affected style numbers to reflect 3.6g ZPA. (Quality Assurance completed request on January 13, 2011)
- Perform a review of all qualification reports to ensure all ZPA ratings for all product families are correctly reported (Engineering to complete by February 14, 2011)
- Identification of potentially affected customers (Marketing to complete by February 15, 2011)
- Notification of potentially affected customers (Marketing to complete by February 28, 2011).
- Correct ZPA rating on the Relay Selection Disk to 3.6g ZPA (Marketing to complete by October 30, 2011)

"The customers and the quantity data are still being collected at this time. Depending upon a Licensee's specified ZPA requirements, the lower ZPA rating of relays could possibly create a substantial safety hazard. If a higher ZPA rating is required by the Licensee, please contact ABB Coral Springs Customer Support at 1-800-222-1946 or (954) 825-0606 on available solutions.

"If you have any questions regarding this notice, please contact the Quality Manager, Mr. Chad Buchwalter, directly at (954) 825-0604."

* * * UPDATE FROM CHAD BUCHWALTER TO HOWIE CROUCH VIA FAX ON 2/8/11 @ 0857 EST * * *

ABB Inc. updated their initial report to state that they had previously made 10 CFR 21.21 notifications on ZPA deviations for the COM relays (see EN #30753). Additionally, they provided a list of customers who may have received the subject relays. No nuclear power plants were listed on the customer roster.

Notified R1DO (Bellamy), R2DO (Hopper), R3DO (Duncan), R4DO (Clark) and Part 21 Group via email.