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Event Notification Report for May 1, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/30/2013 - 05/01/2013

** EVENT NUMBERS **


48569 48952 48954 48959 48982 48984 48985

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Part 21 Event Number: 48569
Rep Org: EMERSON PROCESS MANAGEMENT
Licensee: FISHER DIVISION
Region: 3
City: MARSHALLTOWN State: IA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TRISH CROSSER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 12/07/2012
Notification Time: 09:53 [ET]
Event Date: 11/09/2012
Event Time: [CST]
Last Update Date: 04/30/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
Person (Organization):
PATTY PELKE (R3DO)
JAMES DRAKE (R4DO)
PART 21 GROUP (E-MA)

Event Text

PART 21 - BRACKETS USED PROXIMITY SWITCHES INSTALLED UPSIDE DOWN

"Equipment Affected By This Fisher Information Notice:

"This Fisher Information Notice (FIN) applies to equipment provided to Arizona Public Service Company-Palo Verde Nuclear Generating Station per Fisher Order Number 019-F10051845, Items 0001, 0002, 0004, and 0005 (Arizona Public Service PO# 500559374).

"The affected equipment Is:
"4 [inch] CL900 Fisher HPD valve assemblies with TopWorx C8-24521-E3 proximity switches.

"The equipment is identified by Fisher serial numbers 20417605, 20428975, 20428977, and 20428978 respectively and Arizona Public Service Company tag numbers 1JSGEUV0169, 2JSGEUV0169, 1JSGEUV0183, and 2JSGEUV0183.

"Purpose:

"The purpose of this FIN is to alert Arizona Public Service Company that as of 9 November, 2012, Fisher Controls International LLC (Fisher) became aware of a situation which may potentially affect the safety-related performance of the aforementioned equipment.

"Fisher is informing you of this circumstance in accordance with Section 21.21 (b) of 10 CFR 21.

"Applicability:

"This FIN applies only to the aforementioned equipment supplied by Fisher to Arizona Public Service Company- Palo Verde Nuclear Generating Station.

"Discussion:

"Arizona Public Service Company has determined that the brackets used to install the TopWorx switches were installed improperly by Fisher.

"Specifically, the mounting brackets for the switches were installed upside down. This orientation makes it impossible for the switches to operate properly and to perform their safety-related function.

"While the design used for these brackets was unique and constituted a first-time installation by Fisher, Fisher is in the process of performing a root cause analysis as well as investigating why the error was not detected prior to shipment. Fisher will implement a corrective action to prevent problems like this from reoccurring in the future.

"Additionally specific arrangements are being made with Arizona Public Service Company to correct the problem on the subject serial numbers, at Fisher's cost.

"Action Required:

"Fisher is currently working with Arizona Public Service Company to resolve the situation, including, the implementation of a bracket redesign and testing program to demonstrate the problem has been satisfactorily corrected.

"10 CFR 21 Implications:

"Fisher requests that the recipient of this notice review it and take appropriate action in accordance with 10 CFR 21.

"If there are any technical questions or concerns, please contact:
"George Baitinger;
Manager, Quality;
Fisher Controls International LLC;
205 South Center Street Marshalltown, IA 50158;
Fax: (641) 754-2854, Phone: (641) 745-2026."

* * * UPDATE AT 1634 EDT ON 4/30/2013 FROM CHAD ENGLE TO MARK ABRAMOVITZ * * *

The following information was received via fax:

"After the switches were properly reinstalled it was discovered that due to potential rotation of the valve stem connector when operating the hand wheel, the target magnets could, in some cases, rotate beyond the gap required for switch functionality. This additional discovery is the reason for the issue of this supplemental FIN.

"Fisher is currently working with TopWorx and APS/PVNGS [Arizona Public Service / Palo Verde Nuclear Generating Station] to develop a bracket redesign with adequate guiding which will constrain the magnet/switch gap to within acceptable criteria."

Notified the R4DO (Haire), R3DO (Duncan) and Part 21 Group (via e-mail).

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Agreement State Event Number: 48952
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: FRONTIER EL DORADO REFINING LLC
Region: 4
City: EL DORADO State: KS
County:
License #: 22-B145-01
Agreement: Y
Docket:
NRC Notified By: DAVID WHITFILL
HQ OPS Officer: PETE SNYDER
Notification Date: 04/22/2013
Notification Time: 10:13 [ET]
Event Date: 04/21/2013
Event Time: 01:04 [CDT]
Last Update Date: 04/22/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

SOURCE JAMS AS IT IS MOVED FROM DRYWELL TO SOURCE HOLDER

The following information was received via facsimile from the State of Kansas:

"We [Frontier El Dorado Refining] attempted to move a source from its drywell, into its source holder. The source seems to be stuck in the drywell. There were no reportable personnel exposures. Because of the position of this source, 2 feet inside a large vessel with 5 [inch] steel walls, it is shielded at least as well as inside its holder.

"The shutter in question is on an Ohmart/VEGA model SHLM-CR3 source holder S/N 19077661, containing 2 Ci of Cs-137 in a model A2102 sealed source S/N 0586CO.

"The source is located at approximately 100 feet above the ground. Operations and maintenance personnel were notified of the issue. A wipe sample was collect to check for gross leakage. None was indicated.

"We [Frontier El Dorado Refining] will contact VEGA Americas (formerly Ohmart/VEGA) to arrange for repairs."

Item Number: KS130004

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Agreement State Event Number: 48954
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: MISTRAS GROUP, INC
Region: 4
City: KENT State: WA
County:
License #: WN-IR011-1
Agreement: Y
Docket:
NRC Notified By: JAMES KILLINGBECK
HQ OPS Officer: CHARLES TEAL
Notification Date: 04/22/2013
Notification Time: 19:18 [ET]
Event Date: 04/20/2013
Event Time: [PDT]
Last Update Date: 04/29/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE STUCK IN GUIDE TUBE

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

"Mistras Group, Inc. was conducting industrial radiographic operations at Shell Puget Sound Refinery. After a routine exposure, the radiographer attempted to crank the source back into the camera, but the source became stuck. The source could not make it past a crimp in the guide tube, which was caused earlier when the camera fell on it. The radiography crew moved their restricted area boundaries to increase the size of the restricted area and to provide additional protection to anyone in the area. Fortunately, nobody other than the radiography crew were in that portion of the refinery. The radiography crew and assistant radiation safety officer were able to manually pull the source back into the shielded position in the camera. The highest exposure to any person, as read from a pocket dosimeter, was 10 millirem. Note: This is a preliminary report - we [State of Washington] will obtain additional information from the licensee and provide a more complete report in the near future."

Washington Item Number: WA130001

* * * UPDATE ON 4/29/2013 AT 1931 EDT FROM JAMES KILLINGBECK TO MARK ABRAMOVITZ * * *

The following information was received via fax:

"An industrial radiography crew retracted the source, checked to verify that the source was fully retracted and locked, and discovered that it was not. The crew made more attempts to retract the source, but were unsuccessful. They attempted to straighten out the crank assembly, then the radiographic exposure device fell about 46 inches from a pipe onto a platform, after which the drive cable would not move using the crank handle. The restricted area was expanded to the 2 mR/hr line and facility management and the licensee's radiation safety personnel were notified and traveled to the site. The guide tube was moved onto the platform and lead shot bags were placed onto the collimator to provide extra shielding. Licensee radiation safety staff found that the drive cable was hung up in the crank assembly conduit but moved freely in the source tube. So, the staff manually pulled on the drive cable and returned the source to the fully retracted and locked position in the radiographic exposure device. It was discovered that there was a crimp in the crank assembly conduit that kept the drive cable from moving. The highest pocket dosimeter reading was 18 millirem. The radiographic exposure device was sent to the manufacturer for evaluation."

Notified the R4DO (Haire) and FSME Event Resources (via e-mail).

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Agreement State Event Number: 48959
Rep Org: ALABAMA RADIATION CONTROL
Licensee: BAPTIST MEDICAL CENTER-PRINCETON
Region: 1
City: BIRMINGHAM State: AL
County:
License #: NOT PROVIDED
Agreement: Y
Docket:
NRC Notified By: MYRON RILEY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/23/2013
Notification Time: 13:50 [ET]
Event Date: 03/26/2013
Event Time: [CDT]
Last Update Date: 04/23/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JUDY JOUSTRA (R1DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - FETUS/EMBRYO DOSE EXCEEDED 500 MILLIREM

The following information was obtained from the State of Alabama via facsimile:

"On April 9, 2013, [the Certified Nuclear Medicine Technician] for Baptist Medical Center-Princeton, Birmingham, Alabama, notified the Alabama Office of Radiation Control of a fetal/embryo dose that could be over 500 milliRem.

"On March 1, 2013, a 36 year old female had a thyroidectomy due to thyroid cancer. Following surgery on March 6, the patient had general lab work which included a negative pregnancy test. On March 26, the patient returned for a 50 millicurie I-131 treatment on the remaining thyroid tissue. The technologist administering the test did not confirm, nor was told, that the patient had another pregnancy test prior to the dosing. The pregnancy test conducted on March 26, 2013 was positive. It was confirmed that the embryo exposure was greater than 500 millirem threshold.

"The patient was immediately notified of the positive pregnancy results and was consulted by a OB/GYN physician. The patient received an ultrasound which confirmed the pregnancy at 4 to 5 weeks.

"The information is complete as of 12:45 pm CDT, April 23, 2013."

Alabama Incident 13-15

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Power Reactor Event Number: 48982
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [ ] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: MICHEL CICCONE
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 04/30/2013
Notification Time: 05:06 [ET]
Event Date: 04/30/2013
Event Time: 01:20 [EDT]
Last Update Date: 04/30/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
GORDON HUNEGS (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Defueled 0 Defueled

Event Text

PLANNED MAINTENANCE OF RADIATION MONITORS USED FOR EAL CLASSIFICATION

"Systems affected: Main steam line radiation monitors, MSS-RE75, RE77, and Terry Turbine radiation monitor MSS-RE79.

"Actuations & their initiation signals: None.

"Causes: Preplanned electrical maintenance of radiation monitors power supplies.

"Effect of event on plant: Loss of assessment capabilities from radiation monitors used for EAL [Emergency Action Level] classification.

"Actions taken or planned: Maintenance of electrical power supplies to radiation monitors.

"Additional information: Radiation monitors will be removed from service for approximately 48 hours."

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

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Power Reactor Event Number: 48984
Facility: MILLSTONE
Region: 1 State: CT
Unit: [1] [ ] [ ]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: MARK STRELLO
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/30/2013
Notification Time: 10:45 [ET]
Event Date: 04/30/2013
Event Time: 08:40 [EDT]
Last Update Date: 04/30/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
GORDON HUNEGS (R1DO)

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

Event Text

PLANNED MAINTENANCE OF RADIATION MONITORS USED FOR EAL CLASSIFICATION

"Systems affected: Unit 1 Spent Fuel Pool Island Vent Rad Monitor

"Actuations & their initiation signals: None.

"Causes: Preplanned Chemistry maintenance

"Effect of event on plant: Loss of assessment capabilities from radiation monitors used for EAL [Emergency Action Level] classification.

"Actions taken or planned: Chemistry to perform scheduled maintenance

"Additional information: Radiation monitor will be out of service for approximately 30 minutes."

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

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Power Reactor Event Number: 48985
Facility: VOGTLE
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: NAVEEN KOTEEL
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/30/2013
Notification Time: 13:15 [ET]
Event Date: 04/30/2013
Event Time: 09:45 [EDT]
Last Update Date: 04/30/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
KATHLEEN O'DONOHUE (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 100 Power Operation 100 Power Operation

Event Text

PLANNED MAINTENANCE ON THE TECHNICAL SUPPORT CENTER SUPPORT SYSTEMS

"A condition is being reported per TRM [Technical Requirements Manual] 13.13.1 Emergency Response Facilities Action B.2. The functionality of the Technical Support Center (TSC) has been lost due to planned maintenance activities performed on TSC support systems. Alternate facilities are available to provide emergency response functions and actions are proceeding to return the TSC to functional status with high priority. A 10CFR50.54(q) evaluation has been performed for this planned maintenance activity.

At 102 EDT on 4/30/13, the "TSC has been restored to a functional status. The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Wednesday, May 01, 2013
Wednesday, May 01, 2013