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Event Notification Report for May 20, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/19/2005 - 05/20/2005

** EVENT NUMBERS **


41584 41704 41715 41717 41720

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 41584
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: QUENTIN HICKS
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/10/2005
Notification Time: 11:46 [ET]
Event Date: 04/10/2005
Event Time: 05:00 [EST]
Last Update Date: 05/19/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JAMES NOGGLE (R1)

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

Event Text

SCRAM SIGNAL RESULTING FROM FAILURE OF A SUPPLY VALVE TO THE SCRAM AIR HEADER

"Nine Mile Point Unit 1 received a valid RPS SCRAM signal from high water level in the SCRAM Dump Volume (SDV). While restoring the Hydraulic Control Rod Unit (HCU) for control rod 02-35 to service, the internals to the plug valve for the Instrument Air Supply (116 Valve) to the SCRAM Inlet and Outlet valves failed. This failure caused an approximate 1/2" hole in the SCRAM Air Header, which resulted in the SCRAM Air Header pressure lowering rapidly due to the leak.

"Operators at the HCU recommended isolating the SCRAM Air Header. The Shift Manager was contacted by the job supervisor and received permission to isolate the SCRAM Air Header. SCRAM inlet and outlet valves opened, SDV vents and drains closed due to the loss of SCRAM Air Header pressure. Approximately 3 minutes after SCRAM Air Header depressurization, a full SCRAM signal occurred as expected due to the water level in the SDV. There was no fuel in the Reactor Vessel (RPV). No Control Rod motion occurred due to all Control Rods being inserted or isolated for maintenance.

"Immediate (8 Hour Non-Emergency) notification of this event being made as a result of the requirements of 10CRF50.72(b)3(iv)(A)."

The licensee stated that more information on the event can be found in Nine Mile Point Internal document DER - NM-2005-1565.

The license will be notifying the NRC Resident Inspector.

* * * RETRACTION PROVIDED BY LICENSEE (SHEEHAN) TO NRC (HELD) AT 1739 EDT ON 5/19/05 * * *

"The scram event that occurred on April 10, 2005 was not initiated from a "valid" scram initiation signal (i.e., none of the instrumentation signals identified in Technical Specification Table 3.6.2a triggered the scram). To the contrary, a valve on a CRD hydraulic control unit (HCU) failed and Operations took action to isolate instrument air from the scram air header. This operator action had the identical effect that a scram signal would have had - the scram air header completely vented through the broken valve and caused the scram inlet and outlet valves on the HCUs to open and the scram discharge volume vents and drains to close. At the time, the reactor was defueled and all control rods were either already inserted or properly removed from service for maintenance, thus, the event did not result in any control rod movement (i.e., the system had been properly removed from service and the safety function had already been performed). Subsequent to the initiating event, as per the design of the CRD and RPS systems, the scram discharge volume filled and a full RPS scram signal was generated.
Conclusion:
The scram event that occurred on April 10, 2005, resulted from an invalid scram initiation signal. At the time, the reactor was defueled, the CRD system had been properly removed from service and the safety function had been properly performed (no control rods moved). Thus, pursuant to the guidance in NUREG-1022, it is appropriate to conclude that the event is not reportable under 10CFR50.72(b)(2)(iv) or 10CFR50.73(a)(2)(iv). As such, the 8-hour ENS notification that was made at 11:46 on 4/10/05 (reference Event Number #41584) is being retracted"

The licensee notified the NRC Resident Inspector.

R1DO (Bellamy) was contacted.

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General Information or Other Event Number: 41704
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: CHEM-BIO LABS INC.
Region: 1
City: HATTISBURG State: MS
County:
License #: MS-473-01
Agreement: Y
Docket:
NRC Notified By: BOBBY SMITH
HQ OPS Officer: PETE SNYDER
Notification Date: 05/17/2005
Notification Time: 15:19 [ET]
Event Date: 03/23/2000
Event Time: [CDT]
Last Update Date: 05/17/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RONALD BELLAMY (R1)
LARRY CAMPER (NMSS)

Event Text

AGREEMENT STATE REPORT - LOSS OF ELECTRON CAPTURE DETECTOR

The State provided the following information via email:

"During a routine inspection of Chem-Bio Laboratories, Inc. on March 23, 2000, it was determined that a Perkin Elmer Model 330-0119 electron capture detector, previously possessed by the licensee could not be located. The management representative explained that the owner/authorized user had removed that particular source from the device and placed in storage. She stated that she would continue to look for the source. Shortly after the inspector departed the licensee's facility, a call was made to the MSDH-Division of Radiological Health stating that the missing source had been found. During another routine inspection conducted on March 18, 2004, it was discovered that the source was never located. The licensee stated that she called again to inform someone at DRH that she had mistakenly informed the Agency about the source location and the source had never been found. She stated that she has made every effort possible to locate the source, but has not been successful. The licensee also stated that she was aware that a letter should have been sent to our Agency describing the circumstances surrounding the missing source, but failed to do so.

"Isotope: Nickel - 63
"Activity: 15 mCi (millicuries)
"Date Closed: 4-12-04

"State Event Number: MS-04-002

"Enforcement action taken: Violations cited for failure to secure radioactive material from unauthorized removal or access and failure to properly report lost source and provide a written report to the Agency."

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Power Reactor Event Number: 41715
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [ ] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: JAMES HURCHALLA
HQ OPS Officer: ARLON COSTA
Notification Date: 05/19/2005
Notification Time: 04:37 [ET]
Event Date: 05/18/2005
Event Time: 20:59 [EDT]
Last Update Date: 05/19/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
CHARLES R. OGLE (R2)

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

INADVERTENT DE-ENERGIZATION OF 4160 V SAFETY RELATED A.C. BUS WITH EDG AUTO START

"On 5/18/05 at 20:59 the 1A3 4160 V safety related A.C. bus inadvertently de-energized and the 1A Emergency Diesel Generator [EDG] automatically started and loaded onto the bus. The inadvertent de-energization of the 1A3, 4160 V bus appears to have resulted from testing of the 4160 V under voltage relays. Currently, normal power has been restored to the 1A3, 4160 V bus and the 1A Emergency Diesel Generator has been secured.

"This notification is being made pursuant to 10 CFR 50.72(b)(3)(iv)(A) to be completed within 8 hours as a safety systems actuation of the 1A3, 4160 V under voltage relaying and inadvertent start and load of the 1A Emergency Diesel Generator."

The licensee notified the NRC Resident Inspector.

* * * UPDATE PROVIDED BY THE LICENSEE (HURCHALLA) TO NRC (HELD) AT 2207 EDT ON 5/19/05 * * *

"On 5/18/05 at 20:59 the 1A3 4,160 KV safety related AC bus inadvertently de-energized and the 1A Emergency Diesel Generator (EDG) automatically started and loaded onto the bus. This event was initiated during the performance of a plant surveillance 1-OSP-100.07, to test the 1A3 4,160 KV Bus Under Voltage Relay. The 1A EDG loaded and carried the 1A3 bus. The 1B3 4,160 KV bus was unaffected and the "B" side power remained energized. This update is to provide the following additional information identified during the follow up investigation.

"This update is to identify that HVS-1B, Containment Fan Cooler, did not start as expected after the 1A EDG automatically loaded on the 1A3 4,160 KV Bus. The HVS-1A and HVS-1B were both load shed from the bus prior to closure of the 1A EDG output breaker. The HVS-1A did start as expected following closure of the EDG output breaker. The HVS-1B is on the three (3) second load block for the 1A EDG to restart, but did not start.

"A Root Cause Team has been formed to identify the cause of the initiating event and the auto-start failure of HVS-1B. A Condition Report was generated and a troubleshooting plan has been developed to determine the cause of the initiating event and failure of the HVS-1B to automatically restart.

"The 1B3 4,160 KV safety related AC bus and associated EDG were not affected by this event and remained operable during and following the event. Troubleshooting for the subject failed equipment is ongoing."

The licensee notified the NRC Resident Inspector.

The R2DO (Ogle) was notified.

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Power Reactor Event Number: 41717
Facility: HADDAM NECK
Region: 1 State: CT
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: RALPH F. COX
HQ OPS Officer: ARLON COSTA
Notification Date: 05/19/2005
Notification Time: 09:37 [ET]
Event Date: 05/19/2005
Event Time: 08:49 [EDT]
Last Update Date: 05/19/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
RONALD BELLAMY (R1)

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

Event Text

OFFSITE NOTIFICATION OF OIL SPILL

"Less that one pint of oil spilled to the ground/soil. Soil has been remediated. Offsite notifications made to CT State Police Message Center and CT Department of Environmental Protection."

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Hospital Event Number: 41720
Rep Org: BRYN MAWR HOSPITAL
Licensee: BRYN MAWR HOSPITAL
Region: 1
City: BRYN MAWR State: PA
County:
License #: 37-07722-04
Agreement: N
Docket:
NRC Notified By: MICHAEL BIEDA
HQ OPS Officer: JOHN KNOKE
Notification Date: 05/19/2005
Notification Time: 15:57 [ET]
Event Date: 04/17/2005
Event Time: 15:30 [EDT]
Last Update Date: 05/19/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
RONALD BELLAMY (R1)
CHARLES R. OGLE (R2)
CHRISTINE LIPA (R3)
REBECCA NEASE (R4)
THOMAS ESSIG (EMAIL) (NMSS)

Event Text

PART 21 REPORT - MALFUNCTION OF NOVOSTE INTRAVASCULAR BRACHYTHERAPY BETA-CATH SYSTEM TRANSFER DEVICE

During a medical procedure on a patient, two individual coronary artery locations were being irradiated with Sr-90 (2.05 GBq, serial # ZA-494. The device being used, Novoste Intravascular Brachytherapy Beta-Cath System Transfer (S/N# 90556], hereinafter called "Device", failed to work properly.

The licensee noticed the source did not retract into the Device. At this point the licensee pulled the entire catheter out of the patient, and within one minute was able to return the sources safely into the Device. It was assumed the problem was with the catheter and it's connection to the Device.

The licensee continued to the next location on the patient. Upon attempting to return the source, the licensee noticed the sources were not moving from the patient. Within 5-10 seconds, the licensee pulled the entire catheter from the patient, and then placed the entire system into the "bailout" box for proper shielding from beta radiation. The next day the licensee called Novoste and explained the events. Novoste determined it was a faulty Device and sent the licensee a replacement.

On May 19, 2005 the replacement arrived and the faulty device was sent back to the company.

Page Last Reviewed/Updated Friday, March 30, 2012
Friday, March 30, 2012