Event Notification Report for March 18, 2014

AGREEMENT STATE NOTIFICATION - FOUND DEPLETED URANIUM SHIELD

The following was received from the State of New York via fax:

"On 3/18/2014 NYC sanitation workers clearing a vacant lot in Queens discovered one depleted uranium (DU) shield and the remains of 3 to 4 plastic outer-packs from Mallinckrodt manufactured Mo/Tc radiopharmaceutical generators. Information on the packaging indicates the generators were supplied to NYS Licensee C5413 Triad Isotopes in 2013. Discussions with Triad Isotopes on 3/19/2014 indicate that Mallinckrodt contacted them in October 2013 regarding a shipment of 5 spent generators being returned from Triad to Mallinckrodt via their contractor MDS [that] did not make it to Mallinckrodt in Missouri. The DU shield is being secured by NYC while waiting to be picked up by Triad. NRC Region 3 has been contacted. NYS Incident #1055"

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

REACTOR SCRAM DUE TO FAILURE TO CONTROL MAIN TURBINE MOISTURE SEPARATOR LEVEL

"At 2252 on 03/18/2014, the Unit 3 reactor automatically scrammed due to a turbine trip from a high Main Turbine moisture separator level. Initial indications show the level controller for 3B2 Moisture Separator failed to adequately maintain level. Additionally local manual control attempts failed to restore moisture separator level. Main Steam Isolation Valves remained open with main turbine bypass valves controlling reactor pressure. Reactor feedwater pumps are in service to control reactor water level.

"Primary Containment Isolation System Groups 2, 3, 6 and 8 containment isolation and initiation signals were received. Upon receipt of these signals all required components actuated as required. Neither High Pressure Coolant Injection nor Reactor Core Isolation Cooling initiation signals were received.

"The reactor had been operating near 35% power during scheduled power ascension.

"This event is reportable within 4 hours per 10CFR 50.72(b)(2)(iv)(B) 'any event or condition that results in actuation of the reactor protection system (RPS) when the reactor is critical except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation.' It is also reportable within 8 hours per 10CFR 50.72(b)(3)(iv)(A) and requires an LER within 60 days per 10CFR 50.73(a)(2)(iv)(A).

"NRC Resident Inspector has been notified."

PART 21 - THOMAS AND BETTS PRINTED CIRCUIT BOARDS

The following was received via fax:

"This report documents the supply of faulty Logic Power supply assembly printed circuit boards for a Cyberex 20KVA Model AC Power Supply. These power supplies have the incorrect strap installed on the transformers of Cyberex P/N [Part Number] 30-80-56620 which potentially can lead to the transformer being loose and can cause failure of the power supply. Per the manufacturer, the band should have been made of stainless steel but the bands on the installed transformers were made of carbon steel and a corrosion resistant coating. The details of the potential failure of the power supply and the root cause are being evaluated and will be documented in the final report.

"UCI [United Controls International] reviewed all the orders that were supplied to the customers and determined that two UCI orders are affected and the customer was notified on the day the issue was identified."

Part Number 90-41-974313 (UCI serial numbers 03996-01 -0001, -0002, -0003) and P/N 41-01-596701 (UCI serial numbers 03967-03 -0001, -0002, -0003) supplied to Public Service Electric and Gas (PSEG) are affected.

* * * UPDATE ON 4/17/2014 AT 1442 EDT FROM KORINA LOOFT TO DONG PARK * * *

The following was received via fax:

"This engineering evaluation is being written to document the supply faulty Power supplies for the 20KVA Cyberex Model AC Power supply with the Cyberex part numbers 41-01-596701 and 90-41-974313.

"SUMMARY: UCI issued a certificate of conformance to PSEG for S/N: 003967-03-0001 thru 0003 on December 22nd 2012, to be used in safety related applications where seismic is the only design basis event. During the pre-installation testing in February 2014, PSEG identified loose transformers and a loud noise frequency whine and the power supply boards were returned to UCI. Below table lists the details of the power supplies that were returned to UCI.

"On February 2nd 2014, UCI has initiated part 21 evaluation to determine the root cause for the failure and evaluate if a defect existed. During the evaluation, it was determined that the transformer strap band installed on Cyberex P/N 30-801-56620 transformer at the location T501 should have been made of stainless steel but the strap band on these power supplies was made up of zinc plated carbon steel. Due to this material difference, the transformer warped and it was evident it became loose.

"The installation of the incorrect strap bands on the transformer apply to only one batch of manufactured PCB assemblies. The manufacturer addressed this issue since this was discovered and this was verified by UCI. UCI determined that the order along with the boards that failed pre-installation testing, were the only boards affected by this issue. The customer PSEG was notified on March 13th 2014 and the initial notification letter to NRC was sent on March 19th 2014.

"The above mentioned power supplies were recalled from PSEG and two power supply boards of S/N: 003996-01-0002 and 003996-01-0003 are currently at UCI for evaluation and rework. However the S/N: 003996-01-0001 board has not yet been returned to UCI by PSEG. UCI performed an XRF analysis on one of the affected power supplies per part number lot and on UCI control samples to confirm and compare the material of the transformer strap bands.

"EFFECT OF THE DEFECT: The installation of the incorrect transformer strap band resulted in the loosening of the transformer from the band. When installed in the system, the transformer might become loose and cause a loud whining noise. The installation of the incorrect material band on the transformer might lead to loosening of the transformer and causes whining noise when installed but no functional test failure will be observed. However, the loose transformer affects the safety function of the item during or after seismic event due to loss of structural integrity.

"CORRECTIVE ACTIONS PERFORMED: A UCI corrective action # CAR 14-14 was opened to document the issue found and the corrective and preventive actions taken. As a result, UCI will create two new Commercial Grade dedication procedures for P/N: 41-01-596701 and 90-41-974313 to include the material verification of the transformer bands installed on these power supplies. These new procedures will be used for the existing and future orders of these part numbers.

"All the affected power supply boards except S/N: 003996-01-0001 are currently at UCI undergoing rework to replace the transformer of the incorrect material strap band with a transformer of the correct (stainless steel) strap band. After rework, dedication will be performed per new dedication procedures as specified above."

Notified R1DO (Burritt) and Part 21 Group via email.

60-DAY OPTIONAL TELEPHONIC NOTIFICATION FOR AN INVALID ACTUATION OF CONTAINMENT ISOLATION VALVES

"This 60-day report, as allowed by 10 CFR 50.73(a)(1), is being made pursuant to 10 CFR 50.73(a)(2)(iv)(A) to describe an unplanned, invalid actuation of containment isolation valves which occurred during the most recent refueling outage at Fermi 2. On 3/18/2014, at approximately 1930 EST, shortly after transferring Division 2 Reactor Protection System (RPS B) from the alternate to the normal power supply, Operations personnel noted that an unexpected half-scram occurred. Initial investigation found a fuse in an RPS Power Distribution Panel had blown. Further investigation found that a power contactor had failed causing the fuse to blow. The contactor failure resulted in an invalid half scram and actuations (closure) of Torus Water Management System (TWMS) Outboard containment isolation valves, Division 2 Drywell Pneumatics Inboard and Outboard containment isolation valves and the Drywell Floor and Equipment Drain Sumps Inboard containment isolation valves. All valves operated as expected. Since containment isolation valves in more than one system were actuated by this failure, this event constitutes an event or condition that resulted in manual or automatic actuation of the system listed in paragraph 10 CFR 50.73 (a)(2)(iv)(B)(2) and is reportable under 10 CFR 50.73(a)(2)(iv)(A).

"The NRC Resident Inspector has been informed of this notification."

AGREEMENT STATE - DISCOVERED I-125 SOURCE MISSING FOLLOWING SURGERY

The following information was received from the State of Texas via email:

"UT Southwestern, RSO called to report that an I-125 seed implant [135 mCi] had been lost during a breast implant procedure on 03/18/14. The treatment staff did not notify Radiation Safety until 03/26/14. The room had been cleaned before Radiation Safety had a chance to search. [The] RSO will provide more details in his written report."

Texas Incident #: I-9173

* * * UPDATE ON 4/3/14 AT 1529 EDT FROM ARTHUR TUCKER TO DONG PARK * * *

The following information was received from the State of Texas via email:

"On April 3, 2014, the Agency [Texas Department of Health] contacted the licensee to confirm the activity of the missing I-125 seed. The licensee's Radiation Safety Officer stated the activity was 135 microcuries. Additional information will be provided as it is received in accordance with SA-300."

Notified R4DO (Gepford), FSME Events Resource, and ILTAB via email.

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