Event Notification Report for June 03, 2011

UNEXPECTED EMERGENCY DIESEL GENERATOR ACTUATION

"On 6/3/2011 at 0039 hours, during the performance of a work order to test components associated with Service Water Isolation, Emergency Diesel Generator (EDG) 'A' unexpectedly started automatically and its supply breaker to Safeguards Bus 14 closed. The Control Room staff observed normal voltage on Diesel Generator 'A'. Bus 14 voltage was never lost during this event, however, they also noted an associated Bus 14 undervoltage annunciator on the Main Control Board. Seconds later, Emergency Diesel Generator 'A' tripped on Reverse Power and its supply breaker to Bus 14 tripped open. The initiating action was the removal of the Bus 14 Normal Feed Breaker Control Power Fuses as part of the work order package.

"The Ginna EDG's have the following automatic start signals and logic: manual, safety injection signal (1/2 trains), undervoltage on respective safeguards bus, 'A' EDG Bus 14 or 18 (1 out of 2 degraded voltage + 1 out of 2 loss of voltage), 'B' EDG Bus 16 or 17 (1 out of 2 degraded voltage + 1 out of 2 loss of voltage).

"Investigation has commenced to determine the cause of the EDG start and undervoltage signal.

"The NRC Resident Inspector has been notified."

* * * RETRACTION ON 7/26/11 AT 1214 EDT FROM SLABY TO HUFFMAN * * *

"The purpose of this report is to retract the event discussed in Emergency Notification System report #46917 submitted on June 3rd, 2011. The ENS notification reported an unexpected start of Emergency Diesel Generator `A' during testing of a service water valve isolation circuit. As reported, Emergency Diesel Generator 'A' unexpectedly started and its supply breaker to Bus 14 closed. Seconds later, the Emergency Diesel Generator tripped on reverse power and its output breaker to Bus 14 opened. At the time of the event it was not understood why the diesel generator started. Subsequent troubleshooting and causal investigation identified that the signal was caused by a degraded control relay that unexpectedly changed state when control power was removed. This relay was expected to remain mechanically latched and would have remained in the desired position had control power not been removed as part of the test. Bus 14 voltage remained in the normal operating range throughout the event. Since this was not a valid undervoltage signal, the June 3rd, 2011 event is being retracted. A follow-up report will be made in accordance with 10CFR50.73(a)(1) and 10CFR50.73(a)(2)(iv)."

The NRC Resident Inspector has been notified. R1DO(Henderson) notified. See related EN #47094.

AUTOMATIC SCRAM FOLLOWING A TURBINE TRIP

"Limerick Unit 1 automatically scrammed from 100% power at 1021 EDT hrs on 6/3/11. The RPS actuation occurred as designed upon an automatic trip of the Main Turbine. The cause of the Main Turbine trip is under investigation. Plant response to the Main Turbine trip was per design without complications.

"All control rods fully inserted. No ECCS or RCIC initiations occurred. No Primary or Secondary Containment isolations occurred.

"The plant is currently in Hot Shutdown with the normal Feedwater system maintaining reactor water level, and the Main Turbine Bypass valves maintaining reactor pressure.

"Limerick Unit 2 was unaffected."

The post-scram electrical alignment is normal.

The licensee has notified the NRC Resident Inspector and plans to notify appropriate state and local authorities. The licensee is also planning a press release.

AGREEMENT STATE REPORT - MISSING DEVICES POSSIBLY MIXED WITH SCRAP METAL

The following information was sent by the State of Florida Bureau of Radiation Control via email:

"[The licensee's two] fill detectors were bought in the 1990's and were not in use. The fill detectors were stored in a spare room full of scrap metal. The room was cleaned out in early May and the scrap sent to Alpha Metal Recycling, 2392 NW 147 Street, Opa-Locka, Florida 33054. The recycling plant manager said that the load has already been sent overseas to either China, Pakistan or India. Loss of the material was found when the application for license renewal was being filled out. The licensee will send a written report to Radioactive Materials. Any further action is referred to Radioactive Materials. This office will take no further action on this incident."

The two fill detector sealed sources each contained 100 mCi of Am-241 and were manufactured by Industrial Dynamics (Fil Tech; Model Number FT50; Serial Numbers 1296 and 126).

Florida Incident: FL11-045

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

Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)

INVALID ACTUATION OF EMERGENCY DIESEL GENERATOR

"This report is being made per paragraphs 50.73(a)(1) and 50.73(a)(2)(iv)(A) to address an actuation of Emergency Diesel Generator 'A' on June 3rd, 2011 while performing service water valve isolation signal testing. Emergency AC Electrical power system, including emergency diesel generators, is a system named in 50.73(a)(2)(iv)(B).

"During a refueling outage, testing was in progress to verify that service water isolation valves received the proper close signal during a safety injection. The test configuration required pulling control power fuses for the Bus 14 normal supply breaker to prevent operation and allow for manual relay actuation. Within seconds of pulling these fuses, the control room received a Bus 14 undervoltage annunciator, Emergency Diesel Generator 'A' started, and the generator output breaker closed onto Bus 14. Upon further investigation, the cause of this signal was identified as a degraded control relay that failed to mechanically latch and unexpectedly changed state when control power was removed. This resulted in an invalid undervoltage signal. Bus voltage remained within normal operating range. Given that the diesel generator was in unit mode of operation and was not fully synchronized with the normal bus supply, the diesel generator tripped shortly after starting due to a valid reverse power signal. A field verification and technical review was performed to ensure that this condition did not cause significant stress on the generator or engine.

"This start signal is considered an INVALID signal with respect to 50.73(a)(2)(iv)(A), however the system was not fully removed from service. The 'B' train was not affected by this event. The actuation was considered complete since all necessary components responded to the undervoltage signal as expected under the actual field conditions. The control relay would have remained in the desired position and performed its required function under design conditions with normal control power available. Therefore the degradation was not determined to have an impact on the safety function."

The NRC Resident Inspector was notified. See related EN #46917.

AGREEMENT STATE REPORT - MEDICAL EVENTS INVOLVING PROSTATE SEED IMPLANTS

The following information was obtained from the Commonwealth of Kentucky via fax:

"KY RHB [Radiation Health Branch] was notified via e-mail by the Medical Physicist of the facility of two past medical events. The medical events involved two patients treated for prostate cancer with I-125 and Pd-103 seeds for which the Medical Physicist had developed the treatment plans. The Radiation Oncologist and the Urologist, who performed the procedures determined the dose delivered to the target organ based on D90 was less than 80% using the Variseed Treatment Planning software. The Radiation Oncologist who contoured the prostate and determined the post implant D90 doses, was not aware that a D90 less than 80% of the prescribed dose was a medical event that required reporting to the Radiation Health Branch. The patient treated on 6/3/11 was treated with 101 Bard STM1251, I-125 seeds (0.37 mCi/seed) monotherapy and received a D90 of 76.7%. The intended dose to the prostate was 145Gy and the administered dose was 111.2Gy. The second patient was treated on 4/12/12 with 73 seeds of Theraseed Model 200, Pd-103 (1.1 mCi/seed) as a part of a boost therapy to IMRT [Intensity Modulated Radiation Therapy]. This patient received a post implant D90 of 68.3%. The intended dose to the prostate was 90Gy and the administered dose was 61Gy. The Medical Physicist discovered these two medical events after performing an audit of the facility's permanent implant prostate brachytherapy program since its inception for a total of 71 patients. The State will continue to keep NRC informed of the status of our investigation.

"KY Event Report ID No: KY120013"

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.