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Event Notification Report for May 31, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/27/2011 - 05/31/2011

** EVENT NUMBERS **


46723 46871 46884 46886 46887 46888 46889 46890 46891 46892 46896 46898
46899 46900 46901 46902 46903 46904 46905 46906

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 46723
Facility: FORT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: (1) CE
NRC Notified By: ERICK MATZKE
HQ OPS Officer: DONG HWA PARK
Notification Date: 04/04/2011
Notification Time: 19:51 [ET]
Event Date: 04/04/2011
Event Time: 15:00 [CDT]
Last Update Date: 05/27/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(B) - POT RHR INOP
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
NEIL OKEEFE (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

SCAFFOLDING AFFECTING SAFETY RELATED EQUIPMENT

"At 1500 [CDT], a concern was raised with regard to scaffolding that had been constructed around safety related equipment in the Auxiliary Building which contains both trains of safety injection and containment spray. As a result T.S. 2.0.1 was entered (which is the Fort Calhoun equivalent to standard T.S. 3.0.3). The scaffolding in question was removed and the equipment was returned to operable status and T.S. 2.0.1 was exited at 1726 [CDT]."

The NRC Resident Inspector has been notified.

* * * RETRACTION FROM ERICK MATZKE TO HOWIE CROUCH @ 2027 EDT ON 5/27/11 * * *

"Following the initial report, Fort Calhoun performed a seismic analysis of the impact of the scaffolding previously reported to determine if the equipment in the room would be capable of performing its required safety functions. The evaluation determined that the safety related function of the affected equipment would be able to be accomplished. Therefore, this event is being retracted."

Notified R4DO (Haire). The licensee has notified the NRC Resident Inspector of this retraction.

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Agreement State Event Number: 46871
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: UNIVERSITY OF CALIFORNIA LOS ANGELES
Region: 4
City: LOS ANGELES State: CA
County:
License #: 1335-19
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: JOE O'HARA
Notification Date: 05/21/2011
Notification Time: 16:33 [ET]
Event Date: 04/04/2011
Event Time: 09:00 [PDT]
Last Update Date: 05/21/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL SHANNON (R4DO)
CHRISTIAN EINBERG (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT MISADMINISTRATION OF PROSTATE SEEDS

The following was received via e-mail:

"The patient underwent a permanent seed prostate implant in the UCLA 200 Medical Plaza outpatient surgery suite on 4/4/2011. The patient returned to the UCLA Department of Radiation Oncology on 5/3/2011 for a follow-up visit and a post-implant CT scan. A post-implant treatment plan was performed to verify seed placement and final dosimetry endpoints. The post-implant dosimetry plan indicated a significant number of seeds were implanted outside of the prostate.

"A detailed dosimetry analysis is being performed but is unavailable at the time of this report. This report will provide the details of the intended dose versus the received dose, as well as other supplemental information. This report will be included in the final investigation packet.

"UCLA has notified CDPH RHB [California Department of Public Health Radiologic Health Branch] that the permanent seed implant program has been placed on temporary hold pending review of this procedure. No further procedures have been performed since this discovery.

"This investigation is ongoing."

CA Report Number: 052011

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: 46884
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: IRISNDT INC
Region: 4
City: CORPUS CHRISTI State: TX
County:
License #: 14769
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/25/2011
Notification Time: 14:36 [ET]
Event Date: 05/24/2011
Event Time: [CDT]
Last Update Date: 05/25/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK HAIRE (R4DO)
LYDIA CHANG (FSME)

Event Text

AGREEMENT STATE REPORT - STUCK RADIOGRAPHY CAMERA SOURCE

The following information was received via email:

"Event Location: Flint Hills Resources LP, 2825 Suntide Road, Corpus Christi, Texas 78403.

"On May 24, 2011, the agency [State of Texas] was notified by a licensee that they were unable to retract a 27.7 Curie iridium (Ir) - 192 radiography source into a QSA Delta 880 camera at a field site. The licensee stated that when setting up for a shot, the radiographer ran the crank cables for the camera over a hot pipe. The licensee stated that while conducting a shot, the plastic on the crank cable shield melted. The licensee believes that this may have prevented the radiographer from retracting the source to the fully shielded position. The licensee's source recovery team went to the location and was able to return the source to the fully shielded position. The camera was taken to the licensee's facility for inspection. No one involved in the source recover exceeded any regulatory limits. The investigation into this event is on going. Additional information will be provided as it is received."

Texas Incident number: I - 8856

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Agreement State Event Number: 46886
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: TEAM INDUSTRIAL SERVICES, INC.
Region: 4
City: LAYTON State: UT
County:
License #: UT0600519
Agreement: Y
Docket:
NRC Notified By: GWYN GALLOWAY
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/25/2011
Notification Time: 15:35 [ET]
Event Date: 05/24/2011
Event Time: 12:20 [MDT]
Last Update Date: 05/25/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK HAIRE (R4DO)
LYDIA CHANG (FSME)

Event Text

AGREEMENT STATE REPORT - STUCK RADIOGRAPHY CAMERA SOURCE

The following information was received via email:

"While using a QSA Global 880D radiographic exposure device, the licensee's crew was unable to move the drive cable forward or backward. It appeared that the source was moved slightly out of the fully shielded position when the device was unlocked prior to the attempt to crank out the source. The crew was unable to retract the source and lock the device. A licensee employee trained in source retrieval was sent to the site. The employee disassembled a portion of the drive cable which gave him access to manually pull the drive cable in the direction that would retract the source. The cable was moved approximately 1/4 inch. This placed the source in the fully shielded position and the source was locked in the shielded position.

"Only licensee personnel were potentially exposed to radiation from the device during the incident. Licensee personnel stated that they did not step in front of the camera at any point during the incident. The radiographer used the survey meter to determine where to stand to receive the least exposure while checking the camera. At one point he reached forward with the survey meter and measured 200 mR/hr at the front port of the device. Dose estimates for licensee personnel associated in the incident were well below the limits for occupationally exposed individuals."

Utah Event Report ID Number: UT - 110004

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Agreement State Event Number: 46887
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: XEROX CORPORATION
Region: 1
City: WEBSTER State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT SNYDER
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/25/2011
Notification Time: 16:33 [ET]
Event Date: 03/01/2008
Event Time: [EDT]
Last Update Date: 05/25/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
LYDIA CHANG (FSME)

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

Event Text

AGREEMENT STATE REPORT - MISSING STATIC ELIMINATORS CONTAINING POLONIUM

The following information was received via fax:

"Event location: 800 Phillips Road, Webster, NY 14580

"Reported to [New York State Department of Health] NYS DOH [on] 11/17/2008. Twelve NRD static eliminators containing polonium 210 were inadvertently thrown out in March 2008. The total activity of all twelve sources would have been 334 microCuries in March 2008. They were most likely sent to Genesee Scrap and Tin Baling Co., Inc., at 80 Steel Street in Rochester as part of a large roll-off of assorted scrap. Attempts to locate the missing devices were fruitless. NRD has been contacted with the serial number information.

"A written report received from Xerox November 17, 2008. Procedures have been modified to prevent recurrence. Xerox will inventory their sealed sources two times a year to prevent other losses. NRD has been instructed to send correspondence to Xerox RSO regarding shipment of devices instead of the Xerox end user. Incident Closed."

New York Event Report ID Number: NY - 11 - 04

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: 46888
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: DOMINION RESOURCES INC.
Region: 1
City: NEW HARTFORD State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT SNYDER
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/25/2011
Notification Time: 16:33 [ET]
Event Date: 07/01/2009
Event Time: [EDT]
Last Update Date: 05/25/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
LYDIA CHANG (FSME)

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

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM SIGN

The following information was received via fax:

"Event location: Utica Compression Station, 1103 Higby Road, New Hartford, NY, 13417

"[On] 4/23/10, Dominion Resources called to inform [New York State Department of Health] that one tritium exit sign was found missing after some demolition work at their Utica, NY facility. A written report [was] received [on] 4/29/10.

"During a company wide effort to inventory all tritium exit signs it was discovered that one was missing at their Utica facility. An investigation ensued, and it was determined that during July of 2009, the entire wall on which the exit sign was located was removed during remodeling. The exit sign was likely disposed of in a 30 cubic yard roll-off container owned by Waste Management and is likely in the local AVA landfill. Dominion is reinforcing and enhancing established processes and programs for handling tritium exit signs. This event will be incorporated into training and lessons learned. All other signs at the facility are accounted for, [and] this incident is closed."

New York Event Report ID Number: NY - 11 - 05

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: 46889
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: BED BATH AND BEYOND
Region: 1
City: SARATOGA SPRINGS State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT SNYDER
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/25/2011
Notification Time: 16:33 [ET]
Event Date: 03/31/2010
Event Time: [EDT]
Last Update Date: 05/25/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
LYDIA CHANG (FSME)

Event Text

AGREEMENT STATE REPORT - DAMAGED TRITIUM SIGN

The following information was received via fax:

"Event location: 3064 Route 50, Saratoga Springs, NY, 12866

"A tritium exit sign was found damaged on March 31, 2010, at Bed Bath & Beyond in Saratoga Springs. On April 6, 2010, Shaw Environmental Group was granted reciprocity to survey, decontaminate and package the broken sign. All measurements were found to be below MDA. The broken sign was shipped to Shield Source, Inc, a tritium light manufacturer based in Canada. Written report [was] received [on] 4/29/2010.

"Bed Bath and Beyond has implemented and communicated protocols to its stores for the proper handling of [Tritium Exit Signs] TES. It has also inventoried all of the TES at its sites across the U.S. to re-establish the accuracy of its records and to track the location of TES for proper accounting and handling. This incident is closed.

New York Event Report ID Number: NY - 11 - 06

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Agreement State Event Number: 46890
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: BED BATH AND BEYOND
Region: 1
City: PLAINVIEW State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT SNYDER
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/25/2011
Notification Time: 16:33 [ET]
Event Date: 05/26/2010
Event Time: [EDT]
Last Update Date: 05/25/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
LYDIA CHANG (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIALLY DAMAGED TRITIUM SIGN

The following information was received via fax:

"Event location: 401 South Oyster Bay Road. Plainview, NY, 11803

"[On] 7/15/10, [Bed Bath and Beyond] BBB reported that Shaw Group, Inc. visited Bed Bath and Beyond to package their tritium exit signs for removal. They discovered two signs with letters that did not illuminate. Neither sign showed evidence of damage to the tubes. Both signs were packaged and secured in an electrical room. On June 15, 2010, a Shaw Representative took surveys of the floor and space where the sign was located. All results were below 1000 dpm per 100 square centimeters. Bed Bath & Beyond plans to send the damaged signs to Shield Source, Inc (SSI) and will provide a report within 30 days of the transfer of the damaged signs.

"A letter received [on] July 30, 2010, showing that the lights were returned to Shield Source, Inc. Incident is closed.

New York Event Report ID Number: NY - 11 - 07

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Agreement State Event Number: 46891
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: SUNY AT BUFFALO
Region: 1
City: BUFFALO State: NY
County:
License #: 1049
Agreement: Y
Docket:
NRC Notified By: ROBERT SNYDER
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/25/2011
Notification Time: 16:33 [ET]
Event Date: 08/11/2008
Event Time: [EDT]
Last Update Date: 05/25/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
LYDIA CHANG (FSME)

Event Text

AGREEMENT STATE REPORT - LEAKING SEALED SOURCE FROM A GAS CHROMATOGRAPH

The following information was received via fax:

"Event location: 14 Parker Hall, 3435 Main Street, Buffalo, NY, 14214

"The RSO at [SUNY at Buffalo] called on 08/21/08 to report a leaking nickel 63 sealed source located in a HP gas chromatograph unit. Location of unit is Farber Hall room 2128. Apparently on Monday, August 11, 2008, the researcher was cooking 'stuff' in the oven portion of the unit. Product exploded in the oven and spilled over into the other parts of the unit and landed on the sealed source compromising integrity. Contamination was found in the oven of the unit. SUNY EH&S [State University of New York Environment, Health and Safety] staff performed decontamination of the unit until <100 dpm. No contamination was found outside of the unit. SUNY EH&S staff also surveyed the rooftop of the building as the unit is vented and no contamination was found. SUNY EH&S [gave] the researcher until Friday, 08/29/08 to submit his report of the incident to EH&S. NYS staff visited [SUNY at Buffalo] on 08/26/08 and interview [an individual] who reported that the leak was found during the routine leak testing. When the swipe came back high, he re-swiped the unit and noticed a white powder all over the oven and inside the tubing. [When] asked, the researcher stated that she had dried a silica gel in the oven on 08/11/08. Apparently, the foil cover blew off of the beaker, and the silica gel went all through the machine via an inlet port possibly 'sandblasting' the foil compromising its integrity. Swipe testing by liquid scintillation showed contamination on inlet and outlet and no contamination on the housing or outside the machine. EH&S has decontaminated the machine as much as possible and taken it out of service. EH&S has also contacted the manufacturer of HP 5890. Manufacturer states there is no way to clean it and the machine should be scrapped. EH&S plans to take out the source, scrap metal parts that are not contaminated and hold remaining pieces until a disposal option is available. Written report [was] received [on] 9/11/2008 .

"The unit [is] to be handled as indicated above, and additionally, all researchers will be in-serviced on keeping the inlet to the foil capped when using ovens for other than GC [gas chromatograph] analysis. Incident is closed."

New York Event Report ID Number: NY - 11 - 08

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Agreement State Event Number: 46892
Rep Org: NJ RAD PROT AND REL PREVENTION PGM
Licensee: NUCLEAR DIAGNOSTIC PRODUCTS OF PHILADELPHIA
Region: 1
City: CHERRY HILL State: NJ
County:
License #: 455467
Agreement: Y
Docket:
NRC Notified By: RICHARD PEROS
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/25/2011
Notification Time: 16:53 [ET]
Event Date: 05/25/2011
Event Time: 15:30 [EDT]
Last Update Date: 05/25/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
LYDIA CHANG (FSME)

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

Event Text

AGREEMENT STATE REPORT - MISSING SEALED ROD SOURCE

The following information was received via email:

"At approximately 3:30 p.m. on Wednesday, May 25, 2011, the radiation safety officer (RSO) of Nuclear Diagnostic Products of Philadelphia called to inform the [New Jersey Department of Environmental Protection's Radioactive Materials Program] NJDEPs RMP that a sealed rod source containing approximately 2.68 microCuries of cobalt-57 was unaccounted for at their facility. The source had been returned to the licensee by one of their customers for disposal. The source was secured at their location prior to being shipped for final disposal. In the interim, the room where the source was being secured was painted and materials were moved to a different room while the painting activities occurred. The painting activities began about three weeks ago.

"When the removed materials were returned to the room after the painting was concluded recently, the source could not be found. A search was conducted by the licensee, but, to date, the source cannot be located. The licensee believes the box that contained the source was either inadvertently placed in the garbage for routine disposal or the source was placed into a sharps container for incineration with biohazard materials. The licensee will continue to look, but informed us of the matter after what they believe is a comprehensive search."

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

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Agreement State Event Number: 46896
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: AMC AMERICAN MULTI-CINEMA, INC
Region: 4
City: HOUSTON State: TX
County:
License #: G/L
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: JOHN KNOKE
Notification Date: 05/26/2011
Notification Time: 14:54 [ET]
Event Date: 05/26/2011
Event Time: [CDT]
Last Update Date: 05/26/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK HAIRE (R4DO)
MATTHEW HAHN (ILTA)
LYDIA CHANG (FSME)

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

Event Text

TWO TRITIUM EXIT SIGNS STOLEN FROM MOVIE THEATER

The following information was provided by the State of Texas via email:

"On May 26, 2011, the Agency [Texas Department of Health] was notified during routine inspections of the facility's site safety systems, it was discovered that two tritium exit signs were missing from their fixed mounting positions. These signs were affixed to the walls near exits in a secure manner such that they could only be removed by means of removing safety capped mounting screws and then the use of tools to remove them. In this case, it is apparent that these signs were removed by way of vandalism and were essentially pulled off the walls leaving evidence that they were removed without the knowledge of the site personnel. A report was made to the local police department. The signs were installed new in 2010.

"In addition, this same vandalistic act occurred at the same location as reported to the Agency [Texas Department of Health] on February 2, 2011. At that time, four tritium exit signs were removed. A report was made to local law enforcement. The exit signs are Isolite Model 2040-95S-B-15-WS, and each contain 9.5 Curies of tritium."

Texas Incident: # I-8858

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

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Power Reactor Event Number: 46898
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [ ] [2] [ ]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: JORGE RODRIGUEZ
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/27/2011
Notification Time: 15:13 [ET]
Event Date: 04/03/2011
Event Time: 14:44 [MST]
Last Update Date: 05/27/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
MARK HAIRE (R4DO)

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

Event Text

60-DAY OPTIONAL NOTIFICATION OF INVALID START OF THE 'A' EMERGENCY DIESEL GENERATOR

"The following event description is based on information currently available. If through subsequent reviews of this event, additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10CFR50.73.

"This report is being made under 10 CFR 50.73 (a) (2) (iv) (A) for a reportable invalid actuation.

"On April 3, 2011, at approximately 1444 Mountain Standard Time, Palo Verde Nuclear Generating Station Unit 2 experienced an invalid actuation (start) of the 'A' Emergency Diesel Generator (EDG). EDG 'A' inadvertently started during integrated safeguards surveillance testing to demonstrate that the EDG overspeed trip is not bypassed. Prior to the test, the EDG overspeed governor was actuated, but the butterfly valve was not verified to be fully closed as required. The valve closure actuates a limit switch which activates the interlock that prevents the EDG start following an overspeed trip. The test requires the operator to ensure the butterfly valve is fully closed because it may not fully close as the EDG is not running when it is actuated for the overspeed test.

"When the demand signal was inserted, the EDG started unexpectedly since the butterfly valve was not fully closed and the limit switch was not engaged. EDG 'A' Train completely actuated in the Emergency Mode and the EDG came up to rated speed and voltage as designed. The supporting 'A' train Essential Spray Pond System, used for engine cooling, was already running prior to the test. The Essential 'A' Train EDG Exhaust Room air handling unit started as required.

"No damage occurred to the EDG or related equipment as a result of the unplanned actuation. The EDG was secured and the test was successfully re-performed.

"This report is not considered an LER."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 46899
Facility: SUMMER
Region: 2 State: SC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: ERIC RUMFELT
HQ OPS Officer: JOHN KNOKE
Notification Date: 05/27/2011
Notification Time: 14:50 [ET]
Event Date: 05/27/2011
Event Time: 12:00 [EDT]
Last Update Date: 05/27/2011
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
Person (Organization):
KATHLEEN O'DONOHUE (R2DO)

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 INITIATED DUE TO A HIGH DIFFERENTIAL PRESSURE BETWEEN MAIN STEAM LINES

"At 1200 hours on May 27, 2011, the plant was in Mode 3 during startup from a refueling outage with the main steam isolation valves closed. When the 'C' main steam isolation valve was opened for stroke testing, a safety injection occurred. The safety injection was due to a differential pressure of greater than 97 PSIG between the 'C' main steam line and the other main steam lines. The emergency core cooling system started and injected water into the Reactor Coolant System. All systems responded as expected. Safety injection was secured and the plant was stabilized in Mode 3."

The licensee has notified the NRC Resident Inspector. Licensee will be notifying the State and local government.

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Power Reactor Event Number: 46900
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ANTHONY CHITWOOD
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/27/2011
Notification Time: 20:12 [ET]
Event Date: 05/27/2011
Event Time: 12:12 [PDT]
Last Update Date: 05/27/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
MARK HAIRE (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

LOSS OF UNIT 1 STARTUP POWER RESULTS IN STARTING ALL EMERGENCY DIESEL GENERATORS

"On May 27, 2011, at 1212 PDT, Unit 1 startup power was lost due to actuation of startup transformer 1-1 overcurrent/differential relay 51-87UT11-1, which isolated the 12 kV feeder to startup bus. The loss of offsite startup power caused all Unit 1 emergency diesel generators (EDGs) to start in the standby mode. The EDGs started as designed with no issues observed. No vital loads were affected as a result of the 12 kV bus loss. On May 27, 2011, at 1241 PDT, all Unit 1 EDGs were shut down and returned to auto. Subsequently, startup transformers 1-1 and 1-2 were energized, followed by the 12 kV underground loop, and on May 27, 2011, at 1337 PDT, Unit 1 startup power was declared operable.

"The cause of the event was a human performance error while attempting to test the startup transformer 2-1 overcurrent/differential relay. The maintenance electrical worker inadvertently installed a jumper on the overcurrent/differential relay for startup transformer 1-1.

"Unit 2 startup power was cleared at this time and there was no effect on Unit 2.

"The NRC Resident Inspector was notified."

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Power Reactor Event Number: 46901
Facility: DRESDEN
Region: 3 State: IL
Unit: [ ] [2] [3]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: THOMAS DITCHFIELD
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/28/2011
Notification Time: 17:46 [ET]
Event Date: 05/28/2011
Event Time: 09:12 [CDT]
Last Update Date: 05/28/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JAMNES CAMERON (R3DO)

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

Event Text

LOSS OF INBOUND PHONE CALL CAPABILITIES ON COMMERCIAL AND FTS LINES

"During normal operations, Dresden Station identified issues with site commercial phone lines. Normal commercial phone lines are functioning for outgoing calls and will be used for any required notifications. Incoming calls, however, cannot get through to Dresden. A test of the ENS phone system failed. In addition, the HPN phone line is also affected by this issue. A cell phone number has been provided to the NRC until this issue is corrected. Repair personnel have been contacted and are expediting repairs.

"This condition is reportable under 10 CFR 50.72(b)(3)(xiii) Major Loss of Emergency Preparedness Capabilities."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 46902
Facility: WATTS BAR
Region: 2 State: TN
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: STUART SWITZER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 05/29/2011
Notification Time: 04:25 [ET]
Event Date: 05/29/2011
Event Time: 01:55 [EDT]
Last Update Date: 05/29/2011
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):
KATHLEEN O'DONOHUE (R2DO)

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

Event Text

AUTOMATIC REACTOR TRIP DUE TO TURBINE TRIP

"At 0155 EDT, the Watts Bar Unit 1 reactor tripped from 100% power due to a turbine trip above P-9 (reactor trip on turbine trip permissive). The cause of the turbine trip is under investigation at this time. All systems functioned as designed with the exception of Pressurizer Backup Heaters which failed to energize on lowering Pressurizer pressure.

"The unit is stable in Mode 3 with Auxiliary Feedwater supplying the Steam Generators. The electrical system is in normal shutdown alignment with all Emergency Diesel Generators available in standby. There are no abnormal radiological conditions at this time."

The reason the Pressurizer Backup Heaters failed to energize is unknown at this time. All control rods fully inserted. No relief valves or safety valves lifted. The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 46903
Facility: LIMERICK
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: MARK ARNOSKY
HQ OPS Officer: CHARLES TEAL
Notification Date: 05/29/2011
Notification Time: 07:10 [ET]
Event Date: 05/29/2011
Event Time: 05:02 [EDT]
Last Update Date: 05/29/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
GLENN DENTEL (R1DO)

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

Event Text

AUTOMATIC REACTOR TRIP DUE TO LOW PRESSURE IN EHC SYSTEM

"Limerick Unit 2 automatically scrammed from 75% power while restoring EHC (Electro Hydraulic Control) fluid to number 3 Turbine Control Valve following maintenance work. Preliminary indications as to the cause of the scram indicate a low pressure condition in the EHC system resulting in an RPS actuation.

"All control rods inserted as required.

"No ECCS or RCIC initiations occurred.

"No primary or secondary containment isolations occurred.

"The plant is currently in Hot Shutdown maintaining normal reactor water level with feedwater."

Decay heat is being removed via the bypass valves to the condenser. The plant is in a normal shutdown electrical lineup. There was no impact on Unit 1.

The NRC Resident Inspector has been informed. The licensee will inform the Pennsylvania Emergency Management Agency, Montgomery, Burke, and Chester counties.

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Power Reactor Event Number: 46904
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [ ] [2] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: DOUGLAS FOOTE
HQ OPS Officer: JOHN KNOKE
Notification Date: 05/29/2011
Notification Time: 15:01 [ET]
Event Date: 05/29/2011
Event Time: 09:57 [PDT]
Last Update Date: 05/29/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
MARK HAIRE (R4DO)

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

Event Text

OFFSITE NOTIFICATION DUE TO AN ON-SITE SULFURIC ACID SPILL

"This notification is for San Onofre Units 2 and 3 and is being made in accordance with 10CFR50.72(b)(2)(xi) to report that on 5/29/2011 at 0957 PDT Government agencies were notified of a sulfuric acid spill.

"On 5/28/2011 [at] 1440 PDT, during resin bed regeneration operations at the High Flow Makeup Demineralizer (HFMUD), a sulfuric acid transfer was in progress. When process piping was pressurized, a valve on the discharge side of the process pump experienced a diaphragm failure causing a body to bonnet leak. Operators secured the acid transfer. All the sulfuric acid was contained within the bermed area of the HFMUD.

"Hazardous material teams have contained and cleaned up the spill. Area is secured until repairs can be implemented. All HFMUD operations have been stopped until repairs are completed.

"On 5/29/2011 at 0926, the hazardous material team determined that this event was reportable to government agencies. The following reports were made:

"[At] 0957 PDT San Diego Department of Enviornmental Health [was] called with [a] voice message left.

"[At] 0959 PDT California Emergency Management Agency [was] called. Report number 11-3246.

"[At] 1008 PDT National Response Center [was] called. Report number 977718."

The licensee has notified the NRC Resident Inspector,

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Power Reactor Event Number: 46905
Facility: SURRY
Region: 2 State: VA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: THOMAS OLIVER
HQ OPS Officer: JOE O'HARA
Notification Date: 05/30/2011
Notification Time: 14:59 [ET]
Event Date: 05/30/2011
Event Time: 08:08 [EDT]
Last Update Date: 05/30/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
KATHLEEN O'DONOHUE (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Intermediate Shutdown 0 Intermediate Shutdown

Event Text

SPECIFIED SYSTEM ACTUATION - AFW INITIATION

"Surry Unit 2 is in Intermediate Shutdown and was supplying steam generators with a main feed pump. The second main feed pump is tagged out for maintenance. The running main feed pump exhibited a low oil flow condition. The operating team took the deliberate action to secure the running main feed pump to prevent bearing damage with the knowledge that an Auxiliary Feedwater actuation signal would be generated. The plant was realigned to flow to the steam generators with the condensate pumps and the auxiliary feed pumps were then secured [at] 0821.

"This notification is being made pursuant to 10 CFR 50.72(b)(3)(iv)(A) for 8-hour notification of automatic actuation of AFW. Plant responded as expected. The NRC Resident Inspector has been notified of this event and is on site.

"There were no radiation releases due to this event, nor were there any personnel injuries or contamination events."

Offsite power is normal and emergency diesel generators are operable and available. There was no increase in plant risk as a result of this event.

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Power Reactor Event Number: 46906
Facility: LIMERICK
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: PAUL MARVEL
HQ OPS Officer: JOE O'HARA
Notification Date: 05/30/2011
Notification Time: 15:46 [ET]
Event Date: 05/30/2011
Event Time: 11:50 [EDT]
Last Update Date: 05/30/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
GLENN DENTEL (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Startup 0 Hot Shutdown

Event Text

SPECIFIED SYSTEM ACTUATION - MANUAL REACTOR SCRAM DUE TO DUAL RECIRC PUMP TRIP DURING STARTUP

"Limerick Unit 2 was 'manually scrammed' from 0% power on 5/30/11 at 1150 hours in accordance with plant procedure OT-112 'Recirculation Pump Trip', when both the '2A' and '2B' Recirculation Pumps tripped. The cause of the pump trip is currently under investigation at this time.

"At the time of the 'manual' SCRAM: The Reactor Mode Switch was in 'Startup' Mode 2. All control rods were inserted to 'full-in' position (00). Reactor Shutdown was in-progress in accordance with Plant procedure GP-3 'Normal Plant Shutdown'. No primary or secondary containment isolations occurred.

"The plant is currently in HOT SHUTDOWN maintaining normal Reactor level with Control Rod Drive (CRD) hydraulic and Reactor Water Cleanup (RWCU) systems."

Licensee is investigating a potential issue with the relay logic associated with the scram bypass feature. Offsite power circuits and emergency diesel generators are operable and available. There was no increase in plant risk associated with this event.

The NRC Resident Inspector has been notified.

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