|Entered date||Event description|
|ENS 54095||31 May 2019 14:27:00|
EN Revision Text: PART 21 NOTIFICATION - INTROL POSITIONERS POTENTIAL LATENT DEFECT The following is an excerpt of the Part 21 information received via email: Introl Positioners used by stations in G32 Terry Turbine control applicators have the potential to contain a latent defect. The defect is the result of internal corrosion which has been identified in Tl Operational Amplifiers Part No.TL084CN on the SL3EX Controller Boards of the turbine throttle valve positioner. It is believed the likely cause is associated with the ingress of solder flux into the IC Chip package on the controller board due to delamination caused by the soldering process during fabrication. The corrosion over time can result in intermittent open circuiting and high resistance in the aluminum metallization. Chlorine ionic contamination can also result in high leakage currents within the component circuitry. Failures may be manifested by a reduced valve position signal disproportional to the expected demand condition, no actuation signal (i.e. throttle valve remaining full open), or other anomalous unexpected behavior. There are three TL084CN chips on each SL3EX Controller Board within the positioner assembly. There have been two documented failures to date occurring in 2015 and 2019 in installed systems. Date determination was made: May 29, 2019 Affected sites: Farley, SONGS, Cooper, Almaraz Trillo Nuclear Power Plant (Spain), Clinton, Harris, Wolf Creek, Point Beach, Hatch, Watts Bar, Sequoyah. Stations are advised to work directly with Curtiss-Wright SAS via the technical contacts below. Randy F. Iantorno Project Manager, T: 585.596.3831, M: 585.596.9248, email firstname.lastname@example.org or Justin Pierce 585.596.3866.
The following is a synopsis of information received via E-mail: Shearon Harris Nuclear Plant experienced an overspeed trip of the Turbine Driven Auxiliary Feedwater Pump (TDAFW) on January 18, 2019 during routine system testing. Upon receipt of the initial start signal, the valve remained in the fully open position causing the TDAFW to trip on overspeed. Investigation into the overspeed trip revealed the positioner was not controlling the actuator properly in response to the governor command signal. This situation and subsequent troubleshooting led to replacement with the site spare positioner. Once installed, the system responded as expected and the suspect positioner was sent to Curtiss-Wright SAS (CW SAS) for evaluation. In a joint effort between CW SAS and Paragon Energy Solutions (PES), the positioner was tested and evaluated to determine the cause of the failure. Corrective action which has been, is being, or will be taken: - The three TI chips on the affected board have been successfully replaced at PES. The repaired positioner will be configured and returned to Shearon Harris. - The evaluation of suspect chips has been limited to those removed from the failed positioner, along with some supplied to PES by CW SAS. Work is ongoing in this area. - A complete list of potentially affected installations is listed in the PES Part 21 Report dated May 31, 2019. - Although this defect has the potential of preventing the Electronic Governor Speed Control System (EGSCS) from performing its intended safety function, it does not prevent the Terry Steam Turbine from operating. If the EGSCS fails, the turbine can be operated manually using the Trip and Throttle Valve (TTV) to control speed by regulating steam flow to the turbine. - Steps are being taken to develop a plan to replace chips on affected positioner boards. This is still in the preliminary stages and specific recommendations will follow. Notified R1DO (Carfang), R2DO (Rose), R3DO (Kozak), R4DO (Kellar), Part 21 Reactors E-mail group, and Part 21 Materials E-mail group.
|ENS 54069||17 May 2019 03:35:00|
EN Revision Text: REACTOR TRIP DUE TO SOURCE RANGE HI FLUX SIGNAL This is an 8-hour, non-emergency notification for a valid reactor trip signal with the reactor not critical, and a valid auxiliary feedwater system actuation in accordance with 10 CFR 50.72(b)(3)(iv)(A) - Valid System Actuation.
At 2303 (CDT) on May 16, 2019, the plant was administratively in mode 2 due to withdrawing control rods for startup following refuel. The reactor had not been declared critical. The P-6 permissive at 10E-10 Amps was met for one of two Intermediate Range detectors allowing for block of the Source Range high flux trip (1E5CPS). Prior to performing the block, the Source Range high flux trip setpoint was exceeded and a reactor trip received. All systems responded as expected. A feedwater isolation signal was received due to the reactor trip with feedwater temperature less than 564 degrees Fahrenheit. Auxiliary feedwater was started to maintain steam generator levels. The plant is being maintained stable in mode 3 with no complications. The NRC Resident Inspector was present during the startup and was notified of the reactor trip.
A correction is being made for the sixth sentence in the second paragraph above, which states, 'A Feedwater Isolation signal was received due to the reactor trip with feedwater temperature less than 564 degrees Fahrenheit.' Within this sentence, 'feedwater temperature' is to be replaced with 'reactor coolant system temperature.' The licensee has notified the NRC Senior Resident Inspector.
|ENS 54066||16 May 2019 00:54:00|
The following is a summary of an e-mail received from the State of Florida: On May 15, 2019 at 2327 EDT, the Florida Division of Emergency Management, Radiation Control Duty Officer, contacted the NRC via e-mail to report that all westbound lanes of East Colonial Drive, in Orlando FL, were closed and the entrance and exit ramps to/from State Route 417 were closed. The State Trooper on scene reported that there was a potential release of an unknown quantity of medical grade radioactive material, Molybdenum-99. This material is used in the treatment of cancer. Orange County HAZMAT was dispatched to the scene and requested a call back for assistance. A state inspector was dispatched to the scene. The inspector found no damage to the radioactive material and no contamination. The material was housed in a lead lined box, surrounded by styrofoam, in a cardboard shipping container. There was one person reported with minor injuries due to the crash. Florida Report No.: 2019-2728 Notified DOT Crisis Management Center, DOE and DHS SWO.
Vehicle accident occurred around 2215 EDT on the west bound side of East Colonial Drive at the south bound exit ramp of the 417 involving medical radioisotopes. Tradewind Enterprises Inc (Hillsboro, OR; 503-648-2823) courier vehicle was a small SUV with radioactive placards carrying three packages of Mo-99 in the back of the SUV. Contact cell phone numbers for Orange County Fire are 407-402-8532 and 407-383-9806. State of Florida inspector responded. The boxes did not leave the vehicle nor sustain any damage nor was there any leakage of radioactive material. Surveys of packages showed all within Tl (transportation index), swipes indicated no removable contamination. Custody of packages was taken by driver's supervisor. This incident is closed. Notified R1DO (Carfang) and the NMSS Events Notification E-mail group.
|ENS 54070||17 May 2019 08:06:00||The following was received via e-mail: On May 14, 2019, at approximately 1620 (EDT) Kentucky Transportation Cabinet, (KY RML# 201-086-51) reported that a Humboldt 5001 EZ, serial number 3133 moisture density gauge had been severely damaged and partially buried by a bulldozer, at a road construction project in Madison County located near Richmond KY. The gauge contained 0.37 GigaBq (10 milliCi) Cesium-137 (serial number 8273GQ) and 1.48 GigaBq (40 milliCi) Americium-24:Beryllium (serial number NJ03357). The technician had been taking some readings, while waiting for more rock to be put in place and put the device in safety mode and set it on top of pile of Dense Graded Aggregate. He then walked over about 80 feet to talk to an operator when it was run over by a bulldozer. KY Radiation Health Branch personnel were on the scene at approximately 1800 (EDT) and determined that the top of the source rod had been broken off and the outer case of the gauge was cracked. There was no leakage detected and the survey of the broken case showed readings = 10mR/hr on contact indicating that the shielding had not been compromised. The area was taped off in a 30 foot circle surrounding the damaged device till it was recovered by the Fayette County HAZMAT Team and placed into a 55 gallon drum, sealed and removed to a storage facility. The Radiation Safety Office indicated that a final decision on the disposition of the gauge will be forthcoming, and that retraining of the employee would be a priority, to include emphasis on surveillance and situational awareness at jobsites. KY Event No.: KY190005|
|ENS 54065||15 May 2019 11:11:00||On May 14, 2019, at 1324 EDT the Radiation Safety Officer (RSO) was contacted by the Operation Manager and informed that a source located at a site in Muskegon MI could not be returned to the shielded position by the normal means. The technicians verified the boundary to ensure no unplanned exposure. The RSO called the site technician and went through the source retrieval procedure. The source was a SPEC model 150 camera with 89 Ci Ir-192 source. The RSO went to the site and was able to determine the location of the source and put temporary shielding on it. The RSO determined the source tubing was crimped and was able to straighten the tube. The source was retracted into the camera and locked by 1550 EDT. The crimped tubing was replaced with new tubing. The device was tested satisfactorily. There were no over exposures. The doses received during the radiography and retrieval process were: RSO 28 mR, Radiography 23 mR, and Assistant Radiography3 mR.|
|ENS 54033||28 April 2019 14:57:00|
The following was received from the state of Arizona via e-mail: The (Arizona Department of Health Services) received notification that an individual stole (three) industrial radiography cameras and threatened to use them. It is believed that the individual is a current or former worker at the licensee. The isotope is Iridium-192 for all three cameras and the approximate activity amounts are 30 Curies, 49 Curies, and 80 Curies. As of approximately 1120 (MDT), the individual was located, the material was secured, and the (Radiation Safety Office) is waiting to bring the material back to the storage location. The Department has requested additional information and continues to investigate the event. Arizona Incident No.: 19-009 Notified DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, DHS NICC, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and Domestic Nuclear Detection Office Joint Analysis Center (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.pdf
The following is a summary of a telephone call: The sources were safely recovered. They were found in the radiography cameras. It is widely believed that the suspect never removed the sources from the shielded cameras. The cameras have been returned to the storage facility. Notified R4RDO (Young), NMSS Events Notification (email), NMSS (Moore), ILTAB (e-mail), CNSNS Mexico (email), IR MOC (Kennedy), ILTAB (Smith), NMSS INES Coordinator (email), INES National Officer (email). Notified DHS SWO, DOE Ops Center, FEMA Ops Center, HHS Ops Center, DHS NICC, USDA Ops Center, EPA Emergency Ops Center, FDA Emergency Ops Center (email), FEMA NWC (email), DHS Nuclear SSA (email), and Domestic Nuclear Detection Office Joint Analysis Center (email).
|ENS 54053||7 May 2019 13:57:00||The following was received via e-mail: During a routine (Utah Division of Radiation Control) inspection on April 26, 2019, the licensee discovered that two planchet sources containing radioactive materials were missing from its secured laboratory. The sources were used to calibrate a wipe counting system that the licensee rarely used. One source contained 9.9 nanoCuries of strontium-90 (Sr-90) and the other source contained 17.81 nanoCuries of plutonium-239 (Pu-239). The activity of the Sr-90 source was well below the exempt quantity threshold. The inspector gave the licensee until May 3, 2019, to search for the sources and to let the inspector know the results of the search. On May 2, 2019, the licensee informed the Division that, after an exhaustive search, the licensee had failed to locate the sources. Following a review of the applicable rules by Division staff on May 6, 2019, the inspector verified with the licensee that the sources were still missing and informed the licensee of the incident notification requirements and the anticipated enforcement activities to be taken by the Division. Event Report No.: UT190001 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 54027||25 April 2019 12:04:00||At 0918 (EDT) on 4/25/19, with (Saint Lucie) Unit 1 in Mode 1 at 100% power, the reactor automatically tripped due to a Turbine Trip. The reactor trip was uncomplicated with all systems responding normally. Operations is maintaining the plant stable in Mode 3. Decay heat removal is being accomplished by main feed water and the main condenser using the turbine steam bypass valves. Unit 2 is not affected and remains at 100% power. This event is being reported pursuant to 10 CFR 50.72(b)(2)(iv)(B). The NRC Resident Inspector has been notified."|
|ENS 54029||25 April 2019 17:42:00|
The following was received from the state of Arizona via e-mail: The (Arizona Department of Health Services) received notification from the licensee that an individual received a whole body exposure of approximately 290 Rem for the month of March. The individual is believed to be an x-ray technologist that works in the operating room. It is unknown at this time if the individual may also work with radioactive materials. The Department has requested additional information and continues to investigate the event. Additional information will be provided as it is received in accordance with SA-300. Arizona incident Number 19-008. A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
The following was received from the state of Arizona via e-mail: This correspondence is a follow-up to the notification sent (on 4/25/19) regarding an approximate 290 Rem whole body exposure. It was determined through inspector interviews and procedure logs that the individual is an x-ray technologist and does not work with radioactive materials. The individual is the lead (certified radiation technologist) in an (operating room) department of a hospital performing 6-7 fluoroscopic procedures per day. It is believed that the actual exposure was just to the badge and not to the person. Notified R4 RDO (Young), NMSS Events (email), NMSS Director (Kock), and INES (Milligan).
|ENS 54030||26 April 2019 17:22:00||The following was received from the state of Wisconsin via e-mail: On April 26, 2019, Wisconsin Department of Health Services (DHS) was notified that at the licensee's Kaukauna facility, a fixed gauge mounted to a coal chute had been damaged and failed with the shutter closed. The incident occurred on April 22, 2019. Maintenance staffs were repairing a valve located above an Ohmart/Vega Corporation Model SHLG-1 fixed gauge containing 5 mCi of Cs-137. The valve failed, rotated downward, and made contact with the shutter actuator handle which severed the handle from the device. The gauge was not in operation at the time of the incident and the shutter remained in the closed position, the licensee's (Radiation Safety Officer) (RSO) stated on the initial phone call that the shutter is now inoperable. The maintenance staff called the RSO on the day of the incident and he instructed them to cordon off the area and perform surveys of the device. The surveys indicated that the source was not impacted and the RSO later performed confirmatory surveys that yielded similar results. Wisconsin DHS intends to perform a reactive inspection when the licensee's service provider replaces the gauge; the date is still to be determined. Event Report No.: WI 190001|
|ENS 53998||14 April 2019 03:21:00||On April 14, 2019 at 0003 (EDT), Nine Mile Point Unit 1 experienced an automatic reactor scram during reactor startup. The cause of the automatic scram was due to high (Reactor Pressure Vessel) pressure following closure of the turbine stop valves. All control rods fully inserted and all plant systems responded per design following the scram. Following the automatic scram, the High Pressure Coolant Injection (HPCI) System automatically initiated as expected. At Nine Mile Point Unit 1, a HPCI System actuation signal on low Reactor Pressure Vessel (RPV) level is normally received following a reactor scram, due to level shrink. HPCI is a flow control mode of the normal feedwater systems, and is not an Emergency Core Cooling System. At 0004, RPV level was restored above the HPCI System low level actuation set point and the HPCI System initiation signal was reset. Pressure control was established on the Turbine Bypass Valves, the preferred system. No Electromatic Relief Valves actuated due to this scram. Nine Mile Point Unit 1 is currently in Hot Shutdown, with reactor water level and pressure maintained within normal bands. The offsite grid is stable with no grid restrictions or warnings in effect. The unit is currently implementing post scram recovery procedures. The NRC Resident Inspector has been notified. The Licensee will notify the State of New York.|
|ENS 53995||12 April 2019 11:24:00||The following is a synopsis of an event received via email: On April 11, 2019, a trained technician was in the process of performing the biannual inventory/shutter check when the individual reported that Kay Ray Model #7050, Serial #1399, 250 mCi, Cs-137 gauge located on 5B DTU (Deslime Thickener U/Flow) in the Deslime basement had a frozen shutter mechanism and cannot be closed, rendering the shutter non-operable. The gauge won't be replaced until the first time the slurry pipeline goes down for repair. If the line goes down prior to that, the gauge will be replaced at that time. Similar events in the past have never had an exposure to any individuals. In the event of an emergency, the gauge will be removed and placed on a piece of lead and brought to storage.|
|ENS 53960||26 March 2019 16:28:00||The following is a summary of information received from the State of Nebraska: On March 26, 2019, the Nebraska Department of Radioactive Materials received a letter dated March 25, 2019, from the licensee (Flint Hills Resources) concerning the loss of two tritium exit signs, each with an activity of 17.51 Curies. Two H-3 exit signs were lost during recent construction of additional warehouse space on an existing building. One sign was over a personnel door on the wall demolished for the new space and one was on a personnel door proximal to the construction area. NE Item Number: NE190002 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 53957||25 March 2019 17:53:00||The following was received via e-mail: On March 25, 2019, the agency (Texas Department of State Health Services) reviewed a voicemail left on an investigator's office phone line in which a licensee reported a stuck shutter on a gauge. The gauge is a Thermo Fisher Scientific model 7062BP, with serial number S99G0101, containing a 100 millicurie Cesium-137 source with serial number 6551GQ. The shutter is stuck in the open position. Open is the normal operating position. The gauge is located on a 6" line and no exposures are anticipated as a result of this malfunction. The manufacturer has been contacted and service will be scheduled. Updates will be sent in accordance with SA-300. Texas Incident: I-9668|
|ENS 53941||16 March 2019 13:42:00||At approximately 1100 CDT on March 15, 2019, Cooper Nuclear Station was notified by the National Weather Service that the Shubert radio transmission tower was not functioning due to evacuating their office in Omaha as a result of local flooding. This affects the tone alert radios used to notify the public in event of an emergency condition. Loss of function of this tower is reportable at 1100 CDT on March 16, 2019, when the tower could not be restored within 24 hours of the loss. This condition is reportable under 10 CFR 50.72(b)(3)(xiii). A backup notification method is available and will be utilized for notifications if needed. A return to service time for the Shubert tower is not currently available. The NRC Senior Resident Inspector has been informed."|
|ENS 53937||15 March 2019 13:39:00||On March 15, 2019 at 1300 EDT, Indian Point Unit 2 automatically tripped offline from mode 1 - 100% power operations. Reactor Operators verified the reactor trip and the plant is currently stable in mode 3. All automatic systems functioned as required. The auxiliary feedwater system actuated following the trip, as expected. All control rods fully inserted upon the trip, as expected. This event is reportable under 10 CFR 50.72(b)(3)(iv)(A) and 10 CFR 50.72(b)(2)(iv)(B). The unit remains on offsite power in hot standby at normal operating temperature and pressure. Decay heat is being removed from the steam generators via the auxiliary feedwater system and the condensate steam dump valves. Unit 3 remains in mode 6 for a scheduled refueling outage. The licensee notified the NRC Resident Inspector, the local transmission company, and New York State Independent System Operator. The Indian Point Unit 2 automatic trip was caused by the trip of the main generator. The cause of the generator trip is unknown at this time.|
|ENS 53939||15 March 2019 14:37:00|
The following was received via e-mail: On March 14, 2019 around 1430 CDT, Turner Industries Group, LLC was performing work in a permanent shooting cell. Two industrial radiographers got into a verbal altercation, which lead to one industrial radiographer cranking out a source onto the other industrial radiographer. Dose reconstruction indicated less than 2 millirem/hr whole body to the one radiographer. The first radiographer was twelve feet from the four Half-Value Layer (HVL) collimator and ran to a shielded condition within seconds after realizing the source had been cranked out. The second radiographer was behind a shooting cell wall performing the crankout.
"The radiographer performing the crankout has been terminated and led off the property. All access that he had has been revoked and access codes changed.
Louisiana Event Report ID No.: LA20190004
|ENS 53933||14 March 2019 17:08:00||A licensed employee was determined to be under the influence of alcohol during a random test. The employee's access to the plant has been suspended pending an investigation. The licensee notified the NRC Resident Inspector.|
|ENS 53940||15 March 2019 17:37:00||The following was received via e-mail: On March 15, 2019, the University of California Los Angeles (UCLA) notified the Radiologic Health Branch that a medical event involving Y-90 TheraSphere had occurred on March 14, 2019. A patient was prescribed 120 Gy to the left lobe of their liver with Y-90 TheraSpheres. However, the authorized user (physician) was only able to deliver 80.9 Gy (67.4 percent of the prescribed dose) due to suspected complications with the delivery system. UCLA's Office of Environment, Health and Safety (EH&S) team will continue to investigate and notify the BTG Radiation Safety Officer (RSO) group to examine the delivery system. The patient was notified of the under-dosage and potential continuation of their treatment. The patient was discharged in a stable condition." CA 5010 No.: 031419 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 53938||15 March 2019 14:05:00||The following was received via e-mail: On March 14, 2019, the licensee informed the Department (Pennsylvania Department of Environmental Protection (DEP)) of a moisture/density nuclear gauge with a stuck open shutter. It is reportable per 10 CFR 30.50(b)(2). While at a temporary job site, a DEP inspector found a Troxler gauge with a stuck open shutter. The technician did not know how long the shutter had been open and was only able to get the Tungsten sliding block closed by tapping on the gauge. After it was closed the technician was unable to get the sliding block open again. The DEP will update this event as soon as more information is provided. The Department will perform a reactive inspection. More information will be provided upon receipt. Pennsylvania Event Report ID No: PA190008|
|ENS 53932||14 March 2019 16:05:00||The following was received via e-mail: On March 14, 2019, the Texas Department of Health Services was notified by the licensee's radiation safety officer (RSO) that a therapy event had occurred. A patient was scheduled for three fractions using a high dose rate after loader containing a 6.8 curie iridium-192 source. Multiple catheters were to be used. On March 14, 2019, prior to the third fraction, the licensee determined that one of the catheters was shorter than the length required and the patient received 350 centigrays (50 percent) of the prescribed dose to the thigh resulting in the target tissue receiving 50 percent of the prescribed dose (350 centigrays). The third fraction was not administered. The RSO stated they intended to create a new treatment plan to correct the error and insure the intended area receives the correct dose. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 9665 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 53956||25 March 2019 16:37:00||The following was received via e-mail: The department (Colorado Department of Public Health and Environment) received an e-mail notification on March 7th, 2019 reporting two leaking Electron Capture Devices (ECD's). The (ECD's) are associated with Agilent model G239765505 with serial numbers: U1186 and U6642. The semi-annual leak test results show 35300 picocurie/sample for serial number U1186 and 17100 picocurie/sample for serial number U6642. The wipe test results were received by Test America on March 4, 2019. Test America reported that the ECD's were removed from use and the instruments on March 4, 2019 and sent to Detector Service Center, LLC for cleaning and repair. Test America performed surveys for the affected machines and cleaned with a radiacwash solution. A wipe test was done on the instruments and counted by Gas Flow Proportional Counter low background instrument which indicated no removable contamination present. A direct survey with a Ludlum Model 3 Giger Muller detector indicated no fixed contamination. The completion date was reported to be March 5, 2019. Test American has removed the leaking ECD's and will continue 6-month wipe tests as required. Colorado Event Report ID No.: CO190004|
|ENS 53909||3 March 2019 09:54:00||At 0916 EST on March 3, 2019, North Anna Unit 2 declared a Notice of Unusual Event under Emergency Action Level HU 2.1 (fire in/or restricting access to any table H-1 area not extinguished within 15 minutes of control room notification or verification of a control room alarm). At 0906 the control room received a heat sensor alarm for the Unit 2, Reactor Coolant Pump motor cube. The fire brigade was dispatched to the scene where they found no indication of fire, no smoke and no fire damage. There were no actuations associated with the alarm and no redundant indications of fire. There was no effect on plant equipment and no indications of RCS leaks. The site determined that the alarm was invalid and terminated the NOUE. Unit 2 is in a stable condition and in a normal electrical lineup. Offsite support was not requested. The NRC Resident Inspector, State, and local authorities have been notified by the licensee. Notified R2RA (Haney), DNRR (Evans), IRD MOC (Grant), R4RDO (Rose), DHS SWO, FEMA Operations Center, DHS NICC, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).|
|ENS 53908||3 March 2019 00:13:00||On March 2, 2019 at 2237 EST, North Anna Unit 2 reactor was manually tripped, while operating at approximately 12 percent power, due to degrading vacuum in the main condenser. The unit was in the process of a planned shutdown for refueling when condenser vacuum degraded to greater than 3.5 inches of mercury absolute. The operations crew entered the reactor trip procedure and stabilized the unit in Mode 3 at normal operating pressure and temperature. All control rods fully inserted into the core following the reactor trip. The reactor protection system actuation is reportable per 10 CFR 50.72(b)(2)(iv)(B). There were no ESF system actuations. Decay heat is being removed by the Steam Generator Pressure Operated Relief valves. Unit 2 is in a normal shutdown electrical lineup. The NRC Resident Inspectors have been notified. The Louisa County Administrator will be notified."|
|ENS 53903||1 March 2019 04:03:00||On February 28, 2019, at 2217 CST, LaSalle Unit 2 experienced a trip of the 241Y Safety Related Bus during surveillance testing resulting in a valid undervoltage actuation signal to the Common Emergency Diesel Generator ('O' EDG), causing it to start and load to Bus 241Y. The purpose of the surveillance testing was to demonstrate the operability of the breakers necessary to provide the second off site source to Unit 2. This event is reportable in accordance with 10 CFR 50.72(b)(3)(iv)(A), as an event that results in a valid actuation of the emergency AC electrical power system. In addition to the 241Y bus trip and 'O' EDG actuation signal, the following plant responses occurred as designed due to the momentary loss of this AC Bus: "A" RPS de-energized due to the loss of the 2A Reactor Protection System Motor-Generator Set, and the running Unit 2 Fuel Pool Cooling pump tripped. The Non-Safety Related Bus 241X de-energized resulting in a trip of the Unit 2 Station Air Compressor. All systems have been restored and troubleshooting is currently in progress. Unit 1 remained in MODE 1 during this event. The NRC Senior Resident Inspector has been notified."|
|ENS 53899||28 February 2019 11:11:00||The following was received via email from the state of North Carolina: North Carolina Radiation Protection Branch (RMB) was notified on February 22, 2019, that a General Licensee could not account for two Microderm hand-held probes containing two sources each (25 micro Ci of Sr-90 and 100 micro Ci of Tl-204). RMB has been in communications with the General Licensee to ascertain whether or not the devices containing the sources have been returned to the vendor or are indeed lost. At this time, this cannot be verified and the RMB anticipates more information to follow on March 4, 2019. Additional details to follow to complete this event report. NC Event Tracking ID: 190007 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 53885||20 February 2019 15:15:00||The following report was received from the State of California via email: On February 20, 2019, the RSO (Radiation Safety Officer) of G3SoilWorks, Inc. contacted the California Office of Emergency Services about a moisture density gauge that was stolen from the operators vehicle at an apartment complex (in) Newport Beach, CA. The gauge was a CPN MC-3, Serial Number M390705215 (10 mCi Cs-137, 50 mCi Am:Be-241). The incident was reported to the Newport Beach Police Department. The gauge has not been found at this time. California 5010 number: 022019 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 53884||20 February 2019 13:25:00|
The following was received from the licensee via e-mail: The concerned radioactive material is part of an Army Chemical Detection Equipment (CDE) and is called an Improved Chemical Agent Monitor (ICAM) NSN (National Stock Number) 6665-01-357-8502 and Chemical Agent Monitor (CAM), NSN 6665-01-199-4153. Each ICAM and CAM contains 10 mCi of Ni-63. The items with the radioactive material are under US Army NRC License 21-32838-01 issued to the Tank-Automotive and Armaments Command (TACOM). TACOM is located in Warren, MI. The reporting was based on 10 CFR 20.2201(a)(ii) (Reports of Theft or Loss of Licensed Material). Licensed material in a quantity greater than 10 times the quantity specified in Appendix C. The quantity specified in Appendix C is 100 microCi. One ICAM/CAM containing 10 mCi is 10,000 microCi. (The Radiation Safety Officer (RSO)) had reported nine CDE, but after confirming the serial numbers, we determined that one of the CDE (serial number 11769) was under another NRC license 19-10306-01 issued to the US Army Edgewood Chemical Biological Center (ECBC) located in Aberdeen Proving Ground (APG), Maryland. This report is for eight CDE under TACOM's NRC license. We have six ICAMs and two CAMs that are lost for a total of 80,000 microCi. The serial numbers for the ICAMs are Z47-M-13972, Z47-M-13526, Z47-M-01859, Z47-M-15832, Z47-M-21980 and Z47-M-18759. The serial numbers for the CAMs are Z16-M-01075 and Z16-M-01025.
The ICAMs/CAMs are not known to leak and do not have a leak test requirement. The Ni-63 is inside the ICAM/CAM. (The RSO) was notified via e-mail on February 19, 2019, at 1545 EST, by the Army Rad waste agency (Joint Munitions Command (JMC) located in Rock Island, IL) of the following: 'A package containing nine each CDE was in route from APG, Maryland to Pine Bluff Arsenal (PBA), Alabama via (a Common Carrier) and was lost in the possession of (the Common Carrier). The CDE were being sent for demilitarization and eventual disposal of the Ni-63. The subject package was dropped off at (the Common Carrier) in Baltimore, MD on 26 Nov 2018. The tracking system showing the package as 'In (Common Carrier) Possession'.' Prior to the notification on February 19, 2019, JMC called PBA shipping and receiving. PBA personnel indicated that subject package was not received at their location. Also, APG personnel traveled to the (Common Carrier) facility where the items were dropped off. Personnel confirmed that the package was not at that facility. As of February 19, 2019, JMC indicated that (the Common Carrier) has not formally issued the a statement of loss, but that JMC will continue to track this for APG. It was a Local Project for JMC with ID number of APG 2018-001. On February 20, 2019, at 0847 EST, the (RSO) called (the Common Carrier) with the tracking number. (The RSO) spoke to (an individual) who indicated that a case was assigned to the shipment and a claim was put in. (The RSO) was put in contact with the Trace Department, and was then told that the shipment was considered lost. Shipments after 14 days are considered lost. This event is related to NRC Event Number 53888. 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 53883||19 February 2019 15:19:00||On February 19, 2019, at 1307 EST, with the reactor at 100 percent Core Thermal Power and steady state conditions, plant personnel notified the Main Control Room that both doors in the Secondary Containment Airlock on the Reactor Building Fifth Floor were opened simultaneously for a period of approximately five minutes (i.e., from 1253 to 1258 EST). The failure of this interlock, which is intended to prevent both doors from being opened simultaneously, resulted in the Technical Specification (TS) Surveillance Requirement (SR) 220.127.116.11.3 not being met. The maximum Secondary Containment pressure observed during that time remained within TS limits. There were no radiological releases associated with this event. Declaring Secondary Containment inoperable as a result of not meeting TS SR 18.104.22.168.3 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. The repair to the failed interlock is in progress. As a compensatory measure signs are posted on the doors to notify personnel to not access the Reactor Building via those doors.|
|ENS 53886||20 February 2019 17:21:00||The following report was received from the State of Colorado via email: On February 14th, 2019, a written report was received from Cardinal Health detailing the events of a lost package containing 180.3 microCi (shipped activity) Ra-223. The package was lost in transit on February 11th, the intended recipient was in Savannah, GA. The courier for the package was a (Common Carrier). A search by the (Common Carrier) located the package on the side of the road on February 12th in the Savannah, GA area. Regional Cardinal Health technicians were dispatched to the found package and determined that the transport index was as expected and the package indicated no removable contamination. Cardinal Health took possession of the package for decay-in-storage. CO Event Report ID No.: CO190002 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 53975||4 April 2019 09:19:00|
EN Revision Text: AGREEMENT STATE REPORT - UNPLANNED CONTAMINATION The following was received via e-mail: On January 8, 2019, the Agency (Texas Department of State Health Services) was contacted by the license and notified they have some conflicting data that suggest they may have up to three (3) leaking Nickel (Ni) - 63 ten milliCurie sources that may be slightly above the 0.005 microCuries reporting limit. The licensee stated they need to investigate further as a second set of leak tests showed no detectable activity on the same three sources. The three sealed sources in question have been bagged and are slotted for disposal. The licensee will provide additional information as it is received. On January 25, 2019, the licensee contacted the Agency and stated they had leak tested all similar sources in their possession. The licensee found a total of four sources exceeded the limit. The sources are all Ni-63 containing 10 milliCuries. The licensee stated they will dispose of all leaking sources. The licensee stated it believed the sources were manufactured in Singapore. The sources are used in gas chromatographs. The Agency conducted an on site investigation at the facility on March 11, 2019. During the investigation the licensee stated none of their customers who had been provided a device had reported a source that failed a leak test. On April 3, 2019, the Agency was notified by the licensee that they were going to restrict access to a room for more than 24 hours due to fixed and removable radioactive contamination levels. The contamination was found while performing surveys in the area in response to leak test results of four Ni-63 sources exceeding the limit (NMED report number 190032). The licensee will perform bioassay sampling of all individuals who had been in the room. The licensee stated they have begun decontamination of the room. Additional information will be provided as it is received in accordance with SA-300. Texas Incident number: 9648
The following report was received via e-mail: On April 15, 2019, the Agency (Texas Department of State Health Services) was notified by the licensee that they had found additional contamination in the facility and had closed the facility until a full survey can be completed and any areas found to be contaminated released. The licensee is working on a bioassay plan for the employees. Notified the R4DO (Pick) and NMSS (via e-mail).
|ENS 53811||1 January 2019 11:02:00||On January 1, 2019 at approximately 0454 EST, while performing planned maintenance activities on the Feedwater Distributed Control System (FW DCS), it was discovered that the automatic trip instrumentation of the Gland Seal Exhauster (GSE) was inoperable. The automatic GSE trip is assumed in the safety analysis for the Control Rod Drop Accident (CRDA) and is required when Thermal Power is less than or equal to 10%. The automatic trip function of the GSE was inoperable for 1 minute, 19 seconds. No Control Rod movement occurred while the automatic trip of the GSE was inoperable. There was no adverse impact to public health and safety or to plant employees and there was no radiological release. This report is being made pursuant to 10CFR50.72(b)(3)(v)(C) and 10CFR50.72(b)(3)(v)(D). The NRC Resident Inspector has been notified."|
|ENS 53794||19 December 2018 11:10:00||The following was received from the State of Colorado via email: (Colorado Department of Public Health and Environment) CDPHE became aware of a misadministration on the evening of December 18th, 2018; the event was discovered by the licensee on the morning of December 18th, 2018. The event occurred over three consecutive days, December 15th, 16th, and 17th, 2018. Description of the events: The licensee reported that strontium break through occurred on a Braco (Rb-82) generator resulting in levels of Sr-82/Sr-85 exceeding manufacture specified limits. The licensee failed to identify the strontium breakthrough and the doses were subsequently used in patient procedures, eight (8) patients were affected. The licensee has no more information at this time and has been instructed to notify the department as soon as patient dose information becomes available. CDPHE is awaiting a full report by the licensee. Colorado Event Report ID No.: CO180032 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 53788||12 December 2018 17:29:00|
EN Revision Text: MANUAL REACTOR SCRAM DUE TO FAILED OPEN TURBINE BYPASS VALVE At 1351 CST, the reactor was manually shutdown due to 'A' Turbine Bypass Valve opening. The Main Steam Line Isolation Valves were manually closed to facilitate reactor pressure control. Reactor level is being maintained through the use of Reactor Core Isolation Cooling System, Control Rod Drive System, and High Pressure Core Spray System. High Pressure Core Spray System was manually started to initially support reactor water level control. Reactor Pressure is being controlled through the use of the Safety Relief Valves and the Reactor Core Isolation Cooling System. The plant is stable in MODE 3. The cause of the 'A' Turbine Bypass Valve opening is under investigation at this time. The NRC Resident Inspector has been notified.
This is an update to EN # 53788 to correct an error on the event classification block of the form. The original notification did not have the block for 8 hour notification for Specified System Actuation checked. The actuation of Reactor Core Isolation Cooling System was discussed in original notification. The licensee notified the NRC Resident Inspector. Notified R4DO (Taylor).
|ENS 53789||13 December 2018 14:37:00||At 1700 EST on December 12, 2018, a contractor supervisor violated the licensee's Fitness-for-Duty (FFD) program by subverting a follow-up Fitness for Duty Test. The contractor's site access has been terminated. The NRC Resident Inspector was notified. No work was performed on safety related equipment. The licensee has made a PADs entry.|
|ENS 53773||4 December 2018 15:53:00|
The following was received from the Maryland Department of the Environment via phone: On November 29, 2018, at approximately 2230 EST, an unidentified citizen contacted the Prince William, VA police department stating they observed a suspicious person throw a yellow box out of their vehicle and then exit the commuter parking lot at 12745 Minnieville Road, Woodbridge, VA 22192. The response was coordinated by the Virginia Emergency Response Center and Hazardous Materials Office. The responding officer located the yellow case having a radiation warning label affixed and his PRD (Personal Radiation Detector) (indicated that) a radiation source (was) present. The Virginia Department of Fire and Rescue, Virginia Department of Transportation, Virginia Department of Emergency Management, Virginia State Police, and the FBI responded. Spectral analysis identified Cs-137 with readings of approximately 1.5 mR/hr on contact with the case; typical for a Troxler gauge. The outside lock on the case was cut; a Troxler 3430 gauge with shipping papers were present. The trigger lock was in place. The Virginia Department of Health (VDH) did not have the facilities or capability to take possession of the gauge. The gauge was secured in the Hazardous Materials officer's (HMO) vehicle until other arrangements could be made. On November 30, 2018, at approximately 0930 EST, VDH contacted the lead Prince William County HMO and was told that there was information contained in the shipping container with the gauge that identified the owner. VDH received that information at approximately 1000 EST and determined the owner of the gauge to be a Maryland licensee (Kim Engineering). At approximately 1020 EST, the Director of the Virginia Radioactive Materials Program contacted the Maryland Radiological Health Program (RHP) concerning a recovery of a Troxler gauge at a Virginia Department of Transportation park-and-ride. The device was identified as a model 3430, S/N 67880 having an 8 mCi Cs-137 source (5/14/2013), S/N 77-12674, and a (40mCi) Am-241/Be source, S/N 78-8664. The device was last leak tested on 6/22/2018. An official of the Maryland RHP volunteered to drive to Prince William County, VA to retrieve the gauge. Arrangements were (made with) the Maryland official to meet with the Prince William County HMO. At approximately 1315 EST, the State of Maryland official contacted the VDH to confirm transfer of possession of the Troxler gauge to transport it back to Maryland. The Maryland official informed VDH that the licensee notified RHP that someone had stolen a Troxler gauge from the licensee. Maryland agreed to notify the US NRC Operations Center of this incident. Maryland has scheduled a reactive inspection of the licensee to determine the root cause of the loss or theft.
The following is a summary of the additional information was provided by the Maryland Department of the Environment via email: The activity for the Am/Be source, Serial Number: 78-8664, was tested on 6/22/2018 and was less than 185 Bq (0.005 microCuries). Notified R1DO (Lally), ILTAB (Allston - via email), NMSS_events (via email). THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
|ENS 53786||11 December 2018 15:09:00||This 60-day telephone notification is being made in accordance with the reporting requirements of 10 CFR 50.73(a)(2)(iv)(A). The successful, complete train actuation of the 22 Auxiliary Feedwater Pump was initiated by an invalid signal during testing. The Auxiliary Feedwater System was not impacted in its ability to perform its function. There were no safety consequences or impacts to the health and safety of the public as a result of this event. The NRC Resident Inspector has been notified."|