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 Entered dateEvent description
ENS 543641 November 2019 10:03:00On November 1, 2019 at 0316 EDT, Nine Mile Point Unit 2 (NMP2) received Control Room annunciation for HPCS SYSTEM INOPERABLE and inoperable status light indication for TRIP UNITS OUT OF FILE/POWER FAIL. Initial investigation has identified a potential failed 24 vdc power supply which supplies power to the HPCS trip units for system initiation and control. The HPCS system has been declared inoperable per TS 3.5.1 resulting in an unplanned 14 day LCO. All other plant systems functioned as required. NMP2 is currently at 100 percent power in Mode 1. This condition is reportable under 10 CFR 50.72(b)(3)(v)(D) as, '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: (D) Mitigate the consequences of an accident.' The licensee notified the NRC Resident Inspector.
ENS 5436230 October 2019 01:20:00

On 10/30/19 at 0026 EDT, an Unusual Event (HU3) was declared due to a release of flammable gas to the Unit 1 Pipe Penetration area (Reactor Auxiliary Building). The hydrogen supply valve to the area has been isolated. The area is being ventilated and follow-up air sampling will be performed. The NRC Resident Inspector has been notified. Notified DHS SWO, FEMA Ops Center, DHS NICC, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

  • * * UPDATE FROM FRED POLLAK TO DONALD NORWOOD AT 0521 EDT ON 10/30/2019 * * *

The Notice of Unusual Event was terminated at 0454 EDT on 10/30/19. The area has been purged and normal access restored. The licensee notified the NRC Resident Inspector. Notified R2DO (McCoy), NRR EO (Miller), and IRD (Grant). Notified DHS SWO, FEMA Ops Center, DHS NICC, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

ENS 5434824 October 2019 16:25:00At 1035 CDT the Automatic Depressurization System (ADS) was rendered inoperable due to the failure of the 'A' Safety Vent Valve (SVV) Compressor (SVV-C4A) to manually start with SVV-C4B tagged out. System pressure slowly dropped below 131 psig (normal pressure is 165 psig). This caused the ADS safety relief valves to be declared inoperable. The station entered Technical Specification 3.5.1 Condition G. The Required Action was to be in Mode 3 in 12 hours. As a result, the station was in a condition that could have prevented the fulfillment of a safety function. The breaker for SVV-C4B was reset and the clearance for SVV-V4B was released. System pressure was restored to greater than 131 psig at 1116 CDT which allowed exit of the action statement to be in Mode 3 in 12 hours. System parameters are currently stable in the normal pressure range. Investigation for the cause of the system failure is ongoing. No radiological releases have occurred due to this event from the unit. The licensee notified the NRC Resident Inspector.
ENS 5434624 October 2019 11:51:00The following information was received via E-mail: The licensee informed the Department (Pennsylvania Department of Radiation Protection) that a brachytherapy seed set was implanted in the wrong patient. It is reportable per 10 CFR 35.3045(a)(2)(iii)(B). On October 23, 2019, the licensee was performing a permanent brachytherapy during which an incorrect prostate brachytherapy seed set (lsoRay Model CS-1) was brought to the procedure room and 6 Cs-131 seeds were implanted into the prostate of a patient. The procedure was stopped immediately when the error was recognized. The correct seeds were then brought to the operating room and the procedure was completed using the correct seeds. Forty Seven (47) seeds, 85 gray, (3.135 mCi) were prescribed and 3.03 mCi given. The Authorized User notified the urologist and patient this morning (10/24/19). No harm is expected to the patient. The cause of the event is unknown at this time. The Department will perform a reactive inspection. More information will be provided as received. Pennsylvania Event Report ID No: PA190024 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 5432812 October 2019 15:54:00One unopened can of beer was discovered in a break room refrigerator within the plant's Protected Area. The individual that brought in the can of beer was identified. That individual is a Pacific Gas and Electric employee but does not normally work at Diablo Canyon. That individual was brought in to support work during the Unit 2 refueling outage. When questioned, the individual stated that the can of beer had been brought in to give to another person to see if that person liked that brand of beer (the beer was apparently from a small specialty brewery). A behavioral observation was performed on the individual who brought in the can of beer. There was no indication of alcohol use by the individual. The individual's access to the plant has been suspended pending further investigation.
ENS 5432511 October 2019 14:22:00At 1300 EDT, a Technical Specification required shutdown was initiated at Calvert Cliffs Unit 1. Technical Specification Action 3.1.4.C (Restore Control Element Assembly (CEA) alignment) was entered on 10/11/2019 at 1100 EDT, with a Required Action to reduce thermal power to less than 70 percent Rated Thermal Power and restore CEA alignment within 2 hours. This Required Action was not completed within the Completion Time; therefore, a Technical Specification required shutdown was initiated, and this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(i). At 1345 EDT, CEA alignment was restored and Technical Specification 3.1.4 (Control Element Assembly Alignment) was met. Reactor Power is being stabilized. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
ENS 5432611 October 2019 16:35:00The following information was receive from the Texas Department of State Health Services (the Agency) vial e-mail: On October 11, 2019, the Agency was notified by the licensee's radiation safety officer (RSO) that the shutter on a Vega Americas SHLG-2 source holder containing a 5,000 milliCurie cesium-137 source was stuck in the open position. The stuck shutter was found during a routine check of the gauge. Open is the normal operating position. The RSO stated the gauge does not pose an exposure risk to any individual. The RSO stated a service company has been contacted to look at the gauge. The RSO stated they have not determined if they will repair or replace the gauge. Additional information will be provided as it is received in accordance with SA 300. Texas Incident No.: I-9720
ENS 5432711 October 2019 18:29:00The following information was received from the Texas Department of State Health Services (the Agency) via E-mail: On October 11, 2019, the Agency was contacted by the licensee's radiation safety officer (RSO) who reported a medical event had occurred at their facility. The RSO stated that the event involved a patient who was to receive a treatment with yttrium-90 microspheres. The administering physician had difficulties setting up the injection apparatus and installed an additional piece of tubing in-line with the injection tubing. Because of the additional length of tubing, the patient received only five percent of the prescribed activity. The RSO stated there would be no adverse effects on the patient. The RSO stated both the patient and the prescribing physician have been notified of the error. The RSO stated that the bulk of the microspheres (activity) remained in the tubing and no contamination was found in the area where the treatment occurred. The RSO stated the physician decided they would perform the procedure again and use the activity needed to bring total activity administered to the activity initially prescribed. Additional information will be provided as it is received in accordance with SA-300. Texas Incident No.: I-9721 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 5432210 October 2019 12:14:00At 1122 EDT, on October 10, 2019, Duke Energy initiated voluntary notification of North Carolina State and local officials per the guidance in Nuclear Energy Institute (NEI) 07-07, 'Industry Groundwater Protection Initiative - Final Guidance Document,' due to release of tritiated water in excess of 100 gallons. On October 8, 2019, at approximately 1300 EDT, Brunswick plant personnel drilling as part of an ongoing site project, damaged a storm drain discharge line. The resulting leak was isolated and water around the impacted area was sampled for gamma emitters and tritium. No gamma emitters were detected. The tritium concentration was below the Environmental Protection Agency (EPA) drinking water limit of 20,000 pCi/L. The leak has been stopped and excavation and repair efforts are in progress. This notification is being made solely as a four-hour, non-emergency notification for a notification of other government agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
ENS 5432310 October 2019 15:22:00The following information was received via e-mail: A Troxler 3430 portable surface moisture-density gauge, S/N 19274, was damaged when it was hit by an excavator at a temporary job site in Shoreline, Washington. Damage included: the screws had been ripped out of the top shell of the gauge, and the metal base of the gauge was cracked on the side. The gauge operator verified that the source rod was intact and retracted into the safe position, and returned the gauge to the licensee's main office for storage, as directed by his radiation safety officer. A Washington Department of Health inspector surveyed the gauge and verified that the neutron and gamma readings were similar to the radiation profile shown in the sealed source and device registry certificate for the gauge. The inspector checked for removable radioactive material contamination on the outside of the gauge by wiping the crack in the side of the base of the gauge, the seam where the top shell joins with the metal base of the gauge, and the source rod opening and bottom plate. No removable contamination was found. The damaged gauge will be shipped for disposal in the near future. The gauge contained a 40 mCi Am-Be source, S/N 47-14734, and a 4 mCi Cs-137 source, S/N 50-8931. Washington Reference Number: WA-19-028
ENS 543021 October 2019 07:05:00On 10/1/2019, at 0307 CDT, Unit 2 was conducting a normal reactor startup and received a valid Reactor Protection System (RPS) scram. The reactor was critical in MODE 2 at the Point of Adding Heat. Operators began withdrawing Source Range Monitor (SRM) Instrumentation per procedure. When the operator depressed the SRM Drive Out pushbutton to withdraw the last two SRMs (C and D), an unexpected full Reactor Scram was received. Annunciator indication in the Main Control Room indicated a Neutron Monitoring Scram. The Intermediate Range Monitors (IRM) D, E, F, H and G all indicated Upscale High High. There were no Emergency Core Cooling System (ECCS) or Containment Isolation System actuations. All other systems functioned as designed. The cause of the Reactor Scram is still under investigation. This event requires a 4-hour report 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.' This event also requires an 8-hour report 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), (1) Reactor protection system (RPS) including: reactor scram or reactor trip, except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation.' The NRC Resident Inspector has been notified."
ENS 5429930 September 2019 01:22:00On September 29, 2019 at 2228 EDT, during a planned swap of Reactor Building HVAC trains, the exhaust fan discharge damper for the train being removed from service failed to close when the train was shutdown, which resulted in the Technical Specification (TS) for secondary containment pressure not being met for approximately 2 minutes and 15 seconds. The maximum secondary containment pressure observed during that time was approximately 0.1 inches of water gauge (positive). Secondary containment pressure was returned to within the TS operability limit of greater than or equal to 0.125 inches of vacuum water gauge (TS SR 3.6.4.1.1) by restarting the train of RBHVAC. Secondary containment pressure is currently stable. Secondary containment was declared Operable at 2235 EDT. There were no radiological releases associated with this event. Declaring secondary containment inoperable is reportable under 10 CFR 50.72(b)(3)(v)(C) as an event or condition that could have prevented the fulfillment of a safety function needed to control the release of radioactive material. The Licensee has notified the NRC Resident Inspector."
ENS 543031 October 2019 09:15:00The following information was received via E-mail: A general licensee reports that following a recent inventory audit, they could not account for 17 missing tritium exit signs. The missing signs could not be accounted for physically by the licensee or verified through formal documentation that the signs were sent for disposal. The signs are believed to be Safety Light Corporation model number 2040 signs. The serial numbers were not reported. NC Tracking Number: NC 190033 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 5426811 September 2019 17:58:00A non-licensed contract supervisor had a confirmed positive for illegal drugs during a random fitness-for-duty test. The individual's authorization for site access has been terminated. The NRC Resident Inspector has been notified.
ENS 5427011 September 2019 19:00:00The following information was received from the Arizona Department of Health Services via E-mail: The Department (Arizona Department of Health Services) received notification that a tritium exit sign has been lost/stolen. The model is an Isolite 2040 with an activity of approximately 7.5 curies. The Department has requested additional information and continues to investigate the event. Arizona Incident Number: 19-018 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 5426911 September 2019 18:23:00

The following information was received from the Texas Department of State Health Services via E-mail: On September 11, 2019, the Agency (Texas Department of State Health Services) was notified that the licensee had identified that a medical event had occurred at its facility. The licensee reported it had discovered that the 52 palladium-103 seeds (1.292 mCi each) that had been implanted into a patient on August 1, 2019, which were intended to deliver 100 gray to the prostate, were all inferior to the patient's prostate approximately four centimeters. The licensee has notified the referring physician and patient. The licensee stated the current plan is to implant the prostate. There are no significant adverse effects expected. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300.

  • * * UPDATE RECEIVED FROM ART TUCKER TO OSSY FONT ON 09/13/19 AT 1752 EDT * * *

On September 13, 2019, the Agency received additional information on this event. The licensee's report stated that on August 1, 2019, the physician was using ultrasound imaging to locate the prostate (and) misidentified the penile bulb as the prostate. The licensee stated this occurred because the penile bulb was very similar in size (10.8 cc versus 12 cc for the prostate) and they were very close to each other. As a result, 52, 1.292 milliCurie (67.2 milliCurie total) Palladium-103 seeds were placed four centimeters inferior to the prostate. The error was not discovered until September 11, 2019 during the post-implant dosimetry review. The estimated exposure to 90 percent of the penile bulb is 73 gray. The report stated that the patient is elderly and not sexually active; therefore, there is no increased risk of erectile dysfunction. The licensee identified the urethral structure as additional tissue at risk, but expected the effects to be the same as if the seeds had been properly placed at the prostate. The estimated dose to the prostate was 0 gray. Additional information will be provided as it is received in accordance with SA-300. Texas Incident No.: I-9710 Notified R4DO (Alexander) and NMSS Events Notification E-mail group. 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 5426510 September 2019 11:47:00

The following information was received from the Texas Department of State Health Services via E-mail: On September 10, 2019, the Agency (Texas Department of State Health Services) was notified by the licensee that on September 9, 2019, one of its technicians had lost a Troxler model 3440 moisture/density gauge. The gauge contained a 40 milliCurie americium-241 source and an eight milliCurie cesium-137 source. The licensee stated the technician had been working at a temporary job site and had placed the gauge on the tailgate of the truck. The technician left the job site, to get a meal, with the gauge still setting on the tailgate. After traveling about three miles the technician noted the tailgate was down and found the gauge was missing. The technician searched on foot the path they had driven, but did not locate the gauge. On the morning of September 10, 2019, the licensee searched the path traveled by the technician, but did not find the gauge. The licensee stated that the gauge was not in a transport case and the operating rod did not have a lock on it. Therefore, they could not say that there is no chance for an exposure to a member of the general public. The licensee stated they did not know if local law enforcement had been notified at the time of the call to the Agency, but would make sure that they call them and informed them of the event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident No.: I-9708

  • * * UPDATE FROM ARTHUR TUCKER TO BRIAN LIN AT 0753 EDT ON 9/12/2019 * * *

The following information was received via E-mail: On September 11, 2019, the licensee left a phone message informing the Agency (Texas Department of State health Services) that the gauge had been recovered. No additional information was provided. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Alexander), NMSS Events Notification E-mail group, CNSNS (Mexico), and ILTAB (Tucker). 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/Pub122

  • * * UPDATE AT 0959 EDT ON 9/12/19 FROM ART TUCKER TO JEFF HERRERA * * *

The following update was received from the Texas Department of State Health Services via email: On September 12, 2019, the Agency was contacted by the licensee and informed that the gauge had been recovered by a member of the general public on the day of the event (September 10, 2019). The individual who found the gauge contacted the licensee using the information provided on the gauge on September 11, 2019. The individual who recovered the gauge stated they found the gauge near the location the licensee had been using the gauge. The individual who found the gauge did not provide a reason they did not call before September 11, 2019. The gauge was inspected and was not damaged. The source was in the fully shielded position. A source leak test has been completed and sent for analysis. The individual who recovered the gauge stated they did not attempt to operate the gauge. The licensee stated they did not believe the individual who have been exposed because of this event. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Alexander), NMSS Events Notification E-mail group, CNSNS (Mexico), and ILTAB (Email). THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://wwwpub.iaea.org/MTCD/publications/PDF/Pub122

ENS 542531 September 2019 17:44:00A hurricane warning is in effect for St. Lucie County including the plant site. A hurricane warning was confirmed with the State Watch Office at 1717 EDT. As a matter of procedure, St. Lucie Nuclear Power Plant entered an Unusual Event classification for the hurricane warning. State and local officials have been notified by the licensee. The NRC Resident Inspector was notified of this by the licensee. This report is submitted in accordance with 10 CFR 50.72(a)(2)(i) due to the Notice of Unusual Event and 10 CFR 50.72(b)(2)(xi) due to the offsite notification."
ENS 5424930 August 2019 14:42:00The following information was received via facsimile: The New York State Department of Health (NYSDOH) was notified by the radiation safety officer (RSO) of Pall Hauppauge that they had an incident where the source did not retract completely, leaving the source partially exposed for a period of time. According to the RSO, on August 28, 2019 at about 1800 EDT, the source at Vault 4 had gotten stuck three inches above the down (safe) position. All of the safety and alarm systems worked as designed, and the operator did not attempt to enter the irradiator or take any action. The RSO indicated he was able to free the source by lifting it 'just an inch or two' then letting it back down. This is the same vault that had previous stuck source incidents (NY-19-05 and NY-19-06) (EN53984 and EN54025) this year. At that time Nordion removed the vault, re-conditioned it, and returned it to Pall. The RSO contacted Nordion and they are expected to be on-site the week of September 2nd. The vault will not be used until the issue is resolved. The RSO indicated he locked out all operators' key access to the vault until Nordion is on-site. The root cause for the source getting stuck has not yet been determined. DOH will continue to monitor this incident. Paul Hauppauge is licensed to possess Cobalt 60 in sealed source use in a Nordion International dry panoramic storage irradiator. NY Event Report ID No.: NY-19-08
ENS 5422619 August 2019 09:26:00

EN Revision Text: AGREEMENT STATE REPORT - CESIUM-137 SOURCE INVOLVED IN VEHICLE FIRE The following information was received via E-mail: This report is sent for informational purposes. On August 17, 2019, the Agency (Texas Department of State Health Services) received a call from the answering service and was informed that a licensee had reported a fire during transport of a density gauge. The Agency called the licensee, Halliburton Energy Services and was informed of the event. The licensee stated one of their blending trucks had been traveling on highway 285 south near Orla, Texas when the driver saw sparks coming from the road behind their truck. The driver pulled over and when they went to the back of the truck they found a tire had blown out and was now burning. The driver called for help, but by the time the fire department arrived, the truck was fully involved in the fire. The truck was transporting a 100 milliCurie cesium-137 source installed on a pipe. The licensee stated the dose rate at 30 centimeters from the gauge, taken after the fire was extinguished, was 2 millirem per hour, which is normal. The licensee stated the truck and trailer were taken to their facility and a leak test was taken on the gauge. The licensee stated the driver had pulled off the road and traffic was not restricted. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: I-9703 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

  • * * UPDATE FROM ART TUCKER TO DONALD NORWOOD AT 1013 EDT ON 8/19/2019 * * *

The following information was received via E-mail: The Agency received a call from the licensee at 0856 CDT on August 19, 2019. The licensee stated they had conducted additional surveys this morning and found dose rates were as high as five millirem per hour at one meter from the gauge. The licensee contacted their manufacturing section and one of the individuals was familiar with this type of event stated the gauge shielding was probably compromised, but believed the source was undamaged. The licensee stated the gauge would be returned to its manufacturing facility for inspection. No exposure has occurred from this event. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Young) and the NMSS Events Notification E-mail group.

  • * * UPDATE FROM ART TUCKER TO RICHARD SMITH AT 1743 EDT ON 8/28/2019 * * *

On August 28, 2019, the licensee notified the Agency that the results of the leak test performed on the source involved in this event had come back reading 0 dpm. Additional information will be provided as it is received in accordance with SA-300. Notified R4DO (Azua) and the NMSS Event Notification E-mail group.

ENS 534411 June 2018 15:50:00

The following information was received via E-mail: On May 31, 2018, during a turn-around at Calcasieu Refining Co., lockout and tagout procedures were not performed for two fixed gauges. Two non-radiation workers were over-exposed for the limit of 2 mR/hr. External radiation exposures are currently estimated at between 20 to 40 millirem whole body. The two sources were 50 mCi Cs-137 sources in Ohmart Vega Model SH-F1 gauges with serial numbers 70012 and 69998.

This event was reported by the facility on June 1, 2018. LA Event Report ID No.: LA20180010

ENS 534361 June 2018 11:39:00The following information was received via E-mail: On May 31, 2018, the Department (PA DEP Bureau of Radiation Protection) was notified by the licensee that a malfunction of a roll pin on a shutter handle occurred at a temporary jobsite in Eighty Four, Pennsylvania. It is initially reportable per 10 CFR 30.50(b)(2). A roll pin, which holds the shutter handle to the shutter shaft on a Berthhold Model LB 8010 in-line density gauge containing 20 milliCuries of cesium-137 became sheared off during an attempt to move the shutter to the open position, rendering the gauge unusable. The gauge is currently being stored at their Punxsutawney, PA location. The shutter is in the closed position and the gauge is out of service awaiting repair from the manufacturer. There was no other damage to the gauge. No overexposures have occurred. Radionuclide: Cs-137 Manufacturer: Berthold Model: LB 8010 Serial Number: 10485 Activity: 20 mCi The cause of the event has been attributed to normal wear and tear on the gauge. A reactive inspection is planned by the Department. PA Event Report ID No: PA180013
ENS 5430030 September 2019 10:28:00This 60-day telephone notification is being made per the reporting requirements specified by 10 CFR 50.73(a)(2)(iv)(A) and 10 CFR 50.73(a)(1) to describe an invalid actuation of a general containment isolation signal affecting more than one system. On July 31, 2019, at approximately 1650 hours Central Daylight Time (CDT), Browns Ferry Nuclear Plant (BFN), Unit 1 experienced a Primary Containment Isolation System (PCIS) Group 6 isolation during performance of surveillance procedure 1-SR-3.3.6.2.3(A), Reactor/Refueling Zone Ventilation Radiation Monitor 1-RM-90-140/142 Calibration and Functional Test. The Group 6 isolation caused the initiation of Standby Gas Treatment (SBGT) Trains A, B, and C, and Control Room Emergency Ventilation (CREV) subsystem B. Unit 1 H2O2 Analyzer and Drywell Radiation Monitor CAM, 1-RM-90-256, were declared Inoperable and Technical Specifications (TS) Limiting Condition for Operation (LCO) 3.4.5 Condition B was entered. All affected safety systems responded as expected. Plant conditions which initiate PCIS Group 6 actuations are Reactor Vessel Low Water Level (Level 3), High Drywell Pressure, or Reactor Building Ventilation Exhaust High Radiation (Reactor Zone or Refuel Zone). At the time of the event, these conditions did not exist; therefore, the actuation of the PCIS was invalid. This condition was the result of two cleared fuses in the alarm logic. The apparent cause is a ground fault on the A6 Open Drain Input/Output Module. There were no safety consequences or impact to the health and safety of the public as a result of this event. This event was entered into the Corrective Acton Program as Condition Report 1537358. The NRC Resident Inspector has been notified of this event."
ENS 5419131 July 2019 16:20:00On July 31, 2019, at 1206 CDT, Waterford 3 commenced initiation of a plant shutdown as required by Technical Specification (TS) Limiting Condition for Operation (LCO) 3.0.3. Prior to this, on July 31, 2019, at 1108 CDT, the boron injection flow paths were declared inoperable in accordance with LCO 3.1.2.2, 'Flow Paths - Operating,' and the charging pumps were declared inoperable in accordance with LCO 3.1.2.4, 'Charging Pumps-Operating.' This was due to visual examination identifying that propagation had progressed on a previously identified flaw on piping upstream of the header supplying the charging pumps. TS LCO 3.0.3 was entered due to the action statements of LCOs 3.1.2.2 and 3.1.2.4 not being met. LCO 3.0.3 requires that action shall be initiated within one hour to place the unit in a mode in which the specification does not apply by placing it in hot standby within the next 6 hours and cold shutdown within the next 30 hours. At 1206 CDT, Waterford 3 commenced direct boration to the reactor coolant system. This condition meets the reporting criteria of 10 CFR 50.72(b)(2)(i) due to the initiation of plant shutdown required by Technical Specifications and 10 CFR 50.72(b)(3)(v)(A) and (D) due to an event or condition that could have prevented fulfillment of a safety function of structures or systems that are needed to (A) shutdown the reactor and maintain it in a safe shutdown condition and (D) mitigate the consequences of an accident."
ENS 5419031 July 2019 15:55:00

EN Revision Text: DISCOVERY OF CONDITION THAT COULD HAVE PREVENTED FULFILLMENT OF A SAFETY FUNCTION South Texas Project (STP) Unit 1 reactor head vent valve B1RCHCV0601 was declared inoperable on December 29, 2018, STP Unit 1 reactor head vent valve B1RCHCV0602 was declared inoperable on July 30, 2019. Technical Specification 3.3.3.5 requires one of two reactor head vent valves to be operable. This issue placed the plant in a 30-day Technical Specification Action. At 0741 CDT on July 31, 2019, South Texas Project Electric Generating Station (STPEGS) made a determination based on firm evidence that reactor head vent valve B1RCHCV0602 had been inoperable since June 24, 2019. This results in a condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident. This report is being made pursuant to 10 CFR 50.72(b)(3)(v)(D), '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 mitigate the consequences of an accident. The inoperable equipment is required for accident conditions and presents no danger to the health and safety of the public or the safe operation of the units. The NRC Resident Inspector has been notified.

  • * * UPDATE FROM PAUL BURTON TO KERBY SCALES AT 1108 EDT ON 8/21/19 * * *

The Event Date and Time provided in EN# 54190 should have been reported as 7/30/2019 at 1521 CDT, since this was the time of discovery of a condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident. The NRC Resident Inspector has been notified. Notified R4DO (Young)."

ENS 5417318 July 2019 19:03:00The following was received via e-mail: On 07/17/19, the California Governor's Office of Emergency Services contacted the Radiologic Health Branch (RHB) to report a stolen moisture-density gauge. The gauge involved is a Troxler Model 3450A, S/N 483, containing 9 mCi of Cs-137 and 44 mCi of Am-241. The gauge was stolen out of a gauge technician's truck parked at a Motel 6 parking lot around 2100 PDT in Oakland, CA. The user had immediately called the Oakland Police Department and was advised to call back at a later time. On the morning of 7/18/19, the Oakland Police Department was contacted again and they declined to take a report due to high volume of incidents. The gauge was chained to the bed of the truck and there were guards present at the parking lot. The licensee will be posting a reward for the safe return of the gauge. RHB will be following up on this investigation. California 5010 Number: 071719 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 5417218 July 2019 13:22:00The following is an abstract of information received via E-mail: On July 17, 2019, a Capitol Ultrasonics (CU) three-person crew was making exposures on a compressor at a chemical plant at ExxonMobil Refinery, at a temporary jobsite in Baton Rouge, Louisiana. The three-person radiography crew consisted of two radiography instructors and an assistant radiographer. After performing three approximately one minute and 25 second exposures and upon completing the fourth exposure and cranking in the source, the radiography instructor noticed, after rocking the crank-out handle back and forth, that the exposure device auto-lock was not engaging. Before reaching the exposure device, the instructor noticed higher than expected survey readings. Several more attempts were made to crank in the source without success. The instructor at once contacted his Radiation Safety Officer (RSO), as well as the ExxonMobil Safety Superintendent. The crew then immediately extended their restricted area boundary to the 2 mR/hr line. Six to seven radiography technicians of the licensee maintained visual surveillance of the boundary and awaited arrival of their RSO. The exposure device was a QSA Global Model 741OP, serial number, B107, containing 15.1 Ci of Co-60, source Model number, A424-18 and source serial number, 60487B. The lead technician of the crew leading the incident response prior to the arrival of the RSO, received 30 mR on his direct-reading dosimeter (DRD). The RSO received approximately 17 mR on his DRD by the time that the source was finally placed back in the exposure device in the shielded position. An environmental scientist from the Louisiana Department of Environmental Quality made a site visit to the temporary jobsite of the incident and performed preliminary investigation to include observing the successful retrieval of the source on July 17, 2019, by QSA Global. QSA Radiation Technicians received from 40 to 78.3 mR whole body exposure as a result of performing the source retrieval. Louisiana Event Report ID No.: LA 190010
ENS 5413527 June 2019 09:45:00The following was received via e-mail: At approximately 1800 EDT on 6/25/2019, the conductivity of the underwater pool irradiator water rose to 308 microSiemens/cm and remained in this range throughout the night. This was in conjunction with low flow through the water circulation pump. The pump was repaired the morning of 6/26/2019 and subsequent conductivity readings have ranged from 24.3 microSiemens/cm to 13.9 microSiemens/cm. The licensee is currently on a plan of changing the deionization tanks every two days to continue cleaning the water. In addition they are working with a supplier on additional methods to clean the pool water. New Jersey Event Report Identification No.: INV190001-507147
ENS 5412318 June 2019 15:57:00The following information was received from the Ohio Department of Health via E-mail: On 6/17/2019, the licensee reported an incident while shooting at a client location in Bremen, Ohio. They were setting up 2 inch welds on a table in the shooting vault. The spool piece weighed approximately 40 pounds. As the radiographer cranked out the shot at approximately 1130 EDT, he immediately heard a loud noise and tried to crank the shot in, but could not get the source (Ir-192; 63.8 Curies) back into the camera. The vault door was opened slightly to see what had happened. The spool piece had fallen off the table and crushed the guide tube. The door to the vault was shut and licensee staff prepared a plan to get the source back into the camera. The RSO (Radiation Safety Officer) made a 15 second trip into the vault to shield the source using (6) 1 inch long x 2 inch thick x 4 inch wide lead blocks. During this first entry into the vault to put the shielding down, the RSO received a dose of 20 mR. The RSO made a second trip into the vault to put more shielding down and access the situation. During this time he discovered that the drive cable was partially sheared off and the guide tube was crimped at that area. The RSO received an additional 10 mR during this trip. With the shielding in place the licensee measured approximately 0.5 mR/hr outside the shooting vault. Proper source retrieval procedures were followed and the source was retrieved and placed into the camera using source retrieval equipment and new cranks and guide tubes. The Ohio Department of Health, Bureau of Environmental Health and Radiation Protection was contacted by phone at approximately 1430 EDT on 6/17/2019, to inform of what transpired. At no time were there any members of the public exposed. During the whole retrieval process the RSO received a total dose of 55 mR. Ohio Item Number: OH190008
ENS 5411111 June 2019 17:55:00At 1132 CDT on 6/11/2019, both manual primary containment isolation valves in a one-inch service air line were found open. This resulted in an open primary containment penetration. Both valves are required to be closed for Primary Containment Isolation Valve Operability. Both valves were closed and independently verified closed at 1149 CDT on 6/11/2019. This is being reported under 10 CFR 50.72(b)(3)(v)(C) and (D), and 10 CFR 50.72(b)(3)(ii)(B). There was no impact to the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified. The licensee also notified the State of Minnesota State Duty Officer.
ENS 541068 June 2019 22:29:00The following information was received via E-mail: On (6/8/19), Cal OES (California Office of Emergency Services) contacted RHB (Radiologic Health Branch) to report an incident regarding a damaged moisture-density gauge. The incident occurred on 6/7/19, at a temporary job site located at 1627 Fulton Road, Santa Rosa, CA. The gauge involved is a CPN Model MC1, S/N M13044837, containing 10 mCi of Cs-137 and 50 mCi of Am-241. The gauge was run-over by a construction vehicle at the job site. The gauge housing has been damaged and the user was unable to retract the source rod back into shielded position. The RSO contacted a gauge vendor, Pacific Nuclear Technology (PNT), and they immediately responded to the incident at the site. The gauge was secured by PNT and transported back to their storage for disposal. Leak test performed by PNT did not indicate any contamination. The RHB will be following up on this incident. California 5010 Number: 060819
ENS 5407218 May 2019 14:00:00This is a non-emergency notification to the NRC Operations Center in accordance with 10 CFR 50.72(b)(2)(iv)(B) for a valid actuation of the Reactor Protection System (RPS) (four hour notification) and 10 CFR 50.72(b)(3)(iv)(A) for a valid Engineered Safeguards (ESF) actuation (eight hour notification) due to Auxiliary Feedwater (AFW) initiation. Unit 3 manual reactor trip following grid disturbance. Following the grid disturbance, a manual reactor trip was initiated due to lowering steam generator water levels. All control rods fully inserted. AFW started as expected. All other systems responded as expected. Current reactor temperature is 547 degrees F. Current reactor pressure is 2235 psig. Decay heat is being removed through the Atmospheric Steam Dumps (no known primary to secondary Reactor Coolant System leakage exists). The unit is in a normal post-trip electrical lineup. There was no affect on Unit 4. The cause of the grid disturbance is under investigation. The licensee notified the NRC Resident Inspector.
ENS 5406816 May 2019 18:07:00This is a non-emergency notification from Waterford 3. On May 16, 2019, at 1348 CDT, Waterford 3 experienced an automatic reactor trip due to Steam Generator number 1 high level, which was the result of a Main Turbine trip and subsequent reactor power cutback which had occurred at 1345 CDT. The cause of the Main Turbine trip is currently under investigation. Subsequent to the Reactor trip, Main Feedwater Isolation Valves number 1 and number 2 closed on high Steam Generator levels. Emergency Feedwater automatically actuated for Steam Generator number 2 at 1419 CDT and Steam Generator number 1 at 1425 CDT. Main Feedwater was restored to both Steam Generators by 1629 CDT. The plant entered the Emergency Operating Procedure for an uncomplicated reactor trip and is in the process of transitioning to the normal operating shutdown procedure. The plant is currently in Mode 3 and stable with Main Feedwater feeding and maintaining both Steam Generators. The NRC Senior Resident Inspector has been notified. All control rods fully inserted. Decay heat is being removed through the main condenser. The plant is in a normal shutdown electrical lineup.
ENS 5413427 June 2019 09:30:00The following is a summary of the phone conversation with the licensee: Two Ni-63 sources (Agilent Technologies S/Ns PRO30 and U11381) used in an electron capture detector were found to be leaking. Both sources contained 15 mCi Ni-63. Leakages were 0.048 and 0.039 microCuries. Both sources will be transferred to Agilent Technologies for disposal. Leak tests are performed every 6-months. The last leak tests were performed on 01/08/2019. The licensee contacted NRC Region I regarding this event.
ENS 5399713 April 2019 02:04:00

EN Revision Text: HIGH ENERGY LINE BREAK DOOR FOUND IN INCORRECT POSITION RESULTING IN LPCI AND CORE SPRAY BEING INOPERABLE At approximately 1815 CDT on April 12, 2019, High Energy Line Break (HELB) Door-410A in the Reactor Building was discovered in the closed position. HELB Door-410B was previously closed for maintenance. Either Door-410A or Door-410B must be open to support the current HELB analyses. With both doors closed, this is considered an unanalyzed condition resulting in the loss of a post-HELB safe shutdown path. With Door-410A and Door-410B closed, LPCI (Low Pressure Coolant Injection) and Core Spray injection valves in both divisions are no longer considered available. This condition is being reported under 10 CFR 50.72(b)(3)(ii) as an unanalyzed condition that significantly degrades plant safety and 10 CFR 50.72(b)(3)(v) as an event or condition that could have prevented the fulfillment of a safety function. The condition was resolved at approximately 1845 CDT on April 12, 2019 when Door-410A was blocked open. The health and safety of the public was not affected by this condition. The NRC Resident has been notified.

  • * * RETRACTION FROM JESSE TYGUM TO HOWIE CROUCH AT 1330 EDT ON 5/24/19 * * *

Event Notification (EN) #53997, made on 4/13/2019, is being retracted. An engineering evaluation completed subsequent to this event analyzed the discovered condition with both Door-410A and Door-410B being closed. The engineering evaluation determined that the environmental conditions present with both Door-410A and Door-410B closed would not have impacted the availability of both divisions of the LPCI (Low Pressure Coolant Injection) and Core Spray injection valves nor would it have resulted in the loss of a post-HELB safe shutdown path. Therefore, this condition did not meet the criteria for an 8-hour notification per 10 CFR 50.72(b)(3)(ii) as an unanalyzed condition that significantly degrades plant safety or per 10 CFR 50.72(b)(3)(v)(D) as an event or condition that could have prevented the fulfillment of a safety function. The NRC Resident Inspector has been notified. The licensee also notified the Minnesota State Duty Officer. Notified R3DO (Cameron).

ENS 539702 April 2019 18:39:00The following information was received via E-mail: The licensee RSO (Radiation Safety Officer) reported that a Mistras technician lost an INC IR-100 radiography camera, serial number 6744, on April 1, 2019, between approximately 0000 and 0100 PDT. The camera contained an Ir-192 sealed source, number 159E, with 85.3 curies. The radiography camera was left unsecured on the tailgate of a company darkroom vehicle upon departing the licensee's Long Beach office. The camera was being transported to the Chevron refinery in El Segundo for radiographic operations during the night. The lost camera was reported to the Long Beach office (at approximately 0110 PDT) by the technician upon arrival at the El Segundo refinery, and a radiography crew was sent from the Long Beach office to search the route taken by the first individual. The camera was found and recovered by the radiography crew approximately 0130 PDT on the breakdown lane of limited-access CA Hwy 91 westbound, approximately 4 miles from the Long Beach facility (near Wilmington Ave). The recovered radiography camera was returned to the Long Beach facility, where a leak test was performed, showing no leakage. The radiography camera was sent to a repair facility for further inspection. RHB (Radiation Health Branch) will investigate the cause of the incident, take appropriate enforcement action, and ensure appropriate corrective actions by the licensee. California 5010 Number: 040119 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 and/or FAX: Mexico, FDA EOC, NuclearSSA, FEMA National Watch Center, DNDO-JAC. 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.pdf
ENS 5394217 March 2019 14:10:00

EN Revision Text: HIGH PRESSURE COOLANT INJECTION SYSTEM DECLARED INOPERABLE At 0735 CDT on March 17, 2019, the High Pressure Coolant Injection (HPCI) system was isolated due to a water-side leak from the HPCI Gland Seal Condenser. Unit 3 declared the HPCI system Inoperable and entered Technical Specification LCO 3.5.1 Condition C with required actions to verify the Reactor Core Isolation Cooling system is Operable, and to restore the HPCI system to Operable status within 14 days. All other Unit 3 Emergency Core Cooling Systems (ECCS) remain Operable. This condition is being reported pursuant to 10 CFR 50.72(b)(3)(V)(D), '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 mitigate the consequences of an accident.' This is also reportable as a 60-day written report in accordance with 10 CFR 50.73(a)(2)(V)(D). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified of this event.

  • * * RETRACTION FROM WESLEY CONKLE TO HOWIE CROUCH ON 4/23/19 AT 1549 EDT * * *

ENS Event Number 53942, made on March 17, 2019, is being retracted. NRC Notification 53942 was made to ensure that the Eight-Hour Non-Emergency reporting requirements of 10 CFR 50.72 (b)(3)(v)(D) were met when the licensee discovered an event, 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. At 0735 CDT, on March 17, 2019, during the performance of a routine surveillance, a momentary pressure transient of 844 psig from the Feedwater system was introduced into the High Pressure Coolant Injection (HPCI) system discharge and suction piping that ruptured the seal on the gland seal condenser and flooded the U3 HPCI Room. Unit 3 HPCI was declared inoperable due to isolation of the waterside of the HPCl system. On April 11, 2019, a Past Operability Evaluation was completed which determined that the HPCI System remained operable. The evaluation of the potential pressure transient and room flooding concluded that the HPCI System could have performed its specified safety function of vessel injection throughout the time that the gland seal was ruptured. Therefore, this event is not reportable under 10 CFR 50.72(b)(3)(v)(D). TVA's evaluation of this event is documented in the Corrective Action Program in Condition Report 149973. The licensee has notified the NRC Resident Inspector. Notified R2DO (Ehrhardt).

ENS 539804 April 2019 17:36:00The following information was received via e-mail: Louisiana Department of Environmental Quality (LDEQ) was notified of this event on Monday, April 1, 2019. This event occurred in a manufacturing fabrication shop in a fixed shooting bay. On Tuesday, March 12, 2019, the Radiation Safety Officer (RSO) and a radiography trainee were shooting welds at the Steel Forgigs, Inc. (SF) site. The RSO stated the QC/QA (Quality Control/Quality Assurance) safety checks had been performed before the 'radiography work' began. During radiography work of shooting welds and exchanging out pipe to be x-rayed, the trainee proceeded to change out the film on the pipe while the RSO went to retrieve a new piece of pipe. The safety alarm/lights were not flashing and the trainee assumed the source had been retracted into the shielded position. However, the trainee's survey meter saturated and his pocket dosimeter went off scale. The lights and alarm were still not responding. The RSO stated 'I knew the trainee did not exceed the 5 REM exposure limit due to my work experience.' The survey meter was functioning properly when removed from the 'high radiation' field and his pocket dosimeter appeared to function properly when re-zeroed after the off-scale reading. The trainee's personnel monitor was sent to be processed for his personal exposure. The exposure results were 2.488 REM exposure. The equipment involved in the incident was a QSA 880 Delta, s/n D5843, exposure device with a QSA source model A424-9, Ir-192 source, s/n 71973G with an activity of 19 Ci. The internal investigation documented there was no excessive exposure to the trainee. However, the late reporting of the incident, not reporting of the incident by regulatory requirement and no commitment to corrective actions to prevent these events from reoccurring in the future are still outstanding. LDEQ is seeking escalated enforcement actions pertaining to this licensee and NMED incident. Louisiana Event Report ID No.: LA-190005
ENS 539062 March 2019 06:12:00At 0317 CST, the Unit 2 Reactor tripped due to Feedwater Isolation Valve (FWIV) 2-04 going closed. All Auxiliary Feedwater Pumps started due to steam generator Lo-Lo levels. Unit 2 is being maintained in Hot Standby (Mode 3) in accordance with Integrated Plant Operating Procedure IPO-007B. The Emergency Response Guideline Procedure Network has been exited. Decay heat is being rejected to the Main Condenser via the Steam Dump Valves. The cause of the FWIV going closed is currently under investigation. All control rods fully inserted and the reactor trip was uncomplicated. Unit 2 is in a normal post-trip electrical line-up. There was no impact on Unit 1 due to the Unit 2 reactor trip. The licensee notified the NRC Resident Inspector.
ENS 5389825 February 2019 15:43:00The following information was received via e-mail: On February 25, 2019, the Agency (Texas Department of State Health Services) received a report from the licensee's technical representative stating that the shutter on an Ohmart Vega model SH-F1 gauge, containing a 50 millicurie cesium-137 source, failed to shut during maintenance when the handle broke off. Open is the normal operation position of the gauge shutter. No licensee employee received any exposure as a result of this event. The gauge will be repaired in September 2019 during an outage. Additional information will be sent in accordance with SA-300. Texas Incident #: 9659
ENS 5384424 January 2019 11:14:00

EN Revision Text: FAILURE TO CLOSE AND LOCK NUCLEAR GAUGE SHUTTER The following was received via e-mail: Between 2200 EST on January 23, 2019 and 0000 EST on January 24, 2019 a Ronan RLL1 (Density Scale Source) was unbolted from the frame on which it was mounted and placed on the floor. (Source was a Cs-137 0.54 milliCurie decayed to 0.45 milliCurie, Serial #212785A) No permit was pulled to remove the scale source, and the shutter wasn't closed and locked out. After it was unbolted, and was placed on the floor with the beam pointed towards a conveyor belt and the ceiling. Balling line 10, Conveyor 21 was approximately 6 feet above the placed source, and the ceiling is at 60 feet. No employees worked in front of the beam once placed on the floor. No one noticed the scale sitting on the floor unlocked until January 24, 2019 around 1500 EST. Once the source was found, trained personnel put the shutter block in place and locked out the source. The RSO then authorized a permit. Once the source was secured, and permit posted, the RSO did a full investigation. Basic cause - The maintenance employee that unbolted the source entered the area from a direction that could only be accessed during a maintenance down. There was a radiation label on the scale itself, but no sign from his access point.

  • * * RETRACTION ON 2/18/19 AT 1311 EST FROM LAWRENCE GRAY TO THOMAS KENDZIA * * *

Based on the findings of an NRC inspector, this event was determined to not be reportable since the shutter was fully functional and no exposure to personal occurred. Notified R3DO (Duncan), NMSS Events Notification Group by email.

ENS 5382816 January 2019 08:12:00On January 16, 2019, with James A. Fitzpatrick Nuclear Power Plant operating at 100 percent power, the Emergency and Plant Information Computer (EPIC) indicated that Secondary Containment differential pressure exceeded the Technical Specification Surveillance Requirement of greater than or equal to 0.25 inches of vacuum water gauge while isolating Reactor Building Ventilation. The Secondary Containment differential pressure was less than 0.25 inches of vacuum water gauge for approximately ten (10) seconds, and then immediately returned to greater than or equal to 0.25 inches of vacuum water gauge. This condition did not impact the leak tightness of Secondary Containment or the ability of the Standby Gas Treatment system to establish and maintain the required differential pressure. When Secondary Containment did not meet the Technical Specification Surveillance Requirement 3.6.4.1.1 for differential pressure, the Limiting Condition of Operation (LCO) was not met. Therefore, Secondary Containment was inoperable. This event is being reported under 10 CFR 50.72(b)(3)(v)(C). The licensee has notified the NRC Resident Inspector."
ENS 538188 January 2019 15:45:00On January 8, 2019, at 0945 EST Pilgrim Nuclear Power Station discovered that the Reactor Core Isolation Cooling (RCIC) system failed to meet its surveillance test requirements and was declared inoperable; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v), 'event or condition that could have prevented the fulfillment of a safety function: (D), mitigate the consequences of an accident.' There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
ENS 538167 January 2019 12:48:00

EN Revision Text: PART 21 - COMPONENTS PROVIDED AS SAFETY-RELATED SPARE PARTS WITHOUT BEING DEDICATED AMETEK Solidstate Controls (SCI) is providing this report in accordance with 10CFR Part 21 as notice of a process defect that resulted in components being provided as safety-related spare parts without being dedicated. PROBLEM DESCRIPTION: Lack of evidence of dedication testing for AMETEK Solidstate Controls Safety-Related Operational Spare Parts Kits provided with SCI equipment CAUSE: In October 2018, NextEra Seabrook notified SCI of a part number discrepancy with a safety-related fuse that was provided with an operational spare parts kit with an equipment order. After further investigation, it was determined that dedication testing was not performed on the operational spare parts kits provided with the equipment on various jobs in recent years. Generally, spare parts are ordered separately from equipment and a process is in place to direct the parts to quality for commercial grade dedication testing. In this instance, the parts were ordered as a line item on the sale and the parts in question were selected from inventory without being routed through quality for commercial grade dedication. PROBLEM YOU COULD SEE: Evidence of dedication testing is not available for operational spare parts kits which were provided with equipment orders, however, there are no functional concerns with the components provided on these orders. The parts would have been selected at the same time as the parts that were installed in the systems. Additionally, for the commercial grade items provided, there is no history of failure during dedication testing performed by AMETEK either in equipment or during bench testing. ACTION REQUIRED: Aside from printed circuit boards, the parts supplied as operational spare parts will need to be dedicated. AMETEK SCI recommends returning the untested items and will work with (the customer) to arrange returns and retesting. Please contact Mr. Mark Shreve of AMETEK SCI's Client Services group at 1-800-222-9079, 1-614-846-7500 ext. 6332, or mark.shreve@ametek.com. The non-dedicated parts were supplied to Brunswick Steam Electric Plant, Seabrook Station, and North Anna Power Station. In addition, non-dedicated parts were also supplied to the Krsko Nuclear Power Plant in Slovenia and the Maanshan Nuclear Power Plant in Taiwan.

  • * * UPDATE ON 1/31/19 AT 1304 EST FROM ETHAN SALSBURY TO OSSY FONT * * *

The following was received via email from Ametek: After further evaluation, (Ametek) has determined that additional kits are impacted by this issue, but the same customer list and POs apply. No additional customers are impacted and a corrected notification will be provided to customers that have been previously identified. R1DO (Bickett) and R2DO (Lopez) were notified. Part 21 Reactors Group was notified via email.

ENS 538155 January 2019 17:30:00

EN Revision Text: POTENTIAL LOSS OF MSIV SCRAM FUNCTION DURING MAIN STEAM LINE ISOLATION VALVE TESTING At approximately 1040 EST on January 5, 2019, during evaluation of test results for the 'C' Main Steam Isolation Valve (MSIV), it was determined that closure of three of four Main Steam Lines would not necessarily have resulted in a full scram during testing due to failure of a limit switch (LS-6) associated with MSIV-1C while in the test configuration. This condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v), 'Any event or condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to: (A) Shut down the reactor and maintain it in a safe shutdown condition.' The system was restored from the testing configuration at 1057 EST and the failed trip channel was placed in the tripped condition at 1326 EST thus restoring the design function. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified.

  • * * RETRACTION AT 1529 EST ON 02/11/19 FROM JOSEPH FRATTASIO TO JEFF HERRERA * * *

The purpose of the notification is to retract ENS Notification 53815 made on 01/05/19 for Pilgrim Nuclear Power Station. The previous notification reported that there was a potential loss of Main Steam Isolation Valve (MSIV) scram function during main steam line isolation valve testing, at the time of discovery, due to failure of a limit switch (LS-6) associated with MSIV-1C while in the test configuration. Subsequent evaluation has demonstrated that the scram function credited in the design basis was not lost. Specifically, after an Engineering Evaluation, it has been determined that the MSIV position RPS logic was not lost for those functions within the design basis and, as such, was capable of performing its intended safety function. The NRC Resident Inspector has been notified. Notified the R1DO (Cahill).

ENS 538144 January 2019 12:15:00

EN Revision Text: MEDICAL EVENT - Y-90 THERASPHERES ADMINISTERED TO THE WRONG LIVER SEGMENT A medical event occurred on 1/3/2019 at Washington University in St. Louis. The patient treatment plan called for 1.06 GBq of Y-90 TheraSpheres to be administered to Segments 6 and 7 of the patient's liver. However, 1.02 GBq of Y-90 TheraSpheres were administered to Segments 5 and 8 of the patient's liver instead. The patient and the referring physician were notified of the event. Washington University in St. Louis has initiated an investigation of the event.

  • * * RETRACTION ON 1/14/19 AT 1256 EST FROM MAXWELL AMURAO TO THOMAS KENDZIA * * *

The following was received via email from the licensee: As a follow up to the phone call placed today (1/14/19) at 12:56 pm EST, (the licensee radiation safety officer) is writing to retract the report of a event number 53814. The initial report of a suspected medical event with the administration of Y-90 microspheres to a patient was made on 1/4/19 at 12:15 pm EST. After taking the limitations of the imaging software into account, the reviewing team of clinicians have evaluated that the Y-90 microspheres were administered to the correct patient, with the correct dosage and correct route of administration, and in agreement with the Written Directive. Notified R3DO (PELKE) and NMSS vis email. A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

ENS 5374316 November 2018 18:13:00The following information was received via E-mail: On November 16, 2018, the Agency (Texas Department of State Health Services) was notified by the licensee that a medical event had occurred earlier that day. The event occurred when the licensee attempted to treat a patient with 220 grays of Yttrium-90 (TheraSphere) microspheres. After the treatment the injection catheter was removed from the device and placed in a storage container. A survey of the container indicated the dose rate was half of the dose rate prior to injection. The licensee stated they believe only 107.1 Grays of the spheres had been injected into the patient. The licensee did not provide the target organ, but will provide it in the written report. The licensee stated the patient would not experience any adverse effects from the event. The licensee stated no individual performing the treatment received any significant exposure. The licensee stated the area was not contaminated. The licensee did not have a cause for the event, but will provide it once determined. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: I - 9636 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 5367921 October 2018 16:19:00The following information was received via E-mail: On October 20, 2018, the agency (Texas Department of State Health Services) was notified by the licensee's radiation safety officer (RSO) that one of its radiography crews was unable to return an 80 curie iridium-192 source to the fully shielded position in an INC IR 100 exposure device. The RSO stated that the event occurred near Pecos, Texas. The RSO stated that the radiographers had established a 2 millirem boundary. An individual listed on their license responded to perform the source retrieval. The location where the event occurred was remote and the event did not present an exposure risk to any individual. The RSO stated that there are very few people at the site. Once the individual who was sent to retrieve the source arrived, they inspected the exposure device and guide tube. The inspection discovered the radiographers had bent the guide tube to get it through some pipes and the angle of the bend was what had prevented the source from being retracted. The guide tube was straightened and the source was retracted to the fully shielded position at 2100 hours. The guide tube was inspected and did not have any damage. The RSO stated that no overexposures had occurred. Texas Incident Number: 9622
ENS 5362928 September 2018 10:21:00The following information was received via E-mail: On 09/24/2018 the licensee discovered unusual dose rate survey readings on the floor in the treatment area. The licensee notified the Department (South Carolina Department of Health and Environmental Control) on 09/27/2018 via telephone that a potential contamination event had occurred. The licensee is authorized to administer liquid Iodine 131 for the treatment of hyperthyroidism in cats. The last administration occurred on 09/04/2018, with approximately 5 mCi of I-131 administered via syringe to a cat. A BRH (Bureau Radiological Health) Inspector was dispatched to the facility on 09/27/2018 and confirmed contamination of an area of floor in the treatment area. Access to the contaminated area has been restricted and boundaries have been put in place to ensure the dose rate does not exceed .002 rem in any one hour. The Department is conducting an investigation into the incident."
ENS 5354510 August 2018 19:36:00This event occurred on August 9, 2018, at the VA Portland Health Care System, Portland, Oregon. The patient was to receive a prescribed dose of 134 gray to a segment of the liver as a treatment for liver cancer, with Y-90 microspheres. After the procedure, the (actual) dose to the intended segment was estimated as approximately 103 gray, 77 percent of the prescribed dose. The patient has been notified. No harm to the patient is anticipated. 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.