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Event Notification Report for November 21, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/18/2011 - 11/21/2011

** EVENT NUMBERS **


47288 47435 47437 47438 47439 47440 47445 47455 47457 47459 47460 47461

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 47288
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: MIKE HETTWER
HQ OPS Officer: VINCE KLCO
Notification Date: 09/22/2011
Notification Time: 22:20 [ET]
Event Date: 09/22/2011
Event Time: 14:52 [EDT]
Last Update Date: 11/20/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
CHRISTOPHER NEWPORT (R1DO)

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

Event Text

SALT SERVICE WATER PUMP INOPERABILITY DURING POSTULATED DEGRADED VOLTAGE CONDITIONS

"On Thursday, September 22, 2011 at 1452 [EDT], with the reactor at 100% core thermal power and steady state conditions, Pilgrim Nuclear Power Station (PNPS) conservatively declared both Salt Service Water (SSW) subsystems inoperable when engineering analysis determined that inrush current on pump restart may exceed the thermal overload trip relay settings during certain degraded voltage conditions. A 24-hour Limiting Condition for Operation action statement was entered.

"Entergy/Pilgrim is in the process of implementing temporary modifications to correct this issue. This potential concern has no impact on public health and safety. This 8-hour notification is being conservatively reported in accordance with 10 CFR50.72(b)(3)(ii)(B).

"The NRC Resident Inspector has been notified."

The licensee will notify the Massachusetts Emergency Management Center.

* * * RETRACTION FROM DAVID NOYES TO VINCE KLCO ON 11/20/2011 AT 0733 EST* * *

"Event Notification 47288 was conservatively made to ensure that the Eight-Hour Non-Emergency reporting requirements of 10 CFR 50.72 were satisfied pending further evaluation of Salt Service Water (SSW) subsystem operability during certain degraded voltage conditions.

"Pilgrim Station has subsequently evaluated the impact of the Salt Service Water (SSW) pump motor operating load; potential degraded voltage conditions on thermal overload settings; and pump motor restart requirements; and determined that reasonable assurance of SSW subsystem operability existed. Both SSW subsystems were evaluated to be capable of satisfying the system safety function of providing cooling water to the Reactor Building Closed Cooling Water System heat exchangers during accident and transient conditions. Pilgrim 's evaluation considered manufacturer's data for the thermal overload relays, site specific shop testing, and reliable grid conditions which minimize the potential for extended operation with 4 kV buses operating at just above degraded voltage relay trip settings. This past operability evaluation concluded that the SSW pumps would support continuous operation of the SSW subsystems.

"Therefore, the initial 50.72 report is being retracted."

The licensee will notify the NRC Resident Inspector.

Notified the R1DO (Caruso).

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Agreement State Event Number: 47435
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSITY OF PENNSYLVANIA
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: JOE O'HARA
Notification Date: 11/14/2011
Notification Time: 18:49 [ET]
Event Date: 11/10/2011
Event Time: 07:00 [EST]
Last Update Date: 11/14/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN CARUSO (R1DO)
ANDREW PERSINKO (FSME)

Event Text

AGREEMENT STATE REPORT - UNDERDOSAGE OF THERASPHERES

The following report was received via facsimile:

"Event type: A medical event (ME) involving Y-90 TheraSpheres where the patient received an under-dose of 36%, which is reportable under 10CFR35.3045 (a) (1) (ii).

"Notifications: On November 11, 2011, at 0849, the Department's [Pennsylvania Department of Environmental Protection] Southeast Regional Office received notification via email about the ME.

"Event Description: The patient was being treated with MDS Nordion Y-90 TheraSpheres« for disease of the liver and received only 36% of the intended dose. The licensee has notified the patient. No more information is available at this time.

"Cause of the Event: Is unknown at this time and is currently under investigation.

"Actions: The licensee will be submitting a written report within 15 days. The department [Pennsylvania Bureau of Radiation Protection] has planned a reactive inspection for November 17, 2011."

PA Event Report Identification Number: PA110036

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: 47437
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: BAG N SAVE SUPERMARKETS
Region: 4
City: OMAHA State: NE
County:
License #: GL0402
Agreement: Y
Docket:
NRC Notified By: TRUDY HILL
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/15/2011
Notification Time: 14:41 [ET]
Event Date: 01/01/2003
Event Time: [CST]
Last Update Date: 11/15/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4DO)
MICHELE BURGESS (FSME)
DENNIS ALLSTON e-mai (ILTA)

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

Event Text

AGREEMENT STATE REPORT - LOSS OF A TRITIUM SIGN

The following report was received from the state via e-mail:

"Safety Light Model 2040-50-20, Serial Number A10 1821 with 12 Ci of H-3 was shipped in July of 1991 to the facility. In 2002-2003, the facility was remodeled. The facility was sold in 2004. The new owner assumed that they still had the sign and continued to pay the annual fee. This year, one of the owners sold his portion of the business and new staff questioned where the sign was when they received the annual fee notice. The staff believes that the sign was removed at the time of remodeling in 2002-2003."

Nebraska Item Number: NE110009

The licensee determined the sign was lost on 11/4/2011 and reported it to the state on 11/14/2011.

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: 47438
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: UNISOM INDUSTRIES
Region: 1
City: JACKSONVILLE State: FL
County:
License #: 3942-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/15/2011
Notification Time: 15:27 [ET]
Event Date: 11/15/2011
Event Time: [EST]
Last Update Date: 11/15/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN CARUSO (R1DO)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT - SUSPECTED CONTAMINATED PACKAGE

The following report was received from the state via fax:

"The State of Florida received report of potentially breached package that had arrived from Singapore to Jacksonville Florida. Jacksonville Fire Department was initially called and surveyed item, no contamination found. Item was then shipped to repair facility in Jacksonville (Unisom) License #3942-1. This office was contacted by State Warning Point, which sent an Investigator, he found an oily stain on a White 1 labeled package approximately 80cm2. His survey of packaging material and ignition exciters indicated no detectable radiation. Oily substance appeared to only on the outside of shipping container and was not from ignition exciters. No further action will be taken on this incident."

Florida Incident No.: FL11-096

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Agreement State Event Number: 47439
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: TERRACON CONSULTANTS INC
Region: 4
City: GRAND PRAIRIE State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/15/2011
Notification Time: 16:45 [ET]
Event Date: 11/15/2011
Event Time: [CST]
Last Update Date: 11/15/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4DO)
BILL VON TILL (FSME)
DENNIS ALLSTON (ILTA)
MEXICO (fax) ()

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

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following report was received via e-mail:

"On November 15, 2011, the Agency [Texas Department of Health] was notified by the licensee that a Troxler model 3440 moisture/density gauge containing 9 millicuries of cesium-137 and 40 millicuries of americium-241 was stolen. The gauge was locked in the back of a company truck and the truck was parked at the technicians home overnight. When the technician went to the truck to leave, he found the gauge, one lock, and a chain missing. The licensee has notified local law enforcement of the theft. Additional information will be provided in accordance with SA - 300."

Texas Incident: I-8903

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: 47440
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: MISTRAS
Region: 4
City: BENICIA State: CA
County:
License #: 4886
Agreement: Y
Docket:
NRC Notified By: KENT PRENDERGAST
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/15/2011
Notification Time: 19:28 [ET]
Event Date: 11/15/2011
Event Time: 16:00 [PST]
Last Update Date: 11/15/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAIR SPITZBERG (R4DO)
BILL VON TILL (FSME)

Event Text

AGREEMENT STATE REPORT - STUCK RADIOGRAPHY SOURCE

The following report was received via e-mail:

"Stuck 37 Curie radiographic source in an INC IR100 camera. The magnet holding the collimator to the tank came loose and fell on the guide tube, kinking the guide tube. Operators placed lead bags on the source and repaired the kink so that the source could be retrieved. The radiographer received 42 mRem. The RSO received 39 mRem and the assistant received 10 mRem."

California report number: 5010-111411





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: 47445
Rep Org: NJ RAD PROT AND REL PREVENTION PGM
Licensee: ATLANTIC STATES CAST IRON COMPANY
Region: 1
City: PHILLIPSBURG State: NJ
County:
License #: 507414
Agreement: Y
Docket:
NRC Notified By: CATHERINE BIEL
HQ OPS Officer: CHARLES TEAL
Notification Date: 11/16/2011
Notification Time: 10:11 [ET]
Event Date: 10/24/2011
Event Time: [EST]
Last Update Date: 11/16/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN CARUSO (R1DO)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE - SHUTTER FELL OFF FIXED PROCESS GAUGE

"The licensee's two fixed gauges were locked out because of maintenance on refractory equipment occurring the weekend of 10/22/11. On the morning of 10/24/11 it was discovered that the shutter had fallen. The exact timing of when the shutter fell is under investigation. This event resulted in a possible overexposure of members of the public.

"Staff from the NJDEP (New Jersey Department of Environmental Protection) is visiting the site today, 11/15/11."

The gauge is a TN Technologies Model #5204, S/N B585, fixed gauge containing 8 Ci of Cs-137.

NJ Incident #: 410183

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Power Reactor Event Number: 47455
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [ ] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: TIM MILLER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/18/2011
Notification Time: 12:13 [ET]
Event Date: 11/18/2011
Event Time: 05:30 [EST]
Last Update Date: 11/18/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MARVIN SYKES (R2DO)

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

EMERGENCY RESPONSE DATA SYSTEM (ERDS) DISCOVERED TO BE OUT OF SERVICE

"At 0530 EST on 11/18/11, it was identified that communication capability to the NRC ERDS link from the Emergency Response Data Acquisition and Display System (ERDADS) was disabled for St. Lucie Unit 2. The loss of communication occurred due to an issue within the FPL network that was resolved at 1024 EST on 11/18/11. The loss [of the ERDS link was determined to have] occurred on 11/15/11 and is under investigation. The details of this investigation will be documented via the corrective action process. St. Lucie Unit 1 communication capability was maintained by the ERDS modem."

The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 47457
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: JASON KINDRED
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/18/2011
Notification Time: 15:21 [ET]
Event Date: 11/18/2011
Event Time: 13:30 [CST]
Last Update Date: 11/18/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
74.11(a) - LOST/STOLEN SNM
Person (Organization):
DAVID HILLS (R3DO)
MICHAEL WATERS (NMSS)
JANE MARSHALL (IRD)
D. JOHNSON VIA EMAIL (ILTA)

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

LOCAL POWER RANGE MONITOR (LPRM) STORED IN SPENT FUEL POOL CANNOT BE LOCATED

"At 1330 [CST] on 11/18/11, Nuclear Engineering reported to Operations that during a Special Nuclear Material (SNM) Physical Inventory they were unable to locate an individual LPRM [Local Power Range Monitor] detector that was believed to be loose in the bottom of the Spent Fuel Pool. Efforts remain in progress to locate the material in the pool."

The licensee stated that during a previous refueling, a 4-detector LPRM string had been removed from the core and placed in the spent fuel pool. At the time, the string had been cut and a single detector at the bottom of the string had fallen to the bottom of the spent fuel pool under the fuel racks. Today, the licensee attempted to retrieve the LPRM detector for placement in a special storage canister in a controlled location that could be easily inventoried. During the retrieval attempt, the licensee could not locate the LPRM detector. There is no indication at this time that the detector has been inadvertently removed from the spent fuel pool and disposed of. The licensee believes that the detector is still in the pool and just needs to be located. The specific information on the detector was not available at the time of this report but the licensee is conservatively assuming the it contained greater than 1 gram of Uranium-233 and is therefore reportable under 10 CFR 74.11.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 47459
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [ ] [ ]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: AMADO FERNANDEZ
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/19/2011
Notification Time: 16:48 [ET]
Event Date: 11/19/2011
Event Time: 08:28 [MST]
Last Update Date: 11/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
BLAIR SPITZBERG (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

THE LOW PRESSURE SAFETY INJECTION SYSTEM WAS SUBJECTED TO HIGH PRESSURE RESULTING IN BOTH TRAINS BEING DECLARED INOPERABLE

"On November 19, 2011, Unit 1 was in Mode 3. Boration of the four reactor coolant system (RCS) cold leg injection lines was in progress using High Pressure Safety Injection pump 'A'.

"During this activity, 'SI CHK VLV Leak Pressure Hi' alarms were received at 0828 [MST]. The 'A' and 'B' Low Pressure Safety Injection (LPSI) subsystems were declared inoperable because the pressure downstream of the motor operated LPSI injection valves was above 1525 psia. This elevated pressure potentially impacts the ability of the LPSI RCS loop injection valves to open. The high differential pressure may exceed the capability of the motor operator. All four injection line pressures were found above 1525 psia and LCO 3.0.3 was entered due to both trains of LPSI being inoperable. At 0839 [MST], pressure in the 'A' train injection lines was lowered below 1525 psia and 'A' LPSI subsystem was declared operable and LCO 3.0.3 was exited. At 0842 [MST], pressure was reduced below 1525 psia on the 'B' train injection lines and the 'B' LPSI subsystem was declared operable and LCO 3.5.3 condition A was exited.

"This call is being made to report a condition that could have prevented the fulfillment of a safety function required to mitigate the consequences of an accident and unanalyzed condition that existed for 11 minutes while both LPSI subsystems were inoperable.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 47460
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: MARK IHLENFELDT
HQ OPS Officer: VINCE KLCO
Notification Date: 11/20/2011
Notification Time: 02:10 [ET]
Event Date: 11/19/2011
Event Time: 23:12 [CST]
Last Update Date: 11/20/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
DAVID HILLS (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 90 Power Operation 0 Hot Shutdown

Event Text

AUTOMATIC REACTOR SCRAM WHILE PERFORMING TURBINE BYPASS VALVE TESTING

"While performing a regularly scheduled Turbine Bypass Valve surveillance, prior to Turbine Bypass Valve movement, a 'B' half scram [signal] was received. Operators immediately suspended testing. Approximately 10 seconds later, a full Reactor Protection System actuation occurred. Following the reactor scram, reactor water level lowered below the Group II isolation initiation setpoint of +9 inches, [resulting in containment valve isolations]. There were no radioactive releases associated with this event.

"No other alarms were received prior to the RPS actuation. The cause of the reactor scram is under investigation at this time.

"Also, due to the reactor scram, discharge canal temperature rate of change exceeded plant requirements. As a result, the State of Minnesota, and appropriate local agencies will be notified."

All control rods inserted and the scram is considered uncomplicated. The plant is in a normal shutdown electrical configuration.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 47461
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [ ] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: JOHN MAGYARIK
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/20/2011
Notification Time: 20:37 [ET]
Event Date: 11/20/2011
Event Time: 17:58 [EST]
Last Update Date: 11/20/2011
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):
JOHN CARUSO (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 M/R Y 2 Startup 0 Hot Standby

Event Text

MANUAL REACTOR TRIP DUE TO LOSS OF CONDENSER VACUUM DURING STARTUP

Millstone Unit 3 was manually tripped at low power during startup following the loss of condenser vacuum. The loss of vacuum was caused by the loss of the auxiliary steam boiler. The auxiliary steam boiler supplies gland seal steam to the turbine at low power and without the gland seal steam, the licensee could not maintain a condenser vacuum.

All rods fully inserted and there were no complications during the trip. All systems functioned as required and the unit is stable in Mode 3. There was no impact on Unit 2.

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

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