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Event Notification Report for May 3, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/02/2011 - 05/03/2011

** EVENT NUMBERS **


46789 46791 46792 46793 46800 46805 46806 46807 46808 46811 46812 46813
46814

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Agreement State Event Number: 46789
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: IRISNDT INC MATRIX
Region: 4
City: CORPUS CHRISTI State: TX
County:
License #: L04769
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 04/27/2011
Notification Time: 09:30 [ET]
Event Date: 04/25/2011
Event Time: 22:00 [CDT]
Last Update Date: 04/27/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - INABILITY TO RETRACT SOURCE INTO RADIOGRAPHY CAMERA

"On April 26, 2011, the Agency [Texas Department of State Health Services] was informed by a licensee that on April 25, 2011, at 2200 [CDT] hours a QSA model 880D radiography camera containing 92 curies of Iridium (Ir) 192 fell from a 16 inch pipe it was sitting on. The camera landed on the guide tube side of the camera crimping the guide tube near the connection of the guide tube to the camera. This prevented the radiographer from retracting the source into the camera. The radiographers used a hammer and were able to remove the crimp from the guide tube enough to retract the source. No individual involved with the event exceeded an exposure limit based on their electronic dosimetry readings. The radiographer doing most of the source retraction work, radiographer 'A', had an electronic dosimeter reading of 1.5 Rem. The second radiographer, radiographer 'B', received 200 milliRem. The licensee stated that the exposure to the radiographer 'A' was high due to the inability to place shielding over the source due to the crimp being so close to the camera. The personnel dosimetry of the two individuals involved have been sent to the licensee's dosimetry processor for reading. The licensee stated that the camera would be leak tested on April, 26, 2011. The licensee is investigating the event. Additional information will be provided as it is received in accordance with Reporting Material Events SA-300."

Texas Incident Report # I-8839

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Hospital Event Number: 46791
Rep Org: BEAUMONT HOSPITALS
Licensee: BEAUMONT HOSPITALS
Region: 3
City: ROYAL OAK State: MI
County:
License #: 21-01333-01
Agreement: N
Docket:
NRC Notified By: SHERYL SCHULTZ
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/27/2011
Notification Time: 16:05 [ET]
Event Date: 04/27/2011
Event Time: 10:45 [EDT]
Last Update Date: 04/27/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
ANN MARIE STONE (R3DO)
JOSEPHINE PICCONE (FSME)

Event Text

PATIENT RECEIVED LESS THAN PRESCRIBED DOSE DUE TO AN OCCLUSION IN THE DELIVERY CATHETER

A patient received 14.8 Gray rather than the 63 Gray prescribed treatment to the upper portion of the liver using SIRSpheres manufactured by Sirtex. Only 0.7 GBq of the 3 GBq Y-90 microspheres were delivered to the treatment site due to an occlusion in the micro catheter. The treating physician terminated the dose administration after encountering difficulty in "pushing" the syringe contents through the micro catheter. While removing the catheter a small release of microspheres occurred due to the trapped pressure. The spill was contained and immediately cleaned up.

The Hospital contacted the manufacturer and will return the dose unit for analysis. Both the patient and the referring physician have been informed. There was no adverse impact to the patient who has been rescheduled for a compensatory dose next week.

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: 46792
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: NORTHWESTERN MEMORIAL HOSPITAL
Region: 3
City: CHICAGO State: IL
County:
License #: IL-01037-02
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/27/2011
Notification Time: 17:30 [ET]
Event Date: 04/27/2011
Event Time: [CDT]
Last Update Date: 04/27/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANN MARIE STONE (R3DO)
JOSEPHINE PICCONE (FSME)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE DUE TO CLUMPING IN THE DELIVERY DEVICE

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

"The Radiation Safety Officer at Northwestern Memorial Hospital contacted the Illinois Emergency Management Agency on April 26th and reported that a medical event involving radiolabled Theraspheres had occurred. The treating physician attempted to perform radioembolization by placing the Y-90 microspheres in the treatment site using the appropriate Nordion Microsphere Delivery Device. However, increased resistance was felt in the administration syringe and a clump of microspheres developed between the needle injector assembly and the microcatheter connection during the initial bolus flush. Administration was halted as soon as the microsphere flow was slowed and a clump was visualized. Following a second attempt to complete the flush, the microspheres began layering within the outlet tubing. Further flushing of the system with saline did not alter the position of the remaining microspheres. The procedure was halted. Analysis of the system showed that a significant amount of the original dose had not been delivered as intended to the right hepatic lobe of the liver. Approximately 80 percent of the dose was not administered as a result of the failure. The primary cause of this incident is due to the clumping of the microspheres. However, the reason for the clumping is unknown."

The intended dose of Y-90 was 59.4 mCi (2198.8 Mbq) for an exposure of 9750 rad (97.5 Gy).

The administered dose was 22.7 mCi (839.9 Mbq) for an exposure of 3760 rad (37.6 Gy).

Illinois Report Number: IL11049

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Power Reactor Event Number: 46793
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [2] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: BILL BAKER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/27/2011
Notification Time: 18:23 [ET]
Event Date: 04/27/2011
Event Time: 17:01 [CDT]
Last Update Date: 05/02/2011
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DEBORAH SEYMOUR (R2DO)
ERIC LEEDS (NRR)
VICTOR MCCREE (R2RA)
DEBORAH SEYMOUR (R2DO)
JEFFERY GRANT (IRD)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 75 Power Operation 0 Hot Shutdown
2 A/R Y 75 Power Operation 0 Hot Shutdown
3 A/R Y 100 Power Operation 0 Hot Shutdown

Event Text

NOTIFICATION OF UNUSUAL EVENT DUE TO LOSS OF OFFSITE POWER

At 1701 CDT, the licensee declared a Notification of Unusual Event under Emergency Action Level 5.1U due to loss of offsite power for >15 minutes. The loss of offsite power occurred at 1635 CDT and was due to severe weather and winds in the vicinity. When offsite power was lost, all 3 units automatically scrammed. The units are currently stable in Mode 3 with their respective 4KV busses being supplied by the onsite Emergency Diesel Generators[EDG]. The 161KV Athens line is the only offsite power source energized. All onsite safe shutdown equipment is available with the exception of the Unit 3 "B" EDG which was out of service for planned maintenance.

* * * UPDATE FROM BILL BAKER TO HOWIE CROUCH AT 1942 EDT ON 4/27/11 * * *

The system actuations that occurred during the loss of offsite power were actuations of the Reactor Protection System, Primary Containment Isolation System (PCIS) and Emergency Diesel Generators. All primary containment valves actuated by the PCIS operated as expected. Unexpectedly, the Unit 3 "B" Main Steam Isolation Valve indicates intermediate.

Unit 1 High Pressure Coolant Injection actuated when reactor water level reached -45". Reactor Core Isolation Cooling (RCIC) was already initiated at the time.

* * * UPDATE FROM BILL BAKER TO S. SANDIN AT 2153 EDT ON 4/27/11 * * *

Following the loss of offsite power only 12 of the required 100 offsite emergency sirens are operable.

The licensee will inform both state/local agencies and the NRC Resident Inspector.

Notified R2IRC (Wert) of this update.

* * * UPDATE FROM BILL BAKER TO HOWIE CROUCH AT 2303 EDT ON 4/27/11 * * *

As a result of the loss of offsite power, the Diesel-driven Fire Pump auto-started. While the pump was running, the licensee discovered that approximately one quart of oil had leaked from the fire pump into the cold water channel which discharges into navigable waterways. The licensee confirmed this at 1950 CDT by visually identifying a sheen in the channel.

The licensee notified the National Response Center of the spill and, in accordance with their site discharge permit, notified the State of Alabama. This constitutes an Offsite Notification in accordance with 10CFR50.72(b)(2)(xi).

The licensee notified the NRC Resident Inspector. Notified NRC R2IRC (Wert).

* * * UPDATE FROM BILL BUTLER TO HOWIE CROUCH AT 2338 EDT ON 4/27/11 * * *

At 2120 CDT, operators on Unit 1 were controlling reactor water level between 2 and 51 inches when RCIC became sluggish and water level dropped to +2" causing a valid RPS Scram signal as well as PCIS signals 2, 3, 6, and 8. All valves operated as expected and all isolations were completed.

The licensee notified the NRC Resident Inspector. Notified NRC R2IRC (Wert).

* * * UPDATE FROM WILLIAM BAKER TO CHARLES TEAL AT 2338 EDT ON 4/28/11 * * *

"At 1635 CDT following offsite power grid oscillations (due to inclement weather), and a subsequent Unit 1 power reduction from 100% to 75% to attempt to correct the condition, BFNP experienced a complete loss of the 500kV offsite power system. This resulted in an automatic turbine trip and reactor scram of Units 1, 2 and 3. One 161 kV offsite power system (Athens) remains available. This condition is reportable IAW 10CFR50.72(b)(2)(iv)(B) - Any event or condition that results in actuation of the reactor protection system (RPS) when the reactor is critical except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation (4-hour notification). This notification was reported to NRC (Crouch) at 1723 CDT.

"At 1701 CDT, a NOUE was declared (EAL Designator 5.1-U) due to loss of normal and alternate voltage to all 4kV SD (Shutdown) Boards for greater than 15 minutes and at least two Diesel Generators supplying power to unit specific 4kV SD Boards. This condition is reportable IAW 10CFR 50.72(a)(1)(i) - The declaration of any of the emergency classes specified in the licensee's emergency plan (1-hour notification). This notification was reported to NRC (Crouch) at 1723 CDT.

"Following the initial scrams, there were valid actuation signals for RPS (U1/2/3), Containment Isolation Groups 2, 3, 6 and 8 (U1/2/3), HPCI (U1 only), and Emergency Diesel Generators A, B, C, D, 3A, 3C and 3D (EDG 3B is out of service for maintenance). MSIV's (U1 and 3) closed on loss of A and B RPS power, and the U3 B inboard MSIV is indicating 'double lit' (not fully closed) at this time. All other systems responded as expected. This condition is reportable IAW 10CFR50.72(b)(3)(iv)(A) - Any event or condition that results in the valid actuation of any of the systems listed in paragraph (b)(3)(iv)(B), except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation (8-hour notification). The systems with a valid actuation were RPS, Containment Isolation, HPCI and Emergency Diesel Generators. This was reported in an EN# 46793 update to NRC (Crouch) at 1842 CDT.

"At 1820 CDT a determination was made that offsite emergency notification sirens did not meet the minimum required number operable. Seventy of the one hundred sirens are required to be operable and twelve of the sirens are operable at this time. This condition is reportable IAW 10CFR50.72(b)(3)(xiii) - Any event that results in a major loss of emergency assessment capability, offsite response capability, or offsite communications capability (e.g., significant portion of control room indication, emergency notification system, or offsite notification system) (8-hour notification). This was reported in an EN# 46793 update to NRC (Crouch) at 2053 CDT.

"Following auto-start of the diesel driven fire pump, subsequent to the loss of offsite 500kV power system, approximately one quart of oil leaked from the drain plug in the diesel engine of the pump to the plant cold water channel (waters of the United States). This oil produced a "sheen" on the water (confirmed at 1950 CDT) that required a response to the National Response Center IAW 40CFR112.7(a)(4). This condition was reported to the National Response Center at 2055 CDT and assigned spill number 974232. In addition, IAW the BFNP NPDES (National Pollution Discharge Elimination System) permit, the State of Alabama was notified at 2100 CDT of the spill and subsequent notification of the National Response Center. The notification of these outside agencies is reportable IAW 10CFR50.72(b)(2)(xi) - Any event or situation, related to the health and safety of the public or onsite personnel, or protection of the environment, for which a news release is planned or notification of other government agencies has been or will be made. Such an event may include an onsite fatality or inadvertent release of radioactive contaminated materials (4 hour notification). This was reported in an EN# 46793 update to NRC (Crouch) at 2203 CDT.

"At 2120 CDT, Unit 1 received a low reactor water level scram due to reactor water level lowering to +2 inches following sluggish RCIC response at low reactor pressure. At the time of this event RCIC and CRD were injecting to the vessel and the reactor level band specified was +2 to +51 inches. A valid Containment Isolation signal was received and groups 2, 3, 6 and 8 isolated as expected. Water level was immediately restored to within the specified band (RCIC). This condition is reportable IAW10CFR 50.72(b)(3)(iv)(A) - Any event or condition that results in the valid actuation of any of the systems listed in paragraph (b)(3)(iv)(B), except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation (8-hour notification). The systems with valid actuations were RPS and Containment Isolation. The Emergency Diesel Generators were already running at the time of the event. This was reported in an EN# 46793 update to NRC (Crouch) at 2238 CDT.

"The NRC resident has been notified of these 1, 4 and 8 hour reports and EN#46793 updates.

"These conditions and notifications will be captured in the licensee's Corrective Action Program."

* * * UPDATE FROM GIVENS TO HUFFMAN AT 2200 EDT ON 5/2/11 * * *

"At 2050 CDT, on 05/02/2011, the previously declared and reported NOUE (EAL Designator 5.1U) due to loss of normal and alternate voltage to all 4kV SD Boards for greater than 15 minutes and at least two Diesel Generators supplying power to unit specific 4kV SD Boards was terminated due to the conditions requiring entry being resolved. At this time, offsite power has been restored from two 161kV sources (Athens and Trinity), all eight 4kV SD boards are being powered from offsite sources, and six of eight Emergency Diesel Generators (B, C, D, 3A, 3C, 3D) are operable and in standby readiness. Emergency Diesel Generators A and 3B are not operable but are available at this time. All three units remain shutdown, in Mode 4, pending return of the 500 kV grid system. A timeline for return of the 500 kV grid system is yet to be finalized.

"In addition, the previous 8-hour notification of offsite emergency sirens not meeting the minimum required is being updated to reflect current conditions. As of 1015 CDT, on 05/02/2011, repair activities have resulted in 92 of 100 sirens being in operable status, thereby meeting the minimum requirement of 70 operable."

The licensee has notified the NRC Resident Inspector and the State of Alabama.

Notified R2DO (Seymour), NRR EO (Nelson), IRD (Grant), DHS (Daly), and FEMA (Dennis).

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Agreement State Event Number: 46800
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: GREAT SALT LAKE MINERALS CORPORATION
Region: 4
City: OGDEN State: UT
County:
License #: UT2900154
Agreement: Y
Docket:
NRC Notified By: THILIP GRIFFIN
HQ OPS Officer: CHARLES TEAL
Notification Date: 04/28/2011
Notification Time: 17:42 [ET]
Event Date: 04/28/2011
Event Time: [MDT]
Last Update Date: 05/02/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DALE POWERS (R4DO)
JOSEPHINE PICCONE (FSME)

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

Event Text

MISSING THERMO MEASURETECH MODEL 5201 DENSITY GAUGE

The State of Utah is making a preliminary report that a Thermo MeasureTech Model 5201 density gauge was discovered missing. The gauge was attached to a pipe that was removed. That section of pipe had been locked shut and not in use for a period of over 3 years. The last time the gauge was accounted for was October 29, 2010. The licensee is conducting a search of the site to locate the gauge.

* * * UPDATE FROM PHILIP GRIFFIN TO CHARLES TEAL ON 5/2/11 AT 1759 EDT * * *

"The Radiation Safety Officer (RSO) and the Assistant RSO (ARSO) were performing a routine 6-month physical inventory of the devices in the licensee's possession containing radioactive material when they noticed that one of the fixed gauging devices was missing. The device was a Thermo Measuretech Model 5201 (serial #B3988) densitometer containing a 100 mCi Cs-137 source that was attached to a pipe. The device had not been used for more than 3 years prior to the incident, and the licensee had 'locked out' the device at that time with the shutter in the 'closed' position. The RSO had accounted for the gauge during a physical inventory on October 29, 2010. At the time of the incident, the device and the pipe were gone.

"At the time of this report, the RSO and ARSO are continuing to contact anyone who may have any knowledge as to the location/disposition of the device. The RSO and ARSO are also contacting various waste companies and scrap metal companies to see if they received a gauge containing radioactive material, if the company has the capability of measuring for radiation, and to ask them to keep a watch out for the gauge.

"The licensee is undergoing expansion, and employs a number of contractors. The licensee stated that all of the licensee's employees are thoroughly instructed in radiation safety, and that the employees are told that no work involving the licensee's gauges can be done without the RSO or ARSO being present. The licensee's contractors are provided general radiation safety training twice a year.

"The licensee's working theory regarding the loss of the gauge is that a contractor was working in that area of the licensee's facility and was instructed to demolish that portion of the facility. Since contractor often use a demolish that portion of the facility the licensee speculates that a contractor may have placed the gauge in the waste bin with the other materials from the demolition, and the waste bin was then hauled off by a waste disposal company. The licensee is currently attempting to identify any contractors who may have been working in the area of the gauge during the time period from October 29, 2010, to the present."

Notified R4DO (Proulx) and FSME EO (Piccone).


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

Although IAEA categorization of this event is typically based on device type, the staff has been made aware of the actual activity of the source, and after calculation determines that it is a Less than Cat 3 event.

Note: the value assigned by device type "Category 3" is different than the calculated value "Less than Cat 3"

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Power Reactor Event Number: 46805
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: DAVID RENN
HQ OPS Officer: VINCE KLCO
Notification Date: 05/02/2011
Notification Time: 11:28 [ET]
Event Date: 05/02/2011
Event Time: 06:26 [CDT]
Last Update Date: 05/02/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
DEBORAH SEYMOUR (R2DO)

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

SPECIFIED SYSTEM ACTUATION DUE TO A EMERGENCY DIESEL GENERATOR OUTPUT BREAKER TRIP

"At 0626 [CDT] on 05/2/2011, with BFN U1 in Mode 4, Browns Ferry Nuclear Plant, received an 'A' Emergency Diesel Generator output breaker trip for unknown reasons that de-energized the 'A' 4kV Shutdown Board, resulting in a loss of power to RPS 'A' and a subsequent half scram, 'B' CREV and 'B/C' SGT automatic initiation, and Primary Containment isolation for Groups 2, 3, 6 and 8. The PCIS isolation (Group 2) also caused a loss of Shutdown Cooling on U1 which was restored at 0723 following restoration of power to the 'A' 4kV Shutdown Board from offsite 161kV power.

"The general containment isolation signals affecting containment isolation valves in more than one system is reportable as an 8 hour notification to the NRC IAW 10CFR50.72(b)(3)(iv), as any event or condition that results in a valid actuation of any of the systems listed in paragraph (b)(3)(iv)(B), except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation.

"This is also reportable as 60 day written report IAW 10CFR50.73(a)(2)(iv).

"The NRC Resident [Inspector] has been notified of this event.

"This event was entered into the licensee's Corrective Action Program as PER# 362340."

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Fuel Cycle Facility Event Number: 46806
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: MICHAEL GREENO
HQ OPS Officer: BILL HUFFMAN
Notification Date: 05/02/2011
Notification Time: 12:40 [ET]
Event Date: 04/30/2011
Event Time: 10:00 [CDT]
Last Update Date: 05/02/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
40.60(b)(3) - MED TREAT INVOLVING CONTAM
Person (Organization):
DEBORAH SEYMOUR (R2DO)
ERIC BENNER (NMSS)

Event Text

MEDICAL TREATMENT DUE TO POTENTIAL EXPOSURE TO HYDROGEN FLUORIDE

"An employee who had been working in the fluorine plant was treated in the site dispensary for redness around the right eye. The individual was treated for potential HF exposure using saline solution and calcium gluconate. The employee's work coveralls and boots were monitored by Health Physics and were contaminated. The employee returned to work.

The licensee has notified NRC Region II (Gibson).

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Part 21 Event Number: 46807
Rep Org: ABB INC
Licensee: ABB INC
Region: 1
City: FLORENCE State: SC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DENNIS BATOVSKY
HQ OPS Officer: BILL HUFFMAN
Notification Date: 05/02/2011
Notification Time: 17:12 [ET]
Event Date: 05/02/2011
Event Time: [EDT]
Last Update Date: 05/02/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
DEBORAH SEYMOUR (R2DO)
PART 21 E-MAIL GROUP ()

Event Text

NOTIFICATION OF POTENTIAL DEFECT IN SOLID STATE RELAY

Identification of the subject component is as follows: SS5 Solid State Relay, Part Number 611130-T13-N.

"The instantaneous trip function of the relay may actuate at 16 times normal current instead of the design value of 24 times normal current.

"On 3 March, 2011, ABB was notified by Progress Energy - Brunswick plant that spare relays being tested prior to being placed in service were tripping at approximately 4700 amps instead of the expected 7200 amps. Brunswick stated that their applications require having a short time delay for all faults up to the 24 times instantaneous value is critical for system design and compliance with their design basis and licensing documents.

"Subsequent evaluation by ABB Engineering determined that the relay works as intended. However, if there is a fault at the same time the relay is energized, the instantaneous unit becomes more sensitive, and will operate at lower than expected current level.

"For conditions where a fault occurs downstream of an associated in-service circuit breaker, the relay works as intended, for single phase, phase to phase, and three phase fault conditions.

"Sales records show that only four orders of the subject relay were ever shipped, and each of these four orders was with Progress Energy, with the orders all being processed via ABB Medium Voltage Service, in Florence, SC. The order numbers and quantities are as follows, with the first three orders being shipped from ABB Coral Springs, FL and the fourth order shipped from ABB Allentown, PA: AA027730 qty. 10, AA319168 qty. 7, AA319152 qty. 7, and PC06895 qty. 3.

"ABB is taking, or has taken, the following corrective actions:
- Reworked Qty. 23 units for Brunswick to convert the units to Part Number 611130-T11-N, by removing the target circuit. This prevents the pre-mature trip at lower current.
- One additional unit has been retained at ABB Coral Springs to support continued testing to confirm the fault condition.
- Three units have not been accounted for, and are assumed to be in service. (Purchased by ABB Florence for Progress Energy Brunswick 4/11/08, Sales Order PC06895, Relay Serial Numbers 85948, 85949, and 85950)
- The 611130-T13-N relay has been obsoleted to prevent future sales.
- ABB Engineering is determining whether other similar relays of different ratings have a similar defect. Action to complete by July 1, 2011.

"ABB does not have the capability to perform the evaluation to determine if a defect exists, so we are informing the purchasers or affected licensees of this determination so that the purchasers or affected licensees may evaluate the deviation or failure to comply, pursuant to 10CFR 21.21(a).

"ABB recommends that the affected licensees evaluate their specific application and determine whether the deviation described in this notice affects their design basis. If the licensee determines that it does, the relays may be returned to ABB for conversion by removing the target circuit."

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Power Reactor Event Number: 46808
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: MARK GREER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 05/02/2011
Notification Time: 22:55 [ET]
Event Date: 05/02/2011
Event Time: 20:51 [EDT]
Last Update Date: 05/02/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
HAROLD GRAY (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 47 Power Operation 0 Hot Shutdown

Event Text

AUTOMATIC REACTOR SCRAM

"Nine Mile Point Unit 1 experienced an automatic RPS actuation (scram) on Monday, May 02, 2011 at 2051. Cause of the RPS actuation is not understood at this time. All control rods inserted to position 00. N1-EOP-2 entered due to low reactor water level following trip (expected plant response). Reactor pressure stabilized 800 to 1000 psig, reactor water level restored and maintained 53 to 95 inches. Automatic initiation of the High Pressure Coolant Injection system occurred following plant trip (normal actuation)."

The reactor is stable in Hot Shutdown. The licensee characterized the scram as uncomplicated. All rods fully inserted, normal feed water is supplying the reactor with decay heat being removed to the condenser. The unit is in a normal shutdown electrical lineup and the scram had no impact on Unit 2. All systems functioned as required. The unit was operating at 47% power at the time of the event due to feed pump maintenance.

The licensee does not have a first-out indication for the reactor scram and is still investigating the cause of the scram.

The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 46811
Facility: SUMMER
Region: 2 State: SC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: GEORGE ROBERTSON
HQ OPS Officer: CHARLES TEAL
Notification Date: 05/03/2011
Notification Time: 13:02 [ET]
Event Date: 05/03/2011
Event Time: 05:14 [EDT]
Last Update Date: 05/03/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
DAVID AYRES (R2DO)

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

Event Text

TWO APPENDIX R VIOLATIONS THAT CAN ADVERSELY IMPACT ABILITY TO SHUT DOWN PLANT

"On 05/03/2011 at 0514 [EDT] V.C. Summer Nuclear Station (VCSNS) determined the following:

"During circuit analysis review for transitioning the Fire Protection Program to NFPA-0805, VCSNS identified two violations of the Appendix R requirement to maintain one train of systems necessary to achieve and maintain hot shutdown conditions in accordance with Appendix R. Both instances apply to postulated fires in the Main Control Room and Cable Spreading Room.

"In the first instance, circuits were identified in the Main Control Room and Cable Spreading Room that impact a control power circuit that could result in the loss of ability to start the 'B' Emergency Diesel Generator using local controls. Because fires in these areas can result in the need to evacuate the Main Control Room, the inability to start the diesel using local controls could have an adverse impact on the ability to safely shut down the plant.

"In the second instance, VCSNS determined that a fire in either the Main Control Room or Cable Spreading Room could result in a hot short that could actuate a relay and trip all incoming breakers to the B-train essential electrical bus (Bus 1DB). Because fires in these areas can result in a loss of power to the bus, this could have an adverse impact on the ability to safely shut down the plant."

The NRC Resident Inspector has been informed.

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Power Reactor Event Number: 46812
Facility: WATTS BAR
Region: 2 State: TN
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: PETE WILLIAMS
HQ OPS Officer: BILL HUFFMAN
Notification Date: 05/03/2011
Notification Time: 14:18 [ET]
Event Date: 05/03/2011
Event Time: [EDT]
Last Update Date: 05/03/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
DAVID AYRES (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Under Construction 0 Under Construction

Event Text

CONTRACT SUPERVISOR TESTED POSITIVE FOR ILLEGAL DRUG

A contract supervisor had a confirmed positive for an illegal drug during a random fitness-for-duty test. The employee's access to the plant has been terminated. The licensee has notified the NRC Resident Inspector.

Contact the Headquarters Operations Officer for additional details.

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Power Reactor Event Number: 46813
Facility: DUANE ARNOLD
Region: 3 State: IA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: KEN CARLSON
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 05/03/2011
Notification Time: 15:39 [ET]
Event Date: 05/03/2011
Event Time: 13:44 [CDT]
Last Update Date: 05/04/2011
Emergency Class: ALERT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(1) - DEVIATION FROM T SPEC
Person (Organization):
MARK RING (R3DO)
ANNE BOLAND (R3 R)
BRUCE BOGER (NRR)
STEVEN WEST (R3)
WILLIAM GOTT (IRD)
R. BRADSHAW (DHS)
T. KUZIA (FEMA)
S. MORRONE (DOE)
B. EMERSON (HHS)
R. JONES (USDA)

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

ALERT DECLARED DUE TO FIRE AFFECTING ACCESS TO SAFETY RELATED EQUIPMENT

The licensee has declared an Alert due to a hydrogen fire on the hydrogen pad outside the protected area that resulted in evacuating outbuildings (pump house and air compressor buildings) that contain safety related equipment. The Alert is classified under Emergency Action Level HA-3.2 based on report or detection of gases in concentrations higher than lower flammability limit or contiguous to a safe shutdown or vital area. The licensee has also suspended certain security measures under 50.54(x) and 50.54(y). Security measures were suspended due to risks from the fire with no compensatory measures in-place at this time.

The fire involves hydrogen cylinders delivered to the site to a trailer pad outside the protected area. The fire developed while exchanging a newly delivered trailer of hydrogen cylinders with an expended hydrogen cylinder trailer.

The fire brigade has responded and offsite fire departments have responded to the site. Fire water is currently being sprayed on the hydrogen cylinders. There is no indication of any damage to any plant equipment other than the hydrogen trailer area equipment. The driver of the hydrogen supply truck was reported to have sustained some injuries. There are no other reported injuries to plant personnel.

The hydrogen water chemistry system has been isolated and makeup hydrogen to the main generator is isolated. The hydrogen isolation has no impact on the licensee at this time. The plant continues to operate at full power and there have been no immediate impacts from the fire to plant operation.

The licensee has notified State, and local authorities and the NRC Resident Inspector.

* * * UPDATE FROM SCHWERTFEGER TO TEAL AT 1550 EDT ON 5/3/11 * * *

The licensee made a one-hour notification of deviation from technical specifications under 10 CFR 50.54(x) and (y) due to the ongoing hydrogen fire. This was due to safeguards system degradation related to monitoring and detection of the OCA. Contact the Headquarters Operations Officer for details.

R3 IRC was notified of this report.

* * * UPDATE FROM SCHWERTFEGER TO HUFFMAN AT 1925 EDT ON 5/3/11 * * *

The licensee reported all safeguards systems have been restored and they have exited 10 CFR 50.54(x) and (y).

R3 IRC was notified of this report.

* * * UPDATE FROM CARLSON TO HUFFMAN AT 2023 EDT ON 5/3/11 * * *

At 1855 CDT, Duane Arnold has re-classified the hydrogen trailer fire event to an Unusual Event level. The event is classified as an UE under EAL HU-5.1 based on other conditions that exist which, in the judgment of the emergency director, indicate events are in progress or have occurred which indicate a potential for degradation for the level of safety of the plant.

The licensee has allowed access to all areas that were previously restricted due to potential safety concerns from the ongoing fire. The hydrogen trailer cylinders are still being sprayed with water and several cylinders are still showing thermal images above ambient. The licensee will evaluate event termination when the fire can be conclusively demonstrated to be extinguished. The licensee has notified state and local authorities and the NRC Resident Inspector.

NRC Region 3 continues to monitor the event. Notified R3 (West), NRR EO (Holian), FEMA (Via), and DHS (Knox).

* * * UPDATE FROM RUSHWORTH TO KLCO AT 0302 EDT ON 5/4/11* * *

At 0135 CDT on 5/4/11, Duane Arnold terminated from the Unusual Event. The fire was verified to be out, with no hot spots. The hydrogen tanks have been isolated and the licensee verified no hydrogen is present in the area of the hydrogen pad.

The licensee has notified State, local authorities and the NRC Resident Inspector.

R3 IRC was notified of this report. Notified R3 (West), NRR (Boger), FEMA (Via), DHS (Hill), HHS (Collins), USDA (Timmons) and DOE (Yates). Will notify R3DO (Ring), NRR EO (Holian), IRD (Marshall).

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Power Reactor Event Number: 46814
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: JEREMY MORTON
HQ OPS Officer: BILL HUFFMAN
Notification Date: 05/03/2011
Notification Time: 17:55 [ET]
Event Date: 05/03/2011
Event Time: 10:36 [CDT]
Last Update Date: 05/03/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
DAVID PROULX (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

Event Text

NOTIFICATION TO OFFSITE AGENCY REGARDING POTABLE WATER RESIDUAL CHLORINE LEVEL

"The following is a non-emergency notification in accordance with 10CFR50.72(b)(2)(xi), Offsite Notification.

"At 1036, May 3, 2011, Callaway Plant notified the Missouri Department of Natural Resources (DNR) of an issue with the potable water supply system at the facility. This notification to the Missouri DNR was made in accordance with 10 CSR 60-4.055, 'Disinfection Requirements,' due to circumstances that adversely affect the quality of potable water.

"Specifically, loss of function of the potable water chlorine pumps resulted in residual chlorine in the potable water system falling below the levels specified by the regulation. DNR has not restricted drinking of Potable Water at Callaway Plant.

"Required compensatory actions have been initiated, including planned repairs of the potable water chlorination system.

"The NRC Resident Inspectors have been notified."

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