Event Notification Report for February 15, 2011

PART 21 REPORT - MISALIGNED BELL ALARM SWITCH BRACKETS ON 480 VAC CLASS 1E CIRCUIT BREAKERS

"The following event description is based on information currently available. The condition is being reported under 10 CFR 21.21(d)(1).

"On February 15, 2011, Palo Verde Nuclear Generating Station (PVNGS) completed an evaluation of prior deviations related to the alignment of bell alarm switches that were installed by the manufacturer Asea Brown Boveri / ITE Imperial Company (ABB) on K-600S 480 VAC Class 1E circuit breakers. Had the breakers been placed into service as received, the misaligned bell alarm switch brackets could have prevented the automatic or remote closure of the breakers installed in safety-related applications. The station concluded the deviations were defects that are reportable per 10 CFR 21. The discussion below provides the technical details that were discovered for the bracket misalignments and the circumstances for the breakers in which this condition was identified.

"The ABB K-600S breakers contain a protective indication feature related to the overcurrent trip. An overcurrent trip actuates a reset indicator which moves an armature roller away from the bell alarm switch (ABB part number 706747-T07/BBC) to open the alarm switch contact. The alignment of the bell alarm switch bracket affects the range of contact between the bell alarm switch and the reset indicator armature. This alignment is critical because the vibration of breaker closure can cause the switch and the armature to lose contact momentarily to create an unintended 86 lockout and trip the breaker open during the closure sequence. The breaker will not be able to be reclosed until the 86 lockout and the bell alarm switch have been manually reset. This defeats the safety function of the breaker to provide power to the supported component.

"When the condition was identified, the station adjusted the bell alarm switch brackets (ABB part number 709827A00) on the breakers to correct the condition. The breakers were inserted into the intended breaker enclosures after further testing. The breakers were not returned to ABB.

"The first condition that was known to have been documented in the corrective action program was discovered during pre-service testing that occurred on November 5, 2009 . The breaker had been refurbished by ABB and was accepted by PVNGS Quality Control Receiving on October 2, 2009. A similar condition occurred on October 21, 2010, on a new breaker that was accepted on June 3, 2010. The untimely evaluation and defect reporting have been entered into PVNGS's corrective action program.

"This condition has not resulted in any reportable failures of in-service safety-related breakers under 10 CFR 50.73. The extent of this condition has been evaluated under an operability assessment and corrective actions to inspect potentially affected in-service breakers are in progress .

"The manufacturer and refurbisher, ABB, has been notified and since has provided tolerance information and instructions for inspection and adjustment of the bracket alignment .

"The use of ABB / ITE K600S breakers is common throughout the industry in nuclear safety-related applications. The station is unaware of which other licensee's use the bell alarm switch to actuate an 86 lockout feature. The station has not provided any of these breakers from its own stock to any other licensee.

"The PVNGS reporting officer was notified on February 22, 2011."

The licensee notified the NRC Resident Inspector.

MISSING TC-99 GENERATOR

The licensee was shipping a 16 Curie MO-99/TC-99 Generator inside a 49 lb depleted uranium cask with an activity level of 8.09 millicuries of U-238 to a customer in Port Huron, Michigan. Shipping documents indicate that the ground courier (Associated Couriers, Inc.) had taken custody of the shipment from the air courier (AirNet) and transported it to its warehouse near Detroit, Michigan. When the ground courier went to make delivery of the device to the customer, the shipment could not be located. The licensee has contacted both the ground courier and air courier as well as the customers along the delivery route in an attempt to find the device.

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

OFF-SITE NOTIFICATION OF SEWAGE SPILL CONTAINED ON-SITE (<100 GALLONS)

"On February 15, 2011, at about 0830 PST, approximately 65 gallons (calculated maximum of 98 gallons) of partially treated sewage spilled on the ground and into a concrete ditch at San Onofre Nuclear Generating Station (SONGS) at the Mesa area while cleaning up from the plant overflow on 2-11-11. The spill was contained, vacuumed up, and returned to the sewage treatment plant. At approximately 1140 PST, Southern California Edison notified the San Diego Regional Water Quality Control Board, and the San Diego County Department of Environmental Health was notified at 1220 PST.

"Unit 2 is operating at approximately 100% power and Unit 3 is in Mode 3 after a steam generator replacement and refueling outage."

The licensee will notify the Resident Inspector.

AGREEMENT STATE REPORT - POSSIBLE MEDICAL EVENT DUE TO MISADMINISTRATION

This is a preliminary report. Details will be provided at a later date.

During a general chart review, the licensee discovered that two pediatric patients were administered doses of P-32 albumin that appear to be in excess of 100% of the prescribed doses. The first event occurred approximately four months ago. The second event occurred approximately two months ago. These events may have each provided 1000 Rads excess dose to target tissue. The events may or may not involve a dispensing error. The doses were administered to tissue surrounding extremity joints of the two pediatric patients.

Physicians do not expect any patient impact or unfavorable outcome from these misadministration.

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.