ML18081A465

Draft NRC Form 361A, Fuel Cycle and Materials Event Notification Worksheet

ML18081A465
Person / Time
Issue date:	09/27/2018
From:	NRC/OCIO
To:
References
Download: ML18081A465 (1)

Text

Page of NRC FORM 361A U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-XXXX EXPIRES: (MM/DD/YYYY)

(MM-YYYY) OPERATIONS CENTER Estimated burden per response to comply with this voluntary collection request: 30 minutes. The information provided will be used for evaluation of licensee event description, facility status and for input to the public website.

Send comments regarding burden estimate to the Information Services Branch (T-2 F43), U.S. Nuclear Regulatory FUEL CYCLE AND MATERIALS Commission, Washington, DC 20555-0001, or by e-mail to Infocollects.Resource@nrc.gov, and to the Desk Officer, EVENT NOTIFICATION Office of Information and Regulatory Affairs, NEOB-10202, (3150-XXXX), Office of Management and Budget, Washington, DC 20503. If a means used to impose an information collection does not display a currently valid OMB WORKSHEET control number, the NRC may not conduct or sponsor, and a person is not required to respond to, the information collection.

EN #

NRC OPERATIONS TELEPHONE NUMBERS: PRIMARY - 301-816-5100 or 800-532-3469, BACKUPS - [1st ] 301-951-0550 or 800-449-3694,

[2nd] 301-415-0550 and [3rd] 301-415-0553. Licensees who maintain their own ETS are provided these telephone numbers.

FAX - 301-816-5151, EMAIL - hoo.hoc@nrc.gov Notification Time Facility or Organization License # Name of Caller/Title Call Back #

Event Time & Zone Event Date Location of Event (Include County and State) Portion of Plant Affected (If applicable)

EVENT CLASSIFICATIONS EVENT TYPES INCIDENT REPORTS (30.50, 40.60, 70.50)

(a) PROTECTIVE ACTION GENERAL EMERGENCY* FUEL CYCLE 20.2201 LOSS / THEFT PREVENTED 20.2202 ACTUAL / THREATENED (b)(1) UNPLANNED SITE AREA EMERGENCY MEDICAL / ACADEMIC OVEREXPOSURE CONTAMINATION 20.2202 ACTUAL / THREATENED (b)(2) SAFETY EQUIPMENT ALERT TRANSPORTATION RELEASE FAILURE (b)(3) MEDICAL TREATMENT NOTIFICATION OF UNUSUAL EVENT* WASTE MANAGEMENT 21.21 DEFECT / NONCOMPLIANCE WITH CONTAMINATION INCIDENT REPORT INDUSTRIAL/ COMMERCIAL 26.791 FITNESS FOR DUTY (b)(4) FIRE / EXPLOSION TRANSPORATION EVENT FOREIGN EVENT 35.3045 MEDICAL EVENT 70.52 CRITICALITY / SNM LOST 70.52 ACTUAL / ATTEMPTED INFORMATION ONLY OTHER (Specify) 36.83 IRRADIATOR EVENT THEFT 39.77 RUPTURED WELL CRITICALITY CONTROL 4-OTHER (Specify)

LOGGING SOURCE HOUR (BULLETIN 91-01) 39.77 IRRETRIEVABLE WELL CRITICALITY CONTROL 24-LOGGING SOURCE HOUR (BULLETIN 91-01) 40.26 TAILINGS / WASTE OTHER NON-CFR

• ONLY UNDER OLD 1981 ORDER DAM FAILURE REQUIREMENT WILL NOTIFICATIONS YES NO BE Anything Unusual or not understood? Yes (Explain below) No NRC REGION STATE(s)

Did all systems function as required? Yes No (Explain below)

LOCAL OTHER GOVERNMENT AGENCIES Additional Information on page 2? Yes No PRESS RELEASE Event Description (Include: Systems affected, actuations and their initiating signals, causes, effect of event on plant, actions taken or planned, etc.) (Continue on Page 2)

NRC FORM 361A (MM-YYYY) Continued on next page

Page of NRC FORM 361A U.S. NUCLEAR REGULATORY COMMISSION (MM-YYYY) FUEL CYCLE AND MATERIALS OPERATIONS CENTER EVENT NOTIFICATION WORKSHEET (Continued) EN #

RADIOLOGICAL / CHEMICAL RELEASES: CHECK OR FILL IN APPLICABLE ITEMS Isotope Activity Physical Form Chemical Form Stack Liquid Effluent Other (Specify)

Monitor Reading Alarm Setpoint ONGOING RELEASE PERSONNEL EXPOSURE / CONTAMINATION DATA TERMINATED RELEASE Number of Personnel Exposed Number of Personnel Contaminated OFFSITE RELEASE Maximum External Dose Maximum External Level ONSITE AREAS EVACUATED Maximum Internal Dose Maximum Internal Level OFFSITE PROTECTIVE Critical Organ (if known) Critical Organ (if known)

ACTION RECOMMENDED DEGRADED CRITICALITY SAFETY CONTROLS FOR ACCIDENT SCENARIO(S) (BULLETIN 91-01)

ALL BUT SINGLE DEFICIENT SAFETY SAFETY SIGNIFICANCE >45% MINIMUM CRITICAL MASS ALL CONTROLS LOST CONTROLS LOST ANALYSIS UNKNOWN PRESENT OR READILY AVAILABLE Number and Types of controls necessary under normal operating conditions Number and Types of controls which functioned properly under upset conditions Number and Types of controls necessary to restore a safe situation Safety Significance of Events Safety Equipment Status Status of Corrective Actions Event Description (Continued) (Include: Systems affected, actuations and their initiating signals, causes, effect of event on plant, actions taken or planned, etc.)

NRC FORM 361A (MM-YYYY)