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Event Notification Report for January 18, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/14/2011 - 01/18/2011

** EVENT NUMBERS **


46528 46529 46531 46534 46536 46537 46538 46539 46540 46542 46544 46545
46546 46547

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Agreement State Event Number: 46528
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: SAINT NICHOLAS HOSPITAL
Region: 3
City: SHEBOYGEN State: WI
County:
License #: 117-1302-01
Agreement: Y
Docket:
NRC Notified By: CHRIS TIMMERMAN
HQ OPS Officer: JOE O'HARA
Notification Date: 01/10/2011
Notification Time: 14:29 [ET]
Event Date: 01/10/2011
Event Time: [CST]
Last Update Date: 01/10/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
JIM LUEHMAN (FSME)

Event Text

AGREEMENT STATE REPORT - NUMEROUS MEDICAL EVENTS FROM PROSTATE BRACHYTHERAPY

The following was received from the state via fax;

"In July 2010, the Wisconsin Department of Health Services (DHS) sent out an In Information Notice to all licensees who perform prostate brachytherapy and asked them to perform a comprehensive review of all prostate brachytherapy cases to determine whether any medical events had occurred. On January 10, 2011, the licensee's Radiation Safely Officer reported the identification of five medical events involving permanent implants of I-125 for prostate brachytherapy where the total dose delivered differs from the prescribed dose by 20% or more. The licensee is identifying a medical event of any case where D90<135 Gy or D90>195 Gy for patients who receive seed implants only. [D90 is a recognized value in the regulatory guidelines and means a dose of 90% to the prostate. Anything outside of the D90 value is considered to be a medical event.] The licensee performed a comprehensive review of all 44 prostate implants performed since August 2003. The licensee's five medical events include one overdose to the prostate and four underdoses to the prostate. All were patients who received seed implants only. No medical events were identified involving doses to other organs or tissue above 0.50 Sv and 50% more than the expected dose. The licensee has notified the referring physicians and will not be notifying the affected patients per DHS 157.72(1)(e).

"Overdoses (medical event criteria used: D90>195 Gy): 11/13/2008: 199.15 Gy

"Underdoses (medical event criteria used: D90<135 Gy): 2/9/2007: 100.20 Gy; 11/12/2007: 127.34 Gy; 6/16/2008: 130.12 Gy; and 7/13/2010: 116.16 Gy"

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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Agreement State Event Number: 46529
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: ST. VINCENT HOSPITAL
Region: 3
City: GREEN BAY State: WI
County:
License #: 009-1303-01
Agreement: Y
Docket:
NRC Notified By: CHRIS TIMMERMAN
HQ OPS Officer: PETE SNYDER
Notification Date: 01/10/2011
Notification Time: 14:29 [ET]
Event Date: 01/10/2011
Event Time: [CST]
Last Update Date: 01/10/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
JIM LUEHMAN (FSME)

Event Text

AGREEMENT STATE REPORT - PROSTATE BRACHYTHERAPY MISDOSING

The following information was received from the State of Wisconsin via fax:

"On January 10, 2011, the licensee's Radiation Safety Officer reported the identification of ten medical events involving permanent implants of I-125 for prostate brachytherapy where the total dose delivered differs from the prescribed dose by 20% or more.

"During a recent routine inspection, Department of Health Services inspectors determined that the licensee was not reviewing prostate brachytherapy cases against medical event criteria. The licensee is identifying as a medical event any case where D90<135 Gy or D90>195 Gy for patients who receive seed implants only, and D90<100 Gy or D90>145 Gy for patients who receive seed implants in conjunction with external beam therapy (combined therapy). The licensee performed a comprehensive review of all 82 prostate implants performed since August 2003. The licensee's ten medical events include six overdoses to the prostate and four underdoses to the prostate. No medical events were identified involving doses to other organs or tissue above 0.50 Sv and 50% more than the expected dose. The licensee has notified the referring physicians and will not be notifying the affected patients per DHS 157.72(1).

"Overdoses (medical event criteria used - D90>195 Gy): 12/23/2003: 204.95 Gy; 10/27/2004: 160.49 Gy {combined therapy, medical event criteria used - D90>145 Gy}; 1/20/2006: 211.23 Gy; 6/14/2006: 207.03 Gy; 9/5/2007: 205.7 Gy; and 10/17/2007: 210.47 Gy.

"Underdoses (medical event criteria used - D90<135 Gy): 9/26/2003: 123.03 Gy; 10/31/2003: 116.78 Gy; 1/14/2004: 126.73 Gy; and 3/31/2009: 123.74 Gy.

"DHS will send a special inspection team to determine the root cause(s) of these medical events on February 2, 2011."

WI Event Report ID No.: WI 110001

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: 46531
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: PAULA GERFEN
HQ OPS Officer: JOE O'HARA
Notification Date: 01/10/2011
Notification Time: 19:39 [ET]
Event Date: 01/10/2011
Event Time: 13:21 [PST]
Last Update Date: 01/14/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
BOB HAGAR (R4DO)

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

BOTH TRAINS OF AUXILIARY BUILDING VENTILATION BECAME INOPERABLE

"On January 10, 2011, at 1321 PST, Diablo Canyon Power Plant, Unit 2, entered Technical Specification Limiting Condition of Operation (TS LCO) 3.0.3, when both trains of Auxiliary Building Ventilation System (ABVS) became inoperable following closure of damper M-4 and the ensuing loss of both exhaust fans E-1 and E-2. TS LCO 3.0.3 was exited on January 10, 2011, at 1342 following a status reset and selection of fan E-2. This provided a ventilation flowpath and use of both exhaust fans in the Safeguards mode. Both trains of Auxiliary Building Ventilation are operable. This 8-hour non-emergency report is made pursuant to 10 CFR 50.72(b)(3)(v)(D)."

The unit is not in a TS LCO. All 3 unit EDG's are operable and offsite power is in the normal lineup.

The NRC Resident Inspector has been notified.


* * * UPDATE FROM WES FIANT TO DONALD NORWOOD AT 0021 EST ON 1/14/2011 * * *

"On January 13, 2011, at 1603 PST, engineering determined that a single failure design vulnerability exists at Diablo Canyon Power Plant Units 1 and 2.

"Engineering review of the control logic of the ABVS determined that while in Buildings Only (non-safeguards) alignment or during system realignment from Safeguards Only to Buildings Only alignment, failure of damper M-4A or M-4B (series dampers) could result in the control logic securing both ABVS exhaust fans. This would prevent ABVS actuation on receipt of a valid safeguards actuation signal. When this occurs, a control room alarm is actuated, which requires the operators to reset the control logic from the control room, thereby re-enabling the capability of the ABVS to respond to a safeguards actuation signal. The Unit 2 event on January 10, 2011, at 1321, occurred due to this single failure vulnerability when the control system attempted to restore the ABVS alignment from Safeguards Only to the Buildings Only alignment. This design vulnerability is currently mitigated by maintaining the ABVS in either of the two safeguards alignments (Safeguards Only or Buildings and Safeguards).

"This single failure design vulnerability is an 8-hour non-emergency report made pursuant to 10CFR50.72(b)(3)(ii)(B) for an event that resulted in the nuclear power plant being in an unanalyzed condition for both Unit 1 and Unit 2."

The licensee will notify the NRC Resident Inspector. Notified R4DO (Hagar).

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Agreement State Event Number: 46534
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: STERIS ISOMEDIX OPERATIONS
Region: 4
City: EL PASO State: TX
County:
License #: L04268
Agreement: Y
Docket:
NRC Notified By: RAY JISHA
HQ OPS Officer: JOE O'HARA
Notification Date: 01/11/2011
Notification Time: 18:27 [ET]
Event Date: 01/10/2011
Event Time: 19:00 [CST]
Last Update Date: 01/14/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BOB HAGAR (R4DO)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE REPORT - SPOOL VALVE FAILURE ON IRRADIATOR

"A pool type irradiator experienced a drive mechanism failure on one of the two racks. This caused the 1.2 M Curie of Co-60 to remain stuck in the retracted position. It remained there for one hour until the operators discovered that a spool valve was stuck. Once the valve was freed the source rack returned to the pool as normal. The licensee is investigating the equipment malfunction and will submit further information when available."

There were no personnel injuries.

TX Incident No: I- 8809

* * * UPDATE FROM BLANCHARD TO KLCO ON 1/14/11 AT 1355 EST * * *

"At approximately 1900 [CST] on January 10, 2011, a licensee operating a pool-type irradiator in El Paso, TX, experienced a drive mechanism failure on one of two source racks. This caused the 1.2MCi of Cobalt-60 (Co-60) to fail to descend into the pool. The source rack remained in the lifted position for approximately one hour until the operators discovered that a spool valve was stuck. A piece of pipe was removed to allow the piston to vent, thus bypassing the valve. The source rack returned to the pool in a controlled, normal descent. The licensee is investigating the equipment malfunction and will submit further information when available.

"The initial report stated that the source rack had remained in the retracted position. Wording has been changed to more clearly describe, and clarify, that the source rack was stuck outside the pool (unshielded) for approximately one hour. There were no problems with the rack or the sources, the only issue was the spool valve malfunction."

Notified R4DO (Hagar) and FSME (Villamar)

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Agreement State Event Number: 46536
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: FMC LITHIUM
Region: 1
City: BESSEMER CITY State: NC
County:
License #: 036-2384-0G
Agreement: Y
Docket:
NRC Notified By: WILLIAM JOHNSON
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/13/2011
Notification Time: 15:30 [ET]
Event Date: 09/18/2010
Event Time: 20:30 [EST]
Last Update Date: 01/13/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LAWRENCE DOERFLEIN (R1DO)
GLENDA VILLAMAR (FSME)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT INVOLVING AN EXIT TRITIUM SIGN DESTROYED IN A FACILITY FIRE

The following information was received by facsimile:

"The RPS [North Carolina Radiation Protection Section] received a voice message on 1-6-2011 from the FMC Lithium RSO [Radiation Safety Officer]. The RSO wanted RPS to contact him concerning removing an Exit Sign from his current inventory of sources. [RPS] was able to get in touch with the RSO on Wednesday, January 12, 2011 and the RSO stated on the phone than he needed to remove the Exit Sign because there was a fire at the facility on September 18, 2010 that shut down the facility for two weeks and damage was around $500,000. RPS explained to the RSO that he should have responded and reported the incident/fire immediately to our office.

"[RPS] received a call back from the RSO for FMC Lithium concerning which Exit Sign was affected by fire on September 18, 2010. The General License Number: 036-2384-0G has 6 Cs-137 gauges that are active and one Cs-137 gauge in storage. Also, they have 22 Tritium exit lights in service on and before the fire on September 18, 2010. The reason the RSO reported the Exit Sign on 1-12-2011 was he was going to order a replacement for the one that was destroyed in the fire and he was getting ready to perform a Radiation Training Session for their employees. The source that was destroyed was: Manufacturer: Shield, Model: SLX-60, Serial Number: 10-21664, Source: H-3, Activity: 0.230 mCi ea., Location: SO Building 1st floor. Installed: Aug/2010"

North Carolina Event: 11-02

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Agreement State Event Number: 46537
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: LADNER TESTING
Region: 4
City: JACKSON State: MS
County:
License #: MS-382-01
Agreement: Y
Docket:
NRC Notified By: JULIA RALSTON
HQ OPS Officer: VINCE KLCO
Notification Date: 01/13/2011
Notification Time: 16:03 [ET]
Event Date: 01/12/2011
Event Time: 15:00 [CST]
Last Update Date: 01/13/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BOB HAGAR (R4DO)
LARRY CAMPER (FSME)
ILTAB via email ()

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - THEFT OF A NUCLEAR DENSITY GAUGE

The following information was received by e-mail:

"The licensee's RSO [Radiation Safety Officer] contacted DRH [Mississippi Division of Radiological Health] to report the theft of their Troxler Model 3440 (S/N 26434) nuclear gauge that was secured in the back of their stolen white Ford F-150 pick-up truck parked in the licensee's fenced lot. The truck and gauge were estimated to have been stolen between 1500 [CST] and 1530 [CST]. The gauge was stored in the yellow plastic transport case with Radioactive Yellow II labels attached.

"The licensee was instructed by DRH to send in a written report describing the incidents leading up to the event that occurred on January 12, 2011, and any corrective actions or follow up performed. Once the gauge is located, DRH will survey and retrieve the gauge. DRH will notify NRC Operations. Event is under investigation and enforcement action may be required by DRH.

"Jackson City Police was notified by the licensee. Mississippi State Department of Health (MSDH) notified Mississippi Emergency Management and Mississippi Homeland Security. MSDH issued a press release January 13, 2011. DRH will notify NRC Operations."

Gauge Isotopes: Cs-137(9 mCi) and Am/Be-241 (40 mCi).

Mississippi Event Number: MS-11-001

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Power Reactor Event Number: 46538
Facility: HOPE CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: KENNETH BRESLIN
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/14/2011
Notification Time: 11:49 [ET]
Event Date: 01/14/2011
Event Time: 04:26 [EST]
Last Update Date: 01/14/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
LAWRENCE DOERFLEIN (R1DO)

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

LOSS OF ENS AND ERDS CAPABILITY DUE TO A FAILURE OF THE PHONE SYSTEM UPS

"On January 14, 2011 from 0426 to 0551 [EST] the NRC ENS phone line was lost for Hope Creek and Salem Units 1 and 2. The loss of the phone lines occurred during planned island ring bus switching and was caused by a failure of the phone system Uninterruptible Power Supply (UPS). The phone system UPS was manually restored by Information Technology personnel and the phone line was verified to be operational. The loss of the phone line had no effect on plant operations and all three units remain at 100% power.

"Additionally, Emergency Response Data System (ERDS) capability was lost during this time period and has been restored.

"The station has initiated a prompt investigation into the cause of the failure of the phone system UPS to properly transfer.

"No personnel injuries resulted from the event.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 46539
Facility: FARLEY
Region: 2 State: AL
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: DARRIN GARD
HQ OPS Officer: VINCE KLCO
Notification Date: 01/14/2011
Notification Time: 12:47 [ET]
Event Date: 01/14/2011
Event Time: 11:25 [CST]
Last Update Date: 01/14/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
BRIAN BONSER (R2DO)

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

TECHNICAL SUPPORT CENTER OUT OF SERVICE DUE TO PLANNED MAINTENANCE

"The Technical Support Center HVAC unit has been removed from service for a planned maintenance outage with an expected duration of 8 hours. A 10 CFR 50.54(q) evaluation has been performed for this outage and the current level of effectiveness of the FNP [Farley Nuclear Plant] Emergency Plan is maintained. Alternate Technical Support Center capability has been verified in accordance with site procedure FNP-0-EIP6.0, Technical Support Center Setup and Activation. Technical Support Center HVAC is expected to be returned to service at 1925 [CST] on 1/14/11."

The licensee notified the NRC Resident Inspector.

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Non-Agreement State Event Number: 46540
Rep Org: INDIANA MICHIGAN POWER
Licensee: AMERICAN ELECTRIC POWER
Region: 3
City: ROCKPORT State: IN
County: SPENCER
License #: GL-704402-14
Agreement: N
Docket:
NRC Notified By: PHILIP C. CASPER
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/14/2011
Notification Time: 13:50 [ET]
Event Date: 01/14/2011
Event Time: 10:00 [EST]
Last Update Date: 01/14/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
GLENDA VILLAMAR (FSME)

Event Text

FIXED GAUGE SHUTTER UNABLE TO CLOSE DUE TO MECHANICAL FAILURE

"On Friday, January 14, 2011 at approximately 1000 Hrs (EST) one of [the] facility Assistant RSO was advised that one of our devices was inoperable. This was due to a failure in the cable handle bracket mechanism, not the source itself. The handle that operates the cable that opens and closes the level indicator is held in place by a bracket that is mounted (bolted) to the side of the equipment. The lower lever pivot (hinge) bracket failed, probably due to age, resulting in an inability to operate the mechanism as designed. The radiation source is located between two Gas Recirculation Hoppers approximately 10-15 feet away.

"The equipment has been tagged pending repair, and affected employees were notified.

"A manufacturer's authorized repair technician has been scheduled to make repairs on Thursday, January 20, 2011. Upon completion of repairs and after the device has been inspected and placed back in service [the licensee] shall notify [the NRC] in writing.

"Location:

Indiana Michigan Power
A Division of American Electric Power
Rockport Plant
Spencer County
2791 North US Hwy 231
Rockport, IN 47635

"Isotopes: Cs-137
Quantities: 100mCi
Chemical/Physical Form: Gas Recirculation Hopper Level Indicator
Manufacturer: Texas Nuclear
Device Model: 5197
Device Serial Number: LE/LX 5705
Source Serial Number: B2147

"No personnel exposure or injuries sustained."

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Power Reactor Event Number: 46542
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: GREG MERTA
HQ OPS Officer: VINCE KLCO
Notification Date: 01/14/2011
Notification Time: 14:31 [ET]
Event Date: 01/14/2011
Event Time: 08:40 [CST]
Last Update Date: 01/14/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MICHAEL KUNOWSKI (R3DO)

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

TECHNICAL SUPPORT CENTER OUT OF SERVICE DUE TO MAINTENANCE

"At 0840 [CST] on Friday, January 14, 2011, a portion of the Duane Arnold Energy Center (DAEC) Technical Support Center (TSC) ventilation was removed from service to conduct maintenance on the charcoal filter medium. The TSC Stand-by Filter Unit (TSC-SFU) was found with deluge water in the bottom of the charcoal filtration bed, and is therefore non-functional.

"Under certain accident conditions the TSC may become unavailable due to the inability of the ventilation system to maintain a habitable atmosphere.

"The licensee has notified the NRC Resident Inspector. This notification is being made in accordance with 10 CFR 50.72 (b) (3) (xiii) due to a loss of emergency response facility."

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Power Reactor Event Number: 46544
Facility: OCONEE
Region: 2 State: SC
Unit: [ ] [ ] [3]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: RANDY TODD
HQ OPS Officer: VINCE KLCO
Notification Date: 01/14/2011
Notification Time: 17:19 [ET]
Event Date: 11/18/2010
Event Time: 02:45 [EST]
Last Update Date: 01/14/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
BRIAN BONSER (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Hot Standby 0 Hot Standby

Event Text

INVALID ACTUATION OF MOTOR DRIVEN EMERGENCY FEEDWATER SYSTEM

"This report is being made per paragraphs 50.73(a)(1) and 50.73(a)(2)(iv)(A) to address an actuation of the Emergency Feedwater (EFW) System on Oconee Unit 3 on 11/18/10 while moving the 3A Motor Driven EFW Pump (MD EFWP) control switch from position 'Auto 1' to 'Auto 2.' EFW is a system named in 50.73(a)(2)(iv)(B).

"The 3A MD EFWP was inadvertently started during operation of the control switch in the Oconee Unit 3 Control Room. The start signal was a manual start when the operator moved the control switch beyond the intended position. The functioning/behavior of the MD EFWP control switch and human error are being investigated in the site corrective action program. This is considered an INVALID signal with respect to 50.73(a)(2)(iv)(A). The manual start only affected the 3A MD EFWP.

"On 11/18/10, a Unit 3 startup from a refueling outage was in progress. Unit 3 was in Mode 3. While performing a step in OP/3/A/1102/001 (Controlling Procedure for Unit Startup), the Operator inadvertently started 3A MD EFWP when positioning 3A MD EFWP control switch from position 'Auto 1' to 'Auto 2.'

"Specific Information Required per NUREG 1022:
(a) The specific train(s) and system(s) that were actuated: The specific train(s) and system(s) that were actuated was the 3A MD EFWP and the A train of EFW. The 3B MD EFWP and the Turbine Driven EFW Pump were not affected by this event.
(b) Whether each train actuation was complete or partial: The manual actuation was considered complete (i.e. all necessary components responded to the start signal to provide EFW to the Steam Generator (SG). The A train control valve (3FDW-315) was open, as expected for the evolutions in progress. This allowed EFW to reach the SG.
C) Whether or not the system started and functioned successfully: The 3A MD EFWP and train started and operated successfully until secured by Operations personnel.

"Initial Safety Significance: None, there was no significant transient.

"Corrective Action(s): EFDW was secured within approximately one minute by placing 3A MD EFWP control switch in the Auto 2 position. This event has been entered into the site corrective action program for resolution."

The licensee notified the NRC Resident Inspector.

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Part 21 Event Number: 46545
Rep Org: ABB INC.
Licensee: ABB INC.
Region: 1
City: CORAL SPRINGS State: FL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: CHAD BUCHWALTER
HQ OPS Officer: VINCE KLCO
Notification Date: 01/14/2011
Notification Time: 18:52 [ET]
Event Date: 01/10/2011
Event Time: [EST]
Last Update Date: 01/14/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
LAWRENCE DOERFLEIN (R1DO)
BRIAN BONSER (R2DO)
MICHAEL KUNOWSKI (R3DO)
BOB HAGAR (R4DO)
PART 21 GRP by email ()

Event Text

PART 21 NOTIFICATION OF POTENTIAL DEFECT FOR OVERCURRENT RELAYS

The following information was received by facsimile:

"This letter is submitted in accordance with 10 C.F.R 21.21(d)(3)(ii) with respect to a failure to comply with the specifications associated with the COM 5, COM 9, and COM 11 Overcurrent Relays. The style numbers for the COM 5 relay are 1326D81A07A. 1326D81A05A, 1326D81A01, 1326D81A02, 1329D12A02, 1329D12A01, 1329D12A06, 1326D81A08, 1329D12A07, 1329D12A05, 1329D12A06, 1329D12A08, 1329D12A09, 1326D81A08A, and 1326D81A09A. The style numbers for the COM 9 relay are 1326D81A10A and 1326D81A10. The style numbers for the COM 11 relay are 1329D12A03, 1326D81A03, and 1326D81A03A.

"The notifying individual is Mr. Pat Wilkinson, General Manager, ABB Inc. (Distribution Automation), 4300 Coral Ridge Rd, Coral Springs FL, 33065.

"Notification regarding the subject relays is as follows: The failure to comply centers around the seismic specification of the COM 5, COM 9, and COM 11 relays. The Zero Period Acceleration (ZPA) rating for the COM 5, COM 9 and COM 11 relays were incorrectly being certified to meet a ZPA rating of 5.6g. The relays only meet a ZPA rating of 3.6g.

"On December 14th, 2010, ABB's Engineering Group, while performing a document review of the ABB's CTR-COM-5 Qualification Conclusion Report, discovered the incorrectly reported ZPA rating. The deviation was identified as a potential defect on January 10, 2011.

"The COM family relays were originally seismically qualified by Westinghouse on July 11, 1977 with a ZPA rating of 5.7g. A second seismic qualification test was performed by an outside vendor on September 12, 2001 with a reported ZPA rating of 3.6g. ABB then transferred the vendor information to its own conclusion report: CTR-COM-5 signed December 14, 2001. The CTR-COM5 conclusion report incorrectly transcribed the ZPA rating of 3.6g from the outside vendor. The CTR-COM-5 conclusion report is the basis for ABB's Relay Selection disk, used by ABB Marketing, and ABB's quality Certificate of Conformance.

"The root cause of this issue was determined to be inadequate review and transfer of the outside vendor's seismic test data.

"ABB is taking, or has taken, the following corrective actions:

- Correct CTR-COM-5 conclusion report to 3.6g ZPA (Engineering completed request on January 11, 2011 )
- Contact all customers with potentially affected open Purchase Orders to ensure acceptance of the 3.6g ZPA rating. Orders on hold until acceptance. (Sales to complete by January 21, 2011)
- Update Certificate of Conformance template for the affected style numbers to reflect 3.6g ZPA. (Quality Assurance completed request on January 13, 2011)
- Perform a review of all qualification reports to ensure all ZPA ratings for all product families are correctly reported (Engineering to complete by February 14, 2011)
- Identification of potentially affected customers (Marketing to complete by February 15, 2011)
- Notification of potentially affected customers (Marketing to complete by February 28, 2011).
- Correct ZPA rating on the Relay Selection Disk to 3.6g ZPA (Marketing to complete by October 30, 2011)

"The customers and the quantity data are still being collected at this time. Depending upon a Licensee's specified ZPA requirements, the lower ZPA rating of relays could possibly create a substantial safety hazard. If a higher ZPA rating is required by the Licensee, please contact ABB Coral Springs Customer Support at 1-800-222-1946 or (954) 825-0606 on available solutions.

"If you have any questions regarding this notice, please contact the Quality Manager, Mr. Chad Buchwalter, directly at (954) 825-0604."

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Power Reactor Event Number: 46546
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: T. W. GATES
HQ OPS Officer: DONALD NORWOOD
Notification Date: 01/15/2011
Notification Time: 13:26 [ET]
Event Date: 01/15/2011
Event Time: 09:33 [CST]
Last Update Date: 01/15/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
BOB HAGAR (R4DO)

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

Event Text

NOTIFICATION OF STATE OF LOUISIANA AGENCIES DUE TO OFFSITE TRANSPORT OF POTENTIALLY CONTAMINATED INJURED INDIVIDUAL

"In response to a personnel injury, River Bend Station notified the State of Louisiana Governor's Office of Homeland Security and the Louisiana Department of Environmental Quality that a potentially contaminated employee was being transported offsite for medical attention.

"Later, it was determined by River Bend Radiation Protection technicians that the employee was not contaminated. State of Louisiana agencies were notified that no contamination was found on the employee, the gurney, or the ambulance.

"The NRC Senior Resident Inspector was notified."

The injured individual was non-responsive when transported. At the time of this report, no other details concerning the injured individual's condition were available.

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Non-Agreement State Event Number: 46547
Rep Org: ELI LILLY AND COMPANY
Licensee: ELI LILLY AND COMPANY
Region: 3
City: INDIANAPOLIS State: IN
County:
License #:
Agreement: N
Docket:
NRC Notified By: STAN HANPTON
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 01/17/2011
Notification Time: 10:48 [ET]
Event Date: 01/14/2011
Event Time: [EST]
Last Update Date: 01/17/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
LAURA PEARSON (ILTA)
LARRY CAMPER (FSME)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

LOST TRITIUM EXIT SIGNS

A major renovation was performed in two floors of Building 22 on the Eli Lilly Campus. This renovation was completed in December, 2010. An inventory of tritium exit signs was performed and eight exit signs on the two floors were found missing and presumed disposed of during the renovation. The exit signs each contained approximately 10 Curies of tritium. The licensee will perform wipe tests but expects negative results since the concrete surfaces were all covered with carpet, tile, or wall coverings.

Four Evenlite Model 201 serial numbers 57281, 59311, 57381, 57421
Four SRBT Model BX serial numbers C035796, C035795, C035790, C035789

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

Page Last Reviewed/Updated Thursday, March 29, 2012
Thursday, March 29, 2012