Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 53526 | 26 July 2018 17:51:00 | At 1040 (EDT) on July 26, 2018, a contractor supervisor violated the licensee's Fitness-for-Duty (FFD) program by subverting the Fitness for Duty program. The contractor's site access has been terminated. The licensee notified the NRC Resident Inspector. |
| ENS 53492 | 6 July 2018 16:32:00 | The following is an excerpt from a report received from the state of Louisiana via email: On June 12, 2018, the Radiation Safety Officer (RSO) for MISTRAS Group, Inc. (MGI), received a Landauer Corporation dosimetry report for an Excessive Exposure to the whole body. The report indicated that an instructor received a whole body exposure of 5168 mR during the month of May, yielding a whole body cumulative exposure to date of 5618 mR. A MGI two-person crew, composed of a radiography instructor and a radiography trainee were making exposures at a temporary jobsite located at the Bechtel Liquid Natural Gas Project at Sabine Pass, Louisiana in Cameron Parish. The exposure device was a QSA GLOBAL Model 880D loaded with a 74 Ci Ir-192 source. When the RSO informed the instructor of the reported excessive exposure, the instructor claimed that one day during May 2018, he had dropped his badge while he and his trainee were performing panoramic exposures, but did not notice the badge missing until after the exposure was completed. The instructor stated he searched for his badge and recovered it from the platform approximately one foot directly below the area being radiographed for a 90-second exposure. Upon further questioning of the above instructor, the RSO learned the body badge had been dropped and inadvertently exposed on May 10, 2018. The RSO stated the instructor failed to report the incident on the date of occurrence. The instructor claimed his direct-reading pocket dosimeter had not gone off-scale or received a high reading. The instructor stated that he believed his badge had only been missing for a single exposure. Health Physics calculations performed by the RSO using the isotope, activity, distance and exposure time provided to him by the instructor do not adequately account for the above excessive exposure in terms of the claimed single inadvertent exposure to the badge, as described. Instead of promptly utilizing the Louisiana Department of Environmental Quality (LDEQ) required emergency hotline number, the RSO for the licensee sent an email to an LDEQ radioactive materials inspector on June 25, 2018 at 11:59 am (CDT), approximately 13 days after the RSO for the licensee first discovered the excessive exposure. Event Report ID No.: LA 180013 |
| ENS 53356 | 22 April 2018 04:28:00 | On April 22, 2018 at 0222 EDT, Watts Bar Nuclear Plant (WBN) Unit 2 entered TS (Technical Specifications) LCO (Limiting Condition for Operation) 3.0.3 due to both trains of the Residual Heat Removal System (RHRS) becoming inoperable. During surveillance testing, the gas void values on Emergency Core Cooling System (ECCS) piping common to both trains did not meet acceptance criteria. This caused both RHRS trains to become inoperable. Operations subsequently vented the RHRS to meet the acceptance criteria and exited TS LCO 3.0.3 at 0227 EDT. More frequent surveillances will be conducted to monitor gas void volumes while additional analysis is being performed to determine corrective actions. The NRC Resident Inspector has been notified.
This event is being retracted. The initial report was based on a conservative acceptance criteria for gas accumulation adopted on April 19, 2018 when it was determined that the previously used acceptance criteria for gas accumulation in the ECCS was non-conservative. Additional analysis has subsequently been performed and determined that a higher gas accumulation acceptance criteria does not challenge operability. With a void of less than the acceptance criteria, in the event of ECCS actuation, the system piping support loads will remain within structural limits and the piping system will remain operable. Therefore, both trains of Unit 2 RHRS were operable and the previously reported 10 CFR 50.72(b)(3)(v)(B) event is being retracted. The NRC Resident Inspector staff has been informed of this event retraction. Notified R2DO (Desai) of this retraction. |
| ENS 53355 | 22 April 2018 02:34:00 | On April 21, 2018 at 2152 EDT, Watts Bar Nuclear Plant (WBN) Unit 1 entered TS (Technical Specifications) LCO (Limiting Condition for Operation) 3.0.3 due to both trains of the Residual Heat Removal System (RHRS) becoming inoperable. During surveillance testing, the gas void values on Emergency Core Cooling System (ECCS) piping common to both trains did not meet acceptance criteria. This caused both RHRS trains to become inoperable. Operations subsequently vented the RHRS to meet the acceptance criteria and exited TS LCO 3.0.3 at 2222 EDT. More frequent surveillances will be conducted to monitor gas void volumes while additional analysis is being performed to determine corrective actions. The NRC Resident Inspector has been notified.
This event is being retracted. The initial report was based on a conservative acceptance criteria for gas accumulation adopted on April 19, 2018 when it was determined that the previously used acceptance criteria for gas accumulation in the ECCS was non-conservative. Additional analysis has subsequently been performed and determined that a higher gas accumulation acceptance criteria does not challenge operability. With a void of less than the acceptance criteria, in the event of ECCS actuation, the system piping support loads will remain within structural limits and the piping system will remain operable. Therefore, both trains of Unit 1 RHRS were operable and the previously reported 10 CFR 50.72(b)(3)(v)(B) event is being retracted. The NRC Resident Inspector has been informed of this event retraction. Notified R2DO (Ehrhardt). |
| ENS 53334 | 13 April 2018 20:01:00 | At 1555 EDT, the Unit 2 'CD' Emergency Diesel Generator (EDG) automatically started and loaded to 4kV Safeguards bus T21C. Testing was in-progress and the start was unplanned. Unit 2 is currently defueled. Unit 1 remains stable at 100 percent power. The South Spent Fuel Pit Cooling Train lost power due to a load shed. The South Spent Fuel Pit Cooling Pump was restarted on 2 'CD' EDG at 1614 EDT. The North Spent Fuel Pit Cooling Train remained in-service the entire time. There was no observable change in Spent Fuel Pool temperature. This event is reportable under 10 CFR 50.72(b)(3)(iv)(A), specified system actuation of an emergency diesel generator, as an eight (8) hour report. The NRC Resident Inspector has been notified. |
| ENS 53328 | 12 April 2018 17:36:00 | At 1148 EDT on April 12, 2018, a 16.2 ounce bottle of Kombucha tea was found in a small refrigerator in the Administration Building inside the Protected Area. The bottle was found to have a small amount missing from the contents. Kombucha tea is a fermented tea containing trace amounts of alcohol, and is legally sold without restrictions. Dominion Energy Nuclear Connecticut had previously notified its workforce that Kombucha tea was prohibited from being consumed or carried onsite. The owner has not yet been determined. This is considered an alcoholic beverage and is being reported pursuant to the requirements of 10 CFR 26.719 as a 24 hour report. The NRC Resident Inspector, the State of Connecticut, and local authorities have been notified. |
| ENS 53310 | 3 April 2018 02:53:00 | On April 3, 2018 at 0019 (EDT), the Susquehanna control room received indication that a loss of Secondary Containment Zone 3 differential pressure had occurred. Control room operators noted the loss following completion of surveillance testing. The cause is under investigation. Zone 3 differential pressure was restored to greater than 0.25 inches WC (water column) at 0145 (EDT). Zone 3 differential pressures being less than 0.25 inches WC constitutes a loss of Secondary Containment based on not meeting requirements of SR (Surveillance Requirement) 3.6.4.1.1. This event is being reported under 10 CFR 50.72(b)(3)(v)(C) and per the guidance of NUREG-1022, Revision 3, Section 3.2.7, as a loss of a Safety Function. There is no redundant Susquehanna Secondary Containment system. The NRC Resident Inspector has been notified. |
| ENS 53292 | 27 March 2018 14:33:00 | The following was received from the State of Illinois via email: On March 27, 2018, the agency (Illinois Emergency Management Agency) was contacted by the licensee's radiation safety officer to report a missing 10 microCi Am-241 source. The source assay date was not immediately available. Reportedly, forms were distributed to the authorized users who would perform the physical inventory. An investigation is ongoing to determine the last physical inventory and responsible individuals. A full report is pending from the licensee by April 26, 2018. A comprehensive source inventory is to be completed within the week. Additional updates will be provided as they become available. Item Number: IL 180024 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. |
| ENS 53291 | 26 March 2018 20:07:00 | At 1839 Eastern Daylight Time (EDT) on March 26, 2018, a Main Control Room (MCR) alarm was received for low control room positive pressure. At 1840 EDT, a Control Room Envelope (CRE) door was found ajar and immediately closed. Technical Specification 3.7.10, Control Room Emergency Ventilation System (CREVS), was declared not met for both trains and Condition B entered. At 1840 EDT on March 26, 2018, the alarm cleared, CREVS was declared operable and LCO (Limiting Condition for Operation) 3.7.10, Condition B was exited. The safety function of the CRE boundary is to ensure the in-leakage of unfiltered air into the CRE will not exceed the in-leakage assumed in the licensing basis analysis of Design Basis Accident (DBA) consequences to CRE occupants. From 1839 EDT to 1840 EDT, WBN (Watts Bar Nuclear) was unable to validate that CREVS could fulfill its required Safety Function. This event is being reported pursuant to 10 CFR 50.72(b)(3)(v)(D). A watch has been posted at the door to prevent recurrence. The NRC Resident Inspector has been notified. |
| ENS 53289 | 26 March 2018 17:02:00 | The following is an excerpt from a report received from the State of Nevada: At 1000 PDT on March 26, 2018, the State of Nevada Radiation Control Program was informed by Aztech Materials and Testing, LLC, that a Humboldt, Model 5001EZ, Serial Number 3491, containing 10 mCi of cesium-137 and 40 mCi americium-241:beryllium, was stolen from the licensee's vehicle. The gauge was secured with two locks in the back of a pickup truck. The State is following the incident and working with local authorities to develop a press release. Local law enforcement and the FBI have been notified. Follow-up information will be provided to NRC on the recovery of the stolen gauge and entered into NMED (Nuclear Material Events Database).
The following information was received via E-mail: The State of Nevada Radiation Control Program has been informed by the Las Vegas Metropolitan Police Department that the stolen portable nuclear gauge has been recovered. Below is the notification: 'All items were recovered in a stolen vehicle (abandoned, no suspects located). Patrol officers will be releasing the items back to Aztech.' The NMED report will also be updated. Notified R4DO (Gaddy). Notified via E-mail ILTAB (Whitney) and NMSS Events Notification. 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 53288 | 26 March 2018 11:51:00 | At 1058 Eastern Daylight Time (EDT) on March 26, 2018, a Main Control Room (MCR) alarm was received for low control room positive pressure. At 1100 EDT, a Control Room Envelope (CRE) door was found ajar and immediately closed. Technical Specification 3.7.10, Control Room Emergency Ventilation System (CREVS), was declared not met for both trains and Condition B entered. At 1100 EDT on March 26, 2018, the alarm cleared, CREVS was declared operable and LCO (Limiting Condition for Operation) 3.7.10, Condition B was exited. The safety function of the CRE boundary is to ensure the in-leakage of unfiltered air into the CRE will not exceed the in-leakage assumed in the licensing basis analysis of Design Basis Accident (DBA) consequences to CRE occupants. From 1058 EDT to 1100 EDT, WBN (Watts Bar Nuclear) was unable to validate that CREVS could fulfill its required Safety Function. This event is being reported pursuant to 10 CFR 50.72(b)(3)(v)(D). The NRC Resident Inspector has been notified. |
| ENS 53269 | 18 March 2018 16:16:00 | At 1158 CDT on March 18, 2018, the Unit 1 reactor automatically scrammed due to a Reactor Protection System (RPS) signal generated from High Reactor Steam Dome Pressure in response to Turbine Control Valve Closure. The reactor had been operating at 100 percent power. Investigation is in progress. All control rods fully inserted into the core. Main Steam Isolation Valves remained open with Main Steam Relief Valves (MSRVs) operating on the initial transient as expected. Main Turbine Bypass Valves are currently controlling reactor pressure. Reactor Feedwater pumps remained in service to control reactor water level. Primary Containment Isolation Signals Groups 2, 3, 6, and 8 containment isolation and initiation signals were received. Upon receipt of these signals all required components actuated as required. All safety system operated as expected. At no time was public health and safety at risk. This event is reportable within 4 hours per 10 CFR 50.72(b)(2)(iv)(B) 'any event or condition that results in actuation of the Reactor Protection System (RPS) when the reactor is critical except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation.' It is also reportable within 8 hours per 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, except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation' and requires an LER within 60 days per 10 CFR 50.73(a)(2)(iv)(A). The NRC Resident Inspector has been notified. |
| ENS 53268 | 18 March 2018 12:34:00 | At 2007 (EDT) on 3/17/18, a security Officer reported finding a container of herbal tea (Kombucha) on a platform in the Unit 1 Emergency Switchgear Room, which is located inside the Protected Area. Kombucha tea is a fermented tea containing trace amounts of alcohol, and is legally sold without restrictions. Dominion had previously notified its workforce that Kombucha tea was prohibited from being consumed or carried on-site. This is considered an alcoholic beverage and is being reported under the requirements of 10 CFR 26.719. The individual who brought the beverage on-site was identified and escorted out of the Protected Area. The NRC Resident Inspector has been notified. The licensee will also be contacting the County Administrator for Louisa County, Virginia. |
| ENS 53267 | 16 March 2018 22:04:00 | At 1604 (CDT) on March 16, 2018, Browns Ferry Nuclear Plant (BFN) Engineering reported an unanalyzed condition affecting the Residual Heat Removal (RHR) heat exchangers in a postulated fire event. It was discovered that the Residual Heat Removal Service Water (RHRSW) heat exchanger piping associated (with) the credited heat exchangers in the NFPA 805 Nuclear Safety Capability Analysis (NSCA) could experience water hammer damage. Fire damage to the cables for the RHRSW outlet motor operated valves could cause the valves to spuriously open and drain the RHRSW piping. Subsequent starting of the RHRSW pumps on the affected header could cause water hammer loads and damage the piping. Review of NFPA 805 analyses show the cables associated with this condition are routed in Fire Areas 01-03, 02-03, 02-04, 03-03, 16 and 23. There are 11 cases where the deterministically credited heat exchanger could be affected. Compensatory fire watch measures have been established. This event requires an 8 hour report in accordance with 10CFR50.72(b)(3)(ii)(B), 'Any event or condition that results in: (B) The nuclear power plant being in an unanalyzed condition that significantly degrades plant safety. CR 1139620 documents this condition in the Corrective Action Program. The NRC Resident Inspector has been notified.
NRC notification 53267 was made to ensure that the eight-hour non-emergency reporting requirements of 10 CFR 50.72 were met when the licensee discovered an unanalyzed condition with the potential to significantly degrade plant safety. On August 22, 2018, an independent analysis was completed which determined that the RHRSW system would remain functional during the postulated scenario. Based on this analysis, a revised functional evaluation was performed by BFN which determined that the condition did not constitute an unanalyzed condition that significantly degraded plant safety. For credited RHR heat exchangers for fire events in Fire Areas 01-03, 02-03, 02-04, 03-03, 16, and 23, the RHRSW piping will remain intact and the valves will operate manually after a water hammer event. This condition did not significantly degrade plant safety and is therefore not reportable under 10 CFR 50.72(a)(2)(ii)(B). On November 16, 2018, TVA canceled the 60 day report which had been submitted for this condition. TVA's evaluation of this event notification is documented in the corrective action program. The licensee has notified the NRC Resident Inspector. Notified the R2DO (Shaeffer). |
| ENS 53234 | 28 February 2018 14:45:00 | The following report was received from the State of Arkansas via e-mail: At approximately 1127 CST on 2/28/2018, the Arkansas Department of Health (ADH) Radioactive Materials Program received a phone call from the licensee stating that during routine shutter tests the gauge shutter handle fell off and the shutter is stuck open. The gauge is a Vega America Corporation (Ohmart) Model A-2102, serial number 6997, originally containing 1.5 Curies (Cesium-137) on 4/30/1968 (calculated current activity approximately 475 milliCuries). Discussion with the licensee indicates that the gauge is mounted on a digester, outside of normal employee traffic. It is normally open during operations and is only closed during maintenance of the digester, which is not planned. Cautionary signage is already present. The licensee representative stated that the staff will be made aware of the situation. Licensee maintenance is assessing the situation and will advise the ADH Radioactive Materials program of the plan for handling this situation. The State of Arkansas is awaiting a written report from the licensee and final disposition information for the gauge. The State's event number is AR-2018-003. |
| ENS 53233 | 28 February 2018 14:33:00 | The following information was received via E-mail: QSA Global reported via telephone on 2/28/2018 that a package shipped via (a common carrier) on 2/19/2018 (shipping documents prepared on 2/16/2018), containing two Model A424-9 Ir-192 industrial radiography sealed sources within a Model 650L source changer, was reported as missing via telephone by (the common carrier) at 1030 EST on 2/28/2018. (The common carrier) trace was already initiated and in progress, and tracking indicates last known package location was (the common carrier) hub in Memphis, TN. This was a RQ UN2916, Yellow-III, Type B package with a Transport Index of 1.9 at time of shipment. Package dimensions were 26x22x34 cm. Source changer SN 263. Sources - SN 63782G (111.6 Ci on 2/14/2018) and 73783G (108.0 Ci on 2/14/2018). This situation is an immediately reportable event per regulation. The search for the missing package is ongoing. Agency (Massachusetts Radiation Control Program) currently considers this docket to still be OPEN. Package Origin: Burlington, MA, USA Intended Destination: Bogota, Columbia Notified External: DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, DHS NICC Watch Officer, and EPA EOC. Notified External via E-mail: FDA EOC, NuclearSSA, FEMA NRCC SASC, FEMA National Watch Center, DNDO-JAC.
QSA Global reported to the Agency that the package was received at its intended destination on 2/26/2018. Agency considers this event to still be OPEN. Massachusetts Radiation Control Program updated Tennessee Division of Radiological Health. Notified R1DO (Bickett), NMSS EO (Rivera-Capella), ILTAB (English), IRD MOC (Pham), and NMSS Events (email). Notified External: DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, DHS NICC Watch Officer, and EPA EOC. Notified External via E-mail: FDA EOC, NuclearSSA, FEMA NRCC SASC, FEMA National Watch Center, DNDO-JAC.
The following was received from the Commonwealth of Massachusetts via email: QSA Global provided a 30-day written report received by the Agency on 3/9/18. Agency telephone discussions with QSA Global and (the common carrier) were held on 3/12/18. The following information is provided in order to report previously unreported details: (1) QSA Global confirmed that the 650-L Source Changer is itself a Type B package and was not shipped in an overpack container and therefore was the shipping container, (2) (the common carrier) indicated, as a corrective action, this situation would be included in the lessons learned portion of annual refresher training presented to (the common carrier) employees. In this case, although QSA Global had contact with the international customer on 2/21/18 and 2/23/18, the customer did not follow-up to inform QSA Global when the item actually arrived on 2/26/18 (two days before it was reported to Agency as missing by QSA Global on 2/28/18). Agency considers this event to be CLOSED. Massachusetts Radiation Control Program updated Tennessee Division of Radiological Health. NMED number: 180099 Massachusetts Event: 15-3140 Notified R1DO (Jackson), NMSS EO (Rivera-Capella), ILTAB (Ahern), IRD MOC (Pham), and NMSS Events (email). THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web. |
| ENS 53221 | 20 February 2018 15:36:00 | At 0925 (EST) on February 20, 2018, a non-licensed supervisory contractor subverted a random Fitness for Duty test. The contractor's site access has been terminated. The NRC Resident Inspector was notified. |
| ENS 53264 | 15 March 2018 15:57:00 | On 2/19/2018, a crew was performing work at the Phillips 66 Refinery in Billings, Montana. While moving the source into the open position, a loud noise was heard originating from the exposure set up area. The crew immediately attempted to crank the source back into the fully shielded position, but the attempt was unsuccessful. It was determined that the part to be inspected had tipped over and fallen onto the source tube, resulting in a crimp which prevented the source from being retracted into the fully shielded position. The source was shielded with lead plates, the crimp reduced, and the source successfully retracted into the fully shielded position. No members of the general public were exposed to any radiation and no workers received a dose exceeding the limit for personnel working with radiation sources. The source tube involved in this incident has been removed from service and destroyed. The exposure device involved in this incident has been inspected, checked for proper functionality, found to be in working order, and returned to service. The device was a QSA 880D exposure device containing an Iridium-192 source. |
| ENS 53222 | 20 February 2018 16:45:00 | On 2/16/18, the calorimetric portion of Surveillance Requirement (SR) 3.2.3.3 for Limiting Condition for Operations (LCO) 3.2.3.1 was performed in accordance with University of Florida Test Reactor (UFTR) procedures. Reactor power was stabilized at an indicated power of approximately 94 percent with actual thermal power (calculated by heat balance) at approximately 98kW (98 percent RTP) (rated thermal power). Indicated power was then adjusted to approximately 99 percent to ensure adequate margin to the license limit of 100kW thermal steady-state (100 percent RTP). At no time was actual reactor power allowed to exceed the license limit. The reactor was then shutdown and secured to perform post-calorimetric verifications. SR 3.2.2.1 and 3.2.3.1 were performed satisfactorily just prior to operation to verify the High Reactor Power trip function and setpoint. Reactor Power Channel 1 was set to actuate at 110 percent and Reactor Power Channel 2 was set to actuate at 108 percent. At about 1400 on 2/19/18, during review of surveillance parameters and discussion with the operators, UFTR management determined that Limited Safety System Setting 2.2.1 and LCO 3.2.2.1 had been violated. The Technical Specifications allowable value for the automatic High Reactor Power trip function is less than or equal to 110 percent RTP. There was a period of approximately 5 hours of operation prior to adjustment of the power channels, however, during which actual thermal power was greater than indicated power (but less than 100kW thermal). During this period, if a power excursion had occurred, the High Reactor Power trip would have actuated at approximately 114 percent RTP. This condition is reportable in accordance with Sections 6.7.2.a.3 and 6.7.2.a.4 of the UFTR Technical Specifications. As described above, this condition was corrected by adjusting indicated power on both reactor power channels to greater than actual thermal power. The NRC Project Manager, assigned inspector, and Non-Power Reactor Licensing Branch Chief (acting) have been notified.
If a power excursion during the period of operation prior to adjustment of the power channels, Reactor Power Channel 2 would have provided a High Reactor Power trip at approximately 112% RTP. Notified NRR PM (Hardesty) and NRR ENC (Reed). |
| ENS 53214 | 15 February 2018 17:36:00 | A can of alcohol (8.4 ounces) was discovered unopened in a refrigerator inside the protected area. Site security took possession of the can of alcohol. The owner of the can of alcohol is unknown. This report is being made under 10 CFR 26.719(b)(1) as a 24 hour telephone notification. The can had an expiration date of April 2017. The licensee notified the NRC Resident Inspector and the Regional Inspector. |
| ENS 53199 | 7 February 2018 17:02:00 | The following was received from the State of Colorado via email: Red Rocks Radiation Oncology received a package of Ra-223 Xofigo that had removable contamination levels of approximately 23,000 cpm on the outside of the package. The Ra-223 package was delivered by a Cardinal courier from the Cardinal Health facility in Denver, CO which distributes all radiopharmaceuticals (license CO 392-03 is the Cardinal Health license for general radiopharmaceuticals, they share the same building as CO 1219-01). The inner packaging of the Ra-223 shipment did not evidence removable contamination, nor did the car used to transport the Ra-223 package. Cardinal Health has received the wipes and decontamination waste from Red Rocks Radiation Oncology to attempt to determine the isotope causing the removable contamination. The investigation is currently ongoing. Event Report ID No.: CO180003 |
| ENS 53198 | 7 February 2018 15:04:00 | At approximately 1040 CST, seven (7) Dresden Nuclear Power Station Offsite Emergency Notification sirens (i.e., Siren Nos. DR1, DR4, DR5, DR6, DR9, DR10, and DR11) were inadvertently activated. The Kendall County, IL Emergency Management Agency notified the Exelon Generation Company, LLC. Emergency Response Organization that at 1040 CST, a contract individual inadvertently cut a wire that resulted in the actuation of these seven sirens for three minutes. The contract organization personnel are addressing the issue with the sirens. The Kendall and Will County Emergency Management Agency contacted Exelon Generation Company regarding this event. This notification is being made in accordance with 10 CFR 50.72(b)(2)(xi) as an event where other government agencies were notified. The NRC Resident Inspector has been informed of this notification. The sirens are operable. |
| ENS 53197 | 6 February 2018 16:10:00 | The following information was received from the State of California via email: On February 6, 2018, at approximately 0845 (PST) (the RSO) of Southwest Calibration & Training, Radioactive Materials License #7567-36, contacted RHB (CA Radiologic Health Branch) Brea concerning the moisture/density gauge, CPN, MC1-DRP, serial #MD40507411 (Cs-137 0.375 GBq, Am-241 1.8 GBq) that had been stolen from a transport vehicle (in) Indio, CA at approximately 0800 (PST). At 0930 (PST), the RSO of Premier Testing & Inspection, Inc., telephoned RHB Brea to inform that the Authorized User had contacted local law enforcement in Indio, (CA) and was filling out a police report with them. A copy of the theft report will be forwarded to the RHB Brea office to be included as part of this report. (The RSO for Premier Testing & Inspection, Inc.) will contact local newspapers to attempt to retrieve the stolen radioactive gauge as well as notifying local servicing vendors of radioactive gauges to be alert for the serial number of the stolen gauge in case it turns up for service. The investigation will continue to determine if the radioactive gauge can be recovered in a reasonable time frame. This is being reported to the NRC Operations Center as a 24-hour report under 10CFR30.50(b)(2) since the radioactive gauge has been stolen and it cannot be determined what condition the sources are currently in. 5010 NUMBER: 020618 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 53184 | 26 January 2018 01:37:00 | At 1901 PST on January 25, 2018, the Control Room received a fire alarm, followed by screen wash and 480v load center alarms a few minutes later. The intake operator and on-site fire department personnel were promptly dispatched to the scene and confirmed within 15 minutes there was no active fire. As a conservative measure, off-site fire assistance was initially requested, however (this request) was canceled a short time later. While on-site fire personnel were locally assessing the damage to screen wash pump 1-2, a brief flare-up occurred at the pump motor which was immediately extinguished. Units 1 and 2 remained stable and two screen wash pumps remain available. There is no risk to plant safety or personnel and both units continue to operate at power. Current efforts are focused on determining the cause of the situation. The licensee notified the NRC Resident Inspector and CAL FIRE. The licensee issued a media/press release. |
| ENS 53171 | 17 January 2018 16:45:00 | On January 15, 2018 a medical event occurred at the licensed facility in which a patient received a prescribed dose less than 80 percent of the target dose to the liver. The dose was delivered via Y-90 microspheres. The State will investigate this medical event.
On January 15, 2018, a patient was prescribed a dose of 130 Gy (2.789 GBq) for the left lobe of the liver involving two dose vials of Y-90 MDS Nordion TheraSphere microspheres. The first dose vial was administered without issue. The second dose vial was then primed and prepped as normal, however, a train of bubbles was noted in the line between the dose vial and the patient prior to administration. Due to the proximity of gastric artery relative to point of administration and the possibility that the bubbles could cause the flow to reflux into this artery (which could permanently damage the stomach), the AU (Authorized User) determined the best course of action was not to administer the second dose vial. The therapy procedure was then halted and rescheduled to complete on Thursday, January 18th. The administered dose was 84.9 Gy (1.760 GBq) to the left lobe of the liver. The dose was therefore 65% of the prescribed dose, a 35% difference. The difference between the prescribed and administered dose to the liver is 45.1 Gy (4510 rem). Therefore, the dose administered exceeds +/- 20% of prescribed dose and differs from the prescribed dose by more than 50 rem to an organ (liver). The referring physician has been notified as well as the patient. This event was reported to the Oregon Agreement State program on January 16, 2018. The licensee has removed all Y-90 therapy tubing sets from the same lot number for return and analysis by the vendor. Tubing sets from a different lot number were provided to interventional radiology for future cases. Notified R4DO (Proulx) and NMSS Events Resource (email). State Event Report ID No.: OR-18-0001 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 53172 | 17 January 2018 19:42:00 | The following information was received from the State of California via E-mail: The California Radiation Control Program (CDPH-RHB) was notified by US CBP (Customs and Border Patrol) on 1/12/18 that a shipping container that had arrived at the Oakland port triggered a radiation detector upon attempting to depart the port. The shipping container contained scrap metal that was later determined to have been rejected at a South Korea port due to radiation detected upon receipt there. The Oakland port CBP personnel detected Cs-137, with a maximum dose rate on the outside of the shipping container of 86 microR/hr (gross). The radiation apparently had not been detected when the container was shipped out of the Oakland port to South Korea. The shipping container was held at the Oakland port by CBP until Tuesday 1/16/18, when it was released to AS Metals with the provision that CDPH-RHB would be present when the container was opened to determine the source of the radiation and subsequent disposition. CDPH-RHB went to a scrap yard site on 1/16/18 and found the source of the radiation was a gauge that was labeled (in handwriting as the original gauge label was missing) as containing 100 mCi of Cs-137. The gauge shutter was locked in the closed position. Dose rates were measured as approximately 40 mR/hr contact and 3 mR/hr at one foot distance, and the radioactive material was confirmed to be Cs-137. The apparent generally licensed gauge, which appeared very old, is being held in secure storage by AS Metals pending an attempt by CDPH-RHB to identify the general licensee who lost control of the gauge. This may be difficult due to the missing original label on the gauge, and because AS Metals has not been able to determine how or where they came into possession of the gauge. California 5010 Number: 011618 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 53154 | 6 January 2018 18:14:00 | At 1126 (CST), main steamline radiation monitor 2-RE-2326 (Main Steamline 2-02) reading was determined to be erratic and was declared non-functional. With this radiation monitor non-functional, all of the emergency action levels for a steam generator tube rupture in steam generator 2-02 could neither be evaluated nor monitored. This unplanned condition is reportable as a loss of assessment capability per 10 CFR 50.72(b)(3)(xiii). Comanche Peak Nuclear Power Plant (CPNPP) has assurance of steam generator integrity and fuel cladding integrity and there is a negligible safety significance to the current condition from a public health and safety perspective. Additionally, compensatory measures are in place to assure adequate monitoring capability is available to implement the CPNPP emergency plan in the unlikely event of challenges to the steam generator or fuel cladding. The N16 (Nitrogen-16) radiation monitor serves as a backup with alarm function and Radiation Protection technicians have been briefed on taking local readings with a Geiger-Mueller tube on MSL (Main Steam Line) 2-02. Corrective actions are being pursued to restore 2-RE-2326 to functional status. The NRC Resident Inspector has been notified. |
| ENS 53147 | 4 January 2018 17:57:00 | On January 4, 2018, at 1410 hours EST, with the reactor at approximately 100 percent power and steady state conditions, the winter storm across the Northeast caused the loss of offsite 345 kV Line 342. Reactor power was reduced to approximately 81 percent and a procedurally required manual reactor scram was initiated. All control rods fully inserted. As a result of the reactor scram, indicated reactor water level decreased, as expected, to less than +12 inches resulting in automatic actuation of the Primary Containment Isolation Systems for Group II - Primary Containment Isolation and Reactor Building Isolation System, and Group VI - Reactor Water Cleanup System. Reactor Water Level was restored to the normal operating band. The Primary Containment Isolation Systems have been reset. The Reactor Protection System signal has been reset. Following the reactor scram, the non-safety related Control Rod Drive Pump "B" tripped on low suction pressure. Control Rod Drive Pump "A" was placed in service. All other systems operated as expected, in accordance with design. This event is reportable per the requirements of Title 10, Code of Federal Regulations (CFR) 50.72 (b)(2)(iv)(B) - "RPS Actuation" and 10 CFR 50.72 (b)(3)(iv)(A) - "Specified System Actuation. This event had no impact on the health and/or safety of the public. The NRC Resident Inspector has been notified. The main steam isolation valves are open with decay heat being removed via steam to the main condenser. Offsite power is still available from 345kV line 355. As a contingency, emergency diesel generators are running and powering safety busses per licensee procedure. The licensee notified the Commonwealth of Massachusetts. The licensee will be notifying the town of Plymouth as part of their local notifications. The licensee will be issuing a press release. |
| ENS 53149 | 5 January 2018 12:16:00 | The following report was received via email from the Virginia Office of Radiological Health: On January 4, 2018, the Radiation Safety Officer of the licensee reported that the metal (insertion) rod that enables the source holder to move to its 'ON' position (moves the source in and out of the vessel) broke during routine periodic maintenance. The gauge is a Texas Nuclear Model 50315, serial number B0047, with a 100 milliCurie Cesium-137 source (effective 1993). The gauge is used to measure the density of material inside a process vessel. The gauge is currently in its normal operative state, which is to send a signal to the detector to control density in the vessel. The source was pushed back into the vessel to allow for normal operation after the rod broke, but it is not able to be removed. The licensee has contacted ThermoFisher Scientific for further actions. Virginia Event Report ID No.: VA-18-001 |
| ENS 53137 | 23 December 2017 05:00:00 | High Pressure Core Spray System was declared inoperable due to the discovery of a through-wall leak on the Minimum Flow line. Leak rate is 60 drops per minute from ASME Class 2 Piping. The leak has been isolated and the High Pressure (Core Spray) System has been placed in Secured Status. High Pressure Core Spray is considered a single train safety system. Inoperability of (the) High Pressure Core Spray System is considered an 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 mitigate the consequences of an accident. This event is being reported in accordance with 10 CFR 50.72(b)(3)(v)(D). The NRC Senior Resident Inspector was notified. Technical Specifications Limiting Condition for Operation 3.5.1 Condition B was entered, requiring restoration of the High Pressure Core Spray System in 14 days. The licensee plans to notify State and Local Governments (Lake, Geauga, and Ashtabula Counties). |
| ENS 53100 | 30 November 2017 18:14:00 | The following report was received via E-mail: On November 30, 2017, the Agency (Texas Department of State Health Services) was notified by the licensee's consultant that two nuclear gauges were involved in a fire on November 28, 2017. The consultant stated they could not gain access to the gauges until this date. The gauges are Thermo Fisher model 5203 gauges containing a two (2) curie (original activity) cesium-137 source. The consultant stated the dose rate on one of the gauges was reading 180 millirem an hour on a preliminary radiation survey. This dose rate appears to be higher than normal. A contamination survey was performed in the area of the gauges, but the results were not available at the time of the report. The gauges are located 20 - 30 feet above the ground and do not create an exposure risk to any individuals. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: I-9524
The following information was received via E-mail: The licensee has provided the following additional information: The source holders are visibly intact, however they are black with soot. Both of the gauges were surveyed. For B-1228 the readings are normal but B-1227 has a localized spot on the lower left-hand location of the shield where the readings are 180 mR/hr at contact and 14 mR/hr at 1 ft. Additional shielding has been attached to the lower left hand location of the shield to reduce the dose rate to 3 mR/hr at 1 ft. Sealed Source leak tests have been performed and the results will be communicated as soon as they are assayed. No personnel (member of the general public or radiation workers) have been within 5 feet of either source due to the unsafe structural conditions due to the fire. Additional information will be provided as it is received in accordance with SA-300. Notified the R4DO (O'Keefe) and NMSS Events Notification (via e-mail).
The following information was received via E-mail: The licensee reported that the results of the leak test performed on the two gauges indicated the sources were not leaking (less than 0.0001 microCi). Additional information will be provided as it is received in accordance with SA-300. Notified the R4DO (O'Keefe) and NMSS Events Notification (via e-mail). |
| ENS 53151 | 5 January 2018 17:16:00 | The following information was excerpted from a facsimile received from Engine Systems, Inc.: Two thermostatic valve assemblies were supplied by (Engine Systems, Inc.) ESI that were found to have retaining straps, subcomponents of the internal thermostatic element, detached from the correct position. For each valve assembly, one of the thermostatic elements (the centrally located element) contained this defect. The straps are used in conjunction with a spring to retain the element in a closed position. As the temperature of the sensed fluid increases, a temperature sensitive wax expands to open the element while acting against the spring. As the temperature of the fluid decreases, the wax contracts and the spring returns the element to its closed position. Absence or failure of the straps would prevent proper operation of the element. The thermostatic valve assembly is used on an emergency diesel generator (EDG) set to regulate the temperature of lubricating oil (other EDGs use this same type of valve for jacket water temperature regulation). If one of the elements within the assembly were to fail, as is the case with a missing strap, regulating capacity of the thermostatic valve could be affected. However, the failure mode in the case of missing straps is in the open position (element does not return closed) and the remaining eight elements would compensate by closing to regulate the fluid temperature. More importantly, detached retaining straps could migrate to other components in the lube oil system. Acting as foreign material, the straps could adversely affect the ability of these critical components to perform their safety-related function within the emergency diesel generator's lube oil piping. The foreign material aspect of this defect makes it a reportable issue. Information of such defect or failure to comply was obtained on November 22, 2017. This issue is an isolated incident affecting two thermostatic valves supplied to one nuclear plant (DC Cook). The nuclear plant detected the issue during inspection and returned the assemblies to ESI. No further action is required on the part of DC Cook. ESI's investigation revealed that this issue was induced by a test technician who, in an effort to minimize the amount of test fluid remaining in the assembly after pressure testing, manually actuated the center thermostatic element (there are 9 total elements) to drain a small pocket of residual fluid. This effort to prevent the formation of oxidation had an unintended consequence and resulted in a more serious issue. Though this is an isolated incident as it pertains to items supplied from ESI, this same model thermostatic valve assembly is used extensively on EDGs in the nuclear industry. Those customers that perform valve maintenance, including thermostatic element replacement, should be aware of the possibility of the straps becoming detached if care is not taken. If you have any questions, you may call: Tom Horner Quality Assurance Manager Tel: (252) 977-2720 ESI Report ID: 10CFR21-0120, Rev. 0, dated 01/05/18 |
| ENS 53152 | 5 January 2018 16:48:00 | The following was excerpted from an email received from the State of Florida: Received a notification letter from a licensee (NDE, Inc.) reporting a possible overexposure. According to the (Radiation Safety Officer) RSO for NDE, an employee had the leather pouch that his badge and his pocket dosimeter were in cut open resulting in his badge falling out near where radiography was taking place. The missing badge was discovered during a routine check of his pocket dosimeter which read 2 mRem for the shift. The badge was sent to Landauer for analysis and the recorded dose for the time period of Oct. 10 - Nov. 9, 2017 was 23.420 Rem. After conducting interviews, the RSO concluded that the overexposure was due to the badge being so close to the source, and the employee did not receive the recorded dose. After compiling the daily pocket dosimeter readings, the estimated dose to the employee would have been 57 mRem for that time period. Incident Number: FL 18-003 |
| ENS 53083 | 21 November 2017 14:22:00 | On October 6, 2017 at 0910 CDT hours, with Unit 1 in Mode 1 (Power Operation), the 1A Diesel Generator Cooling Water Pump (DGCWP) automatically started. The cause was the misoperation of the 1B/C RHR (Residual Heat Removal) Room Cooler Fan (1VY03C) control switch, which was placed in the start position instead of the intended pull-to-lock position. The start of the 1VY03C fan resulted in the automatic actuation of the 1A DGCWP. This system actuation is reportable in accordance with 10CFR50.73(a)(2)(iv)(A). The invalid actuation was not part of a pre-planned sequence during testing or reactor operation. The 1A DGCWP, an emergency service water system that does not normally run and that serves as an ultimate heat sink, responded satisfactorily. This call is being made in accordance with 10CFR50.73(a)(1), which states that in the case of an invalid actuation reported under 10CFR50.73(a)(2)(iv), other than an actuation of the reactor protection system when the reactor is critical, the licensee may provide a telephone notification to the NRC Operations Center within 60 days after discovery of the event instead of submitting a written Licensee Event Report. The licensee notified the NRC Resident Inspector. |
| ENS 53293 | 27 March 2018 15:59:00 | The following is an excerpt from a report received from the State of Ohio via email: The criteria for a medical event supported by ODH (Ohio Department of Health) is if the 90% prostate volume receives less than 80% of the prescribed dose or more than 120% of the prescribed dose. Upon generating the post treatment plans for nine patients, the Dosimetry staff discovered that four were below 80%. Summary of Prostate Implant Incidents: Case #. Implant Date, Discovery Date, Prescribed Dose (Gy), Estimated D90 (Gy) 1. 9/05/2017, 3/26/2018, 110 Gy, 58.15 Gy 2. 9/28/2017, 3/26/2018, 145 Gy, 100.19 Gy 3. 2/13/2017, 3/26/2018, 110 Gy, 81.28 Gy 4. 2/19/2017, 3/26/2018, 145 Gy, 103.7 Gy Manufacturer: Theragenics Model Number: AgX100 Radionuclide: I-125 Item Number: OH180002 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. |