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Timestamp: 2019-10-19 06:44:58
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Matched Legal Cases: ['art 21', 'art 21', 'ART 21', 'art 21', 'art 21', 'art 21']

NRC: Event Notification Report for December 26, 2012
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Event Notification Report for December 26, 2012
48589 48592 48593 48594 48599 48602 48604 48616 48617 48618 48619 48620
48621 48622 48623 48624 48625
Agreement State Event Number: 48589
Licensee: THERMO SCIENTIFIC PORTABLE ANALYTICAL INSTRUMENTS
City: TEWKSBURY State: MA
NRC Notified By: i
HQ OPS Officer: CHARLES TEAL Notification Date: 12/13/2012
AGREEMENT STATE - POTENTIAL CONTAMINATED SEALED SOURCE
"On 12/13/12, licensee notified this Agency of the 12/12/12 determination of a potential leaking or contaminated sealed source that had been received from an out-of-state vendor. The source being returned to vendor for further analysis. There was no evidence of contamination beyond the source itself."
"The Agency considers this matter to be OPEN pending receipt of written report."
The sealed source contained 0.040 Ci of Cd-109. The manufacturer is Eckert and Zeigler, model XFB-3, with serial number TR2463. 45
Agreement State Event Number: 48592
Licensee: UNIVERSITY OF TOLEDO
License #: 02110490006
HQ OPS Officer: BILL HUFFMAN Notification Date: 12/14/2012
Last Update Date: 12/14/2012
FSME_EVENTS_RESOURCE (E-MA)
AGREEMENT STATE REPORT - UNDERDOSE TO PRESCRIBED TREATMENT LOCATION FOLLOWING A BRACHYTHERAPY TREATMENT
The following information was provided via e-mail from the State of Ohio Bureau of Radiation Protection:
"At 3:10 PM on Dec 13, 2012 the licensee RSO called the Ohio Department of Health Bureau to report a medical event involving a prostate seed underdose.
"A prostate seed implant procedure performed on 11/27/2012 was found to have failed the prescribed dose-volume criteria via post-implant CT performed on 12/10/2012. The target prescription was 160 Gy to the prostate. The patient was implanted with 88 Iodine-125 seeds with a total activity of 33.44 mCi (0.38 mCi / seed). The post-implant dosimetry was shown to have a D90 of ~40% of the prescription dose with a number of seeds outside of the prostate. The actual implanted activity in the prostate gland was 27.36 mCi. Sixteen seeds were found in the perineum outside the target volume of the prostate + 1 cm as PTV. The dose to this area unintended to receive radiation was about 20Gy to the periphery of the contour volume containing all the 16 seeds.
"The physician was informed of the discrepancy on 12/12/2012 and the patient was informed on 12/13/2012. There is no negative impact expected to the patient, the physician indicates. The patient will be re-implanted to correct for the D90 discrepancy.
"The Bureau of Radiation Protection will be sending an inspector the week of December 17 to investigate the incident."
Ohio Report Reference Number: 2012-040
Agreement State Event Number: 48593
License #: 202-161-26
NRC Notified By: MICHELE GREENWELL
HQ OPS Officer: CHARLES TEAL Notification Date: 12/14/2012
MEDICAL EVENT INVOLVING PERMANENT PROSTATE BRACHYTHERAPY IMPLANT
"During a prostate implant the radiation oncologist and urologist encountered issues due to the prostate size, location and pubic arch. Some of the needles became bent during the procedure and the decision was made to abort the implant. While completing the procedure the radiation oncologist revised the written directive to reflect what had occurred and revised the prescribed dose based on the complications."
The patient received 64.51% of the intended dose. The procedure used 14 seeds manufactured by IsoAid with an activity of 0.350 mCi of I-125.
Non-Agreement State Event Number: 48594
Rep Org: METALTEK INTERNATIONAL CARONDELET
Licensee: METALTEK INTERNATIONAL CARONDELET CORPORATION
City: PEVELY State: MO
License #: 24-26136-01
NRC Notified By: CHARLES RUUD
Event Time: 08:45 [CST]
RADIOGRAPHY GUIDE TUBE DAMAGED DURING USE
While performing radiography operations at the Metaltek facility, the stand that the guide tube was resting on fell over and damaged the guide tube. The source was not able to be retrieved. A licensed source retrieval contractor was utilized and the source was restored to its safe position. There were no overexposures to personnel as a result of this event.
The radiography camera was a QSA Amersham model number A-424-14, serial number 39841B.
Agreement State Event Number: 48599
Licensee: WILDLIFE INTERNATIONAL, LTD
City: EASTON State: MD
HQ OPS Officer: BILL HUFFMAN Notification Date: 12/17/2012
Last Update Date: 12/17/2012
AGREEMENT STATE REPORT - MISSING CARBON-14 VIAL
The following information was received via facsimile from the Maryland Department of Environment:
"In compliance with COMAR 26.12.01-01 (Section D-1201.a), Wildlife International, Ltd. is reporting the loss of 1 mCi of Carbon-14 source material. As per the originator, the radioactive material was shipped to Wildlife International, Ltd. as one shipment containing two vials (each vial contained 1 mCi). However, only one vial was received in the Wildlife International, Ltd facilities, swiped and placed in the Wildlife International, Ltd. inventory. Wildlife International, Ltd. is currently investigating the circumstances of the missing/loss Carbon-14 material, coordinating documents and, shipping procedures with the originator and conducting exhaustive searches of the Wildlife International, Ltd. facilities for its recovery."
Agreement State Event Number: 48602
License #: MS-995-01
NRC Notified By: LOREN ROSS
HQ OPS Officer: CHARLES TEAL Notification Date: 12/18/2012
The following was received from the State of Mississippi via email:
"Licensee's RSO contacted DRH (Division of Radiation Health) by telephone on December 11, 2012 to inform the department that a source retrieval was done earlier that morning on exposure device S/N D2652 source S/N 88902B. This was due to a unsecured exposure device falling to the ground from a valve assembly handle it was place on while performing an exposure. When the radiographer tried to crank the source back into the exposure device he noticed a crimp in the guide tube close to the camera. The radiographer then cranked the source back out to the collimator to provide more shielding and then contacted the RSO for source retrieval. The RSO performed the source retrieval within two hours of being called. The RSO received a dose of 32 mR for the retrieval."
Mississippi Report #: MS-12006
Agreement State Event Number: 48604
Licensee: REGENTS OF THE UNIVERSITY OF CALIFORNIA SANTA BARBARA
License #: 1336-42
Event Time: 15:50 [PST]
AGREEMENT STATE REPORT - REMOVABLE CONTAMINATION FOUND ON PACKAGE
The following was received from the State of California via fax:
"On December 17, 2012, UCSB (University of California, Santa Barbara) received an excepted package from Germany containing Carbon 14, 53.2 MBq in liquid form (2 vials each 1.4 mLs) which had removable contamination in excess of 49CFR, Section 173.443, on the outside of the package. The package and inner package did not show signs of damage. Wipes were taken on the outside of the box (4 sides and bottom) using filter paper and wiping 100 cm squared. Vials were placed into a 20 mL vial containing 15 mLs of liquid scintillation cocktail. Vials were then counted on a Beckman LS6000LL, liquid scintillation counter for 2 minutes. All areas of the box were found to be contaminated, with the highest removable contamination at 32,000 dpm/cm squared. The licensee reported this event via CA EMA and notified the final delivery carrier and the company that shipped the package (Sanofi, Frankfort, Germany). Of note, there was a note on the shipping paperwork that when the box arrived at LAX, it was opened by World Carrier personnel to replenish dry ice prior to then transporting it onto the UCSB."
CA 5010 #: 121712
Power Reactor Event Number: 48616
HQ OPS Officer: VINCE KLCO Notification Date: 12/21/2012
Notification Time: 00:06 [ET]
Last Update Date: 12/21/2012
UNANALYZED CONDITION DUE TO AN IDENTIFIED DEGRADED FIRE BARRIER
"During a walkdown on December 20, 2012 at 1600 CST, two degraded Appendix R fire barriers (walls) were identified. These barriers separate the Torus Room (Fire Area IV)/ 'A' RHR Room (Fire Area I) and the Torus Room (Fire Area IV)/ 'B' RHR Room (Fire Area II). The walls separate Appendix R fire safe shutdown divisional equipment.
"A fire watch was established as a compensatory measure immediately following identification of the issue on December 20, 2012. The barrier affecting the 'B' RHR Room has been repaired on both sides. The barrier affecting the 'A' RHR Room has been repaired on the Torus Room side. The discovery of this non-compliance is being reported as an unanalyzed condition as defined by 10CFR50.72(b)(3)(ii)(B).
"The fire watch remains in place until verification of the completed repair is performed."
Power Reactor Event Number: 48617
Event Time: 05:28 [EST]
UNIT 1 AUTOMATIC REACTOR TRIP ON TURBINE TRIP
"Salem Unit 1 has experienced an automatic reactor trip at 0528 [EST] on 12/21/12. The unit tripped due to turbine trip above P-9 [Greater than 49% power]. All shutdown and control rods fully inserted on the reactor trip. Prior to the trip, the unit was operating at 100% when the crew received the OHA [Overhead Alarm] for main power transformer over excitation which actuated generator protection, which initiated the turbine trip. The auxiliary feed water (AFW) system auto started on low steam generator levels as expected on a reactor trip. Numbers 11, 12 & 13 AFW pumps all automatically started to provide feed to the steam generators. The [Operating Crew] entered EOP-Trip-1, then transitioned to EOP-Trip-2 and stabilized the plant.
"The unit is currently in mode 3. The OCC [Outage Control Center] is manned and the cause of the main power transformer over excitation is under investigation at this time. RCS temperature is 547 degrees F, RCS pressure is 2235 psig. The 11-14 RCP's are in service. There is one shut down technical specification action statement in effect. Unit 1 containment APD [Containment Radiation Monitor] is inoperable for DCP [Design Change Package] work. This is a 30 day shutdown LCO that expires on 1/16/2013 at 0830. All ECCS and ESF systems are available. Decay heat removal is being provided by 11 and 12 AFW pumps and the main steam dump system. The 13 AFW pump operation is not required and has been removed from service. The plant is aligned with a normal electrical line-up from offsite power sources. There were no personnel injuries associated with this event
"This event is reportable per 10CFR50.72(b)(2)(iv)(b) due to the automatic reactor trip.
"This event is reportable per 10CFR50.72(b)(3)(iv)(a) due the AFW actuation on low steam generator levels."
There was no lifting of PORVs or primary to secondary leakage. There was no impact on Unit 2.
Power Reactor Event Number: 48618
HQ OPS Officer: HOWIE CROUCH Notification Date: 12/21/2012
ERDS GROUP (EMAI)
CAT TEAM (EMAI)
LOSS OF EMERGENCY RESPONSE DATA SYSTEM (ERDS)
"At approximately 0730 CST, Xcel Energy Monticello Nuclear Generating Plant was informed of a loss of internet and data services due to equipment problems with the Wide Area Network (WAN). The loss of data services resulted in the loss of ERDS communication capabilities with the NRC. Compensatory actions were established to communicate plant parameters verbally via the Emergency Notification System, which was verified functional at 0836 CST.
"The WAN and ERDS were restored at 0921 CST and ERDS was verified functional at 0948 CST.
"This issue is being reported as a loss of communications capability non-emergency event notification under 10CFR50.72(b)(3)(xiii) as defined in NUREG 1022, Rev. 2.
Power Reactor Event Number: 48619
NRC Notified By: TOM HOLT
BOTH UNIT TWO AUXILIARY FEEDWATER PUMPS DECLARED INOPERABLE
"21 Motor Driven and 22 Turbine Driven Auxiliary Feedwater Pumps (AFWP) were declared inoperable at 0900 CST on 12/21/2012 due to the Condensate Storage Tank (CST) temperature exceeding 92F.
"In accordance with procedure C28.6, 'Condensate Storage Tank Freeze Protection System', the maximum CST temperature shall not exceed 92F. This is to ensure the maximum AFWP discharge temperature is less than 100F when an AFWP is at design flow per USAR Table 11.9-2, 'Summary of Assumptions', used in the AFW system design verification analyses.
"LCO 3.7.5 Condition D was entered for two AFW trains inoperable in Modes 1, 2 or 3. The AFWP's could start and run if required at the time of entry.
"Immediate action was taken to reduce the CST temperature. At 1315 CST temperature were lowered below 92F and LCO 3.7.5 condition D was exited.
"This condition is reportable per 10 CFR 50.72(b) (3) (v) (D) as an event or condition that could have prevented the fulfillment of a safety function."
Power Reactor Event Number: 48620
"At approximately 0730 CST, Xcel Energy Prairie Island Nuclear Generating Plant was informed of a loss of internet and data services due to equipment problems with the Wide Area Network (WAN). The loss of data services resulted in the loss of ERDS communication capabilities with the NRC.
"The WAN and ERDS were restored at 0921 CST."
Part 21 Event Number: 48621
NRC Notified By: BRYAN TAUZER
DEFECT DISCOVERED IN COM-5 AND SSC-T PROTECTIVE RELAYS DISTRIBUTED BY ABB, INC.
The following information was obtained by ABB, Inc. via fax:
"ABB Coral Springs received notice from ABB Inc. in Florence, South Carolina of a return request by NextEra Energy (Point Beach Nuclear Plant) for one of [their] COM-5 relays. The customer complaint was identified as 'A pin on the telephone relay fell out'.
"ABB Coral Springs received the relay on October 25, 2012 with the telephone relay armature and armature pivot pin disassembled. The assembly process for the telephone relay armature calls for the armature pivot pin to have a knurl at one end and a flare at the opposite end. The knurl and flare secures the armature to the pivot pin. [ABB's] investigation found that on this telephone relay, the pivot pin was flared on the same end as that which had the knurl. It was determined that this was due to an operator error while performing a secondary operation.
"The telephone relay was stamped with a manufacturing date code 08-38, indicating the thirty-eighth week of 2008. It is important to note the date of manufacture, as in mid-2010 the supplier and the assembly manufacturing process of the pin was changed. The hole and flaring was changed such that it is performed prior to cutting the pin to length, eliminating the secondary operation and potential for error.
"In addition to the change to the flaring process described above, corrective action includes the addition of an additional step to [ABB's] final Product Inspection procedure where all telephone relays are verified to have the knurl at one end of the armature pivot pin and a flare at the opposite end.
"Inspection of [ABB's] stock identified no similar condition.
"[ABB has] identified COM-5 and SSC-T relays which shipped that may have a telephone relay of the same vintage as that of the subject telephone relay. There were eleven orders shipped, totaling twenty-five units to three customers; ABB Inc. Florence, S.C., Exelon Business Services and WESCO Distribution, Inc.. ABB has determined that it does not have the capability to perform an evaluation to determine if a defect exists, and therefore in accordance with 10 CFR 21.21(b), [ABB is] notifying [their] affected customers so that they may evaluate the deviation or failure to comply, pursuant to 10 CFR 21(a).
"A failure of the Telephone Relay to operate on either the COM-5 or SSC-T relay can result in the breaker not tripping during an overload condition. This condition could compromise the ability of the relay to perform its intended safety function.
"[ABB is] providing [their] customers with the option of inspecting for evidence of the knurl and flare or returning the relays so [they] may perform the inspection."
Part 21 Event Number: 48622
Rep Org: TENNESSEE VALLEY AUTHORITY
Licensee: POWER SERVICE SHOPS
City: MUSCLE SHOALS State: AL
NRC Notified By: MARK COOK
PART 21 REPORT - BELDEN WIRE USED ON ENVIRONMENTALLY QUALIFIED FORM-WOUND MOTORS NOT FULLY QUALIFIED
"Potential Condition: Tennessee Valley Authority (TVA) Power Service Shops (PSS) installed Belden EPDM lead wire in the rewind of Environmentally Qualified (EQ) safety-related motors utilizing EPRI Technical Report (TR) 1003481 and TR 1001036. EPRI informed PSS that the Belden EPDM lead wire had not been fully qualified in accordance with EPRI TR 1001036.
"Thirteen (13) motors are affected. Ten (10) Browns Ferry motors, one (1) Watts Bar Unit 2 motor, one (1) Progress Energy [Crystal River] and one (1) Florida Power & Light (FPL) [St. Lucie Plant] . All the customers have been notified of a potential Part 21 condition.
"Recommendation: Immediate Actions:
1.) Review PSS data to determine affected motors.
2.) Establish an Equivalency Evaluation (EE) for Belden EPDM lead wire for EPRI TR 1003481/1001036 utilizing a TVA qualified winding system that included Belden EPDM lead wire (Wyle Test Report 18070-1).
3.) Review Progress Energy and FPL EQ profiles.
4.) Perform a root cause investigation to determine how this issue occurred.
"Evaluation/Action Taken:
1.) Action 1 complete. 13 motors affected and all customers notified.
2.) Action 2 - EE developed and currently being reviewed by affected TVA EQ engineers for approval.
3.) Action 3 - FPL indicated that the FPL motor in question had undergone a recent rewind that replaced the lead. Progress Energy provided the EQ profile on 12/20/12 indicating a significant delta between the Wyle Test Report 18070-1 in Radiation (Normal), Radiation (Accident) and accident temperature (Max). Based on this information, the PSS determination was made that defect in a basic component existed and NRC notification was required in accordance with 10 CFR Part 21, section 21.21(d)(1) and section 21.21(d)(3)(i).
"TVA PSS will provide a follow-up written notification within 30 days pursuant to Part 21.21(d)(3)(ii).
"Point of Contact- Mark E. Cook, (256) 314-7595"
Power Reactor Event Number: 48623
NRC Notified By: BRIAN MAZE
HQ OPS Officer: HOWIE CROUCH Notification Date: 12/22/2012
Event Time: 11:52 [CST]
Last Update Date: 12/22/2012
"On 12/22/2012 at 1152 CST, the Unit 2 reactor automatically scrammed due to actuation of the Reactor Protection System (RPS) from loss of power to RPS. At 1134 CST, the D 4kV Shutdown Board unexpectedly de-energized during performance of post-maintenance testing for the 3D Diesel Generator paralleling circuitry, resulting in loss of power to the 2B RPS subsystem. Primary Containment Isolation System (PCIS) groups 2, 3, 6, and 8 isolations were received along with automatic initiation of A, B, and C Standby Gas Treatment subsystems and A Control Room Emergency Ventilation subsystem due to loss of power to the 2B RPS subsystem. While attempting to reenergize the 2B RPS subsystem, the 2A RPS subsystem was inadvertently de-energized resulting in Unit 2 reactor automatic scram.
"All affected safety systems responded as expected for the loss of RPS and reactor scram. Due to the loss of RPS, the Main Steam Isolation Valves (MSIVs) closed. Reactor pressure did not rise to the automatic initiation set point for Safety Relief Valve (SRV) actuation. Reactor Core Isolation Cooling System (RCIC) and High Pressure Coolant Injection System (HPCI) reactor water level initiation set point of -45" was reached and RCIC and HPCI automatically initiated as designed to restore water level above the initiation set point. Both Recirculation Pumps also tripped on reactor water level of -45". Reactor pressure control was established by manually operating one SRV and water level control established with RCIC. HPCI was returned to standby readiness. The scram was reset, MSIVs were opened, and the Main Condenser was established as a heat sink.
"The scram event from critical is reportable within 4 hours per 10 CFR 50.72(b)(2)(iv)(B). It is also reportable within 8 hours per 10 CFR 50.72(b)(3)(iv)(A) and requires an LER within 60 days per 10 CFR 50.73(a)(2)(iv)(A).
The 2A and 2B RPS subsystems were returned to service. The electrical grid is stable and supplying shutdown loads on Unit 2. Unit 1 and Unit 3 were unaffected and continue to operate at 100% power.
Power Reactor Event Number: 48624
OFFSITE NOTIFICATION DUE TO LOSS OF AMERTAP BALLS
"At 1740 CST, Xcel Energy notified the Minnesota State Duty Officer that up to 1500 Amertap Balls had been lost from the Prairie Island Nuclear Generating Plant Unit 2 Condenser Tube Cleaning System. Since the Minnesota State Duty Officer for the Division of Emergency Management was notified, this constitutes a 4 hour non-emergency notification per 10CFR50.72(b)(2)(xi)."
Power Reactor Event Number: 48625
NRC Notified By: ROGER T. BARNES
HQ OPS Officer: CHARLES TEAL Notification Date: 12/26/2012
"This is a non-emergency eight hour notification for a loss of Emergency Assessment Capability. This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii) because the work activity affects the functionality of an emergency response facility.
"Planned maintenance activities are being performed today (December 26, 2012) to the Technical Support Center (TSC) HVAC. The work entails removing power to the system fan and dampers to perform required preventative maintenance (PM) rendering the TSC HVAC non-functional during the performance of this work activity. This work activity is planned to be performed and completed expeditiously within about 16 hours including establishing and removing the clearance and performing post maintenance testing.
"If an emergency condition occurs that requires activation of the TSC, plans are to utilize the TSC concurrent with this work activity as long as habitability conditions allow. Additionally, plans are in place to expedite the return of the system should an emergency condition occur. The Emergency Response Organization duty team members will be relocated to alternate locations if required by habitability conditions in accordance with emergency implementing procedures.
Page Last Reviewed/Updated Wednesday, December 26, 2012