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| Entered date | Event description | |
|---|---|---|
| ENS 55762 | 2 March 2022 12:04:00 | The following information was received via E-mail: On 01/27/22, Avago Tech reported four tritium exit signs (2.3 Ci each) as lost during their final wrap up shipment for disposal. NMED No.: CO220005 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 55617 | 1 December 2021 14:49:00 | The following was received from the Commonwealth of Virginia (the Agency) via email: On December 1, 2021 at 0525 EST, the Virginia Radioactive Materials Program (RMP) received a report from the licensee that a medical event involving Yttrium-90 microspheres occurred on 11/30/2021 (procedure date). According to the written directive, the prescribed dose to the right liver (treatment site) was 27.6 millicuries (mCi). The procedure was interrupted due to the artery spasm, which could not be identified before the treatment began and as a result, only 14.5 mCi of the prescribed dosage was delivered to the treatment site (right liver). The administered dosage was estimated to be 47% less than the prescribed dose. According to the licensee's preliminary report, no healthy tissue or organ other than the treatment site was exposed because of this event and the patient was notified. The RMP will schedule to investigate the event and this report will be updated when the final investigation report is available. Virginia Event Report ID No.: VA210008 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.
The following retraction was received via email from VA; RMP: On December 6, 2021, the RMP investigated the case and determined that the procedure was terminated due to emergent patient conditions (artery spasm). The licensee revised the written directive within 24 hours after the termination of the procedure. This incident did not meet the criteria of medical event reporting. (RMP) requests to retract this report. Notified R1DO (Dentel) and NMSS Events Notifications via email. |
| ENS 54308 | 2 October 2019 15:15:00 | This report is for an item on U.S. Nuclear Regulatory Commission (NRC) License Number 21-32838-01, Docket Number 030-38500. A 30-day report will be sent to NRC Region III in accordance with the Code of Federal Regulations, Title 10, Part 20.2201. On 17 September, at approximately 0855 EDT, the Marine Corps Combat Development Command (MCCDC) received a phone notification from one of their Installation Safety Managers concerning a possible radioactive device found inside a dumpster at an off base construction development site in Stafford County, VA. MCCDC Safety Personnel inspected the device and did not discover any breaches nor cracks of the large tritium vial. The device contained a tag with the radioactive symbol and the statement 'IF FOUND RETURN TO NEAREST MILITARY ACTIVITY.' The device was recovered and transported to the low-level radioactive waste storage locker on the Quantico Marine Corps Base. Item Name: COLLIMATOR, INFINITY AIMING REFER Nomenclature: COLLIMATOR INF A M1A1 National Stock Code: 1240-00-332-1780 Model: 10556235 Serial Number: 1504 Radionuclide: Tritium (H3) Activity: 10 Curies The Department of the Navy, Naval Sea Systems Command Detachment, Radiological Affairs Support Office, contacted the U.S. Army Tank-automotive and Armaments Command (TACOM) Safety Office via telephone on 1 October 2019. The TACOM Radiation Safety Program Manager notified NRC Region III Senior Health Physicist (Piskura) to verify if this item was reported as lost. She could not verify if the item was previously reported as lost and informed TACOM on 2 October 2019 to notify the NRC Operations Center. Additional information will be provided in the 30-day report. 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 53912 | 6 March 2019 09:24:00 | The following was received via email: Target Rock Modulating Solenoid Operated valves which utilize model 810000-X positioner manufactured and supplied by Target Rock. Target Rock Modulating Solenoid Operated valves are equipped with a separate, remote mounted, positioner unit, which is a closed loop valve position control system. The valve positioner is electronically connected to the valve assembly via a wiring harness. This defect only applies to the current production 810000-X positioner model. All previous versions of the Target Rock Modulating Solenoid Operated valve positioners do not exhibit this defect. Three (3) 810000-X model positioners were returned to Target Rock by Duke Energy Carolinas, LLC, Oconee Nuclear Station for defective operation. Target Rock evaluated these units and found two defective circuits in the positioner PC board at unrelated locations: the 80 V Regulator Circuit and the Close Indication Relay Driver Circuit. Description: 1.) 80 V Regulator Circuit Failure - In the event of a failure of the positioners 80 V Regulator Circuit, the positioner, and therefore its associated modulating solenoid operated valve, will no longer receive voltage from the positioner, resulting in the return spring moving the valve disc to its fail position (fully open or fully closed depending on the design specification requirement). Based on the positioners returned by Duke Oconee, and additional testing performed by Target Rock, this 80 V Regulator Circuit Failure will only occur during initial powering of the device. Positioner units currently in operation, and constantly energized, will not have this failure occur. In the instance where the positioner is powered down and then powered back up during maintenance activity or other event, this failure has the potential to occur upon re-energization of the device. Having said that, should the positioner continue to be operational through power-up, it would be expected to perform its intended function throughout operations. 2.) Close Indication Relay Driver Circuit Failure - In the event of a failure of the positioners Close Indication Relay Driver Circuit, the positioner will be unable to send a signal to indicate the valve has reached its fully closed position. Typically, this circuit is enabled for plant monitoring purposes. This failure has no effect on the ability of the Modulating Solenoid Operated valve or positioner to control fluid flow as intended. Root Cause: 1.) 80 V Regulator Circuit Failure - The defect observed on the 80 V Regulator Circuit is a failure of a Zener reference diode. The Zener reference diode reduces the normal (90 - 140 V) supply voltage to approximately 80 V for this portion of the circuit. In the event of a failure of the Zener reference diode, full input voltage (90 -140 V) is passed to the downstream components in the circuit. The downstream components from the Zener reference diode are not rated for 90 - 140 V operation and fail, rendering the positioner inoperable. 2.) Close Indication Relay Driver Circuit Failure - The defect observed on the Close Indication Relay Driver Circuit was a trace wire in the PCB which had opened (broke) at multiple locations. Corrective Action: Two corrective actions have been put in place. All new 810000-X positioner units manufactured by Target Rock will have these revisions incorporated: 1.) The Zener reference diode for the 80 V Regulator Circuit has been replaced with a different component. The rating for the Zener reference diode has been increased from 30 mA to 73 mA. This upgrade will ensure current ratings are not exceeded during initial powering of the device. 2.) The PCB trace which failed has been upgraded. The trace width has been changed from 12 mil to 70 mil. The wider trace width will be less susceptible to variations in width during the manufacturing process, and in the event of any minor variations in width, will still be sufficient to pass the required current. Should you have any questions regarding this matter, please contact Michael Cinque, General Manager at (631) 293-3800 Very Truly Yours, Michael Cinque General Manager Target Rock, Business Unit of Curtiss-Wright Flow Control Corporation Affected sites are Oconee, Vogtle, South Texas Project, and Millstone. |
| ENS 50206 | 17 June 2014 13:50:00 | At 0749 EDT, Millstone Station Unit 2 removed the Stack Radiation Monitor RM-8169 from service for planned maintenance. Maintenance and testing were completed and the Stack Radiation Monitor was returned to service at 0945 EDT. The licensee informed both State and local agencies and the NRC Resident Inspector. |
| ENS 49706 | 9 January 2014 15:21:00 | Station Personnel simultaneously opened the inner and outer air lock doors from Unit 2 (U2) Reactor Enclosure to the Refuel Floor. Reactor Enclosure Secondary Containment Integrity was declared Inoperable per U2 TS 3.6.5.1.1, due to failure to meet surveillance requirement U2 TS 4.6.5.1.1.b.2, due to the report of both containment airlock doors on 352' momentarily open at the same time. Reactor Enclosure D/P(differential pressure) remained steady at 0.35 inches vacuum water gauge. Reactor Enclosure Secondary Containment Integrity was declared Operable following verification that at least one air lock door to each access of secondary containment was closed per U2 TS 4.6.5.1.1.b.2. Total (Limiting Condition for Operation) time was approximately 5 seconds. The NRC Resident Inspector has been informed. |
| ENS 49702 | 8 January 2014 19:49:00 | At (1010 PST) on 1/08/14, during performance of a surveillance the power supply for ten area radiation monitors in the Reactor Building was found with voltage out of specification. As a result, the affected area radiation monitors were declared non-functional. This condition represents a major loss of assessment capability and is being reported as such under 10 CFR 50.72 (b)(3)(xiii). As directed by station procedures, compensatory measures have been enacted until the power supply is restored. The Resident Inspector has been notified.
The power supply voltage has been restored to specification per applicable station procedures. All affected area radiation monitors have been declared functional. Compensatory measures have been suspended. The licensee has notified the NRC Resident Inspector.
Licensee is retracting this event notification based on the following: Energy Northwest performed an evaluation for the reported out-of-specification voltage condition for the power supply to several radiation monitors in the Reactor Building. The evaluation concluded that the voltage deviation from the -24 VDC set point was small and within the calculated uncertainty for the instrument, and did not result in equipment failure. Therefore, it was concluded that the radiation monitors were functional and that the reported major loss of assessment capability did not occur. The licensee has notified the NRC Resident Inspector. Notified R4DO (Farnholtz). |
| ENS 49701 | 8 January 2014 17:35:00 | On January 8, 2014, at 1439 CST, River Bend Station management determined that a spill discovered on the morning of January 7 was reportable in accordance with NEI 07-07 (Nuclear Energy Institute), Ground Water Protection Initiative. The spill was the result of freeze damage that occurred on a valve connected to the cooling tower blow-down line. Dams were installed to prevent the water from reaching any storm drains, and the spill was confined to the owner-controlled area. Since this system has the potential to contain diluted radioactive plant effluent, samples were collected for analysis. The leak was immediately reduced to a small drip and actions are in progress to completely isolate and repair the valve. The effluent was determined today to contain 4584 pico-curies per liter of tritium, but no detectable gamma activity. The calculated volume of the leak was between 100 and 1200 gallons. This exceeds the NEI reporting criterion of 100 gallons from a source containing licensed material. The Louisiana Department of Environmental Quality was notified at 1549 CST today. This event is being reported in accordance with 10 CFR 50.72(b)(2)(xi) as an event requiring notification of the state government. The NRC resident inspector has been notified. |
| ENS 44805 | 26 January 2009 11:32:00 | The following information was received from AMETEK via facsimile: COMPONENT DESCRIPTION: Electro-mechanical 14 pin relays, with AC voltages of 120 and 240, and DC voltages of 12, 24, 48 and 110. The Tyco/(Potter & Brumfield) relays were removed from the Approved Supplier Listing in 2006. The relays can be installed in Ametek Solidstate Controls equipment, or provided as a spare part. PROBLEM YOU COULD SEE: Nuisance alarming or erratic operation of the equipment. CAUSE: The problem appears to be an age related degradation of unknown cause. A failure analysis performed by First Energy Laboratory Services identified a potential cause as a crinkled appearance on the surface of the moving contact pads resulting in uneven contact with the opposing stationary contact pad. Over time, a layer of oxidation forms on the pads inhibiting electrical contact and increasing resistance. EFFECT ON SYSTEM PERFORMANCE: Potential unstable output voltage caused by intermittent high relay resistance. The relays are generally used for alarm functions but can be used in control circuitry as well. ACTION REQUIRED: Replace all Tyco/Potter & Brumfield relays listed below remaining in service with the approved Ametek Solidstate Controls equivalent. Component: Tyco/Potter & Brumfield Relays SCI PIN 07-740001 - P&B PIN KHAU-17A18-120 SCI PIN 07-740002 - P&B PIN KHAU-17A18-240 SCI PIN 07-740005 - P&B PIN KHAU-17D18-12 SCI PIN 07-740006 - P&B PIN KHAU-17D18-24 SCI PIN 07-740007 - P&B PIN KHAU-17D18-48 SCI PIN 07-740008 - P&B PIN KHAU-17D18-110 The faulty relays are a subcomponent of AMETEK battery chargers, inverters, and uninterruptible power supplies. These types of AMETEK equipment are installed at various reactor licensees. There was no information on which licensees are affected. The manufacturer received notification of the faulty relays from Beaver Valley Power Station. The problem was revealed through a malfunction of a battery charger on 12/11/2008. The manufacturer does not believe that there is an immediate safety concern. |