Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 53793 | 18 December 2018 15:40:00 | On December 18, 2018 at 1126 CST, Arkansas Nuclear One, Unit 1 (ANO-1) reactor automatically tripped due to a loss of the A-1, non-vital 4160V bus. All control rods fully inserted. Loss of the A-1 bus resulted in de-energizing A-3 vital 4160V bus. Emergency Diesel Generator #1, K-4A, started automatically and is currently powering A-3 vital bus. Non-vital buses A-2, H-1, and H-2 and vital bus A-4 transferred power automatically to the Startup Transformer #1. Off-site power remains energized and available for ANO-1. The reason for loss of A-1 bus is unknown at this time. Currently, ANO-1 has stabilized in Mode 3, Hot Standby. Decay heat is being removed by the main condenser using the turbine bypass valves. The loss of the A-1, non-vital bus, is under investigation. The licensee has notified the NRC Resident Inspector and the state. |
| ENS 53792 | 18 December 2018 11:51:00 | The following was received from the state of Kansas via email: Yesterday the Kansas Radiation Control Program was notified by a licensee, Kruger Technology Inc (dba KTI) 22-B659-01, of a Troxler gauge which was hit and damaged at a construction site in Edgerton ,KS. No one was injured. The source was in the shielded position. Initial surveys indicate (that) the shielding is intact. The rod was slightly bent, fortunately the device still fit in the transport case. The licensee reported by phone that the device was hit (at) approximately 1530 CST. The initial report was made to the State at 1615 CST. The RSO was on scene within an hour of the incident. The incident occurred on a new road construction site. It was the end of the day and few workers were present, no public traffic is permitted on the road. The site is an industrial complex in a rural area and there is no public access to the site. Currently the device is secured in the licensee's storage room. An inspector was dispatched this morning to conduct a reactive inspection and verify survey results. More information will be provided to the NRC as it is available, including the device make and model, serial number, survey meter information, verified survey results, more information on how the incident occurred, enforcement actions taken if applicable, and more precise location information. |
| ENS 53741 | 16 November 2018 05:16:00 | On November 16, 2018 at 0202 EST, a potentially contaminated Dominion worker was transported offsite for medical attention. The individual was initially found unresponsive in a contaminated area. A partial survey was performed prior to the individual being transported offsite, and no contamination was found. The individual passed away in transit to the hospital. Follow-up surveys to verify no contamination are ongoing. A notification to OSHA (Occupational Safety and Health Administration) is planned. This event is being reported pursuant to 10CFR50.72(b)(2)(xi) due to notification of an offsite organization and 10CFR50.72(b)(3)(xii) due to a potentially contaminated worker transported offsite. The NRC Resident Inspector was notified.
Follow-up radiological surveys were performed and determined that there was no contamination on the worker, response personnel, or ambulance. The Occupation Safety and Health Administration was notified on 11/16/18. No media release is planned. The NRC Resident Inspector was notified. Notified the R2DO (Sandal) and via E-mail the NRR EO (Miller) and IRD MOC (Gott). |
| ENS 53734 | 11 November 2018 21:59:00 | On November 11, 2018, during ultrasonic data analysis from reactor vessel closure head in-service inspections, signals that display characteristics consistent with primary water stress corrosion cracking in head penetration 33 were identified. No indications of boric acid leakage and no surface indications were detected at this location during bare metal visual inspection. The plant was in cold shutdown at 0% power and in Mode 6 for a refueling outage at the time of discovery. Repair actions will be completed prior to plant startup from the outage. This condition has no impact to the health and safety of the public. This report is being made in accordance with 10 CFR 50.72(b)(3)(ii)(A) for degradation of a principal safety barrier. The licensee notified the NRC Senior Resident Inspector. |
| ENS 53733 | 10 November 2018 17:48:00 | On November 10, 2018, during a planned bare metal visual inspection of the reactor head, boric acid was discovered at a CRDM (Control Rod Drive Mechanism) nozzle to reactor head penetration. Investigation of the source of the boric acid is ongoing. The plant was in cold shutdown at 0% power and Mode 6 for a refueling outage at the time of discovery. Repair actions will be completed prior to plant startup from the outage. All other reactor vessel head penetrations have had a bare metal visual inspection completed with no other indications identified. This condition has no impact to the health and safety of the public. This report is being made in accordance with 10 CFR 50.72(b)(3)(ii)(A) for degradation of a principal safety barrier. The licensee notified the NRC Senior Resident Inspector. |
| ENS 53697 | 27 October 2018 16:52:00 | On October 27, 2018, at 1533 EDT, Watts Bar Nuclear (WBN) Plant Unit 1 reactor was manually tripped due to a failure of the #3 Reactor Coolant Pump normal feeder breaker to close during the planned power transfer to unit power following startup. Concurrent with the reactor trip, the Auxiliary Feedwater system actuated as designed. All Control and Shutdown rods fully inserted. (Main Steam Isolation Valves) MSIVs were required to be isolated due to cooldown. All safety systems responded as designed. The unit is currently stable in Mode 3, with decay heat removal via Auxiliary Feedwater and Steam Generator Atmospheric Dump Valves. Unit 1 is in a normal shutdown electrical alignment. This reactor trip and system actuation is being reported under 10CFR 50.72(b)(3)(iv)(A) and 10CFR 50.72 (b)(2)(iv)(B). There was no effect on WBN Unit 2. The NRC Senior Resident has been notified. |
| ENS 53738 | 15 November 2018 11:13:00 | The following was received from the state of Pennsylvania via email: Notifications: On November 14, 2018, the licensee informed the Department (Pennsylvania Department of Environmental Protection) of a failed shutter. It is reportable per 10 CFR 30.50(b)(2). Event Description: The licensee reported that on October 18, 2018, a IRMS Model TG-2 gauge, serial number 00MO397-15, containing 3000 milliCuries of americium 241 did not properly perform following scheduled maintenance. Specifically, the shutter failed to open completely and then would not open at all. The gauge was taken out of service and a service provider was contacted, responded and corrected the problem. The licensee has since contacted the same service provider and, on November 2, 2018, transferred the device for proper disposal. Licensee and service provider survey results indicated no abnormal amounts of radiation in the area before, during or after the event or removal of the device. There were no overexposures related to this event. Cause of the Event: Equipment failure. Actions: The Department will perform a reactive inspection. More information will be provided upon receipt. PA Event Report ID No: PA180020 |
| ENS 53671 | 17 October 2018 18:34:00 | The following was received from the State of Nebraska: Event type: Equipment Failure as reportable under 10 CFR 30.50, item b.2. and Inoperability of Access Control System under 10 CFR 36.83, item 5. Event description: Nebraska Department of Health and Human Services, Office of Radiological Health was conducting a performance-based inspection of the Becton Dickinson and Company licensee (10-08-01) during the late afternoon (between 2:30 and 3:30 pm) on October 16, 2018. During the inspection, an inspector was able to open an outer door leading from the production floor area to the control room, which is a part of the licensee's controlled access area. The control room also contains an access door which leads to a panoramic, wet source storage irradiator licensed for millions of curies of Co-60. The access door in the control room did not fail and was functioning as intended. The outer door leading to the control room was able to be opened by the inspector only after a routine entry was made. During the initial inspection by the licensee, it was determined that the locking mechanism was loose and did not latch as intended. The licensee was able to repair the locking mechanism within 2 hours and could not open the outer door after a routine entry was made. The State inquired with the Region IV Regional State Agreement Officer (RSAO) in the early afternoon (between 1:30 and 2:30pm) of October 17, 2018 to ask if this incident was a reportable event under 10 CFR 37. The RSAO indicated and agreed that this incident was not a report event under the reporting requirements of 10 CFR 37. Later that afternoon (between 3:30 and 4:00 pm), the RSAO stated that this incident may be a reportable event under 10 CFR 30.50, item b.2. and 10 CFR 36.83, item 5. The State and Region IV staff are scheduled to discuss this further on October 18, 2018, and this incident may need to be retracted. State Event Report ID No.: NE-18-0008
The following retraction was received from the State of Nebraska via email: Please retract this event. This does not meet the reporting requirements of either 10 CFR 30.50 or 10 CFR 36.83 since this outer door is not a part of the access control system. This was reviewed and discussed by State staff and NRC Region IV staff this morning. Notified R4DO (Pick) and NMSS Events Notification (email). |
| ENS 53667 | 15 October 2018 13:45:00 | The following was received from the State of Nebraska via email: This morning at approximately 1030 (CDT), the State of Nebraska was contacted by the RSO of Becton, Dickinson and Company located in Holdrege, NE (NE license # 37-03-01) concerning a 24 hour reportable event. I believe the reporting requirement could be 10 CFR 36.83(a)(1), source stuck in the unshielded position or 10 CFR 36.83(a)(4), failure of the cable or drive mechanism used to move the source rack. Event: Approximately 1930 (CDT) on the night of October 14, 2018, there was an alarm of the source positioning indicators alerting the operators of a moving source. When the source rack failed to reach the rack down position in the allotted time period, a fault was recorded at the control panel. It appeared that the rack was stuck in the up position. The RSO called in at approximately 1940 (CDT) to help investigate the situation. Soon after arriving at the facility, (the RSO) placed a call into MDS Nordion for help with the situation. During the 2 hour time period for MDS Nordion to call back, (the RSO) successfully returned source rack #2 to the shielded position and tried to lower the source rack #1 to its shielded position but was unable to lower source rack #1. They also did some preliminary investigations and assumed that one of the guide cables for source rack #1 had busted. Once MDS Nordion returned their call, it was verified that the guide cable for source rack #1 had busted. MDS Nordion had the operators raise source rack #2 and with source rack #2 in its up position, lower source rack #1. After a couple attempts, they were successful in lowering the source rack #1 to its shielded position. Once source rack #1 was in its shielded position, the operators lowered the source rack #2 to its shielded position. Both were verified by the source down positioning switch. Note: After about 3.5 hours of the sources being stuck in the up position, the rack deluge system (rack sprinkler system) was deployed as a precautionary step to cool the sources and the product close to the sources. The overall time the sources were in the up position was approximately 5 hours. This was Nordion Model JS-8900 commercial irradiator. It was reported that nobody entered the vault while the sources were in the up position and that there is no reason to believe that any addition exposure to the workers was involved in this incident. |
| ENS 53649 | 5 October 2018 17:33:00 | The following was received via email from the State of Nevada: This is an email to report a possible medical event. The licensee is Renown Regional Medical Center, the license number is 16-12-0016-01. Occurrence was 10/5/2018 and reported the same day by Renown's RSO. The administration of Y-90 was given, prescribed dose was 15.66mCi and the delivered dose was 9.86mCi. The reason for this was due to patient intervention, apparently the patient moved and pulled the IV (Intravenous therapy) out. A full report from Renown's RSO has not been received, just the initial report. 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. |
| ENS 53648 | 5 October 2018 15:39:00 | On Friday, October 5, 2018 at 1209 hours, with the reactor at 100 percent core thermal power, Pilgrim Nuclear Power Station (PNPS) automatically tripped due to reactor water level perturbation and receipt of a low reactor water level Reactor Protection System (RPS) signal. The cause of the low reactor water level is under investigation. The plant is in hot shutdown. All other plant systems responded as designed. Pressure is being controlled using the Mechanical Hydraulic Control System and Main Condenser. Reactor water level is being maintained with the feedwater and condensate system. During the automatic reactor scram the plant experienced the following isolation signals as designed: Group 2 Isolation: Miscellaneous containment isolation valves Group 6 Isolation: Reactor Water Clean-up Reactor Building Isolation System Actuation Due to the RPS actuation while critical, this event is being reported as a four-hour, non-emergency notification in accordance with 10 CFR 50.72(b)(2)(iv)(B), 'any event that results in actuation of the reactor protection system (RPS) when the reactor is critical.' This notification is also being made in accordance with 10 CFR 50.72(b)(3)(iv)(A), 'Any event or condition that results in valid actuation of any of the systems listed in paragraph (b)(3)(iv)(B) of this section ... ' (B)(2) 'General containment isolation signals affecting containment isolation valves in more than one system.' This event has no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. The licensee will notify the Massachusetts Emergency Management Agency. |
| ENS 53644 | 4 October 2018 12:29:00 | Degraded or unanalyzed condition due to the possibility for a postulated fire induced hot short to cause a secondary fire in a different fire area, which would be outside the boundaries analyzed for safe shutdown in calculation SSC-001 due to an unfused circuit associated with the 1M43C0001A, Diesel Generator Building Ventilation Fan. This condition is not bounded by existing design and licensing documents. Without overcurrent protection for this circuit, the potential exists that an initial fire event affecting this circuit could cause a short circuit without protection that would cause excessive current through the circuit beyond the capacity rating of the conductors. This could lead to a secondary fire in another plant area where this circuit is routed challenging the ability to achieve and maintain safe shutdown. The postulated event would affect the following fire zones: 1CC-3c (Unit 1, Division 1 4160V and 480V Switchgear Room, 620 feet 6 inch elevation), 1CC-3e (Unit 1 West Corridor North of Elevator, 620 feet 6 inch elevation), DG-1d (Hallway Diesel Generator Building 620 feet 6 inch elevation), and 1DG-1c (Unit 1, Division 1 Diesel Generator Building 620 feet 6 inch elevation). This condition is being reported in accordance with 10 CFR 50.72(b)(3)(ii)(B). Interim compensatory measures (i.e., fire watches) have been implemented for affected areas of the plant. The licensee has notified the NRC Senior Resident Inspector. |
| ENS 53589 | 7 September 2018 20:56:00 | (Indian Point Unit 3) entered Technical Specification 3.0.3 for Safety Injection Boron Injection Tank Header Inoperable due to a thru weld leak at the thermal well rendering two Safety Injection Pumps Inoperable. Plant shutdown was started 1803 hours EDT. The licensee plans to be in Mode 4 at 0600 EDT on 9/8/2018. There is no impact to Unit 2. The licensee notified the NRC Resident Inspector and the State of New York. |
| ENS 53579 | 3 September 2018 15:20:00 | At 1045 (EDT) on 9/3/18, with Unit 1 and Unit 2 at 100% power, off-site power feed to the 'A' Reserve Station Transformer was lost which resulted in a loss of power to Unit 1'J' Emergency Bus. As a result of the power loss, the 1'J' Emergency Diesel Generator started as designed and restored power to the Emergency Bus. During this event, the Unit 1 'A' Charging Pump, 1-CH-P-1A automatically started as designed due to the loss of power event. The valid actuation of these ESF (Engineered Safety Features) components due to the loss of power is reportable per 10 CFR 50.72 (b)(3)(iv)(A). The Unit 1 'J' Emergency bus off-site power source was restored via the Unit 2 'B' Station Service bus and the 1 'J' Emergency Diesel was secured and returned to Automatic. The Unit 1 'A' Charging pump has been stopped and returned to Automatic. Both Units are in a stable condition. The apparent cause for the loss of power appears to be a bird strike to the 'A' RSST (Reserve Station Service Transformer) Overhead Cable. The licensee notified the NRC Resident Inspector. |
| ENS 53564 | 24 August 2018 16:35:00 | The following information was received via E-mail: Oklahoma DEQ (Department of Environmental Quality) notified the Kansas Radiation Control Program of a rejected waste shipment from Kansas. Preliminary information is the waste was not generated from licensed work. A patient who had received what is believed to be an I-131 dose at an unaffiliated facility came in for labs. Blood was drawn and needle was disposed in sharps without the knowledge of contamination by the lab personnel. The survey data on the waste was reported as 500 microR/hr on surface of the waste package. See EN 53561.
The following update was provided via E-mail: The originator of the waste has a radioactive material license, however the package containing the contaminated waste was not from the radiology department where licensed activity occurs. Furthermore the licensee does not use I-131 or any isotope with a half-life nearly as long. (Kansas Radiation Control) will visit the site next week to determine what the dose estimates are for those in the waiting room, lab staff (both blood draw and blood testing), waste transporter and waste handlers. (Kansas Radiation Control) also intend to identify where the blood vial and associated potentially contaminated waste is stored/disposed. It will likely prove impossible to discover the licensee who administered the I-131 to the patient as the individual did not report they were recently treated, there was no surveys in their unrestricted portion of their facility that is unaffiliated with their RAM (radioactive material) work, and the waste is mixed in with several other patients over the course of several days.
The following update was provided via E-mail: Oklahoma DEQ notified the Kansas Radiation Control Program of a rejected waste shipment from Kansas on 8/24/2018. This was reported to the HOO by David Lawrenz on the same day. The Cancer Center of Kansas (CCK) was contacted by Stericycle, the company that handles sharps disposal, August 23, 2018. Stericycle stated they had received a radioactive sharps container from CCK. During a phone call with Stericycle, David Lawrenz learned the sharps container had been picked up last week and delivered to the incinerator facility on Monday August 20th. Preliminary information is the waste was not generated from licensed work. A patient who had received what is believed to be an I-131 dose at an unaffiliated facility came in for labs. Blood was drawn, and needle was disposed in sharps without the knowledge of contamination by the lab personnel. The survey data on the waste was reported as 500 microR/hr. on surface of the waste package on 8/24/18 when (redacted) picked up the container from Stericycle. After (redacted) picked up the sharps container on 8/24/18, it was determined the sharps container came from the CCK lab. (redacted) took surveys on the exterior of the container and found 500 microR/hr for the highest reading prior to returning to CCK. The CCK lab is separate from the CCK radiology department and the sharps containers are used separately as well. The CCK lab is not a restricted area and no radioactive material is used there. Consequently, the sharps from the lab were not monitored for radioactive contamination. With the knowledge that the sharps came from a department that does not handle radioactive material and the fact that so much time had passed we determined the radioactive contamination must have originated from outside CCK. CCK only uses Tc99m. CCK is authorized for 35.100 and 35.200 use only. CCK is a cancer specialty clinic so the most likely scenario is that a patient had very recently undergone I-131 therapy at another facility and then came to CCK for lab work. The discarded lab detritus from that patient was then placed in the sharps container that Stericycle collected. On August 27, 2018 (two individuals from the Kansas Department of Health and Environment) arrived at CCK and met with (the Lab Supervisor). (redacted) took surveys of the sharps container and lab area. This area is separate from the radiology department. No areas were above background. (The Lab Supervisor took Kansas personnel) to the hot lab used under the Adams Diagnostics 12-B880. The rejected waste is now stored for decay in the regulated area. (The Lab Supervisor) surveyed the container at 259 microR/hr on contact. New procedures are being written to include surveys of the labs sharps container to prevent the issue from happening in the future. The licensee was found to not be in violation of any requirements and there will be no enforcement action as a result of this investigation unless new information comes to light. Root cause analysis is a patient failed to follow instructions after the medical procedure." Notified the R4DO (Alexander) and NMSS Events via email. |
| ENS 53561 | 24 August 2018 11:29:00 | The following information was received via E-mail: This morning Oklahoma DEQ (Department of Environmental Quality) Radiation Management learned of an improper disposal of radioactive material in Oklahoma. Stericycle, an autoclave facility authorized to treat biomedical waste, rejected a load of material from a Kansas facility due to radioactivity. It appears the waste was received by SteriCycle on Wednesday, August 22 (because of an error in the report, this isn't totally clear), and is being picked up today (August 24) for return to the generating facility. SteriCycle did not provide DEQ with any specifics on radiation levels measured, quantity, etc. DEQ has notified the Kansas radiation program, which will investigate. SteriCycle identified the waste generator as: Cancer Center of KS - Wichita SteriCycle is located at: Stroud, OK We are informed that Kansas radiation control regulates the facility under the name Via Christi. Since the material is being picked up today, Oklahoma DEQ did not attempt a site visit to investigate the material. We have informed the Kansas radiation program and understand they will be following up. There are no known significant exposures to workers or the public, and none are expected at this time. It is not clear that this is reportable, but we are notifying NRC out of an abundance of caution. See EN# 53564. |
| ENS 53562 | 24 August 2018 15:01:00 | At 0745 EDT on August 24, 2018, the Active Seismic Monitoring System failed a planned surveillance test and was declared inoperable. Compensatory measures to provide alternative methods for event classification of a seismic event have been implemented in accordance with the Fermi 2 Emergency Plan procedures. The compensatory measures include the use of information provided by the United States Geological Survey (USGS) to confirm if an earthquake has occurred within a 100 mile radius. The loss of the Active Seismic Monitoring System is reportable to the NRC within 8 hours of discovery in accordance with 10CFR50.72(b)(3)(xiii). No seismic activity has been felt onsite and the USGS recorded no seismic activity in the area. The NRC Resident Inspector bas been notified.
After further review the Active Seismic Monitoring system was removed from service for planned maintenance for a duration less than 72 hours with appropriate compensatory measures established. Therefore, no major loss of emergency assessment capability occurred. In addition, the surveillance tests were re-performed and the Active Seismic Monitoring System was declared Operable. Therefore, no reportable condition existed and EN 53562 reported on August 24, 20I8 is being retracted. The NRC Resident Inspector has been notified. Notified the R3DO (Hanna). |
| ENS 53560 | 23 August 2018 18:12:00 | The following information was received from the State of Illinois via email: The RSO (Radiation Safety Officer) for Rush University Medical Center in Chicago (IL-01766-01) notified the Agency (Illinois Emergency Management Agency, Bureau of Radiation Safety) at approximately 1600 (CDT) today that a reportable event transpired while attempting to administer Y-90 TheraSpheres. The licensee attempted to administer Y-90 to a patient this morning and was unable to move the dose through the tubing to the patient. A different administration route was selected and also met with inability to deliver the dose. This treatment was aborted. A second patient was scheduled for Y-90 administration this afternoon. The licensee encountered resistance in the second delivery system and was unable to deliver the Y-90 dose. This treatment was also aborted. Both patients were imaged and verified to not have been administered any Y-90. The licensee is currently performing a PET (Positron Emission Tomography) scan on the delivery systems to look for occlusions that may have impeded delivery. IEMA (Illinois Emergency Management Agency) staff has requested information on lot numbers for the individual doses. Details are pending from the licensee on root cause and lot numbers. The licensee will not administer any additional doses from this lot number until root cause is identified. Further details are pending. Illinois Item No.: IL180033 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. |
| ENS 53559 | 23 August 2018 12:11:00 | This is a non-emergency notification from Waterford 3. 10 CFR Part 21 Notification - Defect of Westinghouse 7300 Process Analog Control System circuit cards On August 14, 2018, Entergy Operations, Inc. (Entergy) completed an evaluation of a deviation at Waterford Steam Electric Station, Unit 3 (Waterford 3) which concluded the condition constitutes a defect pursuant to 10 CFR Part 21. The Waterford 3 Site Vice President was notified of the result of this evaluation on August 21, 2018. An interim report stating that an evaluation of this deviation was in progress was submitted to the NRC on July 5, 2018 (Entergy letter W3F1-2018-0040, ADAMS Accession Number ML18186A694). Three Westinghouse 7300 Process Analog Control System (PAC) circuit cards were identified to be failed due to failed hex inverter chips. Some of these cards were installed in applications which support the Ultimate Heat Sink (UHS) at Waterford 3. These PAC cards use Texas Instruments Part Number SN74LS04N, W113 hex inverter chips. The circuit card types of concern are Analog Comparator model number 2838A32G01, Control Board model number 2838A30G011, and Prom Logic model number 2838A33G01. Entergy concluded that this condition could have prevented the UHS from performing its safety function and thus could have created a substantial safety hazard. The NRC Resident Inspector has been notified. |
| ENS 53523 | 24 July 2018 13:40:00 | The following report was received via e-mail: At approximately (2000 hrs. CDT) last night (July 23) a crew working at the DBI, Inc. facility in Tulsa had a casting they were shooting fall on the guide tube, crushing it, so that the source (28 Ci of Ir-192) could not be retracted. The RSO (Radiation Safety Officer) was notified and responded to the scene. DBI is licensed to perform source recoveries which they successfully did. As far as we (Oklahoma Department of Environmental Quality) know right now, there were no over-exposures as a result of this incident. (The state of Oklahoma) will provide details on the equipment involved when we have them. |
| ENS 53521 | 23 July 2018 18:33:00 | The following was received from the State of Texas via email. On July 23, 2018, the licensee reported that one of its Troxler model 3430 moisture/density gauges (SN: 68529) had been run over and damaged by a dozer at a temporary job site. The licensee's technician was performing a moisture test when he saw a dozer moving backward into the area and toward the gauge. The technician yelled at the dozer driver but was unable to get his attention and there was not enough time for the technician to move the gauge. The gauge was severely damaged. The 40 milliCurie americium-241/beryllium source (SN: 47-21269) remained secure in its shielding. The source insertion rod was bent and broken and the 8 milliCurie cesium-137 source, which was still attached to the rod, could not be retracted. The licensee wrapped the exposed cesium source in lead blankets and placed the gauge back into its transport case. The area and dozer tracks were surveyed--there were no readings above background. The exterior of the transport case was surveyed and the highest reading was 0.4 mR/hr at the blanketed source. The damaged gauge was transported to the manufacturer's service center where a technician made the determination it was not repairable. The licensee is storing the gauge at its facility until arrangements can be made for disposal. An investigation into this event is ongoing. More information will be provided as it becomes available in accordance with SA-300. Texas Incident #: 9600 |
| ENS 53518 | 20 July 2018 12:32:00 | EN Revision Text: TEXAS AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE The following information was obtained from the state of Texas via email: On July 20, 2018, the Agency (Texas Department of State Health Services) was notified by the licensee's radiation safety officer (RSO) that he had been contacted by their dosimetry processor and informed that one of his radiographer's dosimeter had read 37.5 rem for the previous month (June, 2018). The RSO stated the report indicated the dose was irregular. The RSO stated the individual had stated they had not lost their badge, but had left it in the radiography truck a few times on their day off. The RSO stated the individual has been removed from all duties that would give them any additional exposure to ionizing radiation. The individual's current dosimeter has been sent to the processor for reading. The RSO stated the exposure to the radiographer this individual had been working with was normal. The RSO stated they would contact Radiation Emergency Assistance Center/Training Site (REAC/TS) and seek assistance. The RSO does not believe the dose is real and is a badge only exposure. The RSO stated the radiographer has not displayed any signs of a high exposure. Additional information will be provided as it is received in accordance with SA-300.
The following information was received from the State of Texas via email: On August 14, 2018, the licensee reported they had received sample results for the blood samples sent to Radiation Emergency Assistance Center/Training Site (REAC/TS). The sample indicated a dose of 0.44 gray. The licensee stated the individual exposed has not complained of any unusual feelings in the hands. The licensee's Assistant Corporate Radiation Safety Officer is going to the location where the individual works to interview. The investigation into this event is on going. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #9597 Notified the R4DO (Deese). INES Coordinator (Milligan) and NMSS Events notified via email. |
| ENS 53517 | 19 July 2018 12:36:00 | At 1300 (EDT) on July 18, 2018, a contractor supervisor violated the licensee's Fitness-for-Duty (FFD) program by subverting the Fitness for Duty process. The contractor's site access has been terminated. The NRC Resident Inspector was notified. |
| ENS 53511 | 17 July 2018 17:01:00 | At 1338 (EDT) on July 17, 2018, Southern Nuclear Operating Company (SNC) determined a contractor supervisor confirmed positive for a controlled substance during a random Fitness-for-Duty (FFD) test. The employee's unescorted access to the plant has been suspended. The Resident Inspector has been notified. |
| ENS 53477 | 28 June 2018 05:37:00 | The following event description is based on information currently available. If through subsequent reviews of this event, additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS (Emergency Notification System) or under the reporting requirements of 10 CFR 50.73. On June 27th, 2018 at approximately 2310 Mountain Standard Time (MST), in Palo Verde Unit 3, the #1 Steam Generator Economizer valve started closing. This caused Steam Generator #1 water level to decrease. Both Feed water pumps speed increased to raise Steam Generator level. At approximately 2311 (MST), the B Main Feed water pump tripped resulting in a Reactor Power Cutback. Steam Generator #1 level continued to decrease resulting in an Automatic Reactor Trip on Low Steam Generator #1 water level. All control rods inserted to shut down the Reactor to Mode 3 using Main Feed water and Steam Bypass. Post trip Steam Generator #1 level then increased and at approximately 2316 (MST) a Main Steam Isolation Signal (MSIS) was received on high Steam Generator level. The 'B' Auxiliary Feed water pump was manually started to maintain Steam Generator water levels and Steam Generator pressure was controlled using the Atmospheric Dump Valves (ADVs). Following the reactor trip, all CEAs (Control Element Assemblies) inserted fully into the core. All systems operated as expected. No emergency plan classification was required per the Emergency Plan. Safety related busses remained powered during the event from offsite power and the offsite power grid is stable. No major equipment was inoperable prior to the event that contributed to the event or complicated operator response. Unit 3 is stable and in Mode 3 feeding Steam Generators with Auxiliary Feed water Pump 'B'. The event did not result in any challenges to fission product barriers and there were no adverse safety consequences as a result of this event. The event did not adversely affect the safe operation of the plant or the health and safety of the public. The NRC Resident Inspector was informed of the Unit 3 reactor trip. Unit 1and Unit 2 were unaffected by the Unit 3 trip. |
| ENS 53457 | 13 June 2018 17:19:00 | The following information was received via E-mail: We (Oklahoma Department of Environmental Quality) have been informed by Universal Pressure Pumping, Inc. that one of their Berthold LB 8010 fixed gauges has experienced a failure of the shutter mechanism resulting in it being stuck in the open position. The gauge has been removed from the truck and is in storage. The licensee has contacted Berthold and is arranging for one of Berthold's technicians to come to their facility to repair the gauge. |
| ENS 53452 | 11 June 2018 13:27:00 | The following was received from the State of Texas via email. On June 11, 2018, the licensee's radiation safety officer (RSO) notified the Agency (Texas Department of State Health Services) that one of their Troxler 3440 moisture/density gauges (SN: 67091), containing a 40 milliCurie americium 241 source and an 8 milliCurie cesium-137 source, could not be accounted for. The gauge was last used at a temporary job site on May 25, 2018. The technician that used the gauge stated to the RSO that he had returned the gauge to the storage area at their facility in Midland, Texas, that afternoon. He further stated the insertion rod was locked. The gauge, along with another, were to have been picked up by, and transferred to, another licensee (a company associated with the licensee) the week of May 28th. On June 4, 2018, the RSO discovered the gauge had not been picked up/transferred nor was it in the storage area. He began an investigation. The RSO interviewed the technician and facility supervisor and reviewed documentation. The gauge had not been used by the licensee since May 25th. The associated licensee conducted a physical inventory of all of its gauges. The associated licensee's RSO was on vacation and could not be reached until June 11th. After it was confirmed with him that the associated company did not have possession or any further knowledge of the gauge, the RSO made the notification. The RSO is continuing his investigation. More information will be provided as it is obtained in accordance with SA-300. Texas Incident #: 9583 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 |
| ENS 53453 | 11 June 2018 14:29:00 | The following was received from the State of Texas via email. On June 11, 2018, the licensee's radiation safety officer (RSO) reported to the Agency (Texas Department of State Health Services) that one of its Humboldt 5001-EZ moisture/density gauges (serial number 4097) containing a 40 milliCurie americium-241/Beryllium source (NJ04418) and a 8 milliCurie cesium-137 source (7146GQ) had been run over by a dump truck at a temporary job site. The upper casing on the gauge was damaged and the guide bar broke off as the rod was taking a reading. The rod was in the ground when hit by the truck. The technician was taking readings when he noticed a dump truck backing up close to his location. He moved to the side and tried to wave the person driving to stop. The truck didn't stop and hit the gauge. The incident was reported by the RSO and stated the area has been restricted access until the device can be recovered. The RSO traveled to the site and accessed the device. The source was successfully pulled/retrieved into the shielded position, surveyed and being transported to a servicing company for possible repair or disposal. The company will provide full details of the incident within the next few days. Investigation ongoing. Texas Incident #: 9584 |
| ENS 53451 | 11 June 2018 10:21:00 | The following was received from the State of Utah via email. The morning of June 10, 2018, the licensee discovered that a portable nuclear density gauge had been stolen from one of their work trucks. The truck had been parked in the driveway of the AGEC's (Applied Geotechnical Engineering Consultants, Inc.) employee's house. The license claims that the gauge was properly stored in storage container that was bolted to the bed of the truck and the tailgate was locked. The licensee explained that the perpetrator broke through the locked tailgate, cut the barriers around the Troxler box, cut the locks on the Troxler box and removed the portable gauge. The Salt Lake City Police Department was also contacted. The licensee will continue to investigate the incident and will submit a written report to the DWMRC (Division of Waste Management and Radiation Control). Event Report ID No.: UT180002 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 |
| ENS 53442 | 2 June 2018 14:32:00 | The following report was received via a fax: Identification of Basic Activity: Eaton NBF66F Relay Basic Activity Supplied By: Framatome Inc. Nature of Defect: While performing analysis on AC Eaton NBF relays, Framatome discovered that, unless a specific application technique is utilized while applying epoxy to the pin within the crossbar, the potential for the epoxy to become foreign material is introduced. This foreign material could migrate to the area between the moving and stationary magnets, preventing the relay from completing its change of state when called upon. This condition does not occur in the de-energized direction. Framatome has not been notified of any occurrence of this condition. A different epoxy application technique was utilized between 2008 and May of 2013 on relays provided to HB Robinson (the only customer requiring the epoxy application by Framatome). Thus, a potential for this defect is limited to those relays provided during that time period. Defect Determination Date: This issue was determined to be a 10 CFR 21 defect on May 31, 2018. Number and Location of Basic Components: 307 potentially affected safety related relays with epoxy applied to their relay pins were supplied to the H.B. Robinson nuclear plant. Corrective Actions to Date: The application process was reevaluated and revised in 2013. Advice related to the Defect: Framatome is working to provide advice to the customer on the path forward related to this defect. |
| ENS 53385 | 4 May 2018 16:20:00 | At 1412 EDT, a portable chemical toilet was found tipped over. Approximately 1 gallon of contents spilled to gravel only. A notification to the Michigan Department of Environmental Quality and local health department is required, as well as a press release. This event is being reported pursuant to 10CFR50.72(b)(2)(xi). The licensee will notify the NRC Resident Inspector. |
| ENS 53383 | 4 May 2018 13:52:00 | The following information was obtained from the state of Texas via email: On May 4, 2018, the Agency (Texas Department of State Health Services) was notified by the licensee that on May 4, 2018, at 0927 hours (CDT), one of their managers had received a phone call from an individual who made a bomb threat against the licensee's offices in Beaumont, Texas. The licensee contacted local law enforcement (LLE) who then contacted the Federal Bureau of Investigation (FBI). LLE responded to the location within 7 minutes of the call to them and the FBI was at the location before the radiation safety officer (RSO) arrived at the office 12 minutes after the call was received. The fire department also responded. The building was evacuated and the FBI, LLE, bomb squad, Fire Marshall, and the RSO inspected the building and the areas around the building. No explosive device was found. The facility was released at 1029 hours (CDT). Additional information will be provided as it is received in accordance with SA-300. TX Incident #: 9568 |
| ENS 53374 | 1 May 2018 20:42:00 | At 1551 hrs (CDT) on 5/1/2018, with the plant in Mode 5, a division one Reactor Pressure Vessel (RPV) Level 1 signal was received; however there was no actual change in RPV level. RPV Level remained at High Water Level supporting refuel operations. This caused an actuation of division one Load Shed and Sequencing system that shed and then re-energized the 15 bus. Division one diesel generator started from standby. Residual Heat Removal pump 'A', which was in shutdown cooling mode, was lost during the bus shed, and was re-sequenced upon re-energization of the 15 bus. Upon restoration of shutdown cooling, the RHR pump discharged into the RPV. RCS temperature increased approximately 5 degrees Fahrenheit as a result of the loss of shutdown cooling. The cause of the actuation signal is under investigation. In accordance with NUREG 1022, Event Reporting Guidelines, this event is conservatively reported under 10 CFR 50.72(b)(2)(iv)(A) as an event that results in emergency core cooling system discharge into the RCS as a result of a valid signal, under 10 CFR 50.72(b)(3)(iv)(B)(8) as an event that results in the actuation of emergency ac electrical power systems, and under 10 CFR 50.72(b)(3)(v)(B) as an event or condition that at the time of discovery could have prevented the fulfillment of a safety function (remove residual heat). The licensee notified the NRC Resident Inspector. |
| ENS 53370 | 30 April 2018 14:18:00 | The following information was obtained from the state of Texas via email: On April 30, 2018, the licensee reported that sometime during the overnight hours of April 28-29, 2018, a Humboldt model 5001 moisture density gauge had been stolen from the back of a company vehicle. The licensee's technician had taken the vehicle with gauge home (to Arlington, TX), contrary to company policy, and had left the gauge chained with locks in the truck. The source rod handle was locked with a padlock. At 0530 (CDT) on April 29th, he discovered the chains had been cut and the gauge stolen. Local law enforcement was notified and the licensee has checked the surrounding area. The licensee will begin checking local pawn shops. More information will be provided as it is obtained in accordance with SA-300. Device: Humboldt Model 5001 - SN: 2821 Sources: Americium-241 - 40 milliCuries - SN: 0379CX; Cesium-137 - 10 milliCuries - SN: NJ-04061 TX Incident #: 9566
The following was received via e-mail: This gauge was recovered today and is being returned to the licensee. Notified R4DO (Azua), ILTAB, NMSS Events Notification, and Mexico 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 |
| ENS 53372 | 30 April 2018 19:21:00 | The following information was obtained from the state of Washington via email: Today, April 30, 2018, the Washington State Department of Health Radioactive Materials Section was notified of a lost portable gauge. The gauge owner, Intermountain Materials Testing (WA RadMat licensee I0578), notified the Emergency Response Duty Officer at 10:15 am (PDT) about the lost gauge. The company RSO was notified of the incident by an employee earlier today. The employee determined the gauge (CPN MC3 S/N M300405776) was missing at approximately 2:35 pm (PDT) Friday, April 27, 2018. This gauge has a 10 mCi (370MBq) Cs-137 source and 50 mCi (1.85 GBq) Am-241 source. The employee searched for the gauge until 4:30 pm (PDT) before he notified the local Richland, WA Police Department. The gauge was presumed to be left on the ground at a job site near the intersection of Queensgate Dr. and Gala Way in Richland, WA, because it was determined to not be in its storage location at a different job site. This incident has been given the Incident ID WA-18-015 and is reportable under 10 CFR 20.2201(a)(1)(ii) and is a 30 day reportable event. Follow up will be supplied as needed. Washington State Incident Number WA-18-015 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 |
| ENS 53361 | 24 April 2018 14:44:00 | At 0357 (PDT), Unit 2 Containment High Range Radiation Monitor RM-31 was declared inoperable due to erratic indication. At this time, Containment High Range Radiation Monitor RM-30 was out of service for routine calibration. With both containment high range radiation monitors inoperable, this impacted DCPP's (Diablo Canyon Power Plant's) ability to evaluate containment radiation data for an unmonitored release in the event of an emergency. Compensatory measures were promptly put in place with the use of a portable radiation monitor as required by emergency preparedness procedures. This condition is being reported as a loss of assessment capability in accordance with 10 CFR 50.72(b)(3)(xiii). Actions are in progress to restore RM-30 and RM-31 to operable status. The NRC Senior Resident Inspector has been notified.
RM-30 was restored to service. Portable radiation monitoring is not required. The licensee will notify the NRC Resident Inspector. Notified R4DO (Vasquez). |
| ENS 53358 | 22 April 2018 22:40:00 | On Sunday, April 22, 2018 at 1646 CDT, a valid actuation of Engineered Safety Feature (ESF) Bus 141 Undervoltage (UV) Relay occurred. At the time, Braidwood Station Unit 1 was performing a pre-planned 1A Diesel Generator (DG) Emergency Core Cooling System (ECCS) Actuation Surveillance, initiating the 1A DG to emergency start and sequence loads on a safety injection signal. Following the 1A DG solely supplying electrical power to Bus 141, the 1A DG lost voltage, resulting in an unplanned UV actuation of ESF Bus 141. The 1A DG output breaker was manually opened and local emergency stop of the 1A DG was attempted. The 1A DG continued to run at idle. Fuel supply was secured to the 1A DG and the engine stopped. Subsequently, operators restored power to ESF Bus 141 from the Unit 1 Offsite Power Source. Shutdown cooling was maintained throughout the event as the 1B Residual Heat Removal train was unaffected by the actuation. This event is reportable under 10 CFR 50.72(b)(3)(iv)(A) for 'Any event or condition that results in valid actuation of any of the systems listed...', specifically 10 CFR 50.72(b)(3)(iv)(B)(8) for the 'Emergency ac electrical power systems, including: emergency diesel generators (EDGs)...'. The licensee notified the NRC resident inspector. |
| ENS 53354 | 20 April 2018 22:22:00 | On Friday, April 20, 2018 at 1730 CDT, during the Braidwood Station Unit 1 refueling outage (A1R20), a scheduled ultrasonic test (UT) was performed on the top head to upper center disc weld of the Unit 1 reactor head. The UT identified 19 indications, 9 of which are not acceptable per ASME Section XI, 2001 Edition, 2003 Addenda, Paragraph IWB-3510. This event is reportable under 10 CFR 50.72(b)(3)(ii)(A) for 'Any event or condition that results in the condition of the nuclear power plant, including its principal safety barriers, being seriously degraded'. The licensee notified the NRC Resident Inspector. |
| ENS 53353 | 20 April 2018 17:57:00 | On Friday, April 20, 2018 at 1042 CDT, Braidwood Station Unit 1 was at 0 percent power in Mode 6. The 1A Diesel Generator (DG) was inoperable with troubleshooting in progress. The 1B DG was being run for a normal monthly run in accordance with 1 BwOSR 3.8.1.2-2, 'Unit One 1B Diesel Generator Operability Surveillance,' and subsequently tripped. The trip was due to a failure of the overspeed butterfly valve actuator and springs, and not an actual overspeed condition. The unit entered Technical Specification (TS) 3.8.2, 'AC Sources - Shutdown,' Condition B for required DG inoperable. All required TS actions were met at the time of the 1B DG inoperability. The offsite power source remains available. At no time was residual heat removal lost. This event is reportable under 10 CFR 50.72(b)(3)(v)(B) for any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to remove residual heat. The licensee has notified the NRC Resident Inspector. |
| ENS 53348 | 19 April 2018 23:41:00 | While performing a turbine startup, a turbine control anomaly caused a steam generator level transient. The rise in steam generator level above the setpoint caused the turbine to automatically trip. The high steam generator level of 73 percent caused a feedwater isolation signal at 2107 EDT, which also tripped both Main Boiler Feed Pumps. The tripping of the Main Boiler Feed Pumps auto started the motor driven Aux Boiler Feed Pumps 21 and 23. The reactor was manually tripped at 2108 EDT in accordance with AOP-FW-1 Loss of Main Feedwater. All control rods inserted. Electrical power is being provided from offsite via the Station Aux Transformer. Decay heat removal is being provided via the Atmospheric Dump Valves. An investigation into the cause of the turbine control anomaly is underway. The NRC Resident Inspector has been notified. The event did not have an affect on Unit 3 and there is no primary to secondary leakage. |
| ENS 53351 | 20 April 2018 15:42:00 | The following information was obtained by the State of Texas via email: On April 20, 2018, a consultant for the company called to inform the Agency (State of Texas) that a fire had damaged part of the refinery. The fire happened yesterday, April 19, 2018 around 1700 CDT. The radiation safety officer has been informed and the two are preparing an assessment of the damage. There are 19 gauges in the location of the fire. The fire was located in the allocation unit where phrase fractions are allocated into different hydrocarbon groups for refinement. All but two gauges have been assessed for damage. The two remaining gauges are 1 milliCurie or less in activity and cannot be checked at this time due to safety issues. Once the area is released for entry the gauges will be checked for damage. An update will be provided with gauge identification and correct activity. Updates will be provided in accordance with SA-300 guidelines. Texas Incident No.: I-9562 |
| ENS 53346 | 19 April 2018 18:16:00 | The following was received from the State of Colorado via email: The Department (Colorado Department of Public Health and Environment) was notified via phone on 4/19/18 at approximately 1552 MDT. A G Wassenaar's RSO notified the Department that a portable gauge had been run over by a vehicle and the vehicle did not stop. At the time of the phone call, the gauge was broken into multiple pieces and the RSO was about to go out on-site to assess the damage. State inspectors are responding immediately as well. Colorado Event Report ID No.: CO180008 |
| ENS 53347 | 19 April 2018 20:00:00 | On Thursday, April 19, 2018 at 1152 CDT, a valid actuation of Engineered Safety Feature (ESF) Bus 141 Undervoltage (UV) Relay occurred. At the time, Braidwood Station Unit 1 was performing a pre-planned Bus 141 Undervoltage Actuation Surveillance, initiating the 1A Emergency Diesel Generator (EDG) to emergency start and sequence loads on the UV signal. Following the 1A EDG solely supplying electrical power to Bus 141, the EDG lost voltage resulting in an unplanned UV actuation of the ESF Bus 141. Subsequently, operators restored power to ESF Bus 141 via crosstie of the Unit 2 offsite power source. Shutdown cooling was maintained throughout the event as the 1B Residual Heat Removal train was unaffected by the actuation. This event is reportable under 10 CFR 50.72(b)(3)(iv)(A) for 'Any event or condition that results in valid actuation of any of the systems listed...', specifically 10 CFR 50.72(b)(3)(iv)(B)(8) for the 'Emergency ac electrical power systems, including: emergency diesel generators (EDGs)...'. The licensee notified the NRC Resident Inspector. |
| ENS 53369 | 30 April 2018 12:34:00 | The following is information received via e-mail: April 19, 2018, (the licensee) called to inquire if one of his facilities had a 'Recordable Event' or if the facility had a 'Reportable Medical Event.' The report and attachments were left in a voice mail at 8:18 pm (CDT). The event occurred under the (Slidell Memorial Hospital) SMH Therapeutic and Diagnostic Radioactive Material License, LA-0783-L02. The event involved 5.4 mCi Tc-99m-Myoview administered to a patient who was scheduled for a lung scan utilizing (approximately) 5.4 mCi Tc-99m-MAA. The technologist depended on the unit dose for 'STAT' used to be MAA and did not verify the unit dose label. This medical event occurred on 04/12/2018. The technologist states that a Myoview cardiac dose was in a pig labelled MAA for a lung scan. The pharmacy pulled the dose records, verified the bar coding and determined the technologist was at error. (The licensee) provided dose calculations for the heart scan dose utilizing 5.4 mCi Tc-99m-Myoview as 0.224 rad effective dose equivalent and highest organ dose of 0.972 rad to the wall of the gallbladder. There were corrective actions (to) retrain the technologist in patient dose verification prior to injection and request their pharmacy change their label fonts to magnification and bolding the unit dose labels. The referring physician and the patient were notified of the error. LDEQ (Louisiana Department of Environmental Quality) considers this incident still open and subject to investigation to determine if this event was caused by the facility personnel or if it is an error caused by the pharmacy personnel. Louisiana Event Report ID No.: LA-180007, T 184299 |
| ENS 53375 | 2 May 2018 17:05:00 | The following information was obtained from the state of Washington via email: (The licensee) called on 4-4-2018 to tell the state that their GL (General License) device failed the shutter test. He said the device was placed out of use and is being sent back to the manufacturer. Washington State Incident Number WA-18-011 |
| ENS 53297 | 29 March 2018 10:31:00 | On 3/27/2018, a patient was implanted with a 83 microCi I-125 seed marker in preparation for a breast tumor surgery. Following the surgery on 3/28/2018, at approximately 1500 EDT, the I-125 seed marker went missing. The operating room was surveyed, and the patient was imaged with no discovery of the I-125 seed marker. 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.p |
| ENS 53272 | 19 March 2018 13:09:00 | Emergency Assessment Capability cannot be performed in the Technical Support Center due to an equipment deficiency in the HVAC system which could impact facility habitability. An Alternate Technical Support Center is in place at the Emergency Offsite Facility. Priority maintenance is in progress to correct the deficiency. The licensee notified the NRC Resident Inspector. |
| ENS 53259 | 13 March 2018 15:54:00 | On March 13, 2018 at 1000 hours (EDT), with the reactor in Cold Shutdown condition, both 345kV incoming power lines and 23 kV Shutdown Transformer became unavailable during the Northeast winter storm. Per procedures, the emergency on-site emergency power supplies (Emergency Diesel Generators) were running and providing power to essential systems. In addition, the back-up Diesel Air Compressor was in service and one Reactor Protection System bus was on the back-up power supply prior to the loss. With both 345kV incoming power lines and 23 kV Shutdown Transformer unavailable, Pilgrim Nuclear Power Station procedures direct a report be made to the NRC per the requirements of Title 10 Code of Federal Regulations 50.72(b)(3)(v), any event that could have prevented the fulfillment of the safety function. No actual loss of safety function has occurred since the on-site emergency power supplies are maintaining the reactor in a safe shutdown condition and removing residual heat. The loss of incoming power is under investigation. This event had no impact on the health and/or safety of the public. The NRC Resident Inspector has been notified. |
| ENS 53256 | 12 March 2018 14:34:00 | A non-licensed supervisor tested positive for alcohol during pre-access screening. The individual's access to the plant was denied. The NRC Resident Inspector has been notified. |
| ENS 53381 | 4 May 2018 12:50:00 | On March 8, 2018, an invalid system actuation occurred while preparations were underway to perform Safety Features Actuation System (SFAS) integrated response time surveillance testing during the recent Davis Besse Nuclear Power Station refueling outage. Several minutes after connecting a data recorder to monitor the Emergency Diesel Generator (EDG) 1 start signal, at 1323 hours (EST), the EDG started with no valid actuation signals or test inputs present. The EDG successfully came up to speed and voltage as expected. The associated essential 4160 volt electrical bus remained energized from the normal power supply, therefore, the EDG output breaker did not close to supply power to the bus. Troubleshooting determined the inadvertent actuation was due to a short in the test lead wires at the recorder connection caused by a faulty test lead. The test lead was replaced and the SFAS surveillance testing completed satisfactorily. This event is being reported as an invalid system actuation per 10 CFR 50.73(a)(2)(iv)(A); this 60-day optional telephone notification is being made per 10 CFR 50.73(a)(i) in lieu of submitting a written Licensee Event Report. The NRC Resident Inspector was notified of the inadvertent EDG start at the time of the event and has been notified of this invalid specified system actuation notification. |