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ENS 545779 March 2020 17:46:00The following is a synopsis of a facsimile that was received from the State of Alabama: On March 9, 2020 at 0825 CDT, the State of Alabama Department of Public Health, Office of Radiation Control, Radioactive Materials Compliance Branch, was notified by licensee Acuren, Inc., that a radiographer attempted to unlock the locking mechanism of an 880D radiography camera and the key broke off in the lock. The licensee stated that the camera is still locked, is now "red-tagged," and is in storage until it can be sent to its vendor QSA for repair. The source was not exposed at the time and it is in the shielded position. Radiation surveys of the device are normal for a shielded position. This event occurred on March 7, 2020. Alabama Event Number: 20-05 The source is believed to be Ir-192. The source strength was not reported.
ENS 545706 March 2020 14:19:00A non-licensed contract supervisor had a confirmed positive for a controlled substance during an initial Fitness For Duty screening test. The individuals plant access has been terminated. The NRC Resident Inspector has been notified.
ENS 5454024 February 2020 19:10:00

The following is a synopsis of a event reported by the state of Texas via email and phone call: On February 24, 2020, the Texas Department of State Health Services (Agency) was contacted by the Braun Intertec Corporation RSO to report a stolen moisture density gauge. The gauge was last seen on February 19, 2020 at the end of work in McKinney Texas. It was locked in a box in the back of a truck which was then driven to Euless, Texas where it reported to stay until February 24, 2020. The truck was then driven to a jobsite in Richardson, TX on February 24, 2020 at which point the employee realized that the locks were gone and the moisture density gauge was removed from the box in the back of the truck. Euless Police were notified. The activity for the density gauge is estimated to be 10 mCi Cs-137 and 40 mCi of Am241/Be. An investigation into this event is ongoing. More information will be provided when obtained in accordance with SA- 300. Texas Incident number: 9746

  • * * UPDATE ON 6/18/20 AT 1721 EDT FROM KAREN BLANCHARD TO ANDREW WAUGH * * *

The following information was received from the state of Texas via email: On June 17, 2020, the Agency was notified by a steel mill in Midlothian, Texas, that it had found a moisture/density gauge in a load of metal from a recycler. The serial number was checked and it was determined to be this licensee's gauge that was stolen February 24, 2020. The licensee was notified and picked up the device on June 18, 2020. The licensee transported the device to a manufacturer's facility in Arlington, Texas, and transferred it for disposal. The manufacturer will complete leak tests and provide the licensee with the results. (There were) no exposures that would exceed any regulatory limit at the steel mill. Investigation will continue to determine if any exposures occurred at the recycler and if the recycler can provide information on where, or from whom, it got the device. More information will be provided as it is obtained in accordance with SA-300. Notified R4DO (Warnick), NMSS Events Notification (email), ILTAB (email), and CNSNS (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 5453320 February 2020 15:04:00(On February 20, 2020, at 1240 EST, the Licensee determined the following information:) This notification is in reference to reports EN 54130 and LER 2019-002, which were retracted. James A. FitzPatrick Nuclear Power Plant received additional information on the technical basis for the retraction. Further review, including testing of the terminal blocks, demonstrated that the short circuit current would result in heat levels in excess of cable insulation ratings. Unprotected DC control circuits for non-safety related DC motors are routed between separate fire areas. A postulated fire in one area can cause a short circuit and potentially result in secondary fires or cable fires in other fire areas where the cables are routed. The secondary fires or cable failures degrade the degree of separation for redundant safe shutdown trains and are outside the assumptions of the 10 CFR 50 Appendix R Safe Shutdown Analysis. This condition is reportable in accordance with 10 CFR 50.72(b)(3)(ii)(B). Compensatory actions per the Technical Requirements Manual (TRM) for affected fire areas have been implemented. A modification to install fuses in the control circuits for 94P-2(M), 31P-7A(M), 31P-7B(M), and 94P-13(M) has been scheduled and shall correct this condition. The NRC Resident Inspector has been notified.
ENS 5424428 August 2019 19:10:00On Wednesday, August 28, 2019, at 1316 CDT, Grand Gulf Nuclear Station experienced a power loss to the Control Room High Pressure Core Spray (HPCS) Instrumentation Panel due to an internal inverter failure. The power loss caused the loss of the HPCS System (a single train system). The minimum flow valve (a Primary Containment Isolation Valve) for HPCS opened due to this power loss as well. This valve was manually closed in response to this, and the outboard isolation requirement for the associated penetration (which) is closed (for the) system remained intact throughout this event. No other accident mitigation systems were affected by this event. The cause of this event is under investigation at this time. The NRC Resident Inspectors were notified. This Condition is an 8-hour reportable condition as an event or condition that could have prevented the fulfillment of a safety function, in accordance with 10 CFR 50.72(b)(3)(v)(D).
ENS 5424328 August 2019 16:35:00

The following is a summary of information received from the State of Oregon via phone call: On August 28, 2019, at 1102 PDT, the Oregon Department of Health and Radiation Protection received a report from the R.S. Davis Scrap Yard, that a moisture density gauge was found in a 55 gallon drum that was crimped at the top so the gauge will not fall out. The gauge is a CPN MC-3 Porta Probe with a 10 mCi Cs-137 source and a 50 mCi Am/Be 241 source. The scrap yard employed a contractor to take radiation readings and perform a swipe test of the gauge. The gauge housing appears to be damaged but the source housing seems intact. The contractor was unable to inspect the bottom of the gauge inside the drum.

The following was measured: A reading of 13 mR/hr on contact at the side A reading of 200 mR/hr on contact at the bottom A reading of 3 mR/hr one foot from the side Swipe Test results were less than background The State of Oregon Radiation Inspector believes the gauge is damaged because normal radiation readings for a similar gauge at one meter would be 0.4 mR/hr. The State of Oregon will be conducting an investigation of this event. The gauge is currently under the control of the scrap yard. Oregon Event Reference Number: 19-0037. 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 5424026 August 2019 15:26:00The following is a summary received via email from the state of Colorado: On August 26, 2019 at 11:13 MDT, the Colorado Department of Public Health and Environment was notified by Ninyo & Moore, that Troxler 3430 moisture density gauge with 9 mCi source of Cs-137 and 44 mCi source of Am/Be was stolen from Colorado School of Mines in Golden, Colorado. The Troxler gauge was last seen on August 23, 2019. Campus police were notified and they have put out a state wide notification informing state police of the missing gauge. Event Report Number: CO 190016. 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 5424126 August 2019 16:41:00A non-licensed contract employee supervisor had a confirmed positive for an illegal drug during pre-access testing. The employee's access to the plant was denied.
ENS 5417621 July 2019 12:08:00On July 19, 2019, DC Cook Unit 2 started experiencing degraded performance on the Unit 2 Non-Essential Service Water System (NESW) which affected one (1) NESW pump. On July 21, 2019, a second NESW pump on Unit 2 experienced degradation. On July 21, 2019, DC Cook Unit 2 elected to do a rapid downpower over approximately 40 minutes and perform a Manual Reactor Trip from 17 percent (rated thermal power) to repair the condition before any threshold was exceeded. The manual reactor trip was completed at 0826 EDT on July 21, 2019. This notification is being made in accordance with 10 CFR 50.72(b)(2)(iv)(B), Reactor Protection System (RPS) actuation as a four (4) hour report, and under 10 CFR 50.72(b)(3)(iv)(A), Reactor Protection System (RPS), as an eight (8) hour report. The DC Cook NRC Resident Inspector has been notified. Unit 2 is being supplied by offsite power. All control rods fully inserted. Aux Feedwater pumps were started as required and are operating properly. Decay heat is being removed via the Steam Generator Power Operated Relief Valves following breaking Main Condenser Vacuum for expedited cooldown of the Main Turbine. Preliminary evaluation indicates all plant systems functioned normally following the reactor trip. DC Cook Unit 2 remains stable in Mode 3. No radioactive release is in progress as a result of this event. Unit 1 was not affected.
ENS 5417519 July 2019 13:05:00At 0945 (EDT) on July 19, 2019, with Unit 2 in Mode 1 and 100 percent power, the reactor automatically tripped due to Loop 2 'B' Main Steam Isolation Valve failing shut. The Auxiliary Feedwater system (AFW) started automatically as a result of the automatic reactor trip. The trip was not complex, with all systems responding normally. Operations stabilized the plant in Mode 3. Decay heat is being removed through the main steam lines through the steam dumps and into the condenser. Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). Due to the valid AFW actuation from the reactor trip, this event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A). Unit 1 was not affected. There was no impact to the health and safety of the public or plant personnel. The NRC Resident Inspectors have been notified. All control rods fully inserted.
ENS 541412 July 2019 18:17:00

This is a summary of information received from the state of Nebraska via phone call: On July 2, 2019, at approximately 1330 CDT, the licensee, Mid-State Engineering and Testing, lost a CPN-International MC Series Protaprobe gauge with 10 mCi Cs-137 and 50 mCi Am/Be-241 sources. This gauge is believed to be lost somewhere between Aurora and Columbus, Nebraska on the route that includes highways 14 and 30. The truck's tail gate was not closed causing the gauge to fall out of the truck. The licensee has attempted to locate the gauge but so far has been unsuccessful. The Nebraska State Patrol has been notified along with the Platte County Sheriff department. This was reported to the State of Nebraska Health and Human Services Agency at 1645 CDT. The State will be issuing a follow up written report later.

  • * * UPDATE ON 7/3/2019 AT 1758 EDT FROM JULIA SCHMITT TO ANDREW WAUGH * * *

This is a summary of information received from the state of Nebraska via phone: On July 3, 2019, the gauge was found by a member of the public and retrieved by the licensee. The gauge does not appear to be damaged. Notified R4DO (Haire), NMSS Events (email), 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://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

ENS 541402 July 2019 14:50:00The following was received from the state of Illinois via email: The Agency (Illinois Bureau of Radiation Safety) was notified at approximately 1530 CDT on 7/1/19, that a medical event had occurred at Alexian Brothers Medical Center, in Elk Grove Village. The circumstances are near identical to those in an event reported by the licensee in February of this year (EN53859). An attempted intravascular brachytherapy procedure utilizing a Novoste BetaCath 3.5F System was aborted when the source train could not successfully reach the intended treatment site after three attempts. The source train was retracted without complication and there were no indications of kinks in the delivery catheter. Aborting the procedure resulted in an underdose exceeding 20 percent of the prescribed dose (prescribed dose was 18.4 Gy of Y-90 and delivered dose was 0.0 Gy). The three attempts also resulted in an exposure exceeding 50 rem to tissue other than the treatment site (treatment site was in the circumflex artery). The source train stopped each of three times 10mm proximal to the treatment site in the junction between the left coronary artery and the circumflex artery. The inadvertently exposed region received approximately 0.98 Gy or a dose equivalent of approximately 100 rem. A reactionary inspection was conducted by Agency staff on the morning of July 2, 2019. A written report was received by the licensee that same day in which tortuous patient anatomy was identified as the root cause. Agency inspectors will meet with the authorized user on the afternoon of July 3, 2019, to discuss each step of the intravascular brachytherapy procedure in an effort to further isolate the root cause. No adverse medical impact is expected to the patient as a result of this event, per the authorized user. Patient has been notified and referring physician was present. This report will be updated as additional information becomes available." Illinois Item Number: IL190016 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 5413828 June 2019 16:48:00The following is a synopsis of an email from the state of Mississippi: On June 28, 2019, the Mississippi Division of Radiological Health (DRH), Radioactive Material Branch, reported that a Troxler moisture density gauge serial number 29421, was stolen on June 26 or 27, 2019, from a person's residence in Moss Point, Mississippi. The gauge was stolen from the back of the company pickup truck; the padlocks on the chains were cut and the gauge was removed from the storage box. The company Radiation Safety Officer (RSO) contacted the Moss Point Police Department. The RSO contacted the state of Mississippi Health Physicist (HP) and the state HP contacted the Department of Homeland Security. The Troxler gauge contained a 9 mCi Cs-137 and a 44 mCi Am/Be-241 sources. Mississippi Report Number: MS-190003 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 537187 November 2018 14:49:00The following was received via email from Texas Department of State Health Services: On November 7th, 2018, the Agency (Texas Department Of State Health Services) was notified by the licensee's radiation safety officer that a moisture density gauge was damaged by heavy equipment (at a construction site in San Antonio, TX). The gauge was manufactured by Troxler, serial number 38348, with Cs-137 (S/N:77-5682) and Am-241:Be (S/N:47-8792) sources of 8 mCi and 40 mCi respectively. The technician was operating the gauge at a construction site and a heavy equipment operator failed to notice the technicians attempts to stop him, and subsequently ran the gauge over. The source rod remained intact, however it could not be retracted into the shielded position. The licensee contacted the manufacturer and received shielding instructions. The gauge and the soil surrounding it were removed and transported to the licensee's office. The gauge will be sent back to Troxler for repair in an approved type package. No overexposures to the technician or to the public were reported. Texas Incident #: I-9631
ENS 536383 October 2018 10:57:00The following was received via email from the State of California: On October 2, 2018, at approximately 0830 (PDT) the, Radiation Safety Officer (RSO) for Geocon, Inc. contacted (California Radiologic Health Branch) RHB Brea concerning the moisture/density gauge, Troxler, model 3440, serial #33877 (Cs-137, 0.333 gigaBecquerel; Am-241, 1.6 gigaBecquerel) that had been stolen along with a transport vehicle parked in San Ysidro, CA, at approximately 0600 to 0700 (PDT), on Friday morning, September 28, 2018. The authorized user whose truck was stolen did not inform the RSO until 1000 to 1030 (PDT) on Monday, October 1, 2018, of the stolen radioactive gauge. The RSO has contacted local law enforcement in San Diego and is awaiting the completed police report, a copy of which he will send to RHB Brea to be included as part of this report. The RSO will contact local newspapers to attempt to retrieve the stolen radioactive gauge as well as notifying local servicing vendors of radioactive gauges to be alert for the serial number of the stolen gauge in case it turns up for service. The investigation will continue to determine if the radioactive gauge can be recovered in a reasonable time frame. California Notices of Violation will be issued to the licensee for failure to report the loss in a timely manner, and loss of control of the radioactive material. California Report No. 5010-100218 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 5354812 August 2018 02:58:00

EN Revision Text: TECHNICAL SPECIFICATION REQUIRED SHUTDOWN - LOSS OF 480 VOLTAGE EMERGENCY BUS On 8-12-18 at 0158 EDT, Beaver Valley Unit 2 experienced a loss of 480 Volt 2P Emergency Bus. This resulted in a Loss of Safety Function due to the 2-2 Emergency Diesel Generator (EDG) being Inoperable coincident with the Residual Heat Release Valve (2SVS-HCV104). A Technical Specification shutdown is required per LCO 3.0.3. The Licensee also stated they were in an unanalyzed condition due to the EDG and Residual Heat Release Valve being inoperable at the same time. The Licensee is shutting down to Mode 5 (Cold Shutdown). The Licensee is notifying the Resident Inspector. The Licensee will be making a Press Release about the unplanned shutdown.

  • * * UPDATE ON 08/16/2018 AT 1424 EDT FROM BLASE BARTKO TO KEN MOTT * * *

On 8-12-18 at 0158 (EDT) Beaver Valley Unit 2 experienced a loss of 480 Volt 2P Emergency Bus. Per operational guidance, this was determined to be a Loss of Safety Function due to the Unit 2 Emergency Diesel Generator (EDG) being INOPERABLE coincident with the Residual Heat Release Valve (2SVS-HCV104) 10 CFR 50.72(b)(3)(v)(B) and (D). This was also reported as an Unanalyzed Condition 10 CFR 50.72(b)(3)(ii)(b). No Press Release was performed for this event. The NRC Resident Inspector was notified. At 0410 (EDT) a Technical Specification Shutdown was commenced 10 CFR 50.72(b)(2)(i). At 2011 (EDT) the 480 Volt 2P Emergency Bus was restored and energized. Further evaluation of the event has determined that this event was not an Unanalyzed Condition and did not result in a Loss of Safety Function. The classifications of Unanalyzed Condition and Loss of Safety Function are being retracted. The accuracy of the existing guidance relative to Safety Function has been entered in the Corrective Action Program and interim actions have been taken to provide accurate guidance. Notified R1DO (Young) via email.

ENS 545716 March 2020 14:02:00The following is a synopsis of information received from the State of Colorado via email: On 7/16/18, the Colorado Department of Health, Hazardous Materials and Waste Management, was informed by the licensee that, after performing a walk-down of their property, two of the three exit signs containing Tritium could not be located. The event occurred in Colorado Springs, Colorado. The missing exit signs had an activity of 9.21 Ci Tritium each. 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 5346621 June 2018 18:12:00The following was received from the state of Utah via E-mail: On June 21, 2018 at 1335 MDT, Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (DWMRC), received written notification from the Church of Jesus Christ and Latter-Day Saints that on June 21, 2018 four tritium exit signs were discovered to having been sent to the landfill for disposal. The licensee will continue to investigate the incident and will submit a written report to the DWMRC. Utah Event Report ID No: UT180004.
ENS 5346521 June 2018 12:07:00The following was received from the state of Oklahoma via phone call and E-mail: On June 20, 2018, at approximately 1615 CDT, Tulsa Gamma Ray, Inc. (License # OK-17178-02) had a failure of the industrial radiography camera leaving the source exposed. The radiography camera is a model QSA 880D, source Spec T5, source strength unknown. The crank was a Sentinel SAN 882 Serial Number 15997. The licensee was authorized to perform a source recoveries, and the Radiation Safety Officer (RSO) successfully recovered the source. The RSO received a dose of 140 mRem as indicated on the RSO's pocket dosimeter. No other exposure information was provide at the time of the report. The state of Oklahoma will provide more information on this event as it becomes available. A State report number will be provided at that time.
ENS 5346320 June 2018 17:51:00On June 20, 2018, at 1145 hours (CDT), during panel walkdown, it was identified that High-Pressure Core Spray (HPCS) injection valve 1E22F004 was in the open position. Valve 1E22F004 is normally closed for containment integrity purposes. Operations personnel verified that the valve was open locally and that the plant computer indicated the valve is in the 'not closed' position. No alarms or status lamps indicated why the valve would be open and there was no valid demand signal. Reactor power, pressure, level, and feedwater parameters remain steady and unchanged, with no indication of HPCS injection having occurred or in progress. A low-water level signal, or a high drywell pressure signal, or manual operation initiates HPCS. When a high-water level in the reactor vessel is detected, HPCS injection is automatically stopped by a signal to close injection valve 1E22F004. With valve 1E22F004 in the open position without a demand signal, closure on a high reactor water level condition was not assured. Therefore, HPCS was declared inoperable. The following Technical Specifications were entered: 3.5.1, Emergency Core Cooling Systems (ECCS) - Operating and 3.6.1.3, Primary Containment Isolation Valves (PCIVs). Subsequently, HPCS injection valve 1E22F004 was observed to be cycling without operator action. The valve was deactivated in the closed position to assure the containment isolation function. The cause of valve 1E22F004 cycling without operator action is under investigation. HPCS is a single train safety system that consists of a single motor-driven pump, a spray sparger in the reactor vessel, and associated piping, valves, controls and instrumentation. HPCS is part of the ECCS network, which also includes Low-Pressure Core Spray, Low-Pressure Coolant Injection, and the Automatic Depressurization system. This event is being reported as an 8-hour non-emergency notification per 10 CFR 50.72(b)(3)(v) 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: (A) Shut down the reactor and maintain it in a safe shutdown condition; (B) Remove residual heat; (C) Control the release of radioactive material; or (D) Mitigate the consequences of an accident.' The licensee notified the NRC Resident Inspector.
ENS 5346220 June 2018 11:39:00On June 20, 2018 at 1003 CDT, the licensee declared a Notification of Unusual Event based on Emergency Action Level (EAL) 6.5.U, toxic gas release on site. The Notification of Unusual Event was terminated at 1025 CDT. The toxic gas release occurred when site personnel were filling a fire suppression carbon dioxide (CO2) tank outside the diesel generator building. The relief valve in the common diesel generator room for Unit 1 and 2 diesel generators inadvertently lifted causing a toxic gas environment by releasing CO2 into the room. The licensee terminated the tank fill stopping the release of CO2, and with the door to the room being opened, the gas cleared in about 20 minutes. The licensee has notified the NRC Resident Inspector. Notified DHS SWO, FEMA Ops, DHS NICC, FEMA NWC (email) and NuclearSSA (email).
ENS 5346119 June 2018 16:00:00The following information was received via E-mail: North Carolina Radioactive Material Branch (NCRMB) is reporting the following event: On 6/19/2018, Memorial Mission Hospital, Asheville (NC License, 0091-6) reported receiving two Biodex PET boxes containing F-18 FDG (fludeoxyglucose) from Cardinal Health, Asheville (NC License, 0794-7). Both boxes were delivered to Cardinal Health, Asheville via courier from Cardinal Health, Charlotte (NC License, 0794-1). Upon receipt of the boxes, Memorial Mission personnel performed surveys and wipes and noted the following contamination for Tc-99m on the boxes with the concentration of contamination being on the side handles of both boxes: Box 1: 88.96 kdpm/300 cm2 Box 2: 46.92 kdpm/300 cm2 No contamination was found inside either of the boxes containing F-18 patient doses and contamination was only on outside handles of both boxes. Memorial Mission confirmed that no further contaminated packages were received. Cardinal Health, Charlotte performed wipes and surveys of its work areas, courier vehicle and personnel. No contamination was found at this location with regards to this event. Cardinal Health, Asheville performed wipes and surveys of its work areas, courier vehicle and personnel. The courier at this location that delivered the two boxes to Memorial Mission Hospital is also a Pharmacy Technician. Removable contamination was found on this person's hands and cleaned. No other contamination was discovered at this location or the courier vehicle. No other notifications were made to any other agencies in NC. NCRMB was notified same day as the event. There are no other generic implications. NCRMB has dispatched an inspector to perform an on-site investigation. This report will be updated once more information is discovered, to include corrective actions and any other info needed to close and complete this report. Reporting Requirement: 10 CFR 20.1906(d)(1): Reports of removable contamination on package > limits in 10 CFR 71.87; removable contamination greater than limits specified in 49 CFR 173.443. NC Tracking Event Number: 180028.
ENS 533897 May 2018 17:40:00A non-licensed supervisor had a confirmed positive result for alcohol during a random fitness for duty test. The employee's access to the plant has been terminated. The NRC Resident Inspector has been notified.
ENS 5346420 June 2018 20:55:00

EN Revision Text: PART 21 - INTERIM REPORT NOTIFICATION The following was received via phone call and email: This report provides notification and interim information concerning an evaluation being performed by AAF Flanders for an unapproved design change in a High Efficiency Particulate Air Filter. An evaluation is underway for filters that underwent a non-approved design change. AAF Flanders has determined that an evaluation cannot be completed within the 60 day period. Discovery of the potential deviation was May 2, 2018. The information required for the 60-Day Interim Report Notification �21.21(a)(2) was provided. We anticipate that the evaluation will be completed by Sept 15, 2018. AAF Flanders is evaluating a potential nonconforming condition associated with filters (model number 0-007-C-42-03-NU-11-13-GG FU5) supplied to Prairie Island Nuclear Generating Plant (PINGP) / Xcel Energy. AAF Flanders notified Prairie Island Nuclear Plant of this potential defect.

  • * * UPDATE ON 9/14/2108 AT 1129 EDT FROM SHAWN WINDLEY TO ANDREW WAUGH * * *

The following information was received via email: A notification was submitted to the Commission with the subject matter of, 'Unapproved Design Change in a High Efficiency Particulate Air Filter.' At this time, the evaluation is pending third party qualification testing of the product. Information obtained from the qualification will be used in the determination of a defect. AAF Flanders had anticipated this process to have been completed by Sept 15, 2018 but because it is still on-going, we request an extension until October 31, 2018 to submit a final report to the Commission. The subject filters (model number 0-007-C-42-03-NU-11-13-GG FU5) supplied to Prairie Island Nuclear Generating Plant (PINGP)/ Xcel Energy had not been installed. AAF Flanders has recalled the subject filters and currently have them segregated and stored at our facility. They pose no threat public safety. Notified R3DO (Hanna) and Part 21/50.55 Reactors Group (email).

  • * * UPDATE ON 10/31/18 AT 1545 EDT FROM SHAWN WINDLEY TO HOWIE CROUCH * * *

The following information was excerpted from information received via email: AAF Flanders had anticipated the qualification process for said filters to have been completed by Sept 15, 2018. AAF requested a second extension by October 31, 2018 to submit a final report to the Commission, however; at this time our qualification is still pending third party approval. AAF Flanders is requesting another extension on the basis of an incomplete qualification of these filters. We anticipate qualification and a completed report on or before 12/15/2018. Notified R3DO (Stoedter) and Part 21/50.55 Reactors Group (email).

  • * * RETRACTION ON 08/20/19 AT 1140 EDT FROM SHAWN WINDLEY TO JEFFREY WHITED * * *

The following information was received via e-mail: AAF Flanders' evaluation of the condition identified in the interim report has been completed. The condition reported has been determined to be not reportable in accordance with 10 CFR 21. The subject filters (model number 0-007-C-42-03-NU-11-13-GG FU5) have passed qualification testing in accordance with the American Society of Mechanical Engineers (ASME) AG-1, Section FC with the new urethane and are fully qualified and listed on the Qualified Products List. The subject filters (model number 0-007-C-42-03-NU-11-13-GG FU5) supplied to Prairie Island Nuclear Generating Plant (PINGP)/Xcel Energy prior to this qualification test had not been installed and were subsequently returned to AAF Flanders. PINGP/Xcel Energy has been notified of the qualification status of the filter model. Notified R3DO (Riemer) and Part 21/50.55 Reactors Group (email).

ENS 5453724 February 2020 14:20:00The following is a synopsis of a email from the state of Georgia: On April 3, 2018, the Georgia Radioactive Material Program was informed that a fixed nuclear gauge on the number 4 Digester had a shutter stuck in the open position (normal operation mode). The shutter was made operable on the same day, that the report was made to the state of Georgia. The gauge is a Kay Ray 7063-P and serial number 9132. The gauge contains 500 mCi of Cs-137. The gauge is in service with all radiation readings acceptable. There was no risk of exposure to employees or members of the public.
ENS 5301413 October 2017 22:46:00On October 13, 2017 at 1700 CDT, Unit 1 High Pressure Coolant Injection (HPCI) was declared Inoperable due to discovery of a leak on a sensing line to 1-PCV-073-0043, Lube Oil Cooler & Gland Seal Condenser Pressure Control Valve. The leak is a steady stream located where the sense line connects to the valve. This constitutes an unplanned HPCI System inoperability and requires an 8 hour ENS notification in accordance with 10 CFR 50.72(b)(3)(v)(D), due to the failure of a single train system affecting accident mitigation and a 60 day written report in accordance with 10 CFR 50.73(a)(2)(v)(D). The NRC Resident Inspector has been notified by the Licensee.
ENS 5301012 October 2017 20:26:00A contract employee supervisor had a confirmed positive for illegal drugs during an initial screening test. The individual's access to the plant has been terminated. The NRC Resident Inspector has been notified by the Licensee.
ENS 5301113 October 2017 13:45:00The following information was received from the State of Ohio via email: On 10/12/17 during an infusion of Y-90 SIRSpheres that began at 11:05 a.m. (EDT), the treatment device malfunctioned and ceased delivery of the radioisotope, resulting in an under-dosing of the patient's liver. No contamination of the facilities or personnel was detected. All activity that was not delivered into the patient was placed back into the acrylic box and secured in the nuclear medicine hot lab for decay. A SIRSpheres representative was present during the treatment, but the cause of the malfunction is not known at this time. Once sufficient decay of the radioisotope has occurred, the delivery device will be shipped to SIRSpheres for technical analysis and root cause determination. The patient was informed on the day of the event. Ohio Item Number: OH170006 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 5299527 September 2017 14:26:00Security personnel reported to the Main Control Room that at time 1000 CDT (on 9/27/2017), an alarm indicated that a secondary containment door was open beyond the normal delay time allowed for entry and exit. Security personnel responded and found the door open and unattended with the dogs extended meaning that the door was unable to be closed. Security personnel secured the door at time 1004 CDT. No deficiencies were found with the door. The fact the door was open and unattended beyond the time allowed for normal entry and exit results in Technical Specification 3.6.4.1 'Secondary Containment-Operating,' not being met because surveillance requirement SR 3.6.4.1.3 is not met. This surveillance requires that doors be closed except during normal entry and exit. By definition in NUREG-1022, when Secondary Containment is inoperable, it is not capable of performing its specified safety function which in turn makes this condition reportable in accordance with 10 CFR 50.72(b)(3)(v)(D). The NRC Resident Inspector has been notified.
ENS 5299427 September 2017 12:38:00The following information was received from the State of Oklahoma via email and a follow-up phone call: Oklahoma Department of Environmental Quality notified us that they were notified on September 27, 2017, at 0907 CDT, by Century Geophysical Corp. (OK-04017-05) that a well logging tool was stuck at approximately 14 feet in a cased borehole. The tool contains a 1 Ci Am/Be source. They will provide more details on the source as soon as they are available. The initial plan is to dig the tool out.
ENS 5301313 October 2017 15:38:00

The following was reported from the State of Mississippi: Description of Incident: Licensee reported that their Niton gun was discovered to be misplaced or stolen on September 8, 2017. A letter was received by Mississippi State Department of Health: Division of Radiological Health (DRH) from the licensee on October 13, 2017 briefly detailing that their equipment had been lost or stolen. DRH intends to issue a violation letter to Southern Recycling due to the late notification. Also, due to lacking information, DRH cannot confirm if the device reported to have been stolen/lost contains radioactive material. DRH has attempted to contact the Licensee a number of times to acquire more information; however, there has been no response. DRH will continue contacting the licensee for more information and will update this report once complete. Isotope(s): Cd-109 (potentially lost source not confirmed), with an activity of 10 mCi. The DRH Health Physicist stated that this would give a reading of approximately 20 mRem at one foot if unshielded. Mississippi has assigned an incident number of MS17006.

  • * * UPDATE AT 1055 EDT ON 10/31/17 FROM H. BENJAMIN CULPEPPER TO S. SANDIN VIA EMAIL * * *

DRH was able to contact Licensee regarding the lost source. Licensee originally bought the device in 2007 to use at their facility. After a period of time, the device was more ineffective than effective, causing the Licensee to send the Niton gun for repairs. Licensee was informed that the source would have to be changed in order to alleviate the issue, but Licensee did not seek that avenue due to high costs. Even with the Niton gun being ineffective, Licensee maintained possession of the device until losing it three (3) years ago. The Licensee's coworker recently reminded them that DRH should be informed about the missing source. After contacting DRH about the missing source, DRH contacted a representative from Thermo Scientific to discuss the lifetime of the source. It was discovered that the source's assay date is 2/1/2006 and was shipped to the first owner on 12/6/2006. No other radioactive material was shipped to the Licensee in question from Thermo Scientific. Knowing that the lost source is Cd-109, which has a half-life = 462.6 days, it was discovered that the 10 mCi source will have decayed (as of today) to an activity level of 0.01618 mCi. Also, if the source was one (1) foot away from the target, the target would receive a dose-rate = 33.86 microR/hr. DRH closed this case on 10/30/2017. Notified R4DO (Werner) and NMSS Events Notification via email.

  • * * UPDATE ON 12/19/2017 AT 0945 EST FROM H. BENJAMIN CULPEPPER TO ANDREW WAUGH * * *

The following report was received via email: The Source Serial Number for the Cd-109 source is U3134. Notified R4DO (Pick) and NMSS Events Notification 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 5292023 August 2017 10:45:00This following report was phoned in, followed by an email: On August 22, 2017, Chesapeake Urology, notified the Maryland Radiological Health Program (RHP) that a male patient was injected with 176.1 microCuries of Ra-223 (Xofigo) instead of 108.4 microCuries of Ra-223 (Xofigo); 62.5 percent greater than the prescribed dose. The wrong unit dose was handed to the authorized user for patient administration. The event occurred at approximately 0930 (EDT) hours on 08/22/2017 at the licensee's address of 21 Crossroads Drive, Suite 200, Owings Mills, MD 21117. Maryland RHP was notified by telephone at 1505 hours. Two patients were scheduled for treatment on August 22, 2017. Both doses were assayed in the morning. Each dose had the proper patient name on the lead pig and on each respective syringe. The incorrect dose was selected and injected without cross referencing the identity of the patient. The event was discovered at approximately 1130 hours when the second Xofigo dose was to be administered. The patient and the referring physician have been informed of the misadministration. A written notification from the licensee is expected in about a week. This is a preliminary notification." 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 545759 March 2020 12:27:00The following information was received from the State of Colorado via email: The licensee reported to the State of Colorado two exit signs missing after renovation. Initial date reported: 8/2/17 Final Decision Material Lost date: 3/5/20 The exit signs have an activity of 7.5 Ci each. 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 5200213 June 2016 13:21:00A non-licensee employee supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been denied. The licensee has notified the NRC Resident Inspector.
ENS 5200614 June 2016 13:44:00

This was reported from the State of Alabama via facsimile: On June 13, 2016, the Radiation Safety Officer for Nucor Steel in Decatur, Alabama notified the Alabama Office of Radiation Control in regards to a piece discovered in scrap metal received via railcar. The piece appears to be a retaining ring approximately the diameter of a dime. The piece is reading over 5,000 mRad/hr at contact using a Ludlum model 15 survey meter. The piece has been secured in a building within the site boundary and away from employees. The licensee is continuing to research where and when the piece arrived onsite. The (Alabama) Office of Radiation Control plans to meet with site personnel on June 16, 2016. As of today, (6/14/16) 1235 CDT, this incident remains open until further investigation can be completed. Alabama Incident # 16-23

  • * * UPDATE AT 1131 EDT ON 06/17/16 FROM MYRON K. RILEY TO S. SANDIN VIA FAX * * *

On June 16, 2016, (representatives from the Alabama) Office of Radiation Control visited the site to conduct measurements and spectrum analysis. The retaining ring read 13.5 mR/hr at contact, 3.6 mR/hr at one foot, and 0.5 mR/hr at three feet with a Fluke 451P #2644, calibrated 12/10/15. Spectrum analysis using a Thermo IdentiFINDER revealed the isotope to be Co-56. This was confirmed through the Joint Analysis Center Collaborative Information System. As of today (06/17/16), 1025 CDT, this incident remains open until disposal options have been completed. Notified R1DO (Kennedy) and NMSS Events Notification via email.

ENS 5199810 June 2016 12:02:00

I. EVENT DESCRIPTION: High enriched scrap fuel material is processed in BWXT NOG-Lynchburg's Uranium Recovery facility to reclaim as much of the uranium as possible. The material is dissolved in acid and transferred to a series of horizontal columns where the acid is neutralized. The solution may be transferred to a set of accountability weigh columns for measurement prior to entering the uranium extraction process. The solution is subsequently transferred to a series of horizontal feed columns. Process water is used to periodically flush the horizontal columns during cleanup for materials accountability. On June 9, 2016, a BWXT Nuclear Criticality Safety (NCS) engineer was notified that a bluish tint had been observed in the favorable geometry process water connection to the horizontal columns. By procedure, a blue dye is added to the acid to aid in its identification in the event of a spill. Further evaluation determined that the favorable geometry process water line was directly connected to the horizontal column system and the presence of the blue dye indicated a potential backflow of uranium bearing solution into the water line. The favorable geometry water line is under constant water pressure. The valves controlling the water flow are normally closed. There is also a check valve in the line to prevent backflow. The line is supplied from a favorable geometry header on the mezzanine above. The header supplies water to other processes in Uranium Recovery, including an unfavorable geometry hot water heater. The Integrated Safety Analysis (ISA) was reviewed and an accident sequence for this potential backflow could not be identified. On June 9, 2016 at 1330 (EDT) it was the determined the accident sequence was unanalyzed and not properly documented in the ISA. Although IROFS (Items Relied on for Safety) listed for other accident sequences were applicable to the backflow scenario, the performance requirements of 10 CFR 70.61 were not maintained. As documented in the ISA, criticality was not 'highly unlikely.' II. EVALUATION OF THE EVENT: Backflow into the favorable geometry water line can only be achieved by a forced flow to overcome the water pressure in the line. The only source for this pressurized flow is during the transfer from the accountability weigh columns to the horizontal column system. The solution is transferred using an air diaphragm pump. A trained and qualified operator opens the valve to initiate the transfer of solution from the accountability weigh columns to the horizontal columns (an uncredited control). The transfer of solution to the horizontal columns is monitored by a trained and qualified operator (an uncredited control). The water heater is substantially upstream of the supply line to the horizontal columns. The direction of flow of the process water in the supply header is away from unfavorable geometry hot water heater. The process water header is a favorable geometry (a credited IROFS). An operator checks the process water pressure on a daily basis (a credited IROFS). If the above existing IROFS and uncredited controls were considered in an ISA accident sequence, the likelihood of a criticality could be demonstrated to be highly unlikely. However, these uncredited controls are not designated as IROFS. Although the as-found condition presented no safety concern, the scenarios as documented in the ISA did not demonstrate that the performance requirements of 10 CFR 70.61 were maintained. There was no immediate risk of a criticality or threat to the safety of workers or the public as a result of this event. Ill. NOTIFICATION REQUIREMENTS: BWXT is making this 24 hour report in accordance with 10 CFR 70, Appendix A, (b)(1), 'Any event or condition that results in the facility being in a state that was not analyzed, was improperly analyzed, or is different from that analyzed in the Integrated Safety Analysis, and which results in failure to meet the performance requirements of 70.61.' IV. STATUS OF CORRECTIVE ACTIONS: A section of the piping from the process water supply header was removed to physically isolate the process water supply from the horizontal columns. Criticality is no longer credible. The hot water heater is the only unfavorable geometry connected to the process water system in the Uranium Recovery facility. The hot water heater was assayed with a gamma survey instrument in several locations along the bottom and up the sides. No counts above background were detected. In addition, multiple liquid samples were taken from the bottom of the water heater and a cartridge filter housing prior to the hot water heater. All samples were well counted and determined to be below the Minimum Detectable Activity (MDA). An investigation of the root causes of this event is ongoing. Corrective actions will be determined as a result of the investigation. The licensee has notified the NRC Resident Inspector and Region II personnel.

  • * * UPDATE AT 0944 EDT ON 06/09/17 FROM ROBERT JOHNSON TO S. SANDIN * * *

I. EVENT DESCRIPTION: On June 10th, 2016 BWXT NOG-Lynchburg notified the NRC of an improperly analyzed condition involving the potential backflow of uranium bearing solution from a fissile solution processing system into the Uranium Recovery process water system. This notification was recorded as Event Notification Number 51998. One of the corrective actions in response to Apparent Violation 70-27/2016-004-01 was to conduct an Extent of Cause review of 'tasks involving ancillary systems (e.g., process water, nitric acid, HF acid, compressed air, steam, etc.) in our Uranium Recovery and Specialty Fuel Facility to verify these systems have documented accident scenarios as needed to meet the requirements of 10 CFR 70.' During the review of a waste processing system in the Specialty Fuel Facility (SFF), an additional potential backflow scenario was identified for a waste processing system. The system consists of a series of four favorable geometry columns. Waste solution is transferred to the columns using a less than or equal to 2.5 liter pump. The transfer of solution to the columns is monitored by a trained and qualified operator. Waste solution transferred to the columns is limited to a concentration of 5 grams 235U/liter as a Routine Operating Limit. A process water line is directly connected to the column system. The water is used to further dilute the concentration of the waste solution to a level that is acceptable for discharge into the hot waste drain (less than 0.04 grams 235U/liter). The column system is equipped with vent lines that overflow to the floor. The pump is capable of over-pressurizing the columns and possibly forcing waste solution into the favorable geometry process water system if the overflow vent lines were to fail. An unfavorable geometry hot water heater is located a significant distance downstream of the connection to the process water system. The Integrated Safety Analysis (ISA) was reviewed and an accident sequence for potential backflow of solution from the waste columns into the process water system could not be identified. II. EVALUATION OF THE EVENT: Administrative IROFS were identified in other accident sequences of the ISA that are applicable to the waste column backflow scenario. These IROFS include the operator control of solution concentration initially transferred to the waste processing system, and the daily check of the process water pressure which limits backflow into the system. Although these IROFS were available and reliable, additional IROFS are needed to meet the performance requirements of 10 CFR 70.61. Neither the operator's monitoring of the solution transfer or the overflow through the column vent lines are credited as IROFS in the ISA. They are considered uncredited safety controls. If either of the uncredited safety controls and the currently existing IROFS could be considered in an accident sequence, the likelihood of a criticality could be demonstrated to be highly unlikely. However, only IROFS documented in the ISA can be credited as preventing a criticality accident. Although the as-found condition presented no safety concern, the scenarios as documented in the ISA did not demonstrate the performance requirements of 10 CFR 70.61 were maintained. On June 8, 2017 at 10:00 am it was the determined the potential backflow of solution from the waste processing system was improperly analyzed and not documented in the ISA. As documented in the ISA, criticality was not highly unlikely. The SFF waste processing system was not in operation at the time of discovery. There was no immediate risk of a criticality or threat to the safety of workers or the public as a result of this event. Ill. NOTIFICATION REQUIREMENT: BWXT is making this 24 hour report to update Event Notification Number 51998 in accordance with 10 CFR 70, Appendix A, (b)(1) - Any event or condition that results in the facility being in a state that was not analyzed, was improperly analyzed, or is different from that analyzed in the Integrated Safety Analysis, and which results in failure to meet the performance requirements of 70.61. IV. STATUS OF CORRECTIVE ACTIONS: The process water line connected to the SFF waste processing system was locked out and posted as 'Out of Service.' Additional corrective actions are to be determined. The Extent of Cause review for AV 70-27/2016-004-01 is complete and the results are being finalized. The licensee informed the NRC Resident Inspector. Notified R2DO (Suggs), NMSS Events Notification, and Fuels Group by email.

ENS 5194319 May 2016 19:10:00The following was reported to the NRC via phone notification and email: As a result of a routine health and safety inspection, Taylor Regional Hospital has reported 13 medical events which occurred (from) 2006 (to) 2011. These medical events are the result of permanent prostate brachytherapy where post implant dosimetry for each of the 13 patients revealed the total dose delivered to the target organ differed from the prescribed dose by 50 REM and 20% or more. The Kentucky Cabinet for Health and Family Services is continuing to communicate with the licensee to ascertain all relevant information related to these events. Event report ID No: KY160004 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 5194419 May 2016 19:17:00

The following was received via FAX: On May 18, 2016, Nuclear Logistics INC. (NLI) determined that a contactor failure that occurred at the Shearon Harris plant had failed due to an auxiliary contact chatter present on the seal-in circuit for the coil voltage. The auxiliary contact chatter was caused by the loss of the shading coils. NLI will be submitting a full report on the issue to the NRC within 60 days. The contactor that failed was a Size 4 Eaton Freedom Series with a special coil for degraded voltage condition. Reference Number: P21-05192016 NLI reported that the following plants have these types of contactor's: Region 2: Oconee, Turkey Point, Shearon Harris and North Anna Region 4: Columbia and Waterford

  • * * UPDATE AT 1832 EDT ON 06/20/16 FROM TRACY BOLT TO DANIEL MILLS * * *

The following is excerpted from the licensee submission: The specific part which fails to comply or contains a defect: The Contactor that failed in service is a Size 4 Eaton Freedom Series with an AZZ/NLI special coil for meeting specific degraded voltage conditions. Extent of condition: Size 3, 4 and size 5 Eaton Freedom Series contactors or starters with an NLI special degraded voltage coil that have been supplied by AZZ/NLI since December 2010. NLI procured the commercial grade contactors and installed the special coil that was required to achieve the specific degraded voltage condition. The units were qualified, dedicated and supplied for safety related applications. The contactors were commercially procured from Eaton, the Original Equipment Manufacturer (OEM). For contactors/starters utilized in continuous duty applications. the OEM shading coils on the contactor core ... have the potential to become loose and fall off. If the shading coils are not in the intended location on the core, there is the potential for excessive chatter to occur on the normally open auxiliary contacts that are closed when the contactor is energized. The safety function of the contactor is to reliably supply uninterrupted power (no contact chatter) to a load on demand. For special degraded voltage applications, the NLI supplied contactor is equipped with an NLI special coil that replaces the OEM coil. When the contactor/starters that have the special coil installed are utilized in a continuous duty operation (continuously energized greater than 60 minutes) the special coil reaches a higher temperature than the original manufacturer's coil. The increased heat is potentially causing degradation of the acrylic resin that is utilized by the manufacturer to hold the OEM shading coils onto the OEM core. After the acrylic resin is no longer providing a secure hold on the shading coils, the shading coils can then become loose from the iron core. Name and address of the individual or individuals informing the Commission. Tracy Bolt, Director of Quality Assurance Nuclear Logistics, Inc. 7410 Pebble Drive Ft. Worth, TX 76118 AZZ/NLI Part 21 Report No: P21-05192016, Rev. 0 Plants potentially impacted include Oconee, Shearon Harris, Columbia, Turkey Point, North Anna, and Waterford. Notified R4DO (Rollins), R2DO (Musser) and Part 21/50.55 Reactors group (via email).

ENS 5194219 May 2016 14:47:00
ENS 5193917 May 2016 18:43:00On May 17, 2016 with the plant in Mode 4 (Cold Shutdown) during a refueling outage, personnel entered the drywell to perform a walkdown. At 0945 CDT, water was identified leaking from flexible hoses located at the inner elbow of MSL (Main Steam Line) B and MSL C. It was concluded that the leakage was from an elbow tap welded to the flexible hoses associated with flow instrumentation on MSL C and MSL B. Due to the refueling outage, the plant subsequently entered Mode 5 at 0955 and is currently in Mode 5 (Refueling) and 0 percent rated thermal power. The degraded component on MSL B was previously replaced in 2008 and on MSL C in 2007. The station has determined that this event is reportable under the provisions of 10 CFR 50.72 (b)(3)(ii)(A) as an event or condition that resulted in the condition of the nuclear power plant, including its principal safety barriers being seriously degraded, as an 8-hour notification. The NRC Resident Inspector has been notified.
ENS 5193316 May 2016 17:12:00The following information was received via E-mail On May 16, 2016 the Agency (Texas Department of State Health Service) was notified by the licensee's radiation safety officer that the facility was unable to isolate a gauge for maintenance when the shutter failed to operate. The gauge is an Ohmart Vega model SHF2 containing a 200 millicurie cesium - 137 source, serial number 7548GK. The shutter was left in the normal operating, unshielded position. The source does not pose any additional risk of exposure to the workers or members of the general public. The RSO stated they have called TechStar to repair the gauge. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: I 9404
ENS 5193616 May 2016 22:39:00The following was received by email: Required information as per 10CFR Part 21.21(d)(4) follows: (i) Name and Address of the individual or individuals informing the Commission Luis Sanchez, Vice President United Controls International 205 Scientific Drive NORCROSS, GA 30092 (ii) Identification of the facility, the activity, or the basic component supplied for such facility or such activity within the United States which fails to comply or contains a defect. Thomas & Betts Power Solutions/Cyberex Printed Circuit Boards (Gate Drive Assemblies P/Ns: 41-01-229677 & 41-01-229678, Reference Oscillator Module P/N: 41-01-808901) & Mersen (formerly Ferraz Shawmut) Fuses P/N: A30QS400-4 items were installed in PSEG (Public Service Enterprise Group) inverter unit and resulted in opening of P/N: A30QS400-4 fuses. When the original equipment was installed this issue was not present. (iii) Identification of the firm constructing the facility or supplying the basic component which fails to comply or contains a defect. United Controls International 205 Scientific Drive Norcross, GA 30092 (iv) Nature of the defect or failure to comply and the safety hazard which is created or could be created by such defect or failure to comply. Opening of the subject fuses prevents operation of the host inverter unit. (v) The date on which the information of such defect or failure to comply was obtained. March 17,2016 (vi) In the case of a basic component which contains a defect or fails to comply, the number and location of these components in use at, supplied for, being supplied for, or may be supplied for, manufactured or being manufactured for one or more facilities or activities subject to the regulations in this Part. The following is a compilation of UCI supplied items with like part numbers as the subject components. Only the printed circuit boards identified by the end-user (supplied under purchase orders 4500576271 (Qty. 1), 4500728702 (Qty. 1), and 4500625591 (Qty. 1)) along with the subject fuses supplied under purchase orders 4500810474 (Qty. 10) and 4500772093 (Qty. 6) are considered to possibly be affected by the end-user's reported issue. (vii) The corrective action which has been, is being, or will be taken; the name of the individual or organization responsible for the action; and the length of time that has been or will be taken to complete the action. UCI is not capable of performing additional evaluation of the subject printed circuit boards because UCI does not have the capability to simulate the in-service condition of these items. UCI suggests that the end-user perform additional evaluations with the subject printed circuit boards installed in their training inverter unit. UCI has requested that the end-user supply additional fuses supplied under purchase orders 4500810474 and 4500772093 for evaluation of current carrying performance since the fuses already provided were open. (viii) Any Advice related to the defect or failure to comply about the facility, activity, or basic component that has been, is being, or will be given to purchasers or licensees. None (ix) In the case of an early site permit, the entities to whom an early site permit was transferred. Not Applicable.
ENS 518463 April 2016 07:13:00

At 2302 (CDT) on April 2, 2016, with the plant shutdown, (with) all control rods inserted in the reactor and while attempting to reset the reactor trip breakers to support outage activities (reset of the main turbine), the reactor trip breakers reopened. This was identified to be due to having both trains of Solid State Protection System (SSPS) out of service while in Mode 5. With both trains of SSPS out of service, a condition was met that would cause a reactor trip signal due to having a general warning condition on both trains. Per procedure, the control rods were incapable of withdrawal and fully inserted. Reactor Coolant System boron was 2280 ppm. There were no actuations as a result of the reactor trip breakers opening due to SSPS being removed from service. The licensee will be notifying the NRC Resident Inspector.

  • * * RETRACTION AT 1635 EDT ON 4/4/16 FROM TIM HOLLAND TO JEFF HERRERA * * *

At 0713 EDT on April 3, 2016, EN #51846 provided notification of a Reactor Protection System actuation as revealed by the reactor trip breakers opening. Upon further investigation, it has been determined that the system actuated during maintenance activities due to a reactor trip signal caused by both trains of the Solid State Protection System (SSPS) being in test. This signal was not in response to actual plant conditions or parameters satisfying the requirements for initiation of the system and was therefore invalid. As such, the notification made by EN #51846 for a valid actuation of a specified system is hereby retracted. In addition, an editorial change to the first sentence of the original notification description is hereby made. The first sentence is revised to read as follows: At 2303 EDT on April 2, 2016, with the plant shut down and all control rods inserted into the reactor, while attempting to reset the reactor trip breakers to support outage activities (reset of the main turbine), the reactor trip breakers reopened. The NRC Resident Inspector will be notified. Notified the R4DO (Kellar).

ENS 5183330 March 2016 16:05:00The following information was received from the State of Florida via email: A Troxler Gauge was run over by heavy equipment at a construction site. The Type B container case was broken open exposing the source. (A Florida State) Inspector was sent to the scene to investigate. State of Florida Incident Number: FL16-047
ENS 5183230 March 2016 15:35:00The following information was received from the State of New York via facsimile: The Licensee's Radiation Safety Officer called on March 29, 2016 to report that during the administration of Y90 to the liver of patient in the Interventional Radiology suite earlier in the day, only 3.9 mCi of the intended 11.7 mCi was administered due to a clogged catheter. (NY State Department of Health) will update after receiving report from the licensee. NY State Incident No.:1136 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 5182829 March 2016 16:31:00

At approximately 1900 EDT on March 28, 2016, an unplanned loss of retail power to the McGuire Meteorological tower occurred. This loss of power impacted communication between the Meteorological tower and the control room, which resulted in a major loss of emergency assessment capability. Compensatory measures existed within the site's emergency planning procedures to obtain meteorological data from the National Weather Service. Meteorological information could have been provided via the emergency notification system to the NRC operations center. Power was restored at 2245 EDT on March 28, 2016. The NRC Resident Inspector has been notified. There was no impact to the public.

  • * * RETRACTION AT 1423 EDT ON 4/19/2016 FROM SCOTT SLIETER TO MARK ABRAMOVITZ * * *

This notification is being made to retract event EN 51828 that was reported March 29, 2016. Based on further investigation, Emergency Plan Implementing Procedures provide acceptable alternative methods to perform emergency assessment that are in addition to the control room indications from the meteorological tower. Furthermore, it was determined that the meteorological tower data was valid and available in the control room during the applicable period. It was therefore determined that no actual or potential major loss of emergency assessment capability existed per 10CFR50.72(b)(3)(xiii). This is consistent with NUREG 1022, rev 3, supplement 1 and NEI 13-01, rev 0. The NRC Resident Inspector has been notified of the retraction. Notified the R2DO (McCoy).

ENS 511346 June 2015 23:19:00

On June 6, 2015, during a review of Independent Spent Fuel Storage (ISFSI) cask loading, plant personnel discovered that for two casks, preferential loading was not used during uniform loading as required by ISFSI Technical Specification 2.1.2, Uniform and Preferential Fuel Loading. ISFSI Technical Specification 2.1.2 requires that a preferential fuel loading configuration (i.e., that fuel assemblies with the longest cooling times shall be loaded into peripheral fuel storage locations) is used during uniform loading. Preferential loading was only partially met for two casks, designated MPC-253 and MPC-257. For these two casks, fuel assemblies with the longest cooling times were placed in the four center cask locations, which are only ones allowed for those assemblies containing control rods. Engineering has performed an evaluation and determined that the fuel casks remain in a safe and analyzed condition.' There is no adverse effect on the health and safety of the public. The NRC Resident Inspector has been informed.

  • * * UPDATE FROM WESLEY FIANT TO DONALD NORWOOD AT 2100 EDT ON 6/9/2015 * * *

A full extent of condition review has determined that 17 of the 29 loaded casks in the Diablo Canyon ISFSI prior to the 2015 campaign were found to be out of compliance with ISFSI Technical Specification 2.1.2, Uniform and Preferential Fuel Loading. The casks were preferentially loaded based on heat load vs cooling time. Engineering has performed an evaluation and determined that the fuel and casks remains in a safe and analyzed condition. There is no adverse effect on the health and safety of the public. The NRC Senior Resident Inspector has been informed. Notified R4DO (Werner).

ENS 511315 June 2015 19:22:00

The following information was provided via email and telephone. Fort Calhoun Station is currently completing a scheduled refueling outage. On June 5, 2015 at 1330 during performance of surveillance testing on the auxiliary feed water system, (Hydraulic Control Valve) HCV-1107A, Steam Generator RC-2A Auxiliary Feedwater Inlet Valve, did not open when given an open signal. HCV-1107A has been declared inoperable. HCV-1107A is required to open to meet the decay heat removal safety function for Steam Generator A. Fort Calhoun Station is in Mode 3 (Reactor Coolant System temperature is greater than 515 degrees Fahrenheit and not critical). With HCV-1107A inoperable and unable to feed the A steam generator both auxiliary feedwater trains are considered inoperable. HCV-1107A is inside the Containment Building. Fort Calhoun Station Technical Specifications 2.5(1)D. requires: With both AFW trains inoperable, then initiate actions to restore one AFW train to OPERABLE status immediately. Technical Specification (TS) 2.0.1 and all TS actions requiring MODE changes are suspended until one AFW train is restored to OPERABLE status. Fort Calhoun Station is evaluating the best approach to repairing HCV-1107A. The Resident Inspector has been notified

  • * * UPDATE PROVIDED BY CHARLIES SMITH TO RICHARD SMITH AT 2300 EDT ON 06/05/2015 * * *

Fort Calhoun Station has determined plant cooldown required to perform repairs. Plant cooldown in progress. The licensee will notify the NRC Resident Inspector. Notified R4DO (Whitten)

ENS 511305 June 2015 15:22:00

The following was received via email: On June 5, 2015, the Arkansas Department of Health (ADH) received notification from the licensee's Radiation Safety Officer (RSO) of a possible medical event that occurred during an Yttrium-90 TheraSpheres procedure on June 4, 2015. The licensee has not completed the investigation and has provided limited information to determine if the procedure constituted a medical event. The patient was treated with Y-90 TheraSpheres. The written directive prescribed a dose of 114 Gy, but received a dose of 18.3 Gy. Preliminary findings seem to indicate that an incorrect dose may have been administered to the patient. The patient and referring physician have been notified. The licensee and ADH are continuing to investigate this event. ADH considers this event to be opened and will provide more information as it becomes available. 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. ARKANSAS EVENT #2015-005

  • * * RETRACTION FROM JARED THOMPSON TO VINCE KLCO ON 7/6/2015 AT 1614 EDT * * *

The following information was received from the State of Arkansas via email: The Arkansas Department of Health (ADH) is requesting the retraction of NRC Event Number (51130). ADH received a report from the licensee dated June 18, 2015. The report and investigation conducted by the licensee determined that this event did not qualify as a reportable medical event. A review of the written directive indicated that the radiation dose that was prescribed by the authorized user was delivered to the patient. The authorized user had intended to prescribe 114 Gray. This was confirmed by ADH after further review of the documentation obtained during the on-site investigation. The patient completed this treatment on June 29, 2015. The licensee has implemented revisions in the treatment procedures for further safety improvements. The ADH considers this event to be closed. Notified the R4DO (Haire) and NMSS Events Notification Group via email.

ENS 5107115 May 2015 07:22:00Class 1E A/C Unit SGK05A cools safety related electrical train 'A' and was found tripped at 0436 (CDT). As a result, the following supported safety related electrical equipment were declared inoperable: 4.16 KV Bus NB01, 480 volt Buses NG01 and NG03, 120 volt Instrument AC Inverters and Buses NN11, NN13, NN01 and NN03, 125 VDC Chargers and Buses NK11, NK13, NK01 and NK03. T/S 3.0.3 was entered from T/S 3.8.7 due to two out of four 120 volt AC Inverters (NN11 and NN13) being inoperable. All electrical systems listed above remain available but are declared inoperable due to inadequate room cooling capability. Plant shutdown to mode 5 commenced at 0530 (CDT). No major equipment is out-of-service. All systems have functioned normally. Plant is currently at 95 % power ramping down. Plant must be in mode 3 by 1136 CDT. No compensatory measures have been established. The NRC Resident Inspector has been notified.