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Event Notification Report for November 9, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/08/2010 - 11/09/2010

** EVENT NUMBERS **


46214 46286 46321 46332 46386 46389 46393 46400 46401 46402 46403 46407

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General Information or Other Event Number: 46214
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: BBC&M ENGINEERING, INC.
Region: 3
City: LIMA State: OH
County:
License #: OH31210250006
Agreement: Y
Docket:
NRC Notified By: MICHAEL SNEE
HQ OPS Officer: ERIC SIMPSON
Notification Date: 08/30/2010
Notification Time: 13:24 [ET]
Event Date: 08/26/2010
Event Time: [EDT]
Last Update Date: 11/09/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TAMARA BLOOMER (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

OHIO AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The following was received from the State of Ohio via e-mail:

"Ohio Department of Health (ODH) was informed on 8/27/10 of an incident involving a portable moisture density gauge. The incident occurred on 8/26/10 at a work site in Lima, Ohio. The incident occurred due to operator error on behalf of a BBC&M Engineering, Inc. (BBCM) employee - the employee backed over the gauge with a BBCM truck. BBCM staff followed established company emergency procedures - the area was cordoned off, all other site personnel were kept more than 20 feet away from area, and a BBCM employee stayed in the area until further notice.

"BBCM obtained a Radiation Alert Monitor and a lead 'pig' from CTS, Inc. and used the monitor at the project site in the area of the damaged gauge, truck, and original testing location of the gauge. The reading near the gauge (at 1 meter) was 2.0 mrem/hr. All other readings taken at the sire measured only background level readings. The gauge was damaged but the radiation sources were not comprised and/or leaking. As the source rod would not retract into the gauge, BBC&M installed a lead cap ('pig') over the rod tip/source end. The gauge was then transported to BBCM's Dublin, Ohio office to be stored until it can be transported to CTS, Inc. for further inspection."

The gauge contains 0.010 Ci Cs-137 and 0.050 Ci Am/Be sources.

Ohio incident #2010-051.


* * * UPDATE FROM STEPHEN JAMES TO JOHN KNOKE AT 1212 EST ON 11/09/10 * * *

"On 11/9/10 ODH inspected licensee and issued Notice of Violation for incident. Licensee has provided additional training for employees. Device was returned to manufacturer for repair."

Source Number: 1
Source/Radioactive Material: SEALED SOURCE GAUGE
Radionuclide or Voltage (kVp/MeV): CS-137
Activity: 0.010 Ci 0.37 GBq

Source Number: 2
Source/Radioactive Material: SEALED SOURCE GAUGE
Radionuclide or Voltage (kVp/MeV): AM-BE
Activity: 0.050 Ci 18.5 GBq

Device Number: 1
Device Name: PORTABLE GAUGE
Manufacturer: TROXLER
Model Number: 3430
Serial Number: 25983

Ohio Item Number: OH100011

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General Information or Other Event Number: 46286
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: CLEVELAND CLINIC FOUNDATION
Region: 3
City: CLEVELAND State: OH
County:
License #: OH02110180013
Agreement: Y
Docket:
NRC Notified By: MICHAEL SNEE
HQ OPS Officer: ERIC SIMPSON
Notification Date: 09/28/2010
Notification Time: 15:01 [ET]
Event Date: 09/27/2010
Event Time: [EDT]
Last Update Date: 11/09/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
STEVE ORTH (R3DO)
KEVIN HSUEH (FSME)

Event Text

OHIO AGREEMENT STATE REPORT - 95% MEDICAL UNDERDOSAGE DUE TO EQUIPMENT FAILURE

The following report was received from the State of Ohio via email:

"On September 27, 2010, the Gamma Knife gave a Fatal Error and terminated treatment to a patient. The error appears to be a failed computer disc drive. The safety system of the Gamma Knife functioned as designed, moving the patient out of the treatment machine and closing the Gamma Knife doors. The patient was safely removed from the treatment room. A service representative was immediately contacted and repair of the Gamma Knife is in progress.

"It is intended to give the remaining dose from the plan to the patient once the Gamma Knife is repaired."

The device in question is a Leksell, Model Perfexion Gamma Knife unit [S/N MV010], which contains a 13,824 Ci Co-60 source. The intended dose was 1400 rad. The delivered dose was 71.5 rad. The target organ was the brain. There is no effect on the patient.

Ohio report #: OH100021.


* * * UPDATE FROM STEPHEN JAMES TO JOHN KNOKE AT 1212 EST ON 11/09/10 * * *

"On 11/9/10 the problem was diagnosed as faulty computer on unit. Computer was replaced and fully tested on 9/28/10. Patient remained in hospital overnight on 9/27/10 and received remainder of treatment on 9/28/10. No adverse effects anticipated due to delay in completing treatment. Licensee has contacted the manufacturer to review this incident for applicability to other units."

Ohio Item Number 100021

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.

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Power Reactor Event Number: 46321
Facility: VOGTLE
Region: 2 State: GA
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: CECIL H. WILLIAMS, JR.
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 10/08/2010
Notification Time: 13:54 [ET]
Event Date: 10/08/2010
Event Time: 11:00 [EDT]
Last Update Date: 11/09/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
GERALD MCCOY (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 98 Power Operation 98 Power Operation

Event Text

INTEGRATED PLANT COMPUTER REMOVED FROM SERVICE FOR UPGRADE WORK

"At 1100, October 8, 2010, Unit 1 Integrated Plant Computer (IPC) was shutdown for upgrade work. This includes the SPDS [Safety Parameter Display System] system which is a function of the IPC. The IPC will be returned to service in approximately two weeks and SPDS function will be restored at that time. In addition, the ERDS [Emergency Response Data System] is out of service and will be restored in the same time frame. Per the 50.54.Q that was prepared by our Emergency Preparedness group, notification has been made to the NRC ERDS group of the unavailability of the ERDS system. While the IPC is out of service, control board indications are being utilized by the control room crew. In addition, the safety-related Plant Safety Monitoring System (PSMS) is OPERABLE. Restoration of SPDS and ERDS functions have been given the highest priority during restoration of the system. Both the NRC Ops Center and the NRC ERDS group will be notified when SPDS and ERDS capability have been restored."

The NRC Resident Inspector has been notified.

* * * UPDATE ON 11/9/2010 AT 1555 EST FROM CECIL WILLIAMS TO MARK ABRAMOVITZ * * *

"On Oct 8, 2010, EN# 46321 was made for notification that the Unit 1 Integrated Plant Computer (IPC) was shutdown for upgrade and that the SPDS function was out of service until the upgrade was completed. The IPC has been returned to service sufficiently to support SPDS Functionality. All data points have been verified and associated Control Room annunciator tested. Therefore, at this time SPDS is considered returned to service. The ERDS function has previously been tested with the NRC ERDS Group and returned to service."

The licensee notified the NRC Resident Inspector.

Notified the R2DO (Blamey).

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General Information or Other Event Number: 46332
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: LEE TESTING & ENGINEERING, INC
Region: 3
City: HILLIARD State: OH
County:
License #: OH31210250011
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/14/2010
Notification Time: 13:43 [ET]
Event Date: 08/30/2010
Event Time: [EDT]
Last Update Date: 11/09/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MONTE PHILLIPS (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

OHIO AGREEMENT STATE REPORT - ABANDONED MOISTURE DENSITY GAUGES

The following information was obtained from the State of Ohio via email:

"On August 11, 2010, the licensee submitted a request to [the State of Ohio to] terminate their portable gauge license. On September 9, 2010, the Ohio Department of Health (ODH) was notified by a third party that Lee Testing had vacated the premises at 3530 Parkway Lane and had left behind a total of seven (7) devices containing radioactive materials. Upon contacting the building owner, it was determined that the licensee had moved out of the building sometime during the prior week, and that the keys to the building and its contents were relinquished to the building owner.

"On September 13, 2010, representatives from ODH and a licensed service provider visited the 3530 Parkway Lane location and removed the seven devices present at that location. This removal was determined to be necessary as authorized under rule 3701:1-38-06(E) of the Ohio Administrative Code (OAC). The seven devices are currently in a safe and secure storage location pending a decision on final disposition.

"ODH is conducting an ongoing investigation.

"The NRC Registry of Radioactive Sealed Sources and Devices indicates that [three Troxler Model] 3411-B gauges contain a Cs-137 source with a maximum activity of 0.33 GBq (9 mCi) and an Am-Be source with a maximum activity of 1.63 GBq (44 mCi). The Registry indicates that [Troxler Model] 3241-C gauge contains an Am-Be source with a maximum activity of 11.1 GBq (300 mCi). The Registry also indicates that the [three Humboldt Scientific Model] 5001 gauges contain a Cs-137 source with a maximum activity of 0.41 GBq (11 mCi) and an Am-Be source with a maximum activity of 1.63 GBq (44 mCi)."

Ohio Report Number: OH100494

* * * UPDATE FROM STEPHEN JAMES TO JOHN KNOKE AT 1212 EST ON 11/09/10 * * *

The state of Ohio provided serial numbers for the following sources:

Source Number: 1
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 47-2403
Radionuclide or Voltage (kVp/MeV): AM-241

Source Number: 10
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 508801
Radionuclide or Voltage (kVp/MeV): CS-137

Source Number: 11
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: NJ00192
Radionuclide or Voltage (kVp/MeV): AM-241

Source Number: 12
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 5843GF
Radionuclide or Voltage (kVp/MeV): CS-137

Source Number: 13
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: NJ00663
Radionuclide or Voltage (kVp/MeV): AM-241

Source Number: 14
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 1195GH
Radionuclide or Voltage (kVp/MeV): CS-137

Source Number: 2
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 00009159
Radionuclide or Voltage (kVp/MeV): CS-137

Source Number: 3
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 475790
Radionuclide or Voltage (kVp/MeV): AM-241

Source Number: 4
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 406594
Radionuclide or Voltage (kVp/MeV): CS-137

Source Number: 5
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 477088
Radionuclide or Voltage (kVp/MeV): AM-241

Source Number: 6
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: 409291
Radionuclide or Voltage (kVp/MeV): CS-137

Source Number: 7
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: Unknown
Radionuclide or Voltage (kVp/MeV): AM-241

Source Number: 8
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: Unknown
Radionuclide or Voltage (kVp/MeV): CS-137
Activity: Ci GBq

Source Number: 9
Source/Radioactive Material: SEALED SOURCE GAUGE
Serial Number: XX00166
Radionuclide or Voltage (kVp/MeV): AM-241

Ohio Item Number: OH100020

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General Information Event Number: 46386
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: WARREN GENERAL HOSPITAL
Region: 1
City: WARREN State: PA
County:
License #: PA-0083
Agreement: Y
Docket:
NRC Notified By: JOE MALNIC
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/03/2010
Notification Time: 09:43 [ET]
Event Date: 11/02/2010
Event Time: [EDT]
Last Update Date: 12/28/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN WHITE (R1DO)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT INVOLVING A MEDICAL EVENT DUE TO A DOSAGE DIFFERING FROM THE PRESCRIBED DOSE

The following information was received via fax from the Commonwealth of Pennsylvania:

"Notifications: On November 2, 2010 PaDEP [Pennsylvania Department of Environmental Protection] Central Office was notified by the licensee of a medical event involving a dosage that differs from the prescribed dose by 20% as required under 10 CFR 35.3045. This event also meets the criteria for Abnormal Occurrence reporting.

"Event Description: On November 2, 2010 a patient was undergoing brachytherapy treatment for prostate cancer. A partial seed implant of 85 Gy was prescribed, however, the full treatment of 144 Gy was implanted. This event was discovered upon completion of the procedure.

"Cause of the Event: Human Error

"Actions: The Department is awaiting more event details at this time and plans to send regional staff to conduct a follow-up inspection. Final event details will be communicated in an NMED and Abnormal Occurrence report."

PA Report ID No.: PA100025

* * * UPDATE FROM DAVID ALLARD TO JOE O'HARA VIA FAX AT 1741 ON 12/28/10 * * *

"NOTIFICATIONS: The licensee called the PaDEP Bureau of Radiation Protection on the afternoon of November 2, 2010 to provide a 24-hour verbal notice of a Medical Event. The event involved a patient dosage that differed from the intended [written directive] dose by greater than 20%, consequently requiring a 24-hour report per 10 CFR 35.3045(a)(1)(i). Subsequently, the licensee provided a written report to PaDEP on November 5th.

"EVENT DESCRIPTION: On November 2, 2010 a patient was undergoing brachytherapy Cesium-131 seed implant treatment for prostate cancer. A partial seed implant of 85 gray (Gy) was directed, with a 45 Gy follow-up external [IMRT] beam therapy. However, the full seed treatment of 114 Gy was implanted. The event was discovered upon completion of the implants.

"CAUSE OF THE EVENT: Human error was the cause of the event. Specifically, the incorrect prescribed prostate dose was entered into the licensee's VariSeed planning system (i.e.114 Gy vs. 85 Gy), and an incorrect seed order was placed with the vendor. The error persisted because the licensee's staff did not directly compare the written directive to the printed treatment plan. Such a comparison would have alerted the staff to the error.

"ACTIONS: The PaDEP performed a reactive inspection at the hospital on 11/4/2010. Warren General also initiated the following changes: Their current Operating Room (OR) "time-out" procedure will be altered to include the expected prescription dose. A copy of the original written directive will be utilized in the OR for reference before and during the implant. Forms will be amended to have the physician's written directive and the planned dose on the same form for easy review and comparison. Lastly, the weekly physics chart review that involves a check of the written directive has been altered such that a summary sheet that is normally used for external beam patients will now also be used for seed implant patients. This event will be also communicated to NRC via NMED. However, there was an initial miscommunication between the licensee and PaDEP. The full treatment of 114 Gy was used, not 144 Gy. Thus, there will not be an Abnormal Occurrence report from PaDEP to NRC."

Notified R1DO(Hansell) and FSME EO(Watson)

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.

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General Information or Other Event Number: 46389
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: DUKE UNIVERSITY MEDICAL CENTER
Region: 1
City: DURHAM State: NC
County:
License #: 032-0247-4
Agreement: Y
Docket:
NRC Notified By: HENRY BARNES
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/03/2010
Notification Time: 13:43 [ET]
Event Date: 10/22/2010
Event Time: 14:45 [EDT]
Last Update Date: 11/03/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN WHITE (R1DO)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT - DOSE ADMINISTERED IN WRONG LOCATION

The following report was received from the State of North Carolina via email:

"The patient has persistent small cell lung cancer after chemotherapy, in an area that has received prior external beam radiation therapy, and was symptomatic. Therefore, a course of endobronchial brachytherapy with a high-dose rate unit (HDR) was recommended to the left upper and left lower lobe bronchus where the tumor was present. The treatment prescription was 10 Gy x 2 fractions to the target volume as defined in the planning CT. The first treatment was delivered between 2 to 3 pm, on Oct 22, 2010. Unfortunately, due to errors in defining the starting dwelling positions of the source during the treatment planning, the actual dose was delivered to the wrong location along the catheters. Details of the process are described below.

"After two endobronchial catheters were placed under bronchoscopy in the OR [operating room], the patient was transferred to Radiation Oncology Department where a CT was obtained for treatment planning purposes. The two catheters were positioned correctly based on CT.

"In the first step of the treatment planning, the locations of the two endobronchial catheters were correctly identified in the CT images. The direction of the catheters was mistakenly reversed afterwards during the treatment planning, thereby changing the starting position of the HDR source. Therefore, instead of the patient being treated correctly to the identified tumor region in the left-sided airways, she was treated to a position more proximally along the path of the catheters (the larynx area). Although the plan was checked by a number of qualified physicists per operational protocol, the subtle orientation error was missed, both in the plan check and in the delivery check. The wrong treatment was delivered around 2:45 pm.

"The error was identified by the planning physicists when they were working on another patient case, about one hour after the patient's treatment. A computerized 3-D plan was generated to calculate the actual location and dose delivered due to this error. The estimated dose to the neck region was about 15-20 Gy. The plan delivered to the patient was also delivered on radiochromic film to confirm the location of the delivered dose.

"The attending physician, clinical director, and the director of physics were all notified immediately after the error was identified and confirmed. The Radiation Oncology Department chair was notified by the clinical director. The Radiation Safety Officer was notified also by the chief physicist.

"The attending physician reviewed the case and the dosimetry, and immediately tried to contact the patient. After several attempts the patient was reached around 6:00 PM and asked to come back to the hospital immediately for observation and prophylactic treatments. The patient was admitted to hospital around 9:00 PM on the same day (the time required for her to travel back to Duke from her home).

"Licensee's evaluation of why the event occurred:
a. Staff physicists were more focused on dose optimization and missed the catheter's orientation.
B The wrong orientation was again missed during the plan and delivery checks.
C. In addition to calculation checks, there was no experimental check, i.e. delivering dose to the film to verify the distance.

"The effect, if any, on the individual(s) who received the administration: The patient was admitted to Duke Hospital immediately after the error was discovered. She remained hospitalized for 4 days during which time she remained relatively asymptomatic. She did not develop increasing hoarseness, shortness of breath, or odynophagia. She underwent fiber optic laryngoscopy 36 hours after her treatment which showed minor edema of the supraglottic larynx but no airway compromise. She received the correct treatment while an inpatient, and after one additional day of observation was discharged home.

"What actions, if any, have been taken or are planned to prevent recurrence:
a. Conducted a root-cause analysis of the event among the physicists.
B. A new and more detailed standard operational procedure (SOP) for this type of treatment was generated by the members of the Brachytherapy team.
C. The existent HDR Patient QA form was edited to add extra check levels that will prevent this error from happening again.
D. A new verification procedure was added to the existent set of verification procedures. It involves the delivery of the treatment on Gafchromic film or alternative imaging device to verify the exact starting point of the treatment. This film will be compared with the plan and will have to be approved by two physicists and the attending for each case.

"Certification that the licensee notified the individual (or the individual's responsible relative or guardian) and if not, why not:
The patient was contacted, was returned to Duke and was admitted for evaluation and management."


Log # NC 10-47

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.

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General Information or Other Event Number: 46393
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: UNIVERSITY OF CALIFORNIA BERKELEY
Region: 4
City: BERKELEY State: CA
County:
License #: 1333-01
Agreement: Y
Docket:
NRC Notified By: KAMANI HEWADIKARAM
HQ OPS Officer: PETE SNYDER
Notification Date: 11/04/2010
Notification Time: 14:25 [ET]
Event Date: 11/04/2010
Event Time: [PDT]
Last Update Date: 11/04/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4DO)
LYDIA CHANG (FSME)

Event Text

AGREEMENT STATE REPORT - LEAKING SEALED SOURCE

The following information was reported via e-mail by the State of California:

"On November 03, 2010, the RSO at UC Berkeley informed the [California] Radiologic Health Branch (RHB) that on 11/01/10 an Electron Capture Device (ECD), S/N F7737 containing 15 mCi of Ni-63, was determined to have leakage in excess of 0.005 microcurie criteria. The leaking source was installed in a Hewlett-Packard gas chromatography unit Mode 5890. Immediately after the leakage was found, the unit was taken out of service. Follow-up surveys performed did not show any area contamination. The maximum contamination found on the internal portion of the ECD outlet port was 0.007 microcuries. The extent of contamination was limited to the ECD and exhaust tubing. No personal contamination was expected since the leakage was limited to the internal parts of the gas chromatography unit and vent tubing.

"The unit was used for routine analysis of organic materials. The leakage may have been due to the routine use over many years (@ 16 years). The University will pursue disposal of this ECD."

California RHB 5010 - 110310.

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Power Reactor Event Number: 46400
Facility: INDIAN POINT
Region: 1 State: NY
Unit: [2] [ ] [ ]
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: NICK LAZZO
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/07/2010
Notification Time: 19:07 [ET]
Event Date: 11/07/2010
Event Time: 18:39 [EST]
Last Update Date: 11/08/2010
Emergency Class: ALERT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
JOHN WHITE (R1DO)
SHER BAHADUR (NRR)
ERIC LEEDS (NRR)
BILL DEAN (R1RA)
BILL GOTT (IRD)
DOYLE (DHS)
BURCKART (FEMA)
TURNER (DOE)
USERY (USDA)
GRUENSPECHT (HHS)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 100 Power Operation 0 Hot Standby

Event Text

ALERT DECLARED DUE TO EXPLOSION IN THE 21 MAIN TRANSFORMER

At 1849 EST, the licensee declared an Alert due to an explosion in the 21 Main Transformer. As a result of the loss of the transformer, Unit 2 experienced a reactor trip. Plant response to the trip was normal and the plant is stable in Mode 3. At 1839 hrs., the licensee activated their Emergency Response Organization. Additionally, there was a report of smoke issuing from a metering station at the site boundary. Offsite assistance has been requested to investigate the metering station. No injuries were reported and the licensee is investigating whether any other equipment damage occurred as a result of the transformer failure.

* * * UPDATE FROM NICK LIZZO TO HOWIE CROUCH AT 2200 EST ON 11/07/10 * * *

"On November 7, 2010, at 1839 hours, the Reactor Protection System automatically actuated at 100% Reactor Power when the 21 Main Transformer failed. The failure resulted in a turbine / reactor trip. All plant equipment responded normally to the unit trip. This is reportable under 10 CFR 50.72(b)(2)(iv). The transformer failure was characterized as an explosion that meets the IPEC [Indian Point Energy Center] EAL criteria 8.2.3. An Alert was declared at 1849 hours. The plant is stable in Mode 3 at this time.

"The Auxiliary Feedwater System actuated following the manual trip, as expected. This is reportable under 10 CFR 50.72(b)(3)(iv)(A). The Emergency Diesel Generators did not start as offsite power remained available and stable. The Station Auxiliary Transformer tap changer has remained at the maximum tap changer position and is inoperable, however the unit remains on offsite power and all electrical loads are stable. No primary or secondary relief valves lifted. The plant is in Hot Standby at normal temperature and pressure with residual heat removal using auxiliary feedwater and normal heat removal through the condenser via steam dumps. There was no radiation released.

"Indian Point Unit Three was not affected by this event and remains at 100% power.

"A post trip investigation is in progress.

"A one hour notification of the Alert Declaration was made to the NRC Emergency Operations Duty Center officer Howie Crouch at 1907 [hrs. EST]."

The licensee has notified the NRC Resident Inspector, the New York State Public Service Commission, New York State EMA and local county officials.

Notified R1DO (White).

* * * UPDATE FROM CHARLES LAVERDE TO HOWIE CROUCH AT 2230 EST ON 11/07/10 * * *

At 2218 EST, the licensee exited the Alert emergency declaration. The exit criteria was that:

1) The plant was in or was proceeding to cold shutdown,
2) No radiation release was in progress or anticipated
3) All radiation levels in the plant were stable or decreasing, and
4) No limitation on access to all plant areas.

The licensee has notified the NRC Resident Inspector. Notified IRD (Gott), R1DO (White), NRR EO (Bahadur), FEMA (Heyman), DHS (Doyle), HHS (Gruenspecht), USDA (John) and DOE (Turner).

* * * UPDATE ON 11/8/2010 AT 1228 FROM MICHAEL McCARTHY TO MARK ABRAMOVITZ * * *

Approximately 50-100 gallons of oil from the transformer reached the Hudson River. The licensee notified the National Response Center and the New York State Department of Environmental Conservation.

The licensee notified the NRC Resident Inspector.

Notified the R1DO (White).

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General Information or Other Event Number: 46401
Rep Org: CURTISS WRIGHT FLOW CONTROL CO.
Licensee: QUALTECH NP
Region: 3
City: CINCINNATI State: OH
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KURT MITCHELL
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/08/2010
Notification Time: 13:48 [ET]
Event Date: 09/16/2010
Event Time: [EST]
Last Update Date: 11/08/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
ANN MARIE STONE (R3DO)
KATHLEEN O'DONOHUE (R2DO)
PART 21 GROUP ()

Event Text

PART 21 REPORT - UPS MOTHERBOARD FAILED PRE-SERVICE INSPECTION

The information below is a summary of a report received via facsimile from QualTech NP dated November 8, 2010.

"This letter provides notification per regulation 10 CFR Part21 concerning the discovery through testing and evaluation of (4) four UPS System motherboards that reported to have failed pre-service inspection prior to installation into a UPS system at Southern Nuclear- Farley Station Unit 1 TDAFWP UPS 'B' Section. Trentec (now known as QualTech NP) provided these safety related motherboards for installation on a UPS system manufactured by (OEM) Dependable Power System.

"The (4) four questionable motherboards were returned to QualTech NP for testing and evaluation to determine operability of their safety function including fit, form and function for use within the UPS System. Southern Nuclear Condition Report, CR2010109013, states 'Motherboard (DPS 20050061, SN 354, Trentec Tag # 7T55201 SN01) with different valued resistors and or different locations than original motherboard...'

"QualTech NP developed a new dedication plan (DPS2010.0 Rev.1) to evaluate the returned motherboards for fit, form and function. The plan involves visual inspection verification - QualTech NP compared the returned boards to DPS BOM lists to identify any differences; and functional performance verification - the functionality of the items were verified by performance testing as factory Go/No Go board tests using a UPS system to the parameters defined in the existing referenced dedication plans.

"Visual inspection of the motherboards found one resistor installed in the wrong location. Performance testing of motherboards found the resistor installed in the wrong location affected the safety function of the UPS system.

"The motherboard with the resistor installed in the wrong location failed to operate during performance testing. The motherboard was reworked by original equipment manufacturer (OEM) who removed the resistor in question and re-installed it in the correct location. The repaired motherboard was performance tested and found acceptable for safety function for use within the UPS system.

"QuaITech NP has reviewed its customer project / PO files and has determined the dedicated UPS system (2) and these motherboards with Date Code 2007 have only been provided to Southern Nuclear-Farley Station Unit 1 & 2 (total quantity- 4). Southern Nuclear- Farley Station Unit 1 & 2 has two (2) motherboards in service. QualTech NP has addressed the dedication and testing of motherboards by the developing a new dedication plan (DPS2010.0 Rev. 1). Southern Nuclear has reviewed and approved this new plan.

"QuaITech NP's conclusion is that the resistor in the wrong location on the motherboard caused the UPS system not to operate during performance testing and established the equipment would not perform its intended safety function. After rework, relocation of the resistor, and retesting the UPS system became operable and was performing its safety related function. QualTech NP has completed testing, evaluation, and repair of motherboards, no further action is required."

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Other Nuclear Material Event Number: 46402
Rep Org: INPO
Licensee: VARIOUS
Region: 1
City: ATLANTA State: GA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: GEORGE MORTENSEN
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/08/2010
Notification Time: 15:53 [ET]
Event Date: 11/02/2010
Event Time: [EST]
Last Update Date: 11/08/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
KATHLEEN O'DONOHUE (R2DO)

Event Text

FITNESS FOR DUTY - SUPERVISOR AT INSTITUTE OF NUCLEAR POWER OPERATIONS TESTED POSITIVE FOR ALCOHOL

A supervisor at the Institute of Nuclear Power Operations (INPO) had a confirmed positive for alcohol during a random fitness-for-duty test. The individual functioned as a supervisor at the Institute of Nuclear Power Operations. The employee's unescorted access has been suspended. Contact the Headquarters Operations Officer for further details.

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General Information Event Number: 46403
Rep Org: VELAN INC
Licensee: FLOWSERVE
Region:
City: QUEBEC, CANADA State:
County:
License #:
Agreement: N
Docket:
NRC Notified By: VICTOR APOSTOLESCU
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/08/2010
Notification Time: 16:02 [ET]
Event Date: 09/15/2010
Event Time: [EST]
Last Update Date: 02/08/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
KATHLEEN O'DONOHUE (R2DO)
PART 21 GP VIA EMAIL ()
RONALD BELLAMY (R1DO)
ANN MARIE STONE (R3DO)
VINCENT GADDY (R4DO)

Event Text

PART 21 REPORT - LIMITORQUE LIMIT SWITCH DEFECT

The following report was received via fax:

"During the performance testing of our valves equipped with Limitorque SMB-00 we found that the limit switch contacts proved to be defective. These tests took place in July 2010. Flowserve was advised and sent in replacement parts that were installed by their representatives. The valve-actuator assemblies were cycled and proper operation was assessed. These valves have been shipped to Dominion Virginia. At the time we considered the issue isolated and did not pursue an in-depth corrective action response from the Supplier.

"Later in September when testing three valves equipped with Limitorque SMB-00 and two valves equipped with Limitorque SMB-2-06, we found again that the limit switch contacts were defective, exhibiting similar problems as found earlier in July. These valves are still at our factory, awaiting the response and corrective action from Flowserve.

"The limit switch boxes (4 gear train limit switches, 16 sets of contacts) appear to be identical on the two types of actuators mentioned above.

"Upon closer examination, we determined that construction and installation elements appear poorly controlled, resulting in unexpected failure to operate due to the contact blade (called finger base by the Manufacturer) not returning to a position where it can make contact again. This was documented internally on a Velan internal deviation report on September 3, 2010.

"We advised Flowserve of our findings on September 15 and issued a formal Corrective Action Request (CAR 25500-73903) on September 16, 2010, with a deadline for responding that expired on October 26, 2010. After a number of follow-ups, we managed to make contact with responsible personnel at Flowserve on October 29. An evaluation report (electrical continuity test performed on sample switch assemblies cycled 2000 times) was submitted to our attention by Flowserve. However, we determined that the test did not answer all our concerns and requested Flowserve to provide additional information. Currently the supplier is engaged in retrieving the defective parts from our facilities and performing additional examinations and tests. The Manufacturer expects to have all necessary tests, examinations and evaluations completed on or before November 19, 2010.

"Based on functional testing performed at Velan we determined that we have no record of similar defects on valve-actuator assemblies produced prior to these events, we therefore believe that the root cause is relatively recent but there is no way to know until Flowserve analyzes and evaluates the deficiency.

"This type of defect has the potential to affect other valve manufacturers who may have installed Limitorque actuators equipped with this type of limit switch but we cannot say if such deviation could create a substantial safety hazard."


* * * UPDATE FROM VICTOR APOSTOLESCU TO DONALD NORWOOD VIA FACSIMILE AT 0804 EST ON 1/24/2011 * * *

On January 14, 2011, Velan received the final report from Flowserve concerning limit switches identified in this notification. Velan has accepted the conclusions in the report.

The following is a synopsis of those conclusions: It was determined that producing a bend in the contact finger cannot occur during normal cyclic operation of the rotor. It is highly likely that the cause of the bent finger assemblies was due to the use of a flat blade screwdriver. A flat blade screwdriver can also exert enough force to damage the cotter pin hole in the spring stud. Based on testing and evaluations of all returned Velan switches and switches from Flowserve stock, a design deficiency has not been identified. Properly set switches will perform their intended functions. A maintenance update will be issued by Flowserve to guide the industry on any recommendations during their regularly scheduled maintenance outages.

Notified R1DO (Newport), R2DO (Sykes), R3DO (Bloomer), and R4DO (O'Keefe). Notified Part 21 Group via E-mail. Notified NRR and NRO via facsimile.

* * * UPDATE AT 1528 ON 2/8/2011 FROM VICTOR APOSTOLESCU TO MARK ABRAMOVITZ * * *

Velan Inc. has issued the final report on this problem with no changes from the January 14, 2011 update.

Notified R1DO (Bellamy), R2DO (McCoy), R3DO (Duncan), and R4DO (Clark). Notified Part 21 Group via E-mail.

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Power Reactor Event Number: 46407
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: RANDY SAND
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 11/09/2010
Notification Time: 15:13 [ET]
Event Date: 11/09/2010
Event Time: 11:39 [CST]
Last Update Date: 11/09/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
ANN MARIE STONE (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 47 Power Operation 47 Power Operation

Event Text

OFFSITE NOTIFICATION - VIOLATION OF THE DISCHARGE PERMIT

"The Minnesota Pollution Control Agency was notified [on 11/9/10] at 1139 hours [CST] today that at Monticello, the Circulating Water and Service Water Streams were simultaneously chlorinated for a duration of approximately one (1) hour. Simultaneous chlorination of these two water streams is a violation of the National Pollutant Discharge Elimination System (NPDES) Permit. Chapter 4, Section 2.3, states, 'The condenser cooling water and the service water shall not be chlorinated simultaneously.' Upon discovery of this event, both the Service Water and the Circulating Water bleach injection skids were secured.

"This event did not result in bleach discharge concentration in excess of the 0.038 ppm concentration set forth in the NPDES permit."

The licensee notified NRC Resident Inspector.

Page Last Reviewed/Updated Tuesday, August 11, 2015
Tuesday, August 11, 2015