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Event Notification Report for December 2, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/01/2011 - 12/02/2011

** EVENT NUMBERS **


45459 47384 47480 47484 47486 47493 47494 47495

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General Information Event Number: 45459
Rep Org: ENGINE SYSTEMS, INC
Licensee: ENGINE SYSTEMS, INC
Region: 1
City: ROCKY MOUNT State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: PAUL STEPANTSCHENKO
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/23/2009
Notification Time: 16:32 [ET]
Event Date: 08/24/2009
Event Time: [EDT]
Last Update Date: 12/01/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
NEIL OKEEFE (R4DO)
J.THORP (e-mail) (NRR)
O.TABATABAI (e-mail) (NRO)

Event Text

INTERIM REPORT ON THERMOSTATIC VALVE FAILURE ON PALO VERDE EDG

"This interim report is being issued because Engine Systems, Inc. (ESI) is not able to complete an evaluation of an identified deviation within the 60 day requirement of 10CFR21.21. The evaluation is expected to be completed no later than November 30, 2009.

"ESI began an evaluation of a thermostatic valve element failure on August 24, 2009. Palo Verde Nuclear Plant notified ESI of the failure as a result of a failure analysis they were performing on a thermostatic valve that had been removed from the lube oil system of their 2A-EDG. The element was in service since April 2008 and Palo Verde verified operation of the element prior to installation.

"The Palo Verde failure analysis determined that one of two elements within the valve was defective. The element failure was attributed to wax leakage past the diaphragm seal on one of two power pills within the element. Evidence of mechanical binding of the piston is believed to have caused the wax leakage. If the piston was jammed, the expanding wax could have over pressurized the diaphragm seal leading to wax leakage. The failure analysis noted the following to support piston binding:

- The piston was initially difficult to remove from its guide tube.
- A gouge was observed on the piston surface.
- The rubber plug within the power pill exhibited brass machining chip debris.

"ESI has been coordinating with Palo Verde and the manufacturer (AMOT) to complete our evaluation and to determine if this is a generic issue or if it is an isolated incident.

"To date, no other similar failures with AMOT thermostatic valves have been reported to ESI."

Palo Verde has Cooper Bessemer KSV-20T diesel engines that use one 6" thermostatic valve in the engine jacket water system and one in the engine lube oil system to regulate system temperatures during engine operation. The thermostatic valve is an AMOT model 6HAS. The AMOT thermostatic valve element (P/N 9760X) is the defective part. ESI did not provide any information on other nuclear power plants that have EDGs that utilize this model thermostatic valve.

* * * UPDATE RECEIVED VIA EMAIL FROM PAUL STEPANTSCHENKO TO DONG PARK AT 1642 EST ON 12/01/09 * * *

"This report is a follow-up to an interim report (10CFR21-0098-INT) issued by Engine Systems, Inc. (ESI) on 10/23/09 which identified a deviation with an Amot thermostatic valve element. The interim report was issued because ESI was not able to complete the evaluation within the 60 day requirement of 10CFR21. The evaluation was completed on 11/30/09 and the deviation was determined be a reportable defect as by defined by 10CFR21.

"The Exelon analysis also reports that similar brass machining debris was observed on the plugs from the other three power pills to varying degrees. None of the stems of these pills displayed evidence of gouging or binding.

"To date, no other similar failures with Amot thermostatic valves have been reported to ESI.

"ESI has contacted the valve manufacturer (Amot) to discuss these findings. A copy of the Palo Verde failure analysis and eleven (11) element assemblies from ESI inventory were sent to Amot for evaluation. The following elements were sent to Amot for evaluation:

"Qty. 8: PIN 9760 X-170' (CES PIN 2-05V-419-107)
"Qty. 3: PIN 9760 X-160' (CES PIN 2-05V-419-109)

"Both part number elements are the same except for the temperature setting ('-170' indicates 170?F nominal and '-160' indicates 160?F nominal).

"Upon completion of their evaluation, Amot has reported the following:

"Fine shavings/powder of brass was observed in some of the element pills.

"None of the pill stems had any evidence of gouging.

"The pills used in the 9760X elements are made by converting another part number pill. This conversion consists of removing the stem from the pill and performing some machining. Amot believes the brass debris may have entered the pill as a result of this conversion process.

"Amot has not made any changes to this conversion process in recent history and has not had reports of similar problems with these elements.

"Machining debris, while undesirable, was evident in other pills which did not exhibit any operability issues; therefore this is not believed to be the cause of the pill failure.

"The primary cause of the failure is believed to be the gouge found in the pill stem. The gouge could have occurred during the conversion process as the stem is removed and handled at that time.

"As a precaution, Amot has made changes to their conversion process for this pill. The drilling fixture was modified to eliminate the possibility of chips entering the pill during the machining operation. This change was made effective 10/22/09.

"A listing of users with the thermostatic valves that contain the Amot 9760X element is provided in the table below.

"Site - Thermostatic Valve - System:
"Braidwood - 6HAS - Lube
"Byron - 6HAS - Lube
"Nine Mile Point - 6HAS- Lube
"Oconee - 4HAS & 6HAS - Water
"Palo Verde - 6HAS - Lube & Water
"South Texas Project - 6HAS - Lube & Water
"Susquehanna - 6HAS - Lube & Water
"Waterford - 5HAS & 6HAS - Lube & Water

"Corrective Action: The element failure at Palo Verde is considered to be an isolated incident related to a gouge in the pill stem. Thus, there is no recommended corrective action for users of the Amot 9760X element. The evaluation also indicated a weakness in Amot's manufacturing process for the element pill which introduced machining debris. While not believed to be the cause of the Palo Verde element failure, machining debris within the element pill is undesirable and increases the potential for failure in the future. Users with thermostatic valves containing Amot PIN 9760X elements should be aware of this issue so that they can monitor their systems for any indications of thermostat element problems.

Notified R1DO (Holody), R2DO (Guthrie), R3DO (Riemer), R4DO (Deese), NRR (Thorp) via e-mail, NRO (Tabatabai) via email.

* * * UPDATE RECEIVED VIA FAX FROM TOM HORNER TO DONG PARK AT 1613 EST ON 04/01/11 * * *

Two sentences were added to address the safety hazard which is created or could be created by this defect.

"This defect could affect operability of the thermostatic valve within the diesel engine cooling water and/or lube oil system, resulting in elevated fluid system temperatures during engine operation. Engine performance and/or load carrying capability could be impacted with the possibility of eventual engine failure, thereby preventing the emergency diesel generator from performing its safety related function."

Notified R1DO (Powell), R2DO (Sykes), R3DO (Peterson), R4DO (Lantz), PART 21 GROUP via e-mail.

* * * UPDATE RECEIVED VIA FAX FROM TOM HORNER TO VINCE KLCO AT 1611 EST ON 12/01/11 * * *

The report was updated to revise part numbers for Oconee, Waterford and Laguna Verde (Mexico). Affected users added include the following: Susquehanna 5th EDG and Ergytech/Iberdroia (Spain).

Notified R1DO (Schmidt), R2DO (Desai), R3DO (Riemer), R4DO (Farnholtz) and PART 21 GROUP via e-mail.

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital Event Number: 47384
Rep Org: JEPPESEN RADIATION ONCOLOGY
Licensee: BAY REGIONAL MEDICAL CENTER
Region: 3
City: BAY CITY State: MI
County:
License #: 21-18585-01
Agreement: N
Docket:
NRC Notified By: DENNIS KEHOE
HQ OPS Officer: JOE O'HARA
Notification Date: 10/28/2011
Notification Time: 15:26 [ET]
Event Date: 01/11/2011
Event Time: 07:00 [EDT]
Last Update Date: 12/01/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
PATTY PELKE (R3DO)
LYDIA CHANG (FSME)

Event Text

MEDICAL EVENT - MISADMINISTRATION OF PROSTATE CANCER SEEDS

During a recent inspection, an NRC inspector noted two cases which occurred on 8/23/11 and 1/11/11, respectively in which two separate patients were under dosed by greater than 20% during prostate cancer treatment using Iodine 125 seeds. The underdose was determined during post operative treatments. The same physician administered the procedure in both cases. The licensee has informed the prescribing physician, and is investigating the cause of the events. There is no long term permanent functional damage suspected to any organ in either case.

The licensee discussed the issue with NRC Region 3 (Gattone).

* * * UPDATE FROM DENNIS KEHOE TO VINCE KLCO ON 11/01/11 AT 1841 EDT * * *

After the licensee reviewed 3 years of medical reports, fourteen patents were found to have been under-dosed greater than 20% of the prescribed dose. Specific under-dose dates were: 4/10/08; 4/21/08; 4/25/08; 9/15/08; 10/17/08; 11/03/08; 2/17/09; 8/27/09; 1/05/10; 1/14/10; 5/25/10; 10/12/10; 5/03/11 and 5/19/11.

The licensee discussed the issue with NRC Region 3 (Gattone).

Notified the R3DO (Valos) and the FSME EO (Camper).

* * * RETRACTION FROM DENNIS KEHOE TO VINCE KLCO ON 12/1/2011 AT 1440 EDT * * *

The licensee is retracting this event due to the fact that the prostate seed implant for all the above 16 referenced events are planned intra-operatively within the operation. The licensee evaluates the seed implants at the end of the implant operation.

Notified the R3DO (Riemer) and FSME (McIntosh).

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: 47480
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: RESEARCH TRIANGLE INSTITUTE
Region: 1
City: RESEARCH TRIANGLE PARK State: NC
County:
License #: 032-0131-1
Agreement: Y
Docket:
NRC Notified By: HENRY BARNES
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/28/2011
Notification Time: 09:17 [ET]
Event Date: 11/18/2011
Event Time: 07:00 [EST]
Last Update Date: 11/28/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WAYNE SCHMIDT (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

NORTH CAROLINA AGREEMENT STATE REPORT - LEAKING SEALED SOURCE

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

"On November 18, 2011, the RSO of Research Triangle Institute (RTI), License Number 032-0131-1, performed a leak test on a sealed source. The results of the leak test revealed greater than 0.005 microcuries of removable contamination. The leak test showed 0.00517 microcuries of removable contamination. Subsequent surveys continued to show elevated results.

"The survey was performed with a Packard 1900 TR liquid scintillation counter, S/N 103761, calibrated Aug. 24, 2011.

"The source was a Ni-63 Electron Capture source. It had been removed from service and placed in storage in 2008. The source was being leak tested to prepare for disposal. Upon determination that the source was leaking, the RSO double-bagged the source, removed it from storage and segregated it, and contacted the waste broker for instructions on source disposal. The RSO performed contamination surveys of the storage area and the area is clean.

"Source information:

"Isotope: Ni-63, Quantity: 11.3 mCi, Mfg: Franklin GNO Corporation, Drawing No: 801-023, Serial Number: 37, Source date: October 20, 1975

"The licensee met all reporting requirements for the 5-day notification of a leaking source and is preparing a report with additional information."

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Agreement State Event Number: 47484
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: SAINT JOSEPH HOSPITAL
Region: 4
City: EUREKA State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KENT PRENDERGAST
HQ OPS Officer: CHARLES TEAL
Notification Date: 11/28/2011
Notification Time: 19:52 [ET]
Event Date: 11/25/2011
Event Time: [PST]
Last Update Date: 11/28/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
JIM LUEHMAN (FSME)

Event Text

AGREEMENT STATE REPORT - PACKAGE CONTAINING RADIOACTIVE MATERIAL LEFT UNATTENDED

The following was received from the State of California via email:

"During the holiday weekend, November 26, 2011, [a carrier] delivered a source containing 11.35 Ci of Ir-192 to Saint Joseph Hospital in Eureka, CA. There were no radiation safety personnel on site to receive the package and [the carrier] left the package with the receptionist, who is not authorized to receive radioactive material. The package was stored in the shipping and receiving area over the weekend. On Monday, November 28, 2011, the RSO became aware that the package had been sitting unsecured in the shipping and receiving area all weekend and notified the CA/RHB (California Radiation Health Branch)."

CA 5010 Number: 112811

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Agreement State Event Number: 47486
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: RADIATION MEDICINE SPECIALISTS OF NE PENNSYLVANIA, P.C.
Region: 1
City: FORTY FORT State: PA
County:
License #: PA-1238
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/29/2011
Notification Time: 08:05 [ET]
Event Date: 04/25/2011
Event Time: 12:00 [EST]
Last Update Date: 11/29/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WAYNE SCHMIDT (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

PENNSYLVANIA AGREEMENT STATE REPORT - UNSECURED RADIOACTIVE SOURCE

The following information was obtained from the Commonwealth of Pennsylvania via facsimile:

"On April 25, 2011, an Ir-192 source (SN# D36C-5591), 3.36 Ci activity, was removed from a Nucletron microSelectron HDR unit, placed into an approved Type A source storage and transportation container, and moved to a secure designated HDR source storage location, awaiting return to the manufacturer. However, due to miscommunication, the source was never shipped back to the manufacturer and as a result, the source was relocated by contractors approximately a month later to an unoccupied storage room in an uncontrolled area of the building. The source was estimated to have decayed to 2.5 Ci. On October 10, 2011, the unoccupied storage room became the office of a new full-time physicist. The activity was estimated to be 0.69 Ci at this time. On October 27, 2011, the source was discovered during a routine inspection by the Department of Environmental Protection and immediately placed back into the permanent storage area within the HDR storage location. It was determined that the badged physicist who occupied the office received 5.6 mrem, however, his subsequent dosimeter reading indicated no measureable radiation exposure. The unmonitored contractor who moved the source was estimated to have received 0.6 mrem.

"The source was returned to the manufacturer via [a national shipper] on November 10, 2011. In the future, the new full-time physicist will maintain control of all sources, as well as document when the sources actually leave the facility to be returned to the manufacturers. The licensee has also modified their policies and procedures. The Department [Pennsylvania Department of Environmental Protection] plans another reactive inspection."

PA Event Report ID: PA110037

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Power Reactor Event Number: 47493
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: MIKE ODELL
HQ OPS Officer: VINCE KLCO
Notification Date: 12/01/2011
Notification Time: 16:05 [ET]
Event Date: 12/01/2011
Event Time: 13:44 [EST]
Last Update Date: 12/01/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
BINOY DESAI (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 5 Startup 5 Startup

Event Text

CONTROL ROOM AIR CONDITIONING AND CONTROL ROOM EMERGENCY VENTILATION SYSTEMS INOPERABLE

"At 1344 hours (EST) on December 1, 2011, the Control Building Instrument Air Dryer failed resulting in loss of control air. As a result, the three Control Room Air Conditioning subsystems required by Technical Specification (TS) 3.7.4, 'Control Room Air Conditioning (AC) System,' and the two Control Room Emergency Ventilation [CREV] subsystems required by TS 3.7.3, 'Control Room Emergency Ventilation (CREV) System,' became inoperable. As a result, this condition could have prevented the fulfillment of the safety function for these systems. Because Brunswick has a shared control room, Unit 1 and Unit 2 entered TS 3.7.3 Required Action C.1, for two CREV subsystems inoperable (i.e., be in Mode 3 within 12 hours) and TS 3.7.4, Required Action E.1, for three Control Room AC subsystems inoperable (i.e., enter LCO 3.0.3 immediately).

"Operability of two Control Room AC subsystems and one CREV subsystem was restored and LCO 3.0.3 was exited, at 1410 hours, when the Instrument Air Dryer was bypassed.

"No power reduction took place as a result of the LCO 3.0.3 entry. This report applies to both Units 1 and 2 and is being made in accordance with 10 CFR 50.72(b)(3)(v)(D), as a condition that at the time of discovery could have prevented fulfillment of the safety function of systems that are needed to mitigate the consequences of an accident.

"The safety significance of this event is considered minimal. The condition existed for approximately 26 minutes. Plant staff took immediate actions to return the equipment to service. For the brief time the Control Room AC and CREV systems were inoperable, performance of plant personnel and equipment in the Control Room was not adversely affected. The maximum Control Room back panel temperature during this event was approximately 68 degrees F. Troubleshooting activities are under way to determine the cause of the Instrument Air Dryer failure."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 47494
Facility: GRAND GULF
Region: 4 State: MS
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: RUSSELL SEARS
HQ OPS Officer: VINCE KLCO
Notification Date: 12/02/2011
Notification Time: 13:21 [ET]
Event Date: 12/02/2011
Event Time: 08:29 [CST]
Last Update Date: 12/02/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
THOMAS FARNHOLTZ (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 87 Power Operation 87 Power Operation

Event Text

FITNESS FOR DUTY REPORT INVOLVING A NON-LICENSED EMPLOYEE SUPERVISOR

A non-licensed employee supervisor had a confirmed positive drug test during random testing. The employee's access to the plant has been terminated. Contact the Headquarters Operations Officer for additional details.

The licensee informed the NRC Resident Inspector.

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Power Reactor Event Number: 47495
Facility: VERMONT YANKEE
Region: 1 State: VT
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: JIM BROOKS
HQ OPS Officer: PETE SNYDER
Notification Date: 12/02/2011
Notification Time: 13:28 [ET]
Event Date: 12/02/2011
Event Time: 09:45 [EST]
Last Update Date: 12/02/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
WAYNE SCHMIDT (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

WRONG TRAIN EMERGENCY DIESEL FUEL RACK TRIP

"While hanging tags on the 'B' Diesel Generator, which was tagged out for maintenance, the operator mistakenly entered the 'A' Diesel Generator Room and tripped the 'A' Diesel Generator fuel rack, making it inoperable. At this time both diesels were inoperable placing the plant in a 24 Hour LCO.

"When the fuel rack was tripped alarms were received in the control room, the operator was immediately contacted and the problem was identified and corrected. Total LCO time was approximately 2 minutes."

The licensee notified the NRC Resident Inspector.

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