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Site Name - City Name State Cd
Report Date Notification Dt Notification Time
Event Date Event Dt Event Time
Event Text
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Curtiss Wright Flow Control Co. - Middleburg Heights OH
Report Date 06/24/2022 13:33:00
Event Date 04/24/2022 0:00:00
EN Revision Imported Date: 12/19/2022
EN Revision Text: PART 21 REPORT - POTENTIAL DEFECT IN QUICK DISCONNECT CONNECTOR CABLE ASSEMBLIES
The following is a synopsis of information received via facsimile:
On April 24, 2022, a potential defect was discovered in a configuration of the 1 « inch Quick Disconnect Connector (P/N: 913602-111) cable assemblies supplied to Duke [(McGuire Nuclear Station)] under procurement document 30129014. During post installation testing by Duke, it was found that one of the cable wires was shorted to ground. This damage could cause the cable assembly to not perform its intended safety function. Upon further investigation, Duke found 9 other cable assemblies to have similar damage. Duke returned the identified cable assemblies to Curtiss Wright who is investigating the issue. Although some testing and verification activities have been completed, additional testing and research is necessary and in progress. The current testing and research is projected to take 30 days and a follow-up letter with results and status will be provided by July 24, 2022.
Currently, McGuire Nuclear Station is the only affected facility.
For additional information, please contact Jim Tumlinson, Director of Operations (256-425-8037), Christopher Covan, Quality Assurance Manager (256-624-7301), or Tim Franchuk of Quality (513-201-2176).
The following is an update received via facsimile:
"After further research on this condition, we have determined there was a defect that was provided to this utility. The nature of the defect is a bushing supplied with these cable assemblies. This bushing was found to have burr edges near the interface of the connector. This burr, when moved up and down the wires during the installation process, has the potential to cause damage. This damage could compromise the integrating of the dielectric characteristic of the supplied connector which could lead to the component not to perform its intended safety function.
"Based on history, where we have never had an issue of this defect being detected either by Curtiss-Wright or Duke Energy, Curtiss-Wright is confident that this is a recent issue and efforts/research are being done to bound this issue to determine the extent of condition. Due to the nature of the damage, we also have a high degree of confidence that the defect would be evident and caught during the pre/post installation testing/inspection of this device which would further prevent them from being installed in the plants.
"All configuration that utilize this defective component were supplied to Duke Energy and installed in the McGuire, Oconee and Catawba operating plants. As of this time, we have identified 11 cables which have this defect and we are working closely with Duke to determine the full extent of condition. These 11 cables have been returned to Curtiss-Wright. Further evaluation will require a projected addition 30 days to continue our evaluation with the help of the utility. Another follow up letter will be issued to the NRC on August 26, 2022."
Notified R3DO (Peterson), R2DO (Miller), and Part 21 Group (by email).
* * * UPDATE ON 08/26/2022 AT 1411 EDT FROM CHRIS COVAN TO ADAM KOZIOL * * *
The following is an update received via facsimile:
"In pursuance of compliance to Federal Regulation 10CFR21, this letter is issued to provide closure for notification issued June 24, 2022 of the potential defect in a configuration of the 1 1/2 Inch Quick Disconnect Connector (P/N: 913602-111) cable assemblies supplied to Duke Energy under procurement documents 30129014, 03121479, 03114993 and 03124438 for of a total of 19 connectors at the McGuire and Catawba Nuclear Power Stations. We have a high degree of confidence that this is limited to these supply of cables.
"Of the 19 connectors, 11 have been returned to Curtiss-Wright and have been confirmed to have the suspected defect. Curtiss-Wright will be working with Duke Energy to have these connector assemblies replaced. Due to the nature of the defect and installation routines of the plant, for items installed at Duke Energy we have reasonable assurance that these connectors do not pose an immediate safety risk but could cause damaged during routine maintenance associated with the connectors and should be replace at earliest convenience.
"To prevent this from reoccurring, Curtiss-Wright will implement an inspection activity to verify the absence of burrs and/or sharp edges of all fittings that could potentially cause damage which could prevent the items from performing its intended safety function.
"For additional information, please contact Jim Tumlinson, Director of Operations (256-425-8037), Christopher Covan, Quality Assurance Manager (256-624-7301), or Tim Franchuk Director of Quality (513-201-2176)."
Notified R3DO (Pelke), R2DO (Miller), and Part 21 Group (by email).
* * * UPDATE ON12/16/22 AT 0932 EST FROM CHRIS COVAN TO THOMAS HERRITY * * *
The following is an update received via facsimile:
"In pursuance of compliance to Federal Regulation 10CFR21, this letter is issued to provide an amendment for notification issued on June 24, 2022 of the potential defect in a configuration of the 11/2 Inch Quick Disconnect Connector cable assemblies supplied to Duke Energy for a total of 460 of connectors only supplied to Oconee, McGuire and Catawba Nuclear Power Stations. This increase of scope is due to new evidence provided by Duke Energy, where this potential defect was found in other lots of material other than the ones previously bound to this condition.
"The nature of the defect is a sharp edge located inside of the supplied reducing bushing which could cause damage to the cables when being installed or removed. These cable assemblies and bushing need to be evaluated to determine if this potential defect has occurred or if there is a potential for damage to occur at the earliest convenience. To the best knowledge of the application, we believe that there is a very low risk of damage to the cable assemblies after installation but this needs to be evaluated at the plants. We have been working with Duke Energy and will continue to support them until this issue is resolved.
"To prevent this from reoccurring, Curtiss-Wright will implement inspection activities to verify the absence of burrs and/or sharp edges of all fittings that could potentially cause damage and prevent the items from performing its intended safety function.
"For additional information, please contact Jim Tumlinson, Director of Operation (256-425-8037) or Christopher Covan, Quality Assurance Manager (256-624-7301), or Tim Franchuk, Director of Quality (513-201-2176).
Notified R3DO (Ruiz), R2DO (Miller), and Part 21 Group (by email).
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Braidwood - Braceville IL
Report Date 10/07/2022 8:35:00
Event Date 10/07/2022 1:19:00
EN Revision Imported Date: 12/14/2022
EN Revision Text: CONTROL ROD DRIVE MECHANISM (CRDM) PENETRATION DEGRADED
The following information was provided by the licensee via fax:
"Control Rod Drive Mechanism (CRDM) penetration 69 degraded.
"At 0119 [CDT] on October 7, 2022, it was determined that the CRDM penetration 69 was degraded because examination identified unacceptable indications in accordance with ASME Code Case N-729-6. Therefore, this event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A).
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
"The notification is being corrected to state:
"At 0119 [CDT] on October 7, 2022, it was determined that the Control Rod Drive Mechanism (CRDM) penetration 69 was degraded because liquid penetrant testing, performed on the seal weld, identified unacceptable indications in accordance with ASME Section III and NRC approved licensee relief request for a previously performed embedded flaw repair. Therefore, this event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A).
"There was no impact on the health and safety of the public or plant personnel."
Notified R3DO (Ruiz).
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Georgia Radioactive Material Pgm - Cumming GA
Report Date 10/25/2022 13:29:00
Event Date 10/18/2022 6:30:00
EN Revision Imported Date: 12/5/2022
EN Revision Text: AGREEMENT STATE REPORT - DAMAGED SEALED SOURCE
The following information was provided by the Georgia Radioactive Material Program via email:
"On 10/18/2022 at 0630 EDT, a Cs-137 vial source was being used to measure dose calibrator constancy. The nuclear medicine [NM] technologist noticed a crack in the bottom of the sealed source vial and possible contamination surrounding the vial.
"The sealed source was placed in a leak proof container, the Radiation Safety Officer (RSO) was notified, and decontamination protocol was followed. A leak test of the vial confirmed there was more than 0.005 microcuries of removable Cs-137 contamination.
"Post-decontamination surveys and wipe tests of the staff and department indicated that there was no contamination in the department, but there was detectable contamination on the hands of one staff member. The staff member is the individual who was handling the sealed source and discovered the crack in the source. He repeatedly scrubbed his hands - first with lukewarm soap and water, then with Bind-It brand radioactive decontamination hand soap until there was no improvement in the surveys of his hands.
"A final survey of the individuals hands hands showed there was no detectable contamination on his left hand. A small area on his right-hand thumb still measured 1000 [Counts Per Minute] CPM above background, and another small area on his right-hand index finger measured 700 CPM above background using a GM probe. Measurements of the contamination on his fingers using the on-site well counter indicated it was Cs-137 contamination.
"Both the Radiation Safety Officer and Medical Director were notified of the incident. The RSO came on-site to supervise decontamination efforts and to secure the leaking source and decontamination waste.
"Dose calibrator measurements of the source by the RSO indicated the source had leaked approximately 6 microcuries total. Since 6 microcuries of Cs-137 is less than 10 percent of the annual limits on intake (ALI) for Cs-137 (100 microcuries ALI for oral ingestion as defined in Appendix B of 10 CFR 20), [the Program's] understanding is no individual bioassay monitoring is required for the individual.
"The sealed source has been placed back within its shielded container, sealed with tape, and marked as leaking and out-of-service. The waste generated during the decontamination process was placed in a leakproof plastic bottle and marked as containing Cs-137. Both items are currently stored in [a secure area]. We are contacting waste disposal companies to arrange disposal of both the leaking sealed source and decontamination waste. The NM staff was re-educated on the requirement to wear disposable gloves at all times while handling radioactive materials, which includes sealed radioactive sources, per the Model Rules for Safe Use of Radiopharmaceuticals."
Georgia Incident Number: 60
The following information is a summary of information received via email:
The licensee supplied an updated report to the state of Georgia. Georgia Radioactive Material Program employees will finalize and close out the report after disposal of the leaking source and contaminated waste.
Notified R1DO (Werkheiser) and NMSS Events Notification email group.
The following information is a summary of information received via email:
The licensee notified the Georgia Radioactive Material Program that the leaking source was returned and received by the manufacturer. The Georgia Radioactive Material Program has closed this report.
Notified R1DO (Cahill) and NMSS Events Notification email group.
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SC Dept of Health & Env Control - Pineville SC
Report Date 10/31/2022 14:24:00
Event Date 10/31/2022 0:00:00
EN Revision Imported Date: 12/29/2022
EN Revision Text: AGREEMENT STATE REPORT - STUCK SHUTTERS
The following was received from the state of South Carolina via email:
"The South Carolina Department of Health and Environmental Control was notified via telephone on 10/31/22 that three fixed gauging device shutters were stuck in the closed position. All three fixed gauging devices are Thermo Fisher Scientific Model 5197 gauging devices, serial numbers B7842, B7847, and B7841. The activity of each gauging device is 100 mCi of Cs-137. The licensee is reporting that all three fixed gauging devices are mounted 12-15 feet above accessible areas. No elevated exposure rates are being reported. Department inspectors will be dispatched to the facility. This event is still under investigation by the South Carolina Department of Health and Environmental Control."
South Carolina Event Number: To be assigned.
"Department inspectors were dispatched to the facility and found the gauges as the licensee described. The gauges were expected to be repaired on 11/02/22. The licensee submitted a 30-day written report dated 11/11/22. The written report indicated the fixed gauging devices were repaired on 11/02/22. The licensee's corrective actions included repairing the fixed gauging devices and updating procedures to include examples of reporting requirements. This event is still under investigation by the South Carolina Department of Health and Environmental Control."
Notified R1DO (Carfang) and NMSS Events Notification email group.
"The licensee reported this event did not result in any personnel exposure to radiation or radioactive material. This event is considered closed."
Notified R1DO (Eve) and NMSS Events Notification email group.
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New York State Dept. of Health - Manhasset NY
Report Date 11/04/2022 12:33:00
Event Date 11/03/2022 14:30:00
EN Revision Imported Date: 12/9/2022
EN Revision Text: AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE
The following information was provided by the New York State Department of Health Bureau of Environmental Radiation Protection (NYSDOH BERP) via fax:
"On November 3, 2022, at approximately 1430 EDT, an authorized user for the licensee had finished conducting soils testing at a temporary job site located in Manhasset, NY and locked the moisture density device in the carrying case within the trunk of their vehicle. The authorized user was conducting concrete work while the gauge was locked in the trunk and returned to their vehicle later to find that the vehicle was stolen, with the gauge locked in the trunk. The authorized user contacted the Radiation Safety Officer (RSO) and Nassau Police immediately and the case was initiated by Nassau [Police] to track this vehicle. The RSO contacted NYSDOH BERP the following morning to report the missing device.
"The following information is available on this device: Make/Model: Troxler 3430 Source 1: Cs-137 (10 millicurie); Source 2: Americium-241:Be (40 millicurie); Device S/N: 20136.
"New York State Department of Health is reaching out to the manufacturer and neighboring regulators to inform them of this event. NYSDOH will continue to monitor this event and provide updates as necessary.
"NY Event Report ID: NYDOH-22-07"
"On November 21, 2022, the licensee notified the NYSDOH BERP that the above mentioned vehicle and device were located by local law enforcement agencies and returned to the licensee. The licensee confirmed that there was no apparent tampering of the device and carrying case, however, the licensee is performing a leak test to confirm sources have not been breached during this incident prior to recommissioning this device into service.
"The licensee is providing a written description of this event including a failure analysis and proposed corrective actions. As a result, NYSDOH will continue to monitor this event and provide updates as necessary. This event is still open as of 11/21/2022."
Notified R1DO (Carfang) and NMSS Events Notification, ILTAB, and CNSC email groups.
"The licensee provided a written report [to NYSDOH] in accordance with 10 CFR 20.2201(b). This report further confirmed the events as previously described, and provided a copy of the police report filed by Nassau County Police Department. In discussion with the licensee, it was proposed that staff are re-trained in security and notification procedures as a preventative measure. The Radiation Safety Officer has purchased Apple AirTags for installation into the device case as an additional tool to rapidly track and locate any missing/stolen gauges in the future as a supplemental mitigation action.
"New York State Department of Health has independently evaluated the investigation, failure analysis, and corrective actions provided by the licensee and has deemed the response and subsequent actions sufficient. NYSDOH has closed this event."
Notified R1DO (Bickett) and NMSS Events Notification, ILTAB, and CNSC email groups.
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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Illinois Emergency Mgmt. Agency - Arlington Heights IL
Report Date 11/04/2022 13:04:00
Event Date 11/03/2022 0:00:00
EN Revision Imported Date: 12/6/2022
EN Revision Text: AGREEMENT STATE REPORT - RADIOPHARMACEUTICAL LOST IN TRANSIT
The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:
"The Agency was notified by Medi-Physics, Inc., doing business as GE Healthcare on the afternoon of 11/3/2022, that a radiopharmaceutical package containing 1.5 millicuries of In-111 was reported as lost while in the care of a common carrier. This does not represent a significant public safety hazard and there is no indication of intentional theft or diversion. Details on the package and shipment are provided below. The Georgia program will be notified along with the US NRC Operations Center.
"The package was shipped on 10/28/2022, from the licensee's facility in Arlington Heights, Illinois to Jubilant Radiopharma in Macon, Georgia. The package made it to the common carrier hub. Thereafter, it could not be accounted for and was declared lost on 11/3/2022. The package activity was 1.5 millicurie at the time of shipment but has decayed to approximately 1.147 millicurie at this time.
"IL Item Number: IL220042"
"No changes in status of the package have been provided by the carrier. The package has now decayed to under 1.0 microcuries of In-111. This matter is considered closed."
Notified R1DO (Bickett), R3DO (Peterson), NMSS (email), and ILTAB (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
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Defense Health Agency (DHA) - Falls Church VA
Report Date 11/17/2022 16:30:00
Event Date 11/17/2022 13:00:00
EN Revision Imported Date: 12/5/2022
EN Revision Text: MEDICAL EVENT - PATIENT UNDERDOSE
The following information was provided by the licensee via email:
"During an SIR [Selective Internal Radiation] Spheres treatment on November 17, 2022, a patient was to receive 10.8 milliCuries of Y-90 [Yttrium-90]. A measurement of the residue radiological waste from the procedure indicated that the patient only received 38 percent of the intended dose or 4.33 milliCuries. The total dose delivered differs from the prescribed dose by 20 percent or more.
"The doctor drew up a dose of 11.4 milliCuries for the procedure. Static readings on the vial averaged 0.205 mR/hr. Post procedure readings averaged 0.127 mR/hr. These readings resulted in the fraction delivered of 38 percent or a total of 4.33 milliCuries. Corrective action is pending."
"The event likely occurred due to microsphere blockage in the microcatheter, resulting from a torturous path to the delivery point required by the patient's vascular anatomy. Sirtex indicated that the spheres must have attached to the catheter walls due to a torturous path (excessive bends in the line)."
Notified R1DO (Cahill) and NMSS Events Notification via email.
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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SC Dept of Health & Env Control - West Columbia SC
Report Date 11/18/2022 17:12:00
Event Date 11/18/2022 10:24:00
EN Revision Imported Date: 12/13/2022
EN Revision Text: AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE
The following information was provided by the South Carolina Department of Health and Environmental Control (The Department) via email:
"The Department was notified on 11/18/22 at 1243 EST via telephone that a Troxler 3400 series portable moisture density gauge, serial number 33556, had been hit by a piece of construction equipment.
"The Troxler 3400 series portable moisture density gauge contains a maximum activity of 9 millicuries of Cs-137 and 44 millicuries of Am-241:Be. The licensee reported the source rod had been dislodged but had been successfully inserted back into the shielded position. A Department inspector was dispatched to the location on 11/18/22 and assisted the licensee in packing the damaged Troxler 3400 series device into the transport container. Dose rate readings using a ND-2000A survey instrument, calibrated 09/16/22 indicated readings as high as 30 mR/hr on the surface of the transport container and less than 1 mR/hr at 1 meter.
"The Troxler 3400 series moisture density gauge was transported and secured at the licensee's storage location and is awaiting shipment back to the manufacturer. This event is still under investigation by the South Carolina Department of Health and Environmental Control."
The following information was provided by the South Carolina Department of Health and Environmental Control (The Department) via email:
"The licensee submitted a written report, dated 11/28/22, outlining the event details and findings. The licensee did not indicate overexposure to any individuals. Records indicate the damaged gauge was not leaking and that the gauge/sources have been transferred to the manufacturer for disposal. This event is considered closed."
Notified R1DO (Henrion) and NMSS Events Notification email group.
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California Radiation Control Prgm - Mojave CA
Report Date 11/24/2022 15:38:00
Event Date 11/23/2022 20:34:00
AGREEMENT STATE REPORT - LOST THEN RECOVERED MOISTURE DENSITY GAUGE
The following information was provided by the California Department of Public Health - Radiation Health Branch (RHB) via email:
"On Wednesday night, November 24, 2022, Arrow Infrastructure Solutions Inc. [doing business as] dba Arrow Engineering [Radiation Safety Officer] RSO [redacted] reported to [California Office of Emergency Services] Cal OES the loss or possible theft of a CPN moisture density gauge, MC-1DR-P (MD70803845) containing sealed sources of Cs-137 (10 mCi) and Am-241:Be (50 mCi), Cal OES Control :22-6906. The loss or possible theft was noticed by the authorized user [AU] at a gas station in Mojave, CA as the user was returning from a jobsite. The AU noticed the truck tailgate down and the CPN gauge missing as they were leaving the gas station after a restroom break, the gauge possibly fell out of the truck on Highway 58 in between Tehachapi and Mojave. The AU retraced their route on the Highway but had not located the gauge so far, they will search again on 11/24/22 during the daylight. The licensee will gather additional information for the follow up investigation and provide additional information to the department as it becomes available.
"UPDATE: The FBI notified RHB Management that the gauge had been found by a member of the public and turned into the Kern County Law Enforcement Agency. The RSO was notified and provided with contact information so the gauge could be retrieved. The RSO was instructed to do a wipe/leak test, get it analyzed quickly, and secure the gauge in storage until a negative result was returned. If a leak is detected, they will coordinate with a service company for repair or disposal. RHB Brea staff will continue with the investigation."
California 5010 Number: 112322
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Georgia Radioactive Material Pgm - Gainesville GA
Report Date 11/25/2022 15:04:00
Event Date 11/16/2022 0:00:00
AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following information was received from the Georgia Radioactive Materials Program via email:
"We received an emailed report of a misadministration, where there was over 50 percent deviation of the prescribed dose. The patient received only 10 percent of the [redacted] prescribed fractioned dose due to equipment malfunction. The patient is scheduled to receive the remainder of the dose at a later time. The licensee will conduct a thorough investigation and provide a formal report as soon as possible. We are still pending the source activity information and event date. We will update as more information comes in."
Georgia incident no.: 61
The following is a synopsis developed from information provided by the Georgia Radioactive Materials Program via email:
Was source able to be retracted to safe position? Yes Manufacturer and Model number of HDR: Elekta's Flexitron Serial number: 00625 Source activity (8.9 Ci); Prescribed dose (750 cGy); Delivered dose (12.7 cGy)
Root Cause: Equipment failure. Assessment by Elekta's field service engineer determined that the Flexitron selector assembly should be recalibrated including lubrication of all brackets on the assembly.
Corrective Action: Recalibration. Following recalibration of the Flexitron selector assembly, the treatment unit functions correctly. Spot checks performed by physics confirmed normal operation of the treatment unit. The treatment unit reentered clinical service the following day and this patient was successfully treated on 11/21/22 for their third fraction and they finished treatment on 11/23/22.
Notified: R1DO (Cahill). Notified via email: NMSS Event Notification.
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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Fermi - Newport MI
Report Date 11/28/2022 8:38:00
Event Date 11/28/2022 4:00:00
EN Revision Imported Date: 12/12/2022
EN Revision Text: HIGH PRESSURE COOLANT INJECTION SYSTEM INOPERABLE
The following information was provided by the licensee via email:
"At 0400 EST on November 28, 2022, during the performance of Division 2 Residual Heat Removal (RHR) cooling tower fan operability and RHR Service Water valve lineup verification, it was reported that the Mechanical Draft Cooling Tower (MDCT) Fan 'B' was making a loud metallic noise. The cause of the metallic noise is unknown at this time. The MDCT fans are required to support operability of the Ultimate Heat Sink (UHS). The UHS is required to support operability of the Division 2 Emergency Equipment Cooling Water (EECW) system. The EECW system cools various safety related components including the High Pressure Coolant Injection (HPCI) system room cooler. An unplanned HPCI inoperability occurred based on inoperable cooling water to the HPCI room cooler, per LCO 3.0.6.
"Investigation into the Division 2 MDCT Fan 'B' abnormal noise is in progress.
"This report is being made pursuant to 10 CFR 50.72(b)(3)(v)(D) based on an unplanned HPCI inoperability.
"The NRC Resident Inspector has been notified."
The following information was provided by the licensee via email:
"The purpose of this notification is to retract a previous Event Notification 56241 reported on 11/28/2022. On 11/28/22, an event notification to the NRC was made when mechanical draft cooling tower (MDCT) Fan B was declared inoperable and issued Limited Condition of Operation (LCO) 2022-0428 for Division 2 MDCT Fan B abnormal noise. The MDCT fans are required to support operability of the Ultimate Heat Sink (UHS) (Technical Specification [TS] 3.7.2). The UHS is required to support operability of the Division 2 Emergency Equipment Cooling Water (EECW) system (TS 3.7.2), which cools various safety related components, including the High-Pressure Coolant Injection (HPCI) system room cooler (TS LCO 3.0.6).
"Subsequent inspection and evaluation determined that the brake noise is expected while fans are running at low speeds. This is supported by plant technical procedure, 24.205.10 `Div. 2 RHR Cooling Tower Fan Operability and RHRSW Valve Line-up Verification' (line item 2.2 in Precautions and Limitations) which states `Chatter from the brakes of the MDCT Fans is expected and no cause for discontinuing the test.' The equipment vendor stated that brake chatter is possible and common given that the internal components are free to move along the splined connections. Internal Operating Experience from experienced station operators and maintenance technicians confirmed that the condition is normal and expected. Both Division 2 MDCTs exhibited the same behavior at low speed and passed surveillance testing satisfactorily.
"No other concerns were noted during fan operation. Therefore, HPCI remained operable and there was no loss of safety function. The event did not involve a condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident under 10 CFR 50.72(b)(3)(v)(D).
"EN 56241 is retracted and no Licensee Event Report under 10 CFR 50.73(a)(2)(v)(D) is required to be submitted."
The NRC Resident Inspector has been notified.
Notified R3DO (Stoedter).
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Colorado Dept of Health - Aurora CO
Report Date 11/28/2022 10:35:00
Event Date 11/28/2022 5:30:00
AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GUAGES
The following information was provided by the Colorado Department of Public Health and Environment (the Department) via email:
"At approximately 0715 MST on November 28, 2022, the Department was contacted by the [Company Radiation Safety Officer] CRSO of Kleinfelder, Inc. (CO 958-01) to inform the Department that two Troxler 3430 (SN 35349 & SN 35335) moisture density gauges were discovered to be stolen from their temporary job site. Each gauge had sealed sources containing not more than 9 mCi of Cs-137 and 44 mCi of Am-241:Be or 66 micro curies of Cf-252. An authorized user arrived at the temporary job site around 0530 MST to pick up supplies when they noticed the door to the container express (conex) box was open. Upon further investigation, it was discovered that both gauges were missing. The site was secured by a security fence and under video surveillance, and that footage is currently under review. The thieves broke the exterior lock to the conex box door and they broke a lock to a job box in the conex box that contained both gauges in their locked transport cases. The job box was also bolted to the ground but those bolts were left intact. The CRSO estimates that the gauges were last seen/used on November 23rd or 24th, but the date of the theft is unclear at this time. Additionally, multiple other contracted companies were targeted in this theft that presumably occurred during the Thanksgiving holiday weekend."
Colorado Event Report ID No.: CO220040
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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Texas Dept of State Health Services - Borger TX
Report Date 11/28/2022 17:12:00
Event Date 11/23/2022 0:00:00
AGREEMENT STATE - STUCK SHUTTER
The following report was received via email from the Texas Department of State Health Services [the Agency]:
"On November 28, 2022, the licensee notified the Agency that it had discovered that the shutter on one of its Ohmart-Vega SH-F1A gauges had been stuck in the closed position since November 23, 2022. The gauge had been closed and locked out on November 22nd for work on the vessel. On November 23rd the gauge was placed back into service. Over the holiday weekend the unit operations had continued to get high readings which would indicate a buildup in the system or a closed shutter. On November 28th the gauge was checked. The licensee's radiation safety officer found the two bolts on the shutter handle were sheared and the shutter was in the fully closed position. No exposures have resulted from this event. An investigation is ongoing. Source: Cesium-137, 5 millicuries, SN: OV-0050 (this SN serves also as the gauge source holder SN). More information will be provided as it is obtained in accordance with SA-300."
Texas Incident Number: I-9966
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Colorado Dept of Health - Englewood CO
Report Date 11/29/2022 10:05:00
Event Date 05/03/2022 0:00:00
AGREEMENT STATE REPORT - LOST EXIT SIGNS
The following information was provided by the Colorado Department of Public Health and Environment via email:
The licensee discovered two tritium exit signs were lost. The exit signs are Isolite Corporation model 2040-60G-20BK signs containing 23 Ci of tritium (H-3) each. This is being reported under Colorado Regulations Section 4.51.1.1 (10 CFR 20.2202(a)(1)(i)).
Colorado Incident No.: CO220041
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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Colorado Dept of Health - Fort Morgan CO
Report Date 11/30/2022 12:25:00
Event Date 11/18/2022 0:00:00
AGREEMENT STATE REPORT - LOST EXIT SIGNS
The following information was provided by the Colorado Department of Public Health and Environment via email:
The licensee discovered four tritium exit signs were lost. The exit signs are Isolite Corporation model 2040-50G-20WH signs containing 11.5 Ci of tritium (H-3) each. This is being reported under Colorado Regulations Section 4.51.1.1 (10 CFR 20.2202(a)(1)(i)).
Colorado Incident No.: CO220042
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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Curtiss-Wright Nuclear Division - Cincinnati OH
Report Date 11/30/2022 13:53:00
Event Date 11/22/2022 0:00:00
PART 21 REPORT - INTERIM REPORT FOR EATON TRM5 TIMING RELAYS
The following is a summary of information provided by the Curtiss-Wright Nuclear Division via email:
QualTech NP discovered the presence of a programmable logic device (a flash-based CMOS (complementary metal-oxide-semiconductor) microcontroller) in the timing relays that was not previously identified for this family of relays. The only affected facility is Perry Nuclear Plant. This could potentially lead to unevaluated electromagnetic interference or radiofrequency interference issues when installed in the plant.
For questions concerning this potential 10 CFR 21 issue, please contact: Tim Franchuk Quality Assurance Director QualTech NP, Curtiss-Wright Nuclear Division (513) 528-7900, ext. 176
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Texas Dept of State Health Services - Queen City TX
Report Date 11/30/2022 17:19:00
Event Date 11/30/2022 0:00:00
AGREEMENT STATE REPORT - STUCK SHUTTER
The following information was provided by the Texas Department of State Health Services (the Agency) via email:
"On November 30, 2022, the Agency was notified by the licensee's radiation safety officer (RSO) that during routine testing the shutter on a Berthold model LB7440 nuclear gauge the shutter failed to close. The gauge shutter is in the open position, which is the normal operating position. The gauge contains a 30 millicurie Cesium - 137 source. The RSO stated the roll pin on the shutter operating arm had broken. The manufacturer has been contacted to repair the gauge. The RSO stated dose rates around the gauge were normal. No individual received any additional exposure as a result of this event. The gauge does not pose an exposure risk. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Number: 9968
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Maryland Dept of the Environment - Newburg MD
Report Date 11/30/2022 18:11:00
Event Date 11/30/2022 11:21:00
AGREEMENT STATE REPORT - MISSING OR POSSIBLY LOST GAUGE SOURCES
The following information was received from the state of Maryland via email:
"A Maryland Department of the Environment (MDE) radioactive materials inspector was performing a close-out survey in support of license termination. The facility is no longer operating with radioactive materials (RAM) and some essential staff are gone. The inspector found that three Cf-252 sources for installed gauges had been changed out. The licensee was unable to provide records for the disposal of the old sources, which are no longer present, the new sources were accounted for.
"The sources of concern are:
"Cf-252; serial # FTC-CF-Z3384; 5.2 Ci Assay date missing. Installed October 2009. Decay corrected activity to November 2022 = about 165mCi or less
"Cf-252; serial # FTC-CF-Z3383; 5.2 Ci Assay date missing. Installed October 2009. Decay corrected activity to November 2022 = about 165mCi or less
"Cf-252; serial # FTC-CF-Z3930: 5.2 Ci Assay date missing. Installed October 2009. Decay corrected activity to November 2022 = about 165mCi or less
"Total Activity: about 495 mCi or less
"The licensee is continuing the search for records of these sources. It does not appear to the licensee that an exposure could result to persons in unrestricted areas. The licensee believes that the sources were sent to ThermoFisher Scientific and is attempting to confirm. MDE is providing this precautionary notification pursuant to 10 CFR 2201(a)(1) using the best available information on the radioactive sources."
Updated activities for sources of concern and results of search for the sources are as follows:
"Cf-252; serial # FTC-CF-Z3384; 10.8 mCi on 25 September 2010. Decay corrected activity November 2022 = 445 microcuries
"Cf-252; serial # FTC-CF-Z3383; 10.8 mCi on 25 September 2010. Decay corrected activity November 2022 = 445 microcuries
"Cf-252; serial # FTC-CF-Z3930: 10.8 mCi on 25 September 2010. Decay corrected activity November 2022 = 445 microcuries
"Total Estimated Current Activity: 1.335 mCi
"The licensee is continuing to search for disposal records for these sources or the sources themselves. It does not appear to the licensee that an exposure could result to persons in unrestricted areas. The supplier, ThermoFisher Scientific, has confirmed that they do not have the sources. The waste disposer, RAM Services, is attempting to confirm their possession or the possibility that the sources remain in the gauge housing. MDE is providing this precautionary notification pursuant to 10 CFR 2201(a)(1) using the best available information at the time. This report principally revises source activities using information from the supplier and continuing efforts of the supplier and waste disposer."
Notified R1DO (Cahill), NMSS Events Notification, and ILTAB via email.
"An MDE radioactive materials inspector was performing a close-out survey in support of license termination. The facility is no longer operating with RAM and some essential staff are gone. All RAM sources had been reportedly removed and disposed. The inspector found that three Cf-252 sources from three installed process gauges had been replenished in the past. Each gauge contained one Cf-252 and one Cs-137 source; the Cs-137 are not normally replaced because of their long half-life. The licensee was unable to provide records for the disposal of the three old Cf-252 sources which were no longer present; the three new Cf-252 sources were accounted for. The sources of concern are:
"Cf-252; serial # FTC-CF-Z3384; 10.8 mCi on 25 September 2010. Decay corrected activity Nov 2022 = 445 microCuries
"Cf-252; serial # FTC-CF-Z3383; 10.8 mCi on 25 September 2010. Decay corrected activity Nov 2022 = 445 microCuries
"Cf-252; serial # FTC-CF-Z3930: 10.8 mCi on 25 September 2010. Decay corrected activity Nov 2022 = 445 microCuries
"Total Estimated Current Activity: 1.335 mCi
"The licensee and vendors continued to search for disposal records for these sources or the sources themselves. At no time did it appear to the licensee that an exposure could result to persons in unrestricted areas. A precautionary Event Report was made on 11/30/22 and updated on 12/01/22. On 12/02/2022 the waste disposer, RAM Services, confirmed by serial number that they have possession of the three old and three new Cf-252 sources in a neutron-shielded container in a secure, licensed facility in Wisconsin. The sources had been removed and misidentified when the gauges were de-sourced for license termination. The intended sources to be removed were three Cs-137 sources; these sources are presently unaccounted for and believed to be remaining in the gauges. The sources are:
"Cs-137; serial # CZ-2586; 30mCi on 10/01/2010. Decay corrected activity 12/01/2022 = 22.68 mCi
"Cs-137; serial # 0950/08; 30mCi on 10/01/2010. Decay corrected activity 12/01/2022 = 22.68 mCi"
"Cs-137; serial # 0949/08; 30mCi on 10/01/2010. Decayed corrected activity 12/01/2022 = 22.68 mCi
"Total Estimated Current Activity: 68.04 mCi
"It appears that the disposer had removed sources without actually verifying the serial numbers, isotopes, and activities of the sources, contrary to the records that were submitted. The source slots in the gauges are not visible and sources are moved remotely. The disposer will investigate and confirm or locate the three Cs-137 sources 12/05-12/09/2022. This is an update to the precautionary notification made 11/30/2022 pursuant to 10CFR 2201(a)(1) using the best available information currently available."
Notified R1DO (Cahill), NMSS Events Notification, 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
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Ohio Bureau of Radiation Protection - Dayton OH
Report Date 12/01/2022 13:51:00
Event Date 09/28/2022 0:00:00
AGREEMENT STATE REPORT - SOURCE INADVERTENTLY SHIPPED
The following information was provided by the Ohio Department of Health via email:
"[The] licensee (NDC Technologies, Inc.) inadvertently shipped a 150 mCi Am-241 source to a customer in Germany. Only the electronic portion of the gauge should have been shipped to that customer. The source was [intended] to be shipped separately to a separate licensed facility in Germany. The source was not handled at the facility in Germany and was immediately sent back. The source has arrived at the NDC facility in Dayton."
Ohio Reference Number: OH220012
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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SC Dept of Health & Env Control - Spartanburg SC
Report Date 12/01/2022 14:24:00
Event Date 06/27/2022 0:00:00
AGREEMENT STATE REPORT - DAMAGED GAUGE
The following information was provided by the South Carolina Department of Health and Environmental Control (the Department) via email:
"On December 1, 2022, at approximately 1400 [EST], the Department was notified by the licensee that its contracted vendor used to replace sources, damaged the threads while attempting to exchange sources on June 27th, 2022. The source is a Berthold Model SSC-100 containing 20 millicuries of Cobalt 60, source serial number 1359/10/21. The source is designed to be mounted onto a dip tube via the use of threads. The source remains in the shielded position on the vessel and the area is roped off. This incident is still under investigation."
South Carolina Event Number: To be announced.
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Flowserve - Lynchburg VA
Report Date 12/01/2022 14:45:00
Event Date 10/05/2022 0:00:00
PART 21 - DEVIATION TO QUALIFIED DESIGN
The following is a summary of information provided by Flowserve - Limitorque via email:
Entergy Waterford 3 informed Flowserve - Limitorque on 10/5/2022 that it discovered that a Peerless 125 volt, 25ft-lb, 56 frame direct current (DC) motor had two fasteners securing the brush holder ring assembly to the motor frame. However, the DC motor assembly used in the qualification test program was assembled with 4 fasteners. Therefore, the use of two fasteners is a deviation to the qualified design. Flowserve is submitting this report as an interim report and is evaluating this deviation to determine whether this condition could potentially affect the safety related function of DC powered Limitorque actuators.
Flowserve is continuing to work with the motor original equipment manufacturer (OEM) to refine the scope of potentially affected motors. Limitorque actuators equipped with Peerless - Winsmith DC electric motors with start torque ratings of 40 ft-lb and larger are not affected by this issue. Limitorque actuators equipped with alternating current (AC) powered electric motors are not affected by this issue.
The evaluation is expected to be completed by 01/27/2023. If there are questions, or addition information is required, please contact Chris Shaffer, Quality Assurance Manager, Flowserve Corporation, Ph: (434) 522-4136.
Known affected plant: Waterford 3 Nuclear Generating Station
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Terracon - Olathe KS
Report Date 12/01/2022 17:49:00
Event Date 12/01/2022 9:30:00
NON-AGREEMENT STATE REPORT - LOST AND RECOVERED RADIOACTIVE SOURCE
The following information is a summary of the information provided by the licensee via telephone and email:
While in transport from Grand Rapids, MI to Franklin, WI, a Troxler moisture density gauge fell off the trailer and into a median of I-94 near Coloma, MI. The gauge was discovered and secured by another company knowledgeable with gauge use until the licensee was able to retrieve it. The licensee has secured and transported the gauge to their office until a service provider can retrieve it. There is no indication that the gauge has leaked. The date the gauge fell off the trailer is unclear at this time. The gauge was in the control of a transportation service beginning 11/30/2022. The Michigan Department of Transportation and Michigan State Police have been notified of the event (complaint number 53-4067-22).
Gauge information: Manufacturer: Troxler Model: 3430 SN: 31413 Source Info: Am241: serial number 47-1397 [nominal 40 mCi] Cs137: serial number 750-6146 [nominal 8 mCi]
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NC Div of Radiation Protection - Durham NC
Report Date 12/02/2022 14:41:00
Event Date 12/01/2022 0:00:00
AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following information was provided by the North Carolina Division of Radiation Protection via email:
"The state of North Carolina Radioactive Materials Branch received a report at 1050 EST on December 2, 2022, from Duke University Medical Center (license number: 032-0247-4) of a possible medical event involving a patient receiving Yttrium-90 therapy for treatment of a liver tumor. The treatment had an intended dosage of 91.6 mCi with a delivered dosage of 54.6 mCi resulting in a 40 percent under dosing that did not appear to involve stasis. The patient and the patient's representative were notified at the time of the treatment and the referring physician was notified the morning of December 2, 2022. The licensee is currently investigating the root cause but initially believes it to be caused by equipment failure. The State is currently investigating and will provide more information as it becomes available."
NC Incident No.: NC220015
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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Georgia Radioactive Material Pgm - Locust Grove GA
Report Date 12/02/2022 14:51:00
Event Date 12/02/2022 0:00:00
EN Revision Imported Date: 12/14/2022
EN Revision Text: AGREEMENT STATE REPORT - LOST GAUGE
The following information was provided by the Georgia Radioactive Material Program via email:
"[The] gauge was placed on the tailgate of a truck by a technician at the Eastman Airport and not secured in the box. It fell out within 4 miles of last use in the city limits of Eastman, Dodge County. The licensee will be contacted for more detailed information. The Georgia Radioactive Material Program will update this report as more information comes in. "
Georgia Incident No.: 62
The following information was provided by the Georgia Radioactive Materials Program via email:
"The Radiation Safety Officer (RSO) stated he informed the local police authority of the lost gauge, and for them to be on the lookout. This is the second incident with the employee and more action will be taken. The RSO and the team went out to look for the gauge today and were unsuccessful in locating it. Upon receipt, we will update this report as more information comes available."
Notified: R1DO (Henrion). Notified via email: NMSS Event Notification and ILTAB.
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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Global Nuclear Fuel - Americas - Wilmington NC
Report Date 12/02/2022 17:02:00
Event Date 12/02/2022 15:30:00
FUEL CYCLE FACILITY - LOSS OR DEGRADATION OF SAFETY ITEMS
The following information was provided by the licensee via email:
"It was discovered on 12/2/2022, that an Item Relied on For Safety (IROFS) had failed because it was determined to not be available and reliable in the sinter test grinder (STG) dust collection system. On 11/29/2022, a mass of dry uranium oxide powder greater than expected was identified in the grinder swarf collection can, prompting a shutdown of the STG and further investigation. Subsequent equipment cleanout identified approximately 28.4 kilograms of dry uranium oxide compared to the system safety limit of 43.39 kg. The investigation determined that the safety limit could have been challenged. The failed IROFS resulted in a failure to meet performance requirements. The STG operation remains shut down.
"Additional controls on moderation remained intact, and at no time was an unsafe condition present.
"Additional corrective actions, extent of condition, and extent of cause are being investigated.
"This event is being communicated to meet the reporting requirements of 10CFR70, Appendix A (b)(2)."
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Browns Ferry - Decatur AL
Report Date 12/03/2022 13:05:00
Event Date 12/03/2022 10:00:00
DEGRADED CONDITION DISCOVERED ON SHUTDOWN COOLING TEST LINE
The following information was provided by the licensee via email:
"On 12/2/2022 at 2330 [CST] during the planned F311 outage on Browns Ferry Nuclear Plant Unit 3, personnel entered the Unit 3 drywell for leak identification. Personnel discovered a through-wall piping leak on a 0.75 inch test line between the two test line isolation valves. This 0.75 inch test line is located on the residual heat removal (RHR) loop 1 shutdown cooling and RHR return line to the reactor vessel. On 12/3/2022 at 1000 CST, Engineering determined this location is classified as ASME Code Class 1 piping.
"This constitutes an 8-hour NRC notification in accordance with 10 CFR 50.72(b)(3)(ii)(A) - Any event or condition that results in the condition of the nuclear power plant, including its principal safety barriers, being seriously degraded.
"The NRC Resident Inspector has been notified."
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Louisiana Energy Services - Eunice NM
Report Date 12/05/2022 12:10:00
Event Date 12/04/2022 9:01:00
UNPLANNED CONTAMINATION
The following information was provided by the licensee via email:
"The plant is in a safe configuration.
"On December 4, 2022 at 0901 MST, water was discovered on the floor of the Liquid Effluent Collection and Transfer System (LECTS) room. A pump had catastrophically failed and resulted in leakage of 170 L of contaminated water from slab tank 3 to the inside of the slab tank berm. Upon arrival of the technician, the pump was stopped and the leak was isolated. Some of the water, estimated to be 10 L, leaked out of the berm. Access to this area was restricted at approximately 1100 MST by roping the area off and posting as a contaminated area. Dose rate readings in the area were taken and found to be less than 1 mr/hr and had not increased from previous surveys performed prior to the spill. Urenco USA (UUSA) expects the area will remain posted until after 1100 MST on December, 5, 2022, therefore the reporting requirement in 10 CFR 70.50(b)(1) will be met. The spill is in the process of being cleaned up.
"This issue has been entered in UUSA's corrective action program as EV 158739."
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Texas Dept of State Health Services - Odessa TX
Report Date 12/05/2022 14:57:00
Event Date 12/05/2022 0:00:00
AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA MALFUNCTION
The following information was provided by the Texas Department of State Health Services via email:
"On December 5, 2022, the licensee reported that an equipment malfunction occurred with a Source Production & Equipment Company, Inc. (SPEC) 150 Radiography Camera, serial number 1524, containing 66 curies of Iridium-192. They were testing the camera in the office because the technician reported it started to hang up several times when retrieving the source and disconnecting the crank cables. The camera was tested and the source was retrieved but they were unable to disconnect the crank cables. They had to cut the locking device, remove the cables, and install a plug. The camera and cables are being transported to a service company for inspection and repair. No additional radiation exposure occurred from the incident. SPEC source serial number DI2710. Additional information will be provided in accordance with SA 300."
Texas Incident No.: I - 9969
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Colorado Dept of Health - Denver CO
Report Date 12/06/2022 12:02:00
Event Date 07/16/2020 0:00:00
AGREEMENT STATE REPORT - LOST EXIT SIGNS
The following information was provided by the Colorado Department of Public Health and Environment via email:
The licensee discovered twelve tritium exit signs were lost. The exit signs are SRB Technologies Model BR20BK containing 20 Ci of tritium (H-3) each. This is being reported under Colorado Regulations Section 4.51.1.1 (10 CFR 20.2202(a)(1)(i)).
Colorado Incident No.: CO220043
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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Kakivic Asset Management - Prudhoe Bay AK
Report Date 12/06/2022 12:05:00
Event Date 12/06/2022 2:00:00
EN Revision Imported Date: 12/29/2022
EN Revision Text: DAMAGED RADIOGRAPHIC CAMERA
The following information was provided by the licensee via email:
"At 0200 YST on December 06, 2022, the radiation safety supervisor (RSS) received a call that the technicians had a source which refused to retract to the safe and secured position. During the exposure, the camera fell approximately 4 feet to the ground and landed on the guide tube, which then didn't allow the source to be returned to a shielded position. The radiographers on site followed their procedure and secured their boundaries and notified the RSS. Two RSSs arrived on site at 0245 YST and were able to safely return the source back to locked position. At 1000 YST, a third RSS arrived on location to assist in retrieval.
"The source that required retrieval was Ir-192 at 80.6 curies in a Type B container/special form."
The licensee reported the following doses received by personnel who assisted in the source retrieval: RSS #1 Right hand 173 mR, Left hand 88 mR, Chest 98 mR, Electronic Dosimetry Reading 60 mR RSS #2 Right hand 138 mR, Left hand 132 mR, Chest 74 mR, Electronic Dosimetry Reading 41 mR RSS #3 Right hand 58 mR, Left hand 240 mR, Chest 40 mR, Electronic Dosimetry Reading 14 mR
Notified R4DO (Gepford) and NMSS Events Notification email group.
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NE Div of Radioactive Materials - Kearney NE
Report Date 12/07/2022 11:02:00
Event Date 12/06/2022 0:00:00
AGREEMENT STATE REPORT - LOST EXIT SIGNS
The following information was provided by the Nebraska Dept. of Health and Human Services via email:
The licensee discovered two tritium exit signs were lost. The exit signs are Isolite model SLX60 containing 7.5 Ci of tritium (H-3) each. This is being reported under 10 CFR 20.2202(a)(1)(i).
Nebraska Incident No.: NE220006
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.pd
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Turkey Point - Miami FL
Report Date 12/08/2022 14:39:00
Event Date 12/08/2022 14:02:00
EN Revision Imported Date: 1/10/2023
EN Revision Text: UNUSUAL EVENT DUE TO EXCESSIVE REACTOR COOLANT SYSTEM LEAKAGE
At 1402 EST Turkey Point Unit 3, while operating at 100 percent, declared an Unusual Event due to unidentified leakage greater than 10 gallons per minute for more than 15 minutes. The abnormal procedure for Reactor Coolant System leakage was entered. The plant remains at 100 percent power. The cause of the leakage is under investigation.
At 1446 EST it was verified that the leak had been isolated. The plant remains at 100 percent power.
Unit 4 was unaffected.
State and local authorities were notified by the licensee.
The NRC Resident Inspector has been notified.
Notified DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), DHS NRCC THD Dest (email), and DHS Nuclear SSA (email).
* * * UPDATE ON 12/08/22 AT 1621 (EST) FROM SZEMEI CHOI TO THOMAS HERRITY * * *
Turkey Point Unit 3 has isolated the leak. The Unusual Event was terminated at 1558 EST.
The NRC Resident Inspector has been notified.
Notified R2DO (Miller), NRR EO (Miller), and IR MOC (Crouch). Notified DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), DHS NRCC THD Dest (email), and DHS Nuclear SSA (email).
* * * RETRACTION FROM BRANDEN NATHE TO DONALD NORWOOD AT 1446 EST ON 1/9/2023 * * *
"Turkey Point Nuclear Unit 3 is retracting this notification based on the following additional information not available at the time of the notification, Following the event for unidentified RCS leakage on 12/8/22 at 1403 EST, additional information demonstrated that an RCS leak did not exist.
"A review of indications showed that the in-service seal water return filter D/P [Differential Pressure] rose from 1 psid to 6 psid with a corresponding rise in VCT [Volume Control Tank] level as would be seen with an increase in excess letdown flowrate. Additionally, the on-contact radiation dose rate from the excess letdown piping in the U3 Pipe and Valve Room was measured by RP [Radiation Personnel] to be significantly higher than normal with no other sources of elevated radiation levels noted.
"Following the closure of CV-3-387, RCS To Excess Letdown HX [Heat Exchanger] Control Valve, a nominal input/output flow balance was able to be restored. Containment parameters including pressure, temperature, sump level and radiation level did not change during the event. Due to the shared nature of piping between excess letdown and seal water return, a challenge to system integrity would not allow RCP [Reactor Coolant Pump] controlled bleed-off to remain in service with a normal flow balance which it has at all times subsequent to the event.
"Turkey Point Nuclear reported initially based on the available information at the time and to ensure timeliness with emergency declaration and reporting notification requirements. The NRC Resident Inspector has been notified."
Notified R2DO (Miller).
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NJ Dept of Environmental Protection - Monroe NJ
Report Date 12/08/2022 17:40:00
Event Date 12/08/2022 0:00:00
AGREEMENT STATE REPORT - RADIOPHARMACEUTICAL MISADMINISTRATION
The following report was received from the New Jersey Department of Environmental Protection (NJDEP), via email:
"The licensee had scheduled two patients who were each to receive 200 mCi of Lu-177. One patient was to receive 200 mCi of Lu-177 Lutathera, while the other was to receive 200 mCi of Lu-177 PSMA. The PSMA patient was mistakenly administered the Lutathera, while the Lutathera patient was mistakenly administered the PSMA.
"Licensee is working with Radiation Safety Officer on steps needed to prevent recurrence.
"NJDEP Actions: Will conduct on-site visit if warranted."
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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Prairie Island - Welch MN
Report Date 12/09/2022 0:19:00
Event Date 12/08/2022 22:01:00
EN Revision Imported Date: 12/22/2022
EN Revision Text: OFFSITE AGENCY NOTIFICATION DUE TO CHEMICAL LEAK
The following information was provided by the licensee via email:
"On 12/8/2022, Prairie Island Nuclear Generating Plant initiated a notification to the State of Minnesota due to a HVAC coolant leak reaching waters of the state. The estimated quantity is 5 gallons of NALCO LCS-60. The leak was due to a failed heat exchanger coil and has been isolated. This notification is being made solely as a four-hour, non-emergency notification for a Notification of Other Government Agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
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Univ Of Utah (UTAT) - Salt Lake City UT
Report Date 12/09/2022 13:07:00
Event Date 12/06/2022 10:30:00
TECHNICAL SPECIFICATION VIOLATION
The following information was provided by the licensee via email:
"On December 6th, 2022, University of Utah Training Reactor (UUTR) was in the process of performing a research sample irradiation. The sample was known to have a negative reactivity worth and was therefore placed in the reactor prior to reactor startup. Upon commencing reactor startup procedures, the reactor operator subsequently terminated the startup attempt after noting that the sample appeared to demonstrate a larger negative reactivity worth than what was initially anticipated. After investigating, we identified that there was an inconsistency/miscommunication regarding the sample materials specifications, and the actual negative sample reactivity worth was a larger negative value than that of the original estimate. Immediately afterwards, we performed an updated materials assessment of the sample, which, following reactor calculations, revealed that the sample indeed demonstrated a larger negativity reactivity worth than was originally predicted. As a result, this report is being submitted in accordance with UUTR Technical Specification (TS) 6.7.2 due to 'observed inadequacy in the implementation of administrative or procedural controls such that the inadequacy could have caused the existence or development of an unsafe condition with regard to reactor operation.'
"In accordance with UUTR TS, the reactor was secured, and Utah Nuclear Engineering Program Director notified, and operations shall not resume unless authorized by the Director."
The NRC Project manager was notified.
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Maryland Dept of the Environment - College Park MD
Report Date 12/09/2022 15:53:00
Event Date 12/08/2022 10:02:00
AGREEMENT STATE REPORT - FAILED CABLE/DRIVE MECHANISM
The following event was received from the state of Maryland via email:
"On December 8, 2022 a UMD [University of Maryland] campus-wide power outage occurred and the panoramic irradiator source rack failed to automatically return to the fully shielded position. Operators responded and while remaining outside of the shielded vault, they manually lowered the sources to the fully shielded position. Shielding remained intact. Radiation levels in the irradiator area are at normal levels and the sources are secured in a safe and legal manner. The irradiator will not be operated until an investigation has been conducted and determined that the irradiator can be operated as normal. There was no risk for exposure to staff or members of the public. Operators are unloading the source rack and investigating to ensure that the sources will automatically return to the fully shielded position when power is lost."
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Wolf Creek - Burlington KS
Report Date 12/12/2022 11:05:00
Event Date 10/13/2022 16:48:00
PART 21 - INADEQUATE TORQUE VALUES
The following information was provided by the licensee via email:
"On October 13, 2022, during Refueling Outage 25, 2 bolts and 2 washers were discovered in the strainer basket upstream of the main steam stop valve in the steam line from the 'A' steam generator. It was determined that these bolts and washers were from the main steam isolation valve (MSIV) upstream of the stop valve. One bolt and one washer were also determined to be missing from the MSIV on the line from the 'B' steam generator. The MSIVs are a similar design as the Main Feedwater Isolation Valves (MFIVs). It appears that the torque values for these backseat bolts provided by the vendor weren't sufficient to prevent the bolts from coming loose. Wolf Creek Nuclear Operating Corporation personnel evaluated the condition and determined that the inadequate torque values provided by the vendor could have constituted a substantial safety hazard if left uncorrected. In particular, if bolts had come loose from the MFIVs, they could have traveled downstream to the steam generators and then challenged the integrity of steam generator tubes.
"The NRC Senior Resident Inspector has been notified.
"This is a non-emergency notification required by 10 CFR 21.21(d)(3)(i).
"A written notification will be provided within 30 days."
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Texas Dept of State Health Services - Houston TX
Report Date 12/13/2022 13:10:00
Event Date 12/12/2022 0:00:00
AGREEMENT STATE REPORT - EQUIPMENT FAILURE TO HOUSE SOURCE
The following information was provided by the Texas Department of State Health Services via email:
"On December 12, 2022, the licensee reported that following a cardiac brachytherapy procedure the source train containing strontium-90 sources could not be fully retracted into the safe position. The device was placed into the emergency shielding box by a staff member. There was no exposure to the patient and there was no overexposure, based on calculations, to the individual who handled the device. The individual's ring and whole body dosimeters will be sent for processing to confirm. A manufacturer's representative responded later in the day and secured the sources into the fully shielded position and assessed the cause. He believed the hemostasis valve had been tightened a little too tight which caused a kink in the catheter that prevented the retraction.
"Device: Novoste Brachytherapy device manufactured by Best Vascular, model A-1000 series, SN: 87690
"Sources: 40 millimeter source train containing 16 Strontium-90 sealed sources with original activity of 34.88 millicuries (June 2002), source manufacturer AEA, model SICW.2, train SN: ZA-706.
"An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."
Texas Incident No.: 9971 Texas NMED No.: TX220040
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Texas Dept of State Health Services - Deer Park TX
Report Date 12/14/2022 15:23:00
Event Date 12/14/2022 0:00:00
AGREEMENT STATE REPORT - OVEREXPOSURE EVENT The following information was provided by the Texas Department of Health Services (the Agency) via email: "On December 14, 2022, the Agency was notified by the licensee's radiation safety officer (RSO) of a potential overexposure event. The RSO reported three of their radiographers were working at a remote site using a 30.4 curie cobalt 60 source. The exposure time for each exposure was two minutes. The distance from the source to the pipe was two feet. During the first exposure, one of the radiographers was between the source and the pipe being tested. The RSO stated the individual stayed in the area for about one minute. The radiographer operating the source was standing behind a brick wall and was unaware of the individual being in the area. The operator thought the others had cleared the area, and it was safe to perform the exposure. The individual who received the exposures stated the noise in the area was too loud to hear their alarming rate meter. The exposed individual's self-reading dosimeter was off scale. All radiographers' dosimeters have been sent to the licensee's dosimetry processor for reading. The RSO stated their calculations indicated the individual could have received 7 rem from this event. The RSO stated the individual exposed had received 12 millirem prior to this event. All three individuals have been removed from any duties that would require any additional exposure. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident no.: 9973 Texas NMED no.: TX220041
Notified R4DO (Drake) and NMSS Events Notification via email.
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Illinois Emergency Mgmt. Agency - Elk Grove Village IL
Report Date 12/14/2022 17:00:00
Event Date 12/14/2022 0:00:00
EN Revision Imported Date: 1/11/2023
EN Revision Text: AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following information was provided by the Illinois Emergency Management Agency (The Agency) via email:
"The Agency was contacted on 12/14/22 by the medical physicist for Alexian Brothers Medical Center to advise that a Y-90 microsphere administration conducted that morning resulted in a reportable under dose. The administered amount was 20.4 percent lower than that specified in the written directive. This was not a stasis case. The licensee has tried multiple times, but has so far been unable to reach the patient for notification. The referring physician has been notified. Agency inspectors have gathered preliminary information but will conduct a reactionary site visit on Tuesday, 12/20/2022. More information will be provided once it becomes available."
Illinois Event Number: IL220043
"When initially reported, this was not identified as a stasis case. Both the patient and the referring physician were notified within 24 hours. Agency inspectors conducted a reactionary site visit on 12/20/2022. Upon further discussion and investigation, the authorized user (AU) and authorized medical physicist (AMP) believe the procedure may have reached stasis. The AMP acknowledged that additional training needed to be provided to the treatment team regarding procedures reaching stasis. The licensee determined the root cause to be failure to identify stasis. Agency inspectors determined the potential root cause as a failure to follow procedures and lack of sufficient training to the newly hired AU regarding stasis. This incident and the licensee's procedures will be reviewed during the next routine inspection. This matter may be considered closed."
Notified R3DO (Edwards) and NMSS Event Notifications via email.
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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PA Bureau of Radiation Protection - Greencastle PA
Report Date 12/15/2022 9:46:00
Event Date 12/02/2022 0:00:00
AGREEMENT STATE REPORT - FOUND GAUGE
The following information was provided by the Pennsylvania Bureau of Radiation Protection (the Department) via email:
"On December 14, 2022, a consultant health physicist informed the Department that a Troxler Model 104-117 nuclear density gauge, serial number 433, containing 3 millicuries of radium-226 beryllium (Ra:Be) had been found. The gauge was found in a trash transfer trailer entering Waste Management, Mountain View Reclamation Landfill on December 2, 2202. This load originated from West Virginia. The load was isolated until consultant health physicist was able to respond on December 13, 2022, to resurvey the trailer. A gamma radiation measurement made at contact with the source housing was 18 milliroentgens/hour. At 1 foot from the approximate location of the source, the gamma dose rate was 5 mrem/hour. No evaluation was made of the neutron dose rate. The device was placed in a locked storage shed posted with a Caution - Radioactive Material sign. The Department was onsite during the recovery of the gauge and continues to investigate its origin.
"The Department will update this event as soon as more information is provided."
Event Report ID No.: PA220030
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Watts Bar - Spring City TN
Report Date 12/15/2022 12:52:00
Event Date 11/24/2022 16:21:00
60-DAY OPTIONAL TELEPHONIC NOTIFICATION OF INVALID ACTUATION OF CONTAINMENT VENTILATION ISOLATION VALVES
The following information was provided by the licensee via email:
"This 60-day telephone notification is being submitted in accordance with paragraphs 10 CFR 50.73(a)(1) and 50.73(a)(2)(iv)(A) to report an invalid Containment Ventilation Isolation (CVI) actuation at Watts Bar Nuclear Plant (WBN) Unit 1.
"On November 24, 2022, at 1621 Eastern Standard Time (EST), the Train B CVI actuated due to an invalid high radiation signal from 1-RM-90-131, Containment Purge Air Exhaust Monitor. Upon investigation, the high radiation signal was caused by a failed power supply. Corrective action included replacing the power supply, 1-RM-90-131 ratemeter, and restoring the system to service.
"Prior to and following the invalid high radiation alarm, all radiation monitors except 1-RM-90-131 were stable at their normal values; therefore, the CVI was invalid. Control room operators performed appropriate checks and confirmed that all required automatic actuations occurred as designed. This event has been entered into the corrective action program as Condition Report 1819098.
"The NRC Resident Inspector was notified."
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Arizona Dept of Health Services - Scottsdale AZ
Report Date 12/15/2022 15:32:00
Event Date 12/14/2022 0:00:00
AGREEMENT STATE REPORT - LEAKING SOURCE
The following information was provided by the the Arizona Department of Health Services (the Department) via email:
"The Department received notification from the licensee of a leak test that exceeded the regulatory limit of 0.005 microcuries. The licensee is going to return the vial to the manufacturer and exchange it for a new vial source. The Department has requested additional information and continues to investigate the event."
[Source information:] "Cs-137 Vial "Serial number: 788-3-11 "Assay date: 11/1/2001
"Additional information will be provided as it is received in accordance with SA-300."
Arizona Incident Number: 22-015
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Texas Dept of State Health Services - Carrollton TX
Report Date 12/16/2022 18:28:00
Event Date 12/16/2022 0:00:00
AGREEMENT STATE REPORT - UNABLE TO RETRACT SOURCE
The following information was provided by the Texas Department of State Health Services (the Department) via email:
"On December 16, 2022, the Department received calls from a licensee reporting an equipment failure with a moisture density gauge. The licensee has been unable to retract the rod with cesium-137 back to the fully shielded position and the source is sticking out about 4 inches. This is for a Humboldt 5001 gauge with 40 millicuries (mCi) of americium [-241] and 10 mCi of cesium-137. The rod is presently in the ground to maintain shielding and will be transported back to the storage site with the rod in a bucket of sand. The licensee plans to transport the gauge the same way to a repair facility tomorrow morning. The dose to personnel has not been above normal working conditions but there may be some dose during transportation. The licensee was reminded to minimize dose as much as possible. Further information will be provided per SA-300."
Texas Incident Number: 9974
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Louisiana Energy Services - Eunice NM
Report Date 12/16/2022 19:16:00
Event Date 12/16/2022 16:45:00
ALERT - SEISMIC EVENT FELT ONSITE
The following information was provided by the licensee via fax and phone call:
"An Alert has been declared at Urenco USA. An Alert is the official designation for an emergency which is contained on the URENCO USA site. No public protective actions are recommended at this time. A seismic event was detected near the facility. A release of hazardous material has not occurred."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
On 12/16/2022 at 1645 MST, Urenco USA declared an Alert due to seismic event felt onsite. The Headquarters Operations Officer was notified of the Alert at 1916 EST (1716 MST). No radioactive release has occurred. A 5.4 magnitude earthquake occurred in western Texas with an epicenter 20 km north-northwest of Midland, Texas. Plant personnel are conducting walkdowns of the site.
The licensee notified state and local authorities.
Notified DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, CISA Central Watch Officer, EPA EOC, FDA EOC (email), FEMA NWC (email), DHS Nuclear SSA (email), DHS NRCC (email), FEMA NRCC SASC (email), FERC (email)
On 12/17/2022 at 1400 MST, Urenco USA terminated the Alert due to a seismic event felt onsite. Urenco USA met conditions for event termination. No damages were found upon completion of site walkdowns. The licensee has notified state and local authorities.
Notified DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, CISA Central Watch Officer, EPA EOC, FDA EOC (email), FEMA NWC (email), DHS Nuclear SSA (email), DHS NRCC (email), FEMA NRCC SASC (email), FERC (email), R2DO (Miller), IR (Ulses), NMSS (Helton)
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Cooper - Brownville NE
Report Date 12/17/2022 4:03:00
Event Date 12/16/2022 23:51:00
MANUAL REACTOR SCRAM
The following information was provided by the licensee via email:
"On December 16, 2022 at 2351 CST, with the Unit in Mode 1 at 13 percent power, a manual scram was inserted due to lowering Reactor Pressure Vessel (RPV) pressure, which occurred following an unexpected opening of Main Turbine Bypass Valve 1. All control rods fully inserted. Following actuation of the manual scram, RPV pressure lowered, resulting in an automatic Primary Containment lsolation (PCIS) Group 1 isolation (expected response). The main steam isolation valves and steam line drain valves all closed. The Group 1 [isolation] has been reset allowing RPV pressure control with steam line drains to the main condenser.
"All systems responded as designed. The plant is stable in Mode 3. Investigation of the bypass valve opening is ongoing.
"This event is reportable under 10 CFR 50.72(b)(2)(iv)(B) RPS Actuation and 50.72(b)(3)(iv)(A) Specified System Actuation.
"There was no impact on health and safety of the public or plant personnel. The NRC Senior Resident Inspector has been notified."
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NC Div of Radiation Protection - Raleigh NC
Report Date 12/19/2022 8:59:00
Event Date 12/13/2022 0:00:00
AGREEMENT STATE REPORT - MISSING SOURCE
The following is a summary information was provided by the North Carolina Division of Radiation Protection via email:
On 12/13/2022, the licensee discovered that a source from a shipment of sources received on 9/1/2022, was missing from their inventory. The licensee conducted surveys of the area and did not detect the source. None of the shipping containers or bags were damaged, indicating that the source was not lost during shipping and was either not included in the original shipment from the shipper or was lost after the licensee received the shipment. The original shipper of the source was contacted and informed of the missing source; they are performing checks to verify if the source was indeed shipped to the licensee.
Source: Am-241/Be Activity: 40 mCi Manufacturer: Eckert & Ziegler Model: K Model, Batch S/N: K364-22
NC Event Number: NC220016
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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Peach Bottom - Philadelphia PA
Report Date 12/19/2022 12:50:00
Event Date 11/11/2022 23:33:00
60-DAY TELEPHONIC NOTIFICATION
The following information was provided by the licensee via email:
"This 60-day telephone notification is being made per the reporting requirements specified by 10 CFR 50.73(a)(1) and 50.73(a)(2)(iv)(A) for an invalid actuation of a primary containment isolation signal affecting more than one system.
"On November 11, 2022, at 2333 hours EST, Peach Bottom experienced an unplanned loss of the #343 Off-Site Startup Source. Due to the temporary loss of power during automatic bus transfers, several systems experienced Primary Containment Isolation System (PCIS) Group II and Group III (GP II/III) isolation signals. Plant Systems impacted by isolation valve closure included: Reactor Water Clean Up (RWCU), Containment Atmospheric Control (CAC), Traversing In-Core Probe (TIP) Purge, Primary Containment Floor and Equipment Drains, and the Instrument Nitrogen system. All equipment responded as designed.
"Plant conditions which initiate PCIS GP II isolation signals are Reactor Vessel Low Water Level, High Drywell Pressure, RWCU system High Flow or RWCU Non-Regenerative Heat Exchanger High Outlet Temperature. The PCIS GP III actuations are initiated by the Reactor Vessel Low Water Level, Primary Containment High Pressure, Reactor Building Ventilation High Radiation or Refuel Floor Ventilation High Radiation. At the time of the event, none of these actual plant conditions existed; therefore, the actuation of the PCIS was invalid.
"The loss of the #343 Off-Site Startup Source was caused by a failed printed circuit card in the programable logic controller (PLC) for the 3435 breaker. There is no time-based maintenance strategy for PLC replacement. The PLC circuit card was replaced, and the breaker restored to full qualification and service. Preventive maintenance strategy will be enhanced to address the identified vulnerability.
"The licensee has notified the NRC Resident Inspector."
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Brunswick - Southport NC
Report Date 12/19/2022 13:12:00
Event Date 12/19/2022 7:35:00
FAILED FITNESS FOR DUTY TEST
The following information was provided by the licensee via email:
"At 0735 EST on December 19, 2022, it was determined that a non-licensed employee supervisor failed a test specified by the Fitness-for-Duty (FFD) testing program. The individual's authorization for site access has been terminated.
"The NRC Resident Inspector has been notified."
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Grand Gulf - Port Gibson MS
Report Date 12/20/2022 0:24:00
Event Date 12/19/2022 21:01:00
MANUAL SCRAM DUE TO LOSS OF FEEDWATER PUMP
The following information was provided by the licensee via email:
"At 2101 [CST] on December 19, 2022, a manual reactor scram was initiated at Grand Gulf Nuclear Station (GGNS). Following the reactor scram, the high pressure core spray (HPCS) system was used to maintain reactor water level. The manual [reactor protection system] RPS actuation is being reported in accordance with 10 CFR 50.72(b)(2) and the HPCS actuation is being reported in accordance with 10 CFR 50.72(b)(3).
"At 2058, GGNS experienced a loss of a condensate booster pump. At 2101, the `A' reactor feedwater pump tripped and the reactor was manually scrammed. All control rods were fully inserted into the core.
"At 2104, the `B' reactor feedwater pump tripped and HPCS was manually started. HPCS was manually injected to maintain reactor water level at 2121. The `A' reactor feedwater pump was successfully restarted at 2126.
"GGNS is currently in Mode 3. Reactor level is being maintained with the `A' reactor feedwater pump and pressure is being maintained with the turbine bypass valves.
"The NRC Resident Inspector was notified."
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Limerick - Philadelphia PA
Report Date 12/21/2022 13:32:00
Event Date 11/02/2022 18:29:00
60-DAY TELEPHONIC NOTIFICATION - INVALID SPECIFIC SYSTEM ACTUATION The following information was provided by the licensee via email: "This 60-day telephone notification is being made per the reporting requirements specified by 10 CFR 50.73(a)(1) and 10 CFR 50.73(a)(2)(iv)(A) to describe an invalid specific system actuation of the Emergency Service Water System (ESW).
"On 11/2/2022, during normal reactor operations, multiple main control room alarms were received for D12 Emergency Diesel Generator (EDG) running and Unit 1 Division 2 Safeguard Battery Ground. The D12 EDG did not start; however, the 'B' ESW Pump auto started. Subsequent troubleshooting determined that the cause of the D12 EDG running alarms and the inadvertent auto start of the 'B' ESW Pump was a malfunction on the D12 EDG speed switch. This event is considered an invalid system actuation because the 'B' ESW Pump started in response to a false signal that the D12 EDG was running when D12 EDG did not start. This was a complete actuation of the ESW System and the system functioned as expected in response to the actuation. The affected ESW Pump was shut down in accordance with plant procedures and the degraded D12 EDG speed switch was replaced. There was no impact on the health and safety of the public or plant personnel. The licensee notified the NRC Resident Inspector."
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Davis Besse - Oak Harbor OH
Report Date 12/23/2022 17:02:00
Event Date 12/23/2022 15:13:00
TECHNICAL SPECIFICATION REQUIRED SHUTDOWN
The following information was provided by the licensee via email:
"At 1513 EST on 12/23/22, a Technical Specification required shutdown was initiated at the Davis-Besse Nuclear Power Station Unit 1. Technical Specification [TS] Action Limiting Condition of Operation [LCO] 3.7.9 for Ultimate Heat Sink water level minimum requirements was not met and condition 'A' was entered on 12/23/22 at 1412 EST with a required action to `Be in Mode 3' with a completion time of 6 hours and `Be Mode 5' with a completion time of 36 hours. This event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(i). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.
"At 1640 on 12/23/22, the NRC granted enforcement discretion for the shutdown requirements of TS LCO 3.7.9 and the shutdown was terminated with the unit remaining in Mode 1."
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Salem - Hancocks Bridge NJ
Report Date 12/24/2022 5:08:00
Event Date 12/24/2022 2:22:00
AUTOMATIC REACTOR TRIP
The following information was provided by the licensee via email:
"At 0222 [EST] on 12/24/22, with Unit 2 at 100 percent power during steady state operation, the reactor automatically tripped and a safety injection actuated due to steam generator differential pressure. The trip and safety injection were not complex, with all systems responding normally post-trip. An actuation of the auxiliary feedwater system occurred following the reactor trip as expected due to low level in the steam generators. The unit is stable in Mode 3. The turbine bypass steam dumps and auxiliary feedwater system are removing decay heat. Salem Unit 1 was not affected.
"Due to the actuation of the reactor protection system while critical, this event is being reported as a four hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). This event is also being reported as an eight hour non-emergency notification in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the auxiliary feedwater system.
"There was no impact to the health and safety of the public or plant personnel.
"The NRC Resident Inspector has been notified."
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Brunswick - Southport NC
Report Date 12/28/2022 9:18:00
Event Date 11/09/2022 9:06:00
INVALID ACTUATION OF CONTAINMENT ISOLATION VALVES
The following information was provided by the licensee via email:
"This 60-day optional telephone notification is being made in lieu of an LER [Licensee Event Report] submittal as allowed by 10 CFR 50.73(a)(1). This notification is made pursuant to the reporting requirements specified in 10 CFR 50.73(a)(2)(iv)(A) for an invalid actuation of one of the systems listed in 10 CFR 50.73(a)(2)(iv)(B).
"At approximately 0906 Eastern Time (EST) on November 9, 2022, an invalid actuation of Group 6 Primary Containment Isolation Valves (PCIVs) (i.e., Containment Atmospheric Control/Monitoring and Post Accident Sampling isolation valves) occurred. In addition, per design, Reactor Building Ventilation isolated and Standby Gas Treatment started. It was determined that this condition was caused by faulty test equipment that was being used during preparation for the Main Stack Radiation Monitor High Radiation Response Time test. This test requires connecting a recording device to monitor for the test start signal on a Unit 2 relay associated with the Main Stack High Radiation signal. The recorder faulted which caused the associated fuse to blow and resulted in Unit 2 receiving a Main Stack High Radiation signal and Group 6 PCIV actuation. It was verified that the radiation monitor was not in trip electrically (i.e., there was no high radiation condition).
"The actuation was not initiated in response to actual plant conditions, it was not an intentional manual initiation, and there were no parameters satisfying the requirements for initiation of the system. Therefore, this event has been determined to be an invalid actuation.
"During this event the PCIVs functioned successfully, and the actuations were complete. This event did not result in any adverse impact to the health and safety of the public."
The NRC Resident Inspector was notified.
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