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Event Notification Report for March 21, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/18/2011 - 03/21/2011

** EVENT NUMBERS **


46670 46675 46680 46681 46682 46685 46686 46687

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Hospital Event Number: 46670
Rep Org: STATE OF FLORIDA
Licensee: ANAZAOHEALTH CORPORATION
Region: 1
City: Tampa State: FL
County:
License #: 2975-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 03/14/2011
Notification Time: 10:53 [ET]
Event Date: 03/09/2011
Event Time: [EST]
Last Update Date: 03/14/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE - DOSE MORE THAN PRESCRIBED

"This information was provided by Danny Ray Jisha, Incident Investigator, Texas Department of State Health Services (DSHS). Two patients identified to have been over dosed with Phosporus-32 (P-32). The first patient received 565 Gy where 300 Gy was prescribed, and the second patient received 507 Gy where 200 Gy was prescribed. It is suspected that Anazaohealth Corporation [Florida] supplied incorrect concentrations/doses of P-32. The Tampa, Florida Inspection Office will investigate."

The over dose took place at the University of Texas Southwestern Medical Center, Dallas, Texas, however the cause appears to be due to improper labeling of the dose material at Anazaohealth Corporation in Tampa, Florida.

This event is being investigated by the State of Florida, Florida Incident # FL11-020, and the State of Texas.

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: 46675
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: LEAF RIVER CELLULOSE
Region: 4
City: NEW AUGUSTA State: MS
County:
License #: MS-565-02
Agreement: Y
Docket:
NRC Notified By: JULIA RALSTON
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/15/2011
Notification Time: 16:43 [ET]
Event Date: 01/10/2011
Event Time: [CDT]
Last Update Date: 03/15/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4DO)
CHRISTEPHER MCKENNEY (FSME)

Event Text

DAMAGED FIXED GAUGE SAMPLE WHEEL

The following report was received via fax.

"Licensee's RSO contacted DRH [Mississippi Department of Radiological Health] by letter to report a malfunction of the sample wheel mechanism in their basis weight fixed gauge (Model No. BWM-H Beta Gauge, Gauge Serial No. 25630138, Source Model No. Amersham Corporation Model SIC.L5, Source Serial No. HW338). The device manufacturer was contacted and a representative removed the original faulty basis weight source head and replaced it with a refurbished unit. The replacement did not function, so the original source head was repaired and reattached. A leak test, survey and inspection were all conducted. As a precaution, the licensee ordered a refurbished source head and the manufacturer's representative came out to replace the original faulty source head. A leak test, survey and inspection were conducted. Leak tests revealed no contamination and surveys were normal."

Source: Sr-90, 15 mCi

Mississippi Tracking Number: MS-11002

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Power Reactor Event Number: 46680
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: WAYNE HARRELSON
HQ OPS Officer: JOE O'HARA
Notification Date: 03/18/2011
Notification Time: 05:32 [ET]
Event Date: 03/18/2011
Event Time: 01:45 [EDT]
Last Update Date: 03/18/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
DON JACKSON (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation

Event Text

CONTROL ROOM BOUNDARY RENDERED INOPERABLE

"On March 17, 2011 during a control room walk-down, it was discovered that a halon bottle located in the control room was removed from its associated piping for scheduled work. The open piping penetrates the control room boundary rendering it inoperable.

"Technical Specification 3.7.6.1 'Control Room Emergency Ventilation System' is applicable in Modes 1, 2, 3, 4, 5 and 6 was entered. Since control room boundary was rendered inoperable, Dominion is reporting that this condition could have prevented the fulfillment of the safety function to mitigate the consequences of an accident. Upon discovery the piping was capped re-establishing the control room boundary.

"Further engineering review will be conducted to more fully evaluate the impact on the control room boundary.

"This condition is being reported pursuant to 10 CFR 50.72(b)(3)(v)(D)."

Offsite power is normal and all emergency diesel generators are operable. There was no increase in plant risk.

The NRC Senior Resident Inspector has been notified.

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Power Reactor Event Number: 46681
Facility: MCGUIRE
Region: 2 State: NC
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JIM DAIN
HQ OPS Officer: CHARLES TEAL
Notification Date: 03/18/2011
Notification Time: 14:40 [ET]
Event Date: 03/18/2011
Event Time: [EDT]
Last Update Date: 03/18/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
REBECCA NEASE (R2DO)
PART 21 GROUP ()

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 N 0 Refueling 0 Refueling

Event Text

PAINT CHIPS DISCOVERED IN WOODWARD GOVERNORS

Woodward governors purchased as nuclear safety related items for use in turbine driven auxiliary feedwater pumps and emergency diesel generators, were found to have paint chips on internal surfaces. These governors were manufactured by Woodward Governor Company, Loveland, CO for use at the McGuire Nuclear Station.

The NRC Resident Inspector has been informed.

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Fuel Cycle Facility Event Number: 46682
Facility: HONEYWELL INTERNATIONAL, INC.
RX Type: URANIUM HEXAFLUORIDE PRODUCTION
Comments: UF6 CONVERSION (DRY PROCESS)
Region: 2
City: METROPOLIS State: IL
County: MASSAC
License #: SUB-526
Agreement: Y
Docket: 04003392
NRC Notified By: BOB STOKER
HQ OPS Officer: CHARLES TEAL
Notification Date: 03/18/2011
Notification Time: 16:30 [ET]
Event Date: 03/08/2011
Event Time: 12:30 [CDT]
Last Update Date: 03/18/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
40.60(b)(3) - MED TREAT INVOLVING CONTAM
Person (Organization):
REBECCA NEASE (R2DO)
MICHAEL TSCHILTZ (NMSS)

Event Text

UNPLANNED MEDICAL TREATMENT OF POTENTIALLY CONTAMINATED INDIVIDUAL

"A contract employee entered the onsite medical facility with a laceration on his right arm. First aid was administered in preparation for transferring to an offsite medical facility. The employee had spreadable contamination on his clothing (60dpm/100cm2). The employee was decontaminated before leaving the site. The employee received 8 stitches at the offsite medical facility."

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Power Reactor Event Number: 46685
Facility: WOLF CREEK
Region: 4 State: KS
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: MARCY BLOW
HQ OPS Officer: VINCE KLCO
Notification Date: 03/19/2011
Notification Time: 06:54 [ET]
Event Date: 03/19/2011
Event Time: 04:04 [CDT]
Last Update Date: 03/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(A) - ECCS INJECTION
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
CHUCK CAIN (R4DO)

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

Event Text

SAFETY INJECTION DISCHARGE TO THE REACTOR

"Following a scheduled plant shutdown for refueling the operators were forced to close the Main Steam Isolation Valves (MSIV's) to limit plant cooldown. While opening MSIV's to restore steam to the secondary, a Reactor Trip and Safety Injection (SI) occurred. The MSIV bypass valves were opened to equalize pressure across the MSIV's. Steam header pressure dipped when the MSIV for 'C' Steam Generator (S/G) was opened. The low steamline pressure bistables are rate sensitive and actuated to cause the SI when steam pressure dipped. Lowest steamline pressure was 1040 psig, the low steam line pressure SI actuates at 615 psig.

"During the SI the PZR [Pressurizer] PORV's cycled approximately 10 times to limit RCS pressure. When the PORV's opened the 'B' PZR Code Safety Main Control Board (MCB) and plant computer alarm actuated but the actual MCB indication did not change nor does plant response indicate that a PZR Code Safety opened. This appears to be an indication problem related to the PORV's cycling."

"All equipment functioned as required."

The station electric buses are aligned to normal offsite power. Decay heat removal is being discharged to the atmospheric relief valves with no indication of primary to secondary leakage.

The licensee notified the NRC Resident Inspector.


* * * UPDATE FROM MARCY BLOW TO DONALD NORWOOD AT 1221 EDT ON 3/19/2011 * * *

"1. The expected system actuations that occurred when the plant experienced a Safety Injection (SI) 03/19/11 at 04:04 CDT, previously reported on EN 46685 for 10CFR50.72(b)(2)(iv)(A), is also reportable under 10CFR50.72(b)(3)(iv)(A) for Specified System Actuation.

"2. During the recovery of the Safety Injection (SI) actuation that occurred 03/19/11 at 04:04 CDT and previously reported on EN 46685, the Safety Injection Signal was reset which blocked any further automatic actuation. This was directed per the appropriate procedure step. There is no Technical Specifications allowed condition for both trains of ECCS to be inoperable, therefore the unit entered Tech. Spec. 3.0.3 due to the Auto SI feature being blocked. LCO 3.5.2 action C.1. directs immediate entry into LCO 3.0.3. The entry into TS 3.0.3 was made at 0411 CDT and exited at 0639 CDT when the Reactor Trip Breakers were reclosed which re-enabled the automatic SI signal. This is reportable under 10CFR50.72(b)(3)(v)(D) for Accident Mitigation.

"NRC Resident was notified of the update."

Notified R4DO(Cain).

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Power Reactor Event Number: 46686
Facility: BYRON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MIKE LINDEMANN
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/19/2011
Notification Time: 16:21 [ET]
Event Date: 03/19/2011
Event Time: 08:00 [CDT]
Last Update Date: 03/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
KENNETH RIEMER (R3DO)

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

Event Text

ULTRASONIC EXAMINATION RESULTS IN INDICATIONS ON TWO REACTOR HEAD PENETRATIONS

"On March 19, 2011, during the Byron Station Unit 1 refueling outage, it was determined that the results of planned ultrasonic (UT) examinations performed on two penetrations of the reactor vessel head would not meet the applicable acceptance criteria. Both require repair prior to returning the vessel head to service. These indications are not in the reactor coolant pressure boundary; however they are very near the toe of the J-groove weld. The examinations were being performed to meet the requirements of 10CFR50.55a(g)(6)(ii)(D) and ASME Code Case N-729-1, to ensure the structural integrity of the reactor vessel head pressure boundary. The UT examinations continue for the remaining head penetrations. All of the penetrations will be examined during the current refueling outage. Repairs are currently being planned and will be competed prior to startup.

"This is reportable pursuant to 10CFR50.72(b)(3)(ii)(A) since the as found indications did not meet the applicable acceptance criteria referenced in ASME Code Case N-729-1 to remain in-service without repair.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 46687
Facility: GRAND GULF
Region: 4 State: MS
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: RICKY LIDDELL
HQ OPS Officer: VINCE KLCO
Notification Date: 03/20/2011
Notification Time: 07:08 [ET]
Event Date: 03/19/2011
Event Time: 22:36 [CDT]
Last Update Date: 03/20/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
CHUCK CAIN (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 96 Power Operation 96 Power Operation

Event Text

HIGH PRESSURE CORE SPRAY VALVE BREAKER OVERCURRENT TRIP SETPOINT OUT OF TOLERANCE

"During testing of the High Pressure Core Spray [HPCS] system minimum flow valve breaker, it was discovered that the overcurrent trip setpoint was out of tolerance. This testing was being performed as a result of a breaker trip that occurred during a surveillance. The discovery occurred while the system was inoperable for maintenance and no TS [Technical Specification] limits or action times were exceeded."

The overcurrent trip setpoint was placed within tolerance and HPCS is in operable status.

The licensee notified the NRC Resident Inspector.

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