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Event Notification Report for January 13, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/12/2006 - 01/13/2006

** EVENT NUMBERS **


40699 42253 42254

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General Information or Other Event Number: 40699
Rep Org: FAIRBANKS MORSE ENGINE
Licensee: FAIRBANKS MORSE ENGINE
Region: 3
City: BELOIT State: WI
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TODD COLLINS
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 04/23/2004
Notification Time: 12:41 [ET]
Event Date: 04/21/2004
Event Time: [CDT]
Last Update Date: 01/12/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
DAVID HILLS (R3)
DAVID SILK (R1)
RUSSELL BYWATER (R4)
VERN HODGE (NRR)

Event Text

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)

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Hospital Event Number: 42253
Rep Org: NEW BRITAIN GENERAL HOSPITAL
Licensee: NEW BRITAIN GENERAL HOSPITAL
Region: 1
City: NEW BRITAIN State: CT
County: HARTFORD
License #: 06-02388-01
Agreement: N
Docket:
NRC Notified By: CELESTE MAJEK
HQ OPS Officer: JOHN MacKINNON
Notification Date: 01/12/2006
Notification Time: 10:18 [ET]
Event Date: 01/11/2006
Event Time: 09:15 [EST]
Last Update Date: 01/12/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
RICHARD CONTE (R1)
GREG MORELL (NMSS)

Event Text

LICENSEE DID NOT HAVE A WRITTEN DIRECTIVE BEFORE ADMINISTERING A DIAGNOSTIC WHOLE BODY SCAN.

A patient had a physicians order to perform a diagnostic whole body scan but the two technologists over-looked that the patient did not have a written directive to give the patient 4.1 millicuries of Iodine-131. The patient got the correct dose of Iodine-131 for his diagnostic whole body scan.

The licensee stated that they were operating under Departmental Protocol for Thyrogen Whole Body Iodine doses.

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Power Reactor Event Number: 42254
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DAVE JESTER
HQ OPS Officer: JOHN KNOKE
Notification Date: 01/12/2006
Notification Time: 16:07 [ET]
Event Date: 01/12/2006
Event Time: 09:20 [EST]
Last Update Date: 01/12/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JOEL MUNDAY (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

CONTROL ROOM AIR CONDITIONING AND CONTROL ROOM EMERGENCY VENTILATION SYSTEMS INOPERABLE

"At 0400 hours on January 12, 2006, 2A Control Building Standby Instrument Air Compressor was taken out of service for scheduled maintenance. Subsequently, at 0920 hours, the in-service 2B Control Building Standby Instrument Air Compressor failed, resulting in the loss of control air. As a result, the three Control Room Air Conditioning subsystems required by Technical Specification (TS) 3.7.4, "Control Room Air Conditioning (AC) System," and the two Control Room Emergency Ventilation subsystems required by TS 3.7.3, "Control Room Emergency Ventilation (CREV) System," became inoperable. As a result, this condition could have prevented the fulfillment of the safety function for these systems. The Control Room AC and CREV systems became inoperable due to loss of control air to the systems. Because Brunswick has a shared control room, Unit 1 and Unit 2 entered TS 3.7.3 Required Action B.1, for two CREV subsystems inoperable (i.e., be in Mode 3 within 12 hours) and TS 3.7.4, Required Action E.1, for three Control Room AC subsystems inoperable (i.e., enter LCO 3.0.3 immediately).

"Operability of two Control Room AC subsystems and one CREV subsystem was restored and LCO 3.0.3 was exited, at 1014 hours, when the 2A Control Building Standby Instrument Air Compressor was restored to service. [The licensee stated the actual maintenance was completed on 2A Control Building Standby Instrument Air Compressor at the time it was restored to service.]

"No power reduction took place as a result of the LCO 3.0.3 entry. This report applies to both Units 1 and 2 and is being made in accordance with 10 CFR 50.72(b)(3)(v)(D), as a condition that at the time of discovery could have prevented fulfillment of the safety function of systems that are needed to mitigate the consequences of an accident.

"The safety significance of this event is considered minimal. The condition existed for approximately 54 minutes. Plant staff took immediate actions to return the equipment to service. For the brief time the Control Room AC and CREV systems were inoperable, performance of plant personnel and equipment in the Control Room was not adversely affected. The maximum Control Room back panel temperature during this event was approximately 73 degrees F.

"Operability of the Control Room AC system and one subsystem of the CREV system were restored at 1014 hours when the 2A Control Building Standby Instrument Air Compressor was restored to service. Troubleshooting activities are under way to determine the cause of the 2B Control Building Standby Instrument Air Compressor failure. Initial indications are that the unloading ability of the 2B Control Building Standby Instrument Air Compressor failed."


The licensee notified the NRC Resident Inspector.

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Friday, March 30, 2012