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 Entered dateEvent description
ENS 537197 November 2018 17:28:00The following information was received from the Commonwealth of Kentucky by email: On 11/6/2018, a former licensee (formerly licensed as Wickliffe Paper Co.) reported discovery of a nuclear gauging device (TN (Texas Nuclear) model 5036 originally containing 200 mCi assayed 12/94) that it was unaware it possessed. The license was terminated on August 9, 2016 and at that time, the former licensee provided information related to the disposition of all devices the licensee was aware it possessed. License termination was due to plant closure. During engineering surveys to assess plant conditions for restart, personnel discovered the device still mounted on plant equipment. The former licensee is taking steps to have the device transferred to a licensed manufacturer for disposal. There is no reason to believe any individuals received any exposure at levels which would exceed the regulatory limits." Kentucky Event: KY180004 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 537165 November 2018 11:26:00The following information was received via email: When conducting the annual reconciliation, Karcher North America, INC. reported eleven lost static eliminators. Static Eliminators: Model: P-2021 8101. Isotope/units: PO-210, 10 mCi ea. Serial Numbers: A2JZ217, A2KH719, A2CP799, A2DM543, A2DT589, A2DU443, A2DU444, A2EZ668, A2GS233, A2JD061, A2JD062. Colorado Event Report ID No.: CO180027 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 537207 November 2018 15:44:00The following information was received by the State of Florida: At noon (on 11/7/18), (Akumin) called (the State of FL Bureau of Radiation Control) to report that both Akumin Hollywood and Akumin Aventura View ordered F-18 Fluciclovine, and received packages that were labeled as F-18 Fluciclovine, but were subsequently notified by their radiopharmaceutical vendor PET NET Solutions-Ft Lauderdale, on Thursday, November 1, 2018 that due to a 'batch error,' the packages actually contained F-18 FDG (Fludeoxyglucose). Three patients were reported as receiving the incorrect radiopharmaceutical. Activity reported as approximately 10 mCi. Florida Incident: FL18-137 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 5370530 October 2018 16:33:00

Replacement camera sources were properly delivered by the common carrier to St. Mary's Hospital located in Jefferson City, Missouri. The sources were received by the Biomed Hospital Imaging Specialist and placed in the biomed office. Currently, the package containing the sources is missing. The licensee investigation continues. Sources are two Gd-153 (10 mCi each) and two Co-57 (0.5 microCi each).

  • * * RETRACTION ON 10/31/2018 AT 1425 EDT FROM KEN WOHLT TO ANDREW WAUGH * * *

This event is being retracted. The sources were discovered to be delivered to SSM Hospital's biomed office instead of nuclear medicine. The sources were secured and in control of the SSM Hospital at all times. There were no exposures to personnel. The licensee notified NRC Region 3 (Warren). Notified R3DO (Stoedter) and NMSS Events Notification and ILTAB 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 5370028 October 2018 21:44:00

This event is being reported pursuant to 10 CFR 50.72(b)(3)(xiii) for a major loss of emergency assessment capability at the Prairie Island Nuclear Generating Plant. At 1435 CDT on October 28, 2018, troubleshooting of the Seismic Monitoring Panel resulting from the receipt of Control Room annunciator 47023-0603 (Seismic Monitor Panel) determined that the '(Operational Basis Earthquake) OBE Exceedance' alarm on the Seismic Monitoring Panel will not alarm and determined the panel is non-functional. The Seismic Monitoring Panel system functions to provide indication that the OBE threshold has been exceeded following a seismic event and is used in the Prairie Island Nuclear Generating Plant Emergency Plan to perform classification of Initiating Condition 'Seismic event greater than OBE levels' and Emergency Action Level HU2.1. Station personnel are monitoring the seismic recorders for event alarms on a 15 minute frequency due to alarm function failure. The station is developing repair plans for restoration of the alarm function. This event does not adversely affect the safe operation of the plant or health and safety of the public.

The licensee has notified the NRC Resident Inspector.

ENS 5369526 October 2018 12:11:00A patient was prescribed 200 mCi of Lutetium-177. Due to dose administration issues, a delivered dose of 135 mCi was received by the patient. The licensee notified the NRC Region 3 contact (Gattone). 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 536465 October 2018 09:52:00

EN Revision Text: MAIN STEAM ISOLATION VALVES EXCEEDED PRIMARY CONTAINMENT LOCAL LEAK RATE ACCEPTANCE CRITERIA At 0520 (CDT), on October 05, 2018, it was discovered that a Primary Containment local leak rate test performed on Main Steam Isolation Valves (MSIV) exceeded its acceptance criteria.

During Mode 1, 2, and 3, Surveillance Requirement 3.6.1.3.10 requires MSIV leakage for a single MSIV line to be less than or equal to 106 standard cubic feet per hour (scfh) when tested at 29 psig and Surveillance Requirement 3.6.1.3.12 requires the combined leakage rate for all MSIV leakage paths to be less than or equal to 212 scfh when tested at 29 psig.

As-found for the 'C' MSIV line leakage results were unquantifiable and gave a (minimum) path value greeter than 160 scfh. This leakage rate lead to Surveillance Requirement 3.6.1.3.10 and 3.6.1.3.12 limits to be exceeded. This event is being reported as a condition of the nuclear power plant, including its principal safety barriers, being seriously degraded per 10 CFR 50.72(b)(3)(ii)(A) since the Primary Containment Isolation Valves leakage limits for MSIVs were exceeded. The NRC Resident Inspector has been notified.

  • * * RETRACTION AT 2320 EDT ON 10/24/2018 FROM THOMAS FORLAND TO MARK ABRAMOVITZ * * *

CNS (Cooper Nuclear Station) is retracting the 8-hour non-emergency notification made on October 5, 2018 at 0520 CDT (EN# 53646). Subsequent evaluation concluded that overall as-found 'C' MSIV leakage rate was not at a level that exceeded the surveillance requirement 3.6.1.3.10 and 3.6.1.3.12 limits and thus the Primary Containment Isolation Valve leakage rate limits for the MSIVs were not exceeded. The NRC Senior Resident Inspector has been notified. Notified the R4DO (Drake).

ENS 536434 October 2018 07:57:00

EN Revision Text: MANUAL REACTOR TRIP DURING LOW POWER PHYSICS TESTING At 0544 EDT on October 4, 2018, with Unit 1 in Mode 2 with reactor power in the intermediate range performing low power physics testing, the reactor was manually tripped due to a rod control urgent failure alarm. 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 system. Unit 2 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 inserted as expected. The cause of the rod control urgent failure is being investigated.

  • * * UPDATE FROM KEVIN LOWE TO DONALD NORWOOD AT 1408 EDT ON 10/19/2018 * * *

This Event Notification is being updated to clarify that the reactor was not critical when this event occurred. Therefore, the reporting requirement is changed from 10 CFR 50.72(b)(2)(iv)(B) to 10 CFR 50.72 (b)(3)(iv)(A). During Dynamic Rod Worth Measurement testing, Control Bank Charlie was inserted approximately 153 steps when the urgent failure occurred (CBC positioned at 75 steps out). Following the scram, additional analysis concluded that the reactor was subcritical when the Reactor Protection System was actuated." The licensee notified the NRC Resident Inspector. Notified the R2DO (McCoy).

ENS 5362626 September 2018 23:25:00

On September 26, 2018 at 1908 CDT. an automatic scram was received on U1 following main generator 345 kV output breaker 7-8 trip with 345 kV output breaker 6-7 already opened for maintenance on line 0401. Following the reactor scram, reactor water level decreased to approximately minus 15 inches, which resulted in automatic Group II and Group Ill isolations (expected response). Reactor pressure rose to approximately 1083 psig, and the 3B and 3C low set relief valves opened briefly to control reactor pressure. Reactor water level and reactor pressure have been restored to their normal bands. All systems responded properly to the event. Unit 1 remains in Mode 3, with reactor pressure being controlled on the turbine bypass valves. The cause and details of the event are under investigation.

Unit 2 was unaffected by the event and remains at 100% power. This report is being made in accordance with 10 CFR 50.72(b)(2)(iv)(B) and 10 CFR 50.72(b)(3)(iv)(A)." All control rods inserted. Decay heat is being removed via the main condenser. The licensee notified the NRC Resident Inspector.

ENS 5362326 September 2018 15:10:00At 0946 CDT on 9/26/2018, a disruption in power to the offsite 138 kV line and the subsequent trip of the Emergency Reserve Auxiliary Transformer (ERAT) Static VAR Compensator (SVC) resulted in a degraded voltage signal on the Division 1- 4.16 kV safety bus. The degraded voltage signal resulted in a trip of the ERAT feed to the bus, blocking closure of the 345 kV Reserve Auxiliary Transformer (RAT) feed to the bus and auto start of the Division 1 Emergency Diesel Generator (EDG). The Division 1 EDG successfully started and re-energized the Division 1- 4.16 kV bus as designed. The unit is stable with the Division 1 EDG carrying the Division 1- 4.16 kV bus. The Ameren Transmission System Operator in St. Louis, MO informed the station that they had received a report that a 138 kV to 13.8 kV transformer at Clinton Route 54 substation was on fire and the South feed to the Tabor substation cycled as a result of this fault. The NRC Resident Inspector and Illinois Emergency Management Agency Resident Inspector have been notified.
ENS 5362526 September 2018 21:43:00

On 9/26/2018 at 1530 EDT, it was discovered that the HPCI system was inoperable due to a blown fuse in the 10C617 Panel, E21-F15A. Therefore, this condition Is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D). The blown fuse also impacts 'A' channel Residual Heat Removal (RHR) subsystem and 'A' Core Spray (CS) subsystem. These Emergency Core Cooling subsystems have been declared inoperable. Remaining Emergency Core Cooling subsystems and the Reactor Core Isolation Cooling (RCIC) system remain OPERABLE.

There was no impact on the health and safety of the public or plant personnel." The licensee notified the NRC Resident Inspector and will notify the local authorities.

ENS 5361924 September 2018 14:06:00On September 22, 2018, at approximately 0050 (CDT), Duane Arnold Energy Center (DAEC) Security was contacted by a site assigned contractor that they had located what appeared to be drug paraphernalia inside the Protected Area. Local Law Enforcement was contacted and responded to DAEC. The Linn County Sheriff's office took the items into evidence for testing to determine if there was any presence of a controlled substance. On September 24, 2018, at 1013, the Linn County Sheriff's office notified DAEC that the items tested positive for the presence of a controlled substance. Therefore, this is being reported in accordance with 10 CFR 26.719. DAEC Site security is working with NextEra Corporate security regarding the investigation into this incident. The Resident Inspector has been notified.
ENS 5366916 October 2018 10:12:00The Clorox Company discovered a missing fixed gauge containing radioactive material. The gauge was a Filtec, model FT-2 containing 100 microCuries of Americium-241. Gauge S/N: 105382; Source S/N: 1786. 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 5360915 September 2018 15:45:00

EN Revision Text: UNUSUAL EVENT DUE TO SITE CONDITIONS PREVENTING PLANT ACCESS A hazardous event has resulted in on site conditions sufficient to prohibit the plant staff from accessing the site via personal vehicles due to flooding of local roads by Tropical Storm Florence. Notified DHS SWO, FEMA OPS, and DHS NICC. Notified FEMA NWC, NuclearSSA, and FEMA NRCC via email.

  • * * UPDATE FROM BRUCE HARTSCOK TO VINCE KLCO ON 9/28/2018 AT 1414 EDT * * *

On 9/18/2018 at 1400 EDT, the Unusual Event at Brunswick was terminated due to the ability to transport personnel to the site. The licensee will notify the NRC Resident Inspectors. Notified the R2DO (Guthrie), NRR EO (Miller) and the IRD MOC (Grant). Notified DHS SWO, FEMA OPS, and DHS NICC. Notified FEMA NWC, NuclearSSA, and FEMA NRCC via email.

ENS 5366011 October 2018 09:39:00

The following information was received by from ABB INC by facsimile: 1. This letter provides a notification of a defect associated with dry type transformer serial # 24-26458. The failure was caused by the breakdown of layer to layer insulation within the 4160 volt winding due to dielectric stress. Deterioration of the insulation resulted in an internal fault within the bravo phase 4160 volt winding, triggering a ground fault trip shutdown of equipment. This failure was reported by Exelon's Clinton Nuclear Station and it is the only known reported occurrence of safety related transformer failure caused by the breakdown of layer to layer insulation. Information is provided as specified in 10 CFR 21 paragraph 21.21(d)(4). 2. Notifying individual: Joey Chandler, Plant Manager, ABB ((PGTR) Power Grids Transformer Division, US), 171 Industry Drive, Bland, VA 24315. 3. Identification of the Subject component: ABB P/N 24-26458 dry type transformer. This transformer is used for stepping down voltage and was intended for providing power to safety related electrical equipment. 4. Nature of the deviation: The Exelon Clinton Nuclear Generating Station shut down due to a ground fault alarm on the 4160 volt side of the stepdown transformer that provides power to numerous safety-related components at the plant. Subsequent troubleshooting of the problem revealed that the dry-type transformer supplying 480 volt power had dielectrically failed due to apparent internal fault within the Bravo phase. Further investigation of this failure revealed an operational voltage design stress on the Nomex 410 insulation between the 4160 volt winding's layers of conductor of greater than recommended by the manufacturer (DuPont) for a 40 year design life. At the time of failure, the subject transformer had been in operation for approximately 33.5 years and had progressed 37 years and two months into its intended 40 year life given the 10/1980 ship date. ABB has no knowledge of any adverse operational variances over the course of the approximate 33.5 year life of operation to be able to assess or comment on this potential impact in terms of life. 5. The function of this dry type transformer is to step voltage down from 4160 volts to 480 volts while providing transfer of power to safety related components. Exelon's Clinton Nuclear Power Station has identified this transformer's power transfer to feed safety related equipment. An interruption of this transfer in power would result in a loss of power to the safety related equipment downstream and could potentially result in a compromise in safety. 6. ABB was notified of this transformer failure on 12/9/2017. This notification was delayed while the failure was being investigated. This investigation is documented in report: Exelon Clinton Failure Analysis_26458_011218 rev5.doc.pdf dated 09/10/2018. 7. Corrective actions include:

  a. Reviewed and verified current electrical engineering safety related design standard for allowable design stress on insulation per DuPont's recommendation for 40 year life. (Complete.)
  b. Reviewed the material used for transformer 24-26458. Found only affected safety related product to be isolated to Clinton Nuclear Station, though records may be incomplete as these records have been archived for over 35 years. (Complete.)
  c. Re-trained all involved personnel of the 10 CFR 21 reporting requirements, and the need to provide an interim report within 60 days of discovery. 
  d. ABB worked directly with Clinton Nuclear to ensure all transformers of respective design was replaced with new transformers following ABB's Technical Evaluation for Nuclear 1E Transformer, Rev. 18 which documents operational design stresses be less than or equal to 30 volts / mil of Nomex 410 insulation between layer to layer of conductor for 40 year life.

8. Recommendation: Because of the possible existence of additional affected transformers, ABB (PGTR) cannot determine the potential for a substantial safety hazard exists at any other licensee's facility. Licensees are requested to evaluate any Gould-Brown Boveri/ITE dry type transformer with the following nameplate identification below. Transformers associated with this identification are recommended to be replaced. kVA: 750AA/ 1000 FA

HV: 4160 Delta Connected
LV: 480 Wye Connected
Class: AA/ FA
Type: Vent
Frequency: 60 Hz
Temp Rise: 80 degrees C
Date of Manufacture: 10/1988 and older models

Questions concerning this notification should be directed to the Quality Manager (Rick Kinder) at the ABB transformer plant in Bland, VA at (276) 688 -3325.

ENS 535771 September 2018 10:43:00While filling up a licensee company truck at a gas station located in Ripley, West Virginia, an individual stole the company truck and its associated radiography camera (QSA 880; S/N 677846;108 Ci; Iridium-192 source). The licensee notified LLEA (West Virginia State Police) and the vehicle was recovered. The licensee inspected the properly secured equipment and observed no impact to the radiography camera. The licensee stated there was no radiological impact to the public or employees. THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
ENS 5354913 August 2018 12:05:00

The following information was received from the State of Texas via email: On August 12, 2018 at approximately 1135 (CDT)., the licensee notified the Agency (Texas Department of State Health Services) that one of its radiography crews had experienced a source disconnect. The event occurred on August 11, 2018, at approximately 1200 (CDT) at a temporary job site near Whitsett, TX. The device involved was an INC IR-100 (SN: 6792) containing a 91 curie iridium-192 source (SN: ZH0109). The crew had set up the device and performed a procedure shot and everything functioned properly. They performed the first shot of the job and the source would not retract into the device--it felt as though it had stuck on something. After a second unsuccessful attempt, the source was cranked back out into the collimator, boundaries set, and an authorized person came to the site and performed the retrieval. The drive cable and source were both new. There was no observable cause for the failure. The device and associated equipment will be sent to the manufacturer for evaluation. Per readings from all three individuals' self-reading pocket dosimeters, there were no overexposures. The source retriever's dosimetry badge is being sent for processing. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300.

  • * * UPDATE FROM KAREN BLANCHARD TO VINCE KLCO ON 8/13/18 AT 1559 EDT * * *

The following update information was received from the State of Texas via email: Clarification: The source assembly (never disconnected) from the drive cable. (The licensee was) unable to retract it back into the exposure device. Notified R4DO (Deese) and NMSS Events Notification Group via email. Texas Incident: I-9606

ENS 535373 August 2018 14:10:00At 0940 EDT on August 3, 2018, the Division 2 Mechanical Draft Cooling Tower (MDCT) fans were declared inoperable due to failure of the over speed fan brake inverter. The brakes prevent fan over speed from a design basis tornado. The MDCT fans are required to support operability of the Ultimate Heat Sink (UHS). The UHS is required to support operability of the Division 2 Emergency Equipment Cooling Water (EECW) system. The EECW system cools various safety related components, including the High Pressure Coolant Injection (HPCI) system room cooler. An unplanned HPCI inoperability occurred based on a loss of the HPCI Room Cooler. Investigation into why the Division 2 MDCT fan over speed brake inverter failed is in progress. This report is being made pursuant to 10CFR50.72(b)(3)(v)(D) based on an unplanned HPCI inoperability. The NRC Resident Inspector has been notified.
ENS 535352 August 2018 16:46:00The following information was received from the State of Louisiana via email: On 07/26/2018, (the) Radiation Safety Officer (RSO) for ExxonMobil Chemical Co. (ExMCo) reported a multi-source gauge failure to the Department (Louisiana Department of Environmental Quality), LDEQ by e-mail. On 07/25/2018 during routine annual maintenance and pm (preventative maintenance) checks it was discovered the level/density gauge had several shutters stuck in the open position. Three sources would not retract into the shielded position. However, the remaining four sources are functioning properly. The gauge is a Berthold Technologies USA multi-source device, Model LB 300 IS, utilizing AEA Technologies, Model CKC.P4 sources. There are seven (nominal) 50 mCi Co-60 sources in the device. The sources involved in this malfunction are source #1 s/n 1369-08-02, source #2 s/n 1370-08-02, and source #6 s/n 1374-08-02. All three sources will not retract into the shielded position. The device has a SS&D Registration # TN-1031-D-801-S. Only one device was manufactured and is no longer being manufactured. The manufacturer is Berthold Technologies GmbH & Co. KG, D-75323 Bad Wildbad Germany. The Berthold Model LB300 IS level density gauge is installed on G-Line High Pressure Reactor Vessel, V5300 and G-Line high pressure separator production line. ExMCo engineers and Flowmaster/Berthold engineers & service company have been contacted to fix the problem by repairing the source holders or replace the device with other comparable technology. Event type: The gauge is installed on processes and does not pose a health and safety threat to the general public or the ExMCo employees. The gauge will remain on the operational process until the repair is made to the device. This is considered an equipment failure for reporting requirements. Event Location: ExxonMobil Chemical Co. Baton Rouge Plastics Plant 11675 Scotland Avenue, (Hwy 19) Baton Rouge, LA 70807, Event description: Shutters stuck in the open position or difficult to operate shutters were detected on a level/density gauge installed on processes at ExMCo. A service company has been contacted to make the repair or replace the device. The Department will be provided a final report with corrective actions. The Department was notified and the incident was reported to the NRC Operation Center. The report to the NRC as required by 10 CFR Part 30.50 (b) (2) and required by LAC 33:XV.341.B.2.b. Louisiana Event: LA 180015
ENS 5352224 July 2018 00:57:00The following event description is based on information currently available. If through subsequent reviews of this event additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS (Emergency Notification System) or under the reporting requirements of 10CFR50.73. This event is being reported pursuant to 10CFR50.72(b)(3)(xiii) as a Loss of Emergency Preparedness Capabilities at Palo Verde Nuclear Generating Station (PVNGS) Unit 2. On July 23, 2018, at approximately 1631 Mountain Standard Time (MST), the Unit 2 control room experienced an unplanned loss of Steam Generator #1 steam line monitor (RU-139), channels A and B. This monitor is used to assess dose projections for Main Steam line exhaust while in Modes 1-4 and is used in the PVNGS Emergency Plan to perform classification of Initiating Conditions 'RS1' and' RG1' and Emergency Action Levels (EALs) 'RS1.2' and 'RG1.2'. The PVNGS Emergency Plan does have two additional EALs that can be assessed for each Initiating Condition. The loss of this monitor constitutes a reportable loss of emergency assessment capability. The NRC Resident Inspector has been informed of this condition.
ENS 5360313 September 2018 14:38:00The following information was received by the State of Texas: On 09/13/2018, the Agency (Texas Department of State Health Services) was notified by a licensee that an employee received a personnel dosimetry report of 16.0 rem for the second quarter of 2018. The employee had received a report of a 3.3 rem exposure for the previous quarter. The licensee suspects that someone tampered with the dosimeter. The employee works in the nuclear medicine department and always leaves the badge attached to the lab coat on the door to the hot lab. Other employees performing similar work only received minimal exposures. Due to the amount of the reported exposure, the agency will conduct an investigation on site. Texas Incident: I-9613
ENS 5350011 July 2018 03:58:00On July 11, 2018, as part of pre-planned maintenance, the site meteorological tower will be removed from service. The tower will be out of service for approximately 11 days. As a result, this is reportable under 10CFR 50.72 (b)(3)(xiii). During the time the data is not available from the meteorological tower; compensatory measures will be in place to obtain the data from the National Weather Service if necessary. The (NRC) Resident Inspector has been notified.
ENS 534874 July 2018 23:19:00The following information was received from the State of Texas by email: On July 4, 2018, the Agency (Texas Department of State Health Services) was notified by the licensee's radiation safety officer (RSO) that one of their crews has experienced a source disconnect. The crew was using a QSA 880D exposure device containing a 70 Curie Iridium - 192 source. The licensee did not have a lot of details on the event, but stated the source had been recovered and that no over exposures had occurred. The licensee stated the connector ball on the drive cable was tested after the event and failed the test. The RSO stated they would provide additional information on July 5, 2018. Additional information will be provided as it is received in accordance with SA-300. Texas Incident- I-9591
ENS 534853 July 2018 19:07:00

EN Revision Text: DISCOVERY OF AN UNANALYZED CONDITION THAT SIGNIFICANTLY DEGRADES PLANT SAFETY On July 3, 2018, while performing a review of Emergency Operating Procedures, a concern was identified regarding the potential for excessive loss of ultimate heat sink inventory (UHS) through the auxiliary feedwater (AFW) system mini-flow recirculation pathway. This condition would have the potential to prevent the ultimate heat sink from providing an adequate inventory of water for a 30-day mission time.

The normal water supply for the Callaway AFW system is the condensate storage tank (CST). The CST is a non-safety grade component. The safety-grade supply for AFW is the essential service water (ESW) system. The ESW system is supplied by the UHS. The UHS thermal performance analysis accounts for a loss of UHS inventory to the AFW system up until the point of the accident sequence that the AFW pumps would be secured. The analysis did not include an allowance for loss of UHS inventory through the AFW mini-flow recirculation pathway following the AFW pumps being secured. The EOP guidance that secures the AFW pumps does not isolate the mini-flow recirculation pathway.

Initial estimates indicate that loss of UHS inventory through the mini-flow recirculation pathway, if not isolated, would preclude the UHS from completing its 30-day mission time. This potential for depletion of the UHS placed the plant in an unanalyzed condition that significantly degraded safety.

Callaway has issued interim guidance to the on-shift personnel regarding this concern to ensure that the ultimate heat sink water level is maintained at a level that will be adequate to mitigate the potential loss of inventory.

This condition is reportable per 10 CFR 50.72(b)(3)(ii)(B) for an unanalyzed condition that significantly degrades safety. The NRC Resident Inspectors have been notified of this condition.

  • * * RETRACTION ON 07/31/2018 AT 1430 EDT FROM LEE YOUNG TO ANDREW WAUGH * * *

Event Notification (EN) 53485, made on July 3, 2018, is being retracted because re-evaluation performed subsequent to the notification has demonstrated, based on actual plant equipment and environmental conditions, that the unanalyzed inventory losses previously reported by EN 53485 would not have depleted the UHS inventory to an unacceptable level during its 30-day mission time. The re-evaluation has led to the conclusion that the previously unanalyzed losses of UHS inventory would not have prevented the UHS from performing its specified safety functions and meeting its 30-day mission time requirements. With the UHS capable of performing its specified safety functions and meeting its 30-day mission time requirements, the systems supported by the UHS would have remained capable of performing their specified safety functions. Based on these considerations, it has been determined that the condition reported in EN 53485 did not result in the plant being in an unanalyzed condition that significantly degraded safety. Consequently, the condition did not meet the criteria for an 8-hour notification per 10 CFR 50.72(b)(3)(ii)(B) for an unanalyzed condition that significantly degrades safety. The NRC Resident Inspector has been notified of the Event Notification retraction. Notified R4DO (Gaddy).

ENS 534843 July 2018 12:00:00At 0954 (EDT) on July 3, 2018, with Unit 1 in Mode 1 at 100 percent power, the reactor was manually tripped due to high steam generator water level. 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. The expected actuation of the Auxiliary Feedwater System (an engineered safety feature) is being reported as an eight hour report under 10 CFR 50.72 (b)(3)(iv)(A). Unit 2 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 inserted and Unit 1 is in an electrical shutdown lineup. The cause of the high steam generator water level transient is being investigated.
ENS 5347828 June 2018 10:10:00The following information was received from the State of Texas via email: On June 27, 2018, the Agency (Texas Department of State Health Services) was notified by the licensee's corporate radiation safety officer (CRSO) that one of his radiography crew had experienced a source disconnect. The crew was using a QSA 880D exposure device containing a 113.1 Curie iridium - 192 source. After completing the first shot on a new location on the pipeline, the crew could not get the source to return to the exposure device. The crew contacted the CRSO and set up new barriers at 2 millirem. The CRSO and a second individual qualified for source retrieval arrived at the site at 1743 hours. The retrieval team (RT) surveyed the guide tube and determined the source was in the collimator. The RT removed the guide tube from the exposure device and removed the camera from the area. Using a set of long tongs, the guide tube was removed from the pipe and the source slid down the guide tube until the connector was exposed. They could see the drive cable had broken near the connector. The source was shielded with bags of lead shot. The CRSO disconnected the broken drive cable from the source pigtail and connected the pigtail to a new drive cable that had been installed on the camera. The source was retracted to the shielded position in the camera. The camera and crank out device and drive cable will be sent to the manufacturer for inspection. No overexposures occurred as a result of this event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident # - 9590
ENS 5346922 June 2018 15:12:00At 0900 (EDT) on June 22, 2018, a non-licensed supervisory contractor subverted a random Fitness for Duty test. The contractor's site access has been terminated. The NRC Resident Inspector was notified.
ENS 5328725 March 2018 23:43:00

On March 25, 2018 at 1616 hours (EDT), with the reactor in cold shutdown condition, two control rod drive piping lines were determined to be potentially inoperable in the event of a design basis earthquake due to support defects. The control rod drive piping forms a portion of the reactor coolant pressure boundary and primary containment boundary. The supports will be repaired prior to plant startup. This event had no impact on the health and/or safety of the public. The NRC Resident Inspector has been notified. The licensee will notify the Commonwealth of Massachusetts.

  • * * RETRACTION FROM JOE FRATTASIO TO HOWIE CROUCH AT 1500 EDT ON 4/13/18 * * *

The purpose of the notification is to retract ENS notification 53287 made on 03/25/18 for Pilgrim Nuclear Power Station. The previous notification reported that control rod drive (CRD) piping could be potentially inoperable in the event of a design basis earthquake, at the time of discovery, due to piping support defects. Subsequent evaluation has demonstrated that the piping was not inoperable. Specifically, after an engineering evaluation, it has been determined that the CRD Hydraulic System operability was never lost and the system was operable, although non-conforming, based on the support configuration not conforming to the pipe support drawings. The affected pipe supports have been restored or reworked to the proper design condition in accordance with the design drawings. The CRD System has subsequently been restored to a fully operable status. Notified R1DO (Jackson) and IRD MOC (Pham).

ENS 5326515 March 2018 22:08:00At 1524 (EDT) on Thursday, March 15, 2018, Operations was notified of a failure to meet Appendix R requirements for Peach Bottom Atomic Power Station (PBAPS) Unit 2 and Unit 3. Valves associated with the feedwater system for both units were not properly considered as Hi-Lo Pressure interface valves as required by the Appendix R program. This results in the susceptibility to a hot short condition that could open valves, diverting flow from the reactor, damage piping and prevent injection. U3 (Unit 3) Fire Safe Shutdown Credited Reactor Core Isolation Cooling (RCIC) System is affected. U2 (Unit 2) is affected by a potential leak path through the Reactor Water Cleanup system. This event is being reported as an occurrence of an event or condition that results in the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety under 10 CFR 50.72(b)(3)(ii). The Station (PBAPS) is performing hourly fire watches for the impacted areas and is also evaluating this condition for corrective action. The licensee notified the NRC Resident Inspector.
ENS 532423 March 2018 02:19:00At 2315 EST on March 2, 2018, Pilgrim Nuclear Power Station (PNPS) determined, based on information received from the Commonwealth of Massachusetts, that there may be a potential loss of offsite response capabilities due to ongoing severe natural hazard conditions (i.e., major winter storm) along the coast of Massachusetts. According to information received by PNPS, towns within the 10 Mile EP Radius could be hampered in implementing some protective actions specified in the emergency plan in the unlikely event an emergency were to occur. There is no condition at the Station that would warrant implementation of any emergency plan at this time. PNPS continues to operate safely and is monitoring the weather conditions closely. The Station maintains emergency assessment, response, and communication capability. This report is being made conservatively in accordance with 10 CFR 50.72(b)(3)(xiii) which is any event that results in a major loss of emergency assessment capability, offsite response capability, or offsite communications capability. As stated previously, the Station maintains emergency assessment, response, and communication capability. The licensee notified the NRC Resident Inspector.
ENS 5320211 February 2018 23:36:00On February 11, 2018 at 2203 (EST), the Susquehanna Control Room received indication that a loss of Secondary Containment Zone 2 differential pressure (DP) had occurred. Control Room operators noted a differential pressure of <.25" WC (inches Water Column) for several seconds. System DP was restored to normal in 1 minute. The cause of the pressure swings is under investigation. Zone 2 differential pressures being less than 0.25" WC constitutes a loss of Secondary Containment based on not meeting requirements of SR 3.6.4.1.1. This event is being reported under 10 CFR 50.72(b)(3)(v)(c) and per the guidance of NUREG 1022 Rev 3 section 3.2.7 as a loss of a Safety Function. There is no redundant Susquehanna Secondary Containment system. The licensee notified the NRC Resident Inspector.
ENS 531921 February 2018 14:23:00

At 1057 CST on February 1, 2018 with the unit in Mode 1 at approximately 27% power, a manual actuation of the Reactor Protection System (RPS) was initiated due to an unexpected trip of the B Recirc Pump with A Recirc Pump in fast speed. B Recirc Pump tripped during transfer from slow to fast speed resulting in single loop operation. Operators were unable to reconcile differing indications of core flow. This resulted in a conservative decision to initiate a manual scram. The cause of the B Recirc Pump trip and the apparent issues with core flow indication are under investigation. The plant is currently stable in Mode 3. The plant response to the scram was as expected. All control rods (fully) inserted as expected; the feedwater system is maintaining reactor vessel water level in the normal control band and reactor pressure is being maintained with steam line drains and main turbine bypass valves. The NRC Senior Resident (Inspector) has been notified.

  • * * RETRACTION AT 1015 EDT ON 03/22/2018 FROM DAVID DABADIE TO OSSY FONT * * *

This event was initially reported under 10 CFR 72(b)(2)(iv)(B) as a manual actuation of the RPS due to an unexpected trip of the B Reactor Recirculation Pump with the A Reactor Recirculation Pump running in fast speed (Single Loop Operations). Operations was unable to reconcile differing indications of core flow and made the conservative decision to perform a planned shutdown in accordance with normal operating procedures. Therefore, this event 'resulted from and was part of a pre-planned sequence during testing or reactor operation' as specified in 10 CFR 50.72(b)(2)(iv)(B), 10 CFR 50.73(a)(2)(iv)(A) and NUREG-1022 Section 3.2.6. Consequently, this event is not reportable as an actuation of RPS. The NRC Resident Inspector has been notified. R4DO (Groom) has been notified.

ENS 531911 February 2018 13:50:00A non-licensed (employee) supervisor had a confirmed positive test for alcohol during a random fitness-for-duty (FFD) test. The individual's unescorted access to the plant has been (terminated). The NRC Resident Inspector has been notified.
ENS 5318023 January 2018 05:02:00

At 0400 (CST) on 1/23/2018 the Braidwood Technical Support Center (TSC) HVAC (Heating, Ventilation and Air Conditioning) Emergency Makeup Air Filter train was taken out of service to perform a planned Makeup Air Filter charcoal replacement. The TSC HVAC Makeup Air Filter train will be rendered nonfunctional during the charcoal replacement. Subsequent charcoal and HEPA filter testing will restore functionality of the TSC HVAC Makeup Air Filter train. The expected duration of the charcoal replacement and subsequent testing is 30 hours. If an emergency is declared requiring TSC activation during the time TSC HVAC is non-functional, the TSC will be staffed and activated using existing emergency planning procedure unless the TSC becomes uninhabitable due to ambient temperature, radiological, or other conditions. If relocation of the TSC becomes necessary, the Emergency Director will relocate the TSC staff to an alternate location in accordance with applicable site procedures. This notification is being made in accordance with 10 CFR 50.72(b)(3)(xiii) due to a major loss of emergency preparedness capability. An update will be provided once the TSC HVAC Emergency Makeup Air Filter train functionality has been restored. The licensee has notified the NRC Resident Inspector.

  • * * UPDATE AT 1645 EST ON 01/26/2018 FROM PAUL ARTUSA TO JEFF HERRERA * * *

On 1/26/18 at time 1539 EST, the TSC HVAC Emergency Makeup Air Filter train was returned to service following the planned Makeup Alr Filter charcoal replacement. Functionality was verified by charcoal and HEPA filter post maintenance testing. The licensee has notified the NRC Resident Inspector. Notified the R3DO (Cameron).

ENS 531536 January 2018 06:05:00

Oyster Creek Declared an Unusual Event HU 6 Hazardous Event for an Abnormal Intake Structure Level Less than or equal to -3.0 feet MSL (Mean Sea Level) on points 23 and 24 in the Main Control Room at time 0524 (EST). The licensee notified the NRC Resident Inspector, State, and local authorities. Notified DHS SWO, FEMA Operations Center, DHS NICC, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

  • * * UPDATE ON 1/6/18 AT 2325 EST FROM JAMES RITCHIE TO BETHANY CECERE * * *

Oyster Creek Terminated Unusual Event HU 6 Hazardous Event for an Abnormal Intake Structure Level at time 2308 (EST). The licensee notified the NRC Resident Inspector, State, and local authorities. Notified R1DO (Werkheiser), NRR EO (King), IRD MOC (Gott), DHS SWO, FEMA Operations Center, DHS NICC, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

ENS 5313220 December 2017 18:18:00On December 20, 2017, at 1040 Eastern Standard Time (EST), the Watts Bar Nuclear Plant (WBN) 1B-B 6.9kV Shutdown Board (SDBD) normal feeder breaker opened. The loss of voltage to the 1B-B SDBD resulted in the start of the 1B-B Motor Driven Auxiliary Feedwater (MDAFW) pump, the Unit 1 Turbine Driven Auxiliary Feedwater (TDAFW) pump, and the start of all four Emergency Diesel Generators (EDGs). Power was restored to the 1B-B 6.9 kV SDBD when it loaded on to its associated EDG. Following initial investigation, the 1B-B 6.9 kV SDBD was transferred to its alternate offsite power source, Common Station Service Transformer (CSST) C at 1217 EST. At 1230 EST, the 1B-B 6.9 kV SDBD alternate feeder breaker opened. The loss of voltage to the 1B-B SDBD did not result in the restart of the 1B MDAFW pump, the Unit 1 TDAFW pump, or EDGs; this equipment remained running from the earlier event. Power was restored to the 1B-B 6.9 kV SDBD when it loaded on to its associated EDG. Restoration of normal offsite power to the 1B-B SDBD was completed at 1654. Other than several common Unit Technical Specifications having not been met, Unit 2 was not operationally impacted by the transfer of the 1B-B Shutdown Board to onsite power and remains in Mode 1 at 100% power. This report is made per 10 CFR 50.72(b)(3)(iv)(A). NRC Resident Inspector has been notified. The licensee investigation continues for the cause of the event.
ENS 5312819 December 2017 17:17:00

During regular power operations at 100% power, DG#1 and DG#2 were declared inoperable due to a common issue associated with indicating lights and the associated sockets installed in various control and auxiliary circuits for both DG's. The indicating lights in question are incandescent 120V AC style 120MB bulbs in a socket with a 550 ohm resistor. Style 120MB light bulbs have a failure mechanism where the bulb can cause a short circuit rather than the more common open circuit that is expected when an incandescent bulb filament fails. Cooper originally believed that the socket's integral resistor was sufficient to protect the circuit. In testing performed by an outside laboratory and confirmed on-site using warehouse stock, it was determined that the integral resistor may not have the power dissipation capability to protect the circuit ln which the light and socket are installed if a bulb fails in short circuit. This condition resulted in both DG's being declared inoperable at 1340 (CST) due to a loss of reasonable expectation that they would meet their safety function required action to start, load and run to support loads required to mitigate the consequences of an accident. This is a loss of safety function under 10CFR 50.72(b)(3)(v)(D) subject to an 8 hour report. As a result of both DG's being inoperable, the Control Room Emergency Filtration System is also inoperable. This is also a loss of safety function subject to an 8 hour report for the same criterion. The Senior Resident has been notified.

  • * * RETRACTION AT 0942 EST ON 02/14/2018 FROM DAVID VAN DERKAMP TO JEFF HERRERA * * *

CNS is retracting the 8-hour non-emergency notification made on December 19, 2017 at 1340 CST (EN# 53128). Subsequent evaluation concluded a postulated lamp short circuit failure in any of the affected circuits would not impact the ability of the Diesel Generators to perform their safety function and therefore, were operable. With DG operability not affected, the Control Room Emergency Filtration System also remained operable. The NRC Resident Inspector has been notified. Notified the R4DO (Werner).

ENS 5312719 December 2017 17:05:00The following information was received from the State of Illinois: The University of Chicago Medical Center reported an underdose of Y90 Theraspheres today (12/19/17) to a patient. 53.4 % of dose was delivered with 46.6% stuck in catheter. 21 mCi was ordered and 11.21 was delivered. CT scan verified dose administered in correct location. On 12/18/17, it was still undetermined why remaining dose hung up in catheter. Additional dose (is) being ordered to complete the therapy as a fractionated dose. The licensee is investigating why the catheter became blocked. A 15 day written report will follow. Illinois Incident: IL177059 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 5311411 December 2017 16:29:00

The following information was received from the State of South Carolina by email: On Monday, December 11, 2017 at (1100 CST), the Department (South Carolina Department of Health and Environmental Control) was notified by (the) Corporate RSO (Radiation Safety Officer) of STERIS Isomedix Services that one of the source racks had been stuck in the 'up' position. The incident happened at (0328 CST) on Saturday, December 8, 2017. The worker saw that there was an unload fault on the system indicating that the rack was stuck so he called maintenance to try to correct the problem. At (0340 CST) the Radiation Safety Officer (and then the corporate RSO were notified) about the event. (The RSO) called and left a message on an employee voicemail rather than calling the 24 hour emergency phone number.

The workers were able to go into the penthouse to correct the problem and lower the source rack back into the pool. The workers found that a carrier had a cracked hinge. They checked all of their other carriers and replaced a total of two carrier doors. The RSO informed the CRSO (Corporate Radiation Safety Officer) that the situation was resolved at (0724 CST). The licensee stated that a written report will be sent within 30 days of the event.

ENS 531098 December 2017 17:26:00The following information was excerpted from an email received from the State of Kansas: The licensee is reporting that an ionizer containing a radioactive source (Model Number P-2063-1000) was lost. The licensee currently has 3 other ionizers of the same model. The device radioactive source was Polonium-210 (SN: A2KT674) with an activity of 31.5 mCi and was last leak tested on 9/20/2016. The device was checked out by the licensee and placed within the secure test floor while testing electrical devices at the Integra Technologies facility. The missing device use was last logged on 8/25/2017. The licensee believes that their maintenance department mistakenly threw the device away. Upon discovering that the device was missing, the licensee searched their facility several times over without finding the device. The prevention for further loss is that the remaining 3 units will be mounted in permanent locations using security screws so they cannot be removed by unauthorized personnel. 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 531088 December 2017 17:25:00U/2 HPCI (Unit 2/High Pressure Coolant Injection) was declared inoperable due to leak by of the pump discharge check valve after pump shutdown from flow testing. This resulted in cycling of the minimum flow valve. The discharge valve was closed to prevent the continued cycling of the minimum flow valve. This condition was identified during normal surveillance testing. The licensee notified the NRC Resident Inspector.
ENS 531077 December 2017 15:03:00This non-emergency notification is being made in accordance with 10 CFR 50.72(b)(2)(xi), any event or situation related to the protection of the environment for which notification to other government agencies has been made. Dominion Energy is in the process of informing the Virginia Department of Health, Department of Environmental Quality, Department of Emergency Management, and the Surry County Administrator of recent groundwater monitoring results at Surry Power Station in accordance with NEI 07-07, Industry Groundwater Protection Initiative (GPI). On December 6, 2017 at 1138 EST, Surry Power Station received analysis results of recent samples from the on-site groundwater monitoring program. As part of the program, 10 new groundwater monitoring wells were recently placed in service within the Protected Area to provide early detection, to better define the site's hydrology, and if necessary, to mitigate any potential leaks. The analysis results from one of the new wells indicated tritium activity level above the GPI communication threshold. Samples were re-analyzed, resulting in different values, with the highest result of 59,300 picoCuries per liter. Since each result was above the voluntary reporting threshold, Surry stakeholder communication was implemented in accordance with the NEI GPI Voluntary Communication Protocol, Criterion 2.2. There are no known active leaks at this location; however, Dominion Energy is continuing to investigate the source of the tritium and the reason for the variability in the sample results. Tritium was not detected in the on-site monitoring locations outside of the Protected Area. No tritium has been detected in the on-site and off-site drinking water wells. Since the activity is contained within the site restricted area, the health and safety of on-site personnel and members of the public are not affected. A 30-day report will be submitted to the NRC in accordance with NEI 07-07. The NRC Senior Resident Inspector has been notified.
ENS 5347426 June 2018 17:30:00The following information was received from the State of Texas: During the review of an event, the Agency (Texas Department of State Health Services) found a letter from a licensee reporting the shutter on a Ohmart model SHD-45 containing a 50 millicurie cesium - 137 source had failed in the closed position. The report was dated November 29, 2017. The shutter did not pose an exposure risk to any individual. The licensee has worked with the manufacturer and the gauge was scheduled to be replaced on June 21, 2018. The Agency has not been able to confirm if the gauge was repaired/replaced. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: I-9588
ENS 5312619 December 2017 12:46:00The following information was excerpted from a facsimile received from Crane Nuclear: This letter provides notification of a defect in a Weak Link Analysis provided to the Tennessee Valley Authority (TVA) by Crane-Aloyco, Inc. (CAI), a Crane Nuclear, Inc. (CNI) predecessor business unit, for a Chapman Gate Valve, Figure L900, Item # 18, Drawing CC05307, Revision B for the Browns Ferry Nuclear (BFN) plant. The subject valve was originally procured from Crane Chapman in 1968. In 1988, TVA requested Crane to supply a Weak Leak Analysis for the original valve. A Weak Link Analysis (OTC-258 Rev.0) was developed by CAI, which identified a maximum thrust capacity of approximately 112,000 lbf. In November 2017, Crane Nuclear, Inc. developed a new Weak Link Analysis for the valve. Crane Nuclear, Inc. provided the new Weak Link Analysis (WL-103 Rev. 0) to TVA on November 17th, 2017. Crane Nuclear. Inc. identified in the new Weak Link Analysis a maximum thrust capacity of approximately 96,000 lbf. CNI is reviewing our records to determine if the maximum thrust rating in any other Weak Link Analyses provided by CNI for gate valve designs with an SMB-4T or SMB-5T actuator exceeds the rating for the thrust bearings. Should you have any questions regarding this matter, please contact me, Joyce Hamman, Director, Safety & Quality at (678) 451-2280, Burt Anderson, Site Leader, at (630) 226-4990, or Samson Kay, Engineering Manager at (630) 226-4983.
ENS 5307416 November 2017 08:17:00At 0008 CST on 11/16/2017, Cooper Nuclear Station (CNS) was notified by Omaha Weather that the NOAA broadcast and the Shubert radio tower for this area is off. This affects the tone alert radios used to notify the public in event of an emergency condition. This is considered to be a major loss of the Public Prompt Notification System capability, and is reportable under 10CFR50.72(b)(3)(xiii). The transmission outage actually began at 2007 (CST), 11/15/2017, but CNS was not notified until 0008 (CST), 11/16/2017. Backup notification methods remained available throughout the period. At time 0447 CST on 11/16/2017, Cooper Nuclear Station was notified that the NOAA broadcast and Shubert radio transmission tower was returned to service. Nemaha County, NE, Richardson County, NE, and Atchison County, MO authorities within the 10 mile EPZ were notified by Cooper Nuclear Station of the condition and the effect on the tone alert radios at 0642 (CST), 11/16/2017. This is reportable under 10CFR50.72(b)(2)(xi) as a 4 hour report. The NRC Senior Resident has been informed.
ENS 5312919 December 2017 18:28:00The following information was excerpted from an email received from the State of Florida: The State of Florida received a notice on 11/15/17 that a Troxler Gauge and a company vehicle was stolen from the licensee by an employee. A City of Orlando Police report was issued (2017-442672). On 12/7/2017, a notice was received from the licensee to inform State of Florida Bureau of Radiation Control that the gauge was found intact and undamaged. The Troxler moisture density gauge is a model number 3440; serial number 27931; Cs-137/AmBe; 8mCi/40mCi. Florida Incident Number: FL17-298. 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 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 5306713 November 2017 03:57:00At 2119 (CST) on 11/12/2017 a Control Room board walk down discovered that both of the Unit 2 Containment Spray Pump control switches were in pull-out. With the control switches in pull-out, the pumps would not automatically start as required. Unplanned TS (Technical Specifications) 3.0.3 was entered at 2119 as a result of not complying with TS 3.6.5, Containment Spray and Cooling Systems, which requires both trains of Containment Spray to be Operable while in Mode 4. Unit 2 had entered Mode 4 at 0303 on 11/12/2017. TS 3.0.3 was exited at 2127 on 11/12/2017 when both Containment Spray Pump control switches were placed in Automatic restoring Operability. Preliminary investigation determined that while Unit 2 was in Mode 5, Surveillance SP 2099, Main Steam Isolation Valve Logic Test, had taken the Containment Spray Pump control switches to pull-out but did not re-align the control switches to automatic after the test was complete. This 8-hour Non-Emergency report is being made per 10 CFR 50.72(b)(3)(v)(D), Accident Mitigation. The NRC Senior Resident Inspector has been informed.
ENS 5313019 December 2017 17:40:00The following was excerpted from an email received from the State of Florida: The State of Florida received a notice of an over-exposure from the licensee. An employee received a whole body dose of 5019 mR read on her dosimeter on 10/10/2017. The investigation determined that the most likely cause of the over-exposure was due to an unusual number of equipment failures with the synthesis units requiring employee intervention to correct the issues. Dose rates and doses to the employee were not being monitored real time. The employee has been retrained on the standard operating procedures. Alarming personal electronic dosimeters have been purchased and are in use to alert personnel of the radiation fields. Florida Incident Number: FL17-299
ENS 530597 November 2017 22:09:00On November 7, 2017 at 1810 (CST), Unit 1 High Pressure Coolant Injection (HPCI), was manually isolated following failure of the remote turbine trip pushbutton to function. Unit 1 HPCI Operability Testing was in progress to the point of securing the HPCI turbine with the remote manual pushbutton. The pushbutton failed to trip the turbine resulting in operator action to lower the flow controller setpoint and isolating the HPCI steam line. HPCI remains isolated and is Inoperable pending resolution of the Turbine Trip circuitry. This event is being reported as a condition that could have prevented fulfillment of a safety function in accordance with 10CFR50.72(b)(3)(v)(D). The HPCI system is a single train system and the loss of HPCI could impact the plant ability to mitigate the consequences of an accident. The Reactor Core Isolation Cooling (RCIC) system was confirmed operable. The NRC Senior Resident Inspector has been notified.
ENS 530556 November 2017 13:21:00The following information was received from the State of Texas by email: On November 6, 2017, the Agency (Texas Department of State Health Services) was notified by the licensee that a shutter was stuck in the closed position. The Ronan SA1 shutter was closed for maintenance on a hopper and failed to reopen. The gauge contains a 50 millicurie Cesium-137 source. The Licensee stated a service company has been contacted to repair the gauges in the next few days. No individual received significant exposure to radiation due to this event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: I-9519
ENS 5304028 October 2017 13:29:00A patient receiving treatment for a liver disease was prescribed 60 milliCuries of Y-90 SIR-Spheres. The delivered dose was calculated to be 11 milliCuries and stasis was not achieved. The patient was notified of the misadministration and is scheduled to receive the fully prescribed dose. 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 5303726 October 2017 17:00:00The following information was received by facsimile from the vendor: Component: Speed switch P/Ns ESl50267C, ESl50267E, ESl50267H, and ESl50267K. Summary: Engine Systems Inc. (ESI) began a 10CFR21 evaluation on September 12, 2017 upon notification of a potential issue with speed switch P/N ESl50267K supplied to Hope Creek Nuclear Generating Station. The speed switch had reportedly failed in service which resulted in a failure to start of the emergency diesel generator (EDG). An analysis performed by Exelon Powerlabs determined the failure was due to a shorted capacitor that is installed on the speed switch's relay output contacts to ground. The evaluation was concluded on October 25, 2017 and it was determined that this issue is a reportable defect as defined by 10CFR Part 21. The speed switch output contacts are utilized in the engine's start circuitry and failure to function properly could adversely affect the safety-related operation of the emergency diesel generator set. Impact on Operability: If the resistance path to ground were sufficiently low, the ability of the relay output contacts to pick-up and/or drop-out associated components would be compromised. The speed switch relays are used in safety-related EDG start circuitry to control various electrical relays. Failure to properly control any of these components could adversely affect the safety-related operation of the emergency diesel generator. Root cause evaluation: The root cause of the failure is a deficiency in the design and selection of the EMC (Electromagnetic compatibility) mitigating components. Consideration was not given for the impact of voltage transients imparted on the capacitors during coil de-energization. For customers without suppression from the inductive kick, the magnitude of voltage transients may be sufficient to damage and ultimately degrade the capacitors to the point of failure. Affected nuclear plants include Nine Mile Point, Quad Cities, Dresden, Davis Besse and Hope Creek.
ENS 5301616 October 2017 08:36:00

The following information was received from the State of California: The Licensee discovered at approximately (1700 PDT) on 10/15/17 that two 3 Ci Am-241Be well logging sources had been stolen from their storage area at Weller Ranch in Kern County. Locks had been cut and the sources were removed from the approximate 12-foot storage pipe. Additionally, an approximate 2500 (pound) calibration water tank was also missing. The FBI was notified by CA Radiologic Health Branch (RHB) at approximately (2030 PDT) on 10/15/17. RHB will be onsite 10/16/17. California 5010 Number: 101517

  • * * UPDATE FROM ROBERT GREGER TO DONALD NORWOOD AT 1511 EDT ON 10/16/2017 * * *

The two well logging sources have been accounted for. An unauthorized individual had accessed the sources, removing them from their storage location on his father's ranch land and discarding them a short distance away without any knowledge of what they were. The unauthorized individual also took the water calibration tank for his personal use. The well logging sources are back in the possession of the licensee. Notified R4DO (Vasquez) , NMSS Events Notification, CNSNS (MEXICO) and ILTAB via email. THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL Category 3 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 some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

ENS 5299125 September 2017 14:04:00The following information was received from the Commonwealth of Pennsylvania via email: Notifications: On September 25, 2017, the licensee informed the Department (PA DEP Bureau of Radiation Protection) of a failure of an electronic component of a fixed gauge. It is reportable per 10 CFR 30.50(b)(2)(i). Event Description: The electronic component of the automatic shutter on an IMS Model 5301-01 gauge containing approximately 20 curies of Cesium-137 failed to close on its own. The licensee immediately notified the RSO, as per their emergency procedure, who was able to remotely log in to the computer software system and bypass the automatic mode to close the shutter. The gauge is housed in a secure and entry restricted enclosure and instructions have been given to all operators to ensure that the shutter is closed while not in use. The manufacturer, IMS, was notified and is scheduled to make repairs on September 26, 2017. All regulatory precautions were taken and no overexposures have occurred. Cause of the Event: Equipment failure. ACTIONS: The Department will perform a reactive inspection. The manufacturer has already been scheduled to correct the problem. More information will be provided upon receipt. PA Event Report ID No.: PA170014
ENS 5301716 October 2017 11:08:00The following information was received from the State of New York via facsimile: On September 21, 2017 the Department (New York State Department of Health) was notified that a Best Medical International, Inc., Model #2301 lodine-125 seed used for localization of non-palpable lesions and lymph nodes was lost. On September 18, a patient was implanted with a 125.2 microCurie lodine-125 seed. The seed was verified to be implanted by use of a survey meter. When the patient returned for explant three days later, the iodine-125 seed could not be detected. The licensee surveyed the patient's vehicle, house, laundry, and trash and no radioactivity was detected. The licensee reported placing the seed 'superficially' within the patient and the licensee speculates that the seed may have become dislodged from the patient at some point between the implant and explant. New York Report ID No.: NYDOH-NY-17-08 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 5297417 September 2017 16:49:00On September 17, 2017, during planned surveillance activities involving Emergency Diesel Generator (EDG) 4, unexpected voltage and frequency indications were noted when EDG 4 was synchronized to Emergency Bus E4. With EDG 4 in manual mode, the Operator responded by lowering load to reopen the EDG 4 output breaker. Opening of the EDG 4 output breaker with the breakers from Balance of Plant (BOP) Bus 2C, which normally feeds the Emergency Bus E4, opened; resulted in de-energizing Emergency Bus E4. The EDG 4 voltage regulator and governor automatically reverted to auto control, and EDG 4 reconnected to Emergency Bus E4. Normal frequency and voltage were restored with EDG 4 in auto control. The momentary power interruption to Emergency Bus E4 resulted in Unit 2 Primary Containment Isolation System (PCIS) Group 2 (i.e., Drywell Equipment and Floor Drain, Residual Heat Removal (RHR) Discharge to Radwaste, and RHR Process Sample), Group 6 (i.e., Containment Atmosphere Control/Dilution, Containment Atmosphere Monitoring, and Post Accident Sampling Systems), and Group 10 (i.e., air isolation to the drywell) isolations. The actuations of Primary Containment Isolation Valves (PCIVS) were completed and the affected equipment responded as designed. Per design, no Unit 1 safety system group isolations or actuations occurred. These actuations are being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A). Additional Unit 2 actuations included PCIS Group 3 (i.e., Reactor Water Cleanup), Reactor Building Ventilation System isolation (i.e., Secondary Containment isolation), and the automatic start of Standby Gas Treatment (SGT) System subsystems A and B. These systems functioned as designed. This event did not impact public health and safety. The NRC Resident Inspector has been notified. The safety significance of this event is minimal. Safety systems functioned as designed following the power perturbation on E4. Plant systems responded as designed. The cause of the event is under investigation.
ENS 5296914 September 2017 16:38:00The following information was received from the State of California via email: On September 14, 2017, (The RSO) of Southwest Calibration & Training notified the RHB Brea office that United Inspection & Testing, Inc., RML # 4788-33, had a Troxler, 3411B, serial #6644 radioactive gauge run over and damaged. On September 14, 2017, RHB Brea contacted (The RSO) of United Inspection & Testing, Inc. (The RSO of United Inspection & Testing, Inc.) informed our office that the radioactive gauge had been run over by a backhoe on the afternoon of September 13, 2017 at approximately 1400 (PDT), at the intersection of Banana Street and Daurin Street at a construction site in Fontana, CA. As a result of the accident the radioactive gauge had the handle broken off. The RSO was able to return the Cs-137 source to its shielded position, but it could not be locked in the shielded position due to the damage to the gauge. The authorized user of the gauge was also struck by the backhoe and died of his injuries. (The RSO of the United Inspection & Testing, Inc.) retrieved the gauge from the accident site and transported it to Southwest Calibration & Training to be inspected. (The RSO) of Southwest Calibration & Training reported that the Troxler radioactive gauge read 0.9 mR/hr at 1 foot. The gauge was extensively damaged and may not be repairable. California 5010 Number: 091417
ENS 5297115 September 2017 15:17:00The following information was received by the State of Illinois by email: IEMA (Illinois Emergency Management Agency) was notified at (1353 CDT) on 9/8/17 that a load of ferrous metal was being rejected from a scrap metal recycling facility (Omnisource in Indiana) back to Gaby Iron in Chicago Heights. The max exposure rate was reported at 20 microR/hour (4 microR/hour background). The load is being returned under DOT SP IN-IL-17-010. The suspect load was inspected Monday, September 11th. An Alnor dew pointer device with an intact 7 microCurie Ra-226 source was recovered. No removable contamination was identified. The device was impounded by IEMA and is pending return to an appropriate entity. No additional radiation sources were discovered and the remainder of the load was released without further restriction. Pending appropriate disposal or return to the manufacturer, this matter is being considered closed. The device was an Alnor Instrument portable gauge; Model 7350; Serial Number 230667. The Amersham sealed source was a model RAM.X452; Ra-226; 7 microCurie activity. NMED Report: IL177030 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 530628 November 2017 15:06:00

The following information was received from the State of Ohio via email: A local Health District employee had a Niton Xlp 300 XRF with a 50 mCi Cadmium-109 source stolen overnight on Saturday, September 2, 2017. It was in the car in their garage and someone came in and took it. The employee had worked late at a job site that day and brought the gauge home instead of returning to the office. Employee's garage door did not close for some reason that night and they were unaware that it was open when they went to bed. There were several other cars broken into that night in employee's neighborhood. A report was filed with local police department. Device has not yet been recovered. Source/Radioactive Material: Sealed Source; Radionuclide: Cd-109; Activity: 50mCi; Device Name: X-RAY Fluorescence (XRF); Model Number: Niton XLp 300; Manufacturer: Thermo Scientific Analytical; Serial Number: 98149. Ohio Item Number: OH170007

  • * * UPDATE AT 0919 ON 11/29/17 FROM STEPHEN JAMES TO MARK ABRAMOVITZ * * *

The following report was received via e-mail: Note: According to device owner, the manufacturer told them that this incident was NOT reportable to their regulatory agency. The owner reported the event on 11/6/17 as a result of more research on their part. UPDATE: The gauge was found by a member of the public in their yard, where it had apparently been abandoned. The local health district was notified based on contact information on case. The case was still locked when found. The device is now back in the possession of the local health district as of 11/27/17. Notified the R3DO (Duncan), NMSS Events Resources and CNSC (via e-mail) . 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 5290916 August 2017 15:41:00On 8/16/2017, at 1039 (EDT), an un-planned trip of the Peach Bottom Station Blackout Transformer 34.5 kV feeder breaker 1005 and a loss of the 191-00 line occurred causing a loss of power to Unit 1 and the TSC. Power was not restored to the TSC or the ventilation system within 1 hour. Power was subsequently restored to the TSC at 1207 hours (EDT) and the ventilation system was restored to available. This report is being submitted pursuant to 10CFR50.72(b)(3)(xiii) as a Major Loss of Emergency Preparedness Capabilities due to a reduction in the effectiveness of the Onsite Technical Support Center (TSC). The NRC Resident Inspector has been informed of this notification.
ENS 5290515 August 2017 14:07:00On August 15, 2017, during evaluation of protection for Technical Specification (TS) equipment from the damaging effects of tornados, Callaway Plant identified a non-conforming condition in the plant design such that specific Technical Specification equipment is considered not to be adequately protected from tornado missiles. The recirculation lines for all three independent trains of Auxiliary Feedwater (AFW) connect to the Condensate Storage Tank (CST) inside the CST Valve House, which is not a tornado missile-resistant structure. The direct impact by a design basis missile could result in crimping of the recirculation lines, thereby creating the potential to cause damage to the Train A and B Motor-Driven Auxiliary Feedwater Pumps (MDAFPs) and the Turbine-Driven Auxiliary Feedwater Pump (TDAFP) by restricting recirculation flow to less than the design requirements. This condition is reportable per 10 CFR 50.72(b)(3)(ii)(B) for any event or condition that results in the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety, and per 10 CFR 50.72(b)(3)(v) for 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, or (D) mitigate the consequences of an accident. These conditions are being addressed in accordance with NRC's Enforcement Guidance Memorandum EGM 15-002 and Interim Staff Guidance DSS-ISG-2016-01 (enforcement discretion and interim guidance documents). The NRC Resident Inspector has been notified.
ENS 5290715 August 2017 16:52:00The following information was provided by the State of California via email: On 08/14/17, RHB (California Radiation Health Branch) received an incident report from Office of Emergency Services regarding a damaged moisture density gauge. A CPN gauge, Model MC-3, S/N M380108935, containing 10 mCi of Cs-137 and 50 mCi of Am-241 was run over by a heavy construction equipment at a job site in the city of Santa Clara, CA. The top of the gauge housing was damaged with a broken rod, however, the user managed to retrieve the source back into shielded position. The damaged gauge was placed in the transport case and taken to the licensee's facility for disposal. Fire department was at the incident site, performed surveys using a survey meter (no survey meter information available) and the readings did not indicate any contamination. According to the gauge user, Fire Department readings indicated 500 uR/hr at the damaged gauge and 6 uR/hr at 15 feet from the gauge. The gauge will be transported to CPN for leak testing and disposal on 08/15/17. RHB will be following up on this incident. California 5010 Number: 081417
ENS 5290615 August 2017 14:24:00Following a panoramic irradiator two day shutdown, a restart with three source racks commenced. Air pressure was applied to raise the source racks. During the restart, two source racks (racks 1 and 3) did not descend into the irradiator pool as designed. During an investigation, two release valves associated with the two source racks did not operate properly. Operators manually released air pressure and all source racks descended into the irradiator pool. The deficient release valves were replaced and the source racks were satisfactorily retested. The source racks all properly descended into the pool. The time the source racks were inoperable for approximately 1.5 hours.
ENS 528918 August 2017 20:22:00On August 8, 2017, at 1554 hours (EDT), during restoration from testing of the High Pressure Core Spray (HPCS) Suppression Pool Level High Instrumentation, unexpected as-left indications were found that impacted both of the required channels of instrumentation. Subsequent venting of the instrumentation lines was completed and both channels of instrumentation are reading consistent with previously taken as-found data. The instrumentation was declared OPERABLE at 1635. The initial cause of the unexpected as-left indications appears to be the introduction of air into the instrumentation lines during the calibration activities. This is considered a loss of safety function based on both of the HPCS Suppression Pool Level High Instrumentation channels being declared INOPERABLE and the loss of the automatic HPCS suction swap to the Suppression Pool on a high level. This event is being reported in accordance with 10 CFR 50.72(b)(3)(v)(D). The (NRC Resident Inspector) has been notified.
ENS 5287628 July 2017 15:22:00

Containment atmosphere oxygen level was measured at 18.4 percent. This is below normal habitability level. The cause of the low oxygen level is a nitrogen leak inside containment Nitrogen has been isolated from containment and operators are preparing to purge containment. The licensee notified the State of California, local authorities and the NRC Resident Inspector. Notified the DHS SWO, FEMA OPS, USDA OPS, HHS OPS, DOE OPS, DHS NICC, EPA EOC. Notified FDA EOC, NuclearSSA, FEMA NWC and FEMA NRCC SASC via email.

  • * * UPDATE FROM ALLEN DURACHER TO VINCE KLCO ON 7/28/17 AT 2142 EDT * * *

The ALERT was terminated on 7/28/17 at 1819 PDT. The containment atmosphere was restored to normal conditions. The nitrogen source was isolated. The cause of the nitrogen leak into containment is under investigation. The licensee will notify the NRC Resident Inspector. The licensee has notified the State of California and the local authorities. The licensee plans to issue a press release. Notified the R4DO (Hay), NRR EO (Miller), IRD MOC (Grant). Notified the DHS SWO, FEMA OPS, USDA OPS, HHS OPS, DOE OPS, DHS NICC, EPA EOC. Notified FDA EOC, NuclearSSA, FEMA NWC and FEMA NRCC SASC via email.

ENS 5287427 July 2017 18:54:00(Unit 2) HPCI was declared inoperable due to improper valve alignment stemming from an incorrect sequence directed from a work order. (Unit 2) HPCI was inoperable for 20 minutes and was manually re-aligned to an operable status. The licensee notified the NRC Resident Inspector.
ENS 5287225 July 2017 11:07:00On July 25, 2017, at 0428 Eastern Daylight Time (EDT) Watts Bar Nuclear Plant (WBN) Unit 2 was in Mode 3, beginning a Reactor Startup. While in the initial phase of withdrawing the first of four Control Rod banks, the two associated group demand position indicators deviated greater than 2 steps from each other. In accordance with Technical Requirement 3.1.7, Position Indication System, Shutdown, with one or more group demand position indicators inoperable, the reactor trip breakers are to be opened immediately. Operations personnel opened the reactor trip breakers immediately by initiating a manual trip of the Reactor Protection System (RPS). The Auxiliary Feedwater system was in service and controlling Steam Generator water levels at the time of the event and did not receive any valid actuation signals. No other system actuations occurred as a result of this reactor trip and all systems operated as designed. The cause of the position indication system inoperability is currently under investigation. NRC Resident Inspector has been notified.
ENS 5287124 July 2017 23:50:00
ENS 5286721 July 2017 10:40:00The following information was received by the licensee via email: Pursuant to 10 CFR 21, this is a non-emergency notification by Susquehanna Nuclear, LLC concerning a defect in an Eaton/Cutler Hammer A200 series starter that failed while in service at Susquehanna Steam Electric Station. The failed starter was manufactured by Eaton Corporation in 2014 and purchased by Susquehanna from AZZ/NLI as part of an MCC bucket assembly. The starter failed with its contacts stuck in the energized state when it was de-energized. A failure analysis identified the contactor sticking to be due to the pole faces of the coil laminations and those of the armature laminations adhering to one another at normal operating temperatures. There was residue/material on the pole faces which closely matched Polydimethylsiloxane (PDMS) and silicone grease. One of the characteristics of PDMS is that at cooler temperatures it is more of a solid consistency, and at higher temperatures it becomes more viscous and tacky. A previous Part 21 report submitted by Curtiss-Wright QualTech NP (Event Notification Number 51611) in December 2015 provided notification of Eaton/Cutler Hammer A200 series starters failures due to silicon based mold release that remained on the molded parts and would come between the moving (magnet) and fixed armatures. The Part 21 stated that when heated for extended period of time, the material would become sticky causing anywhere from a minor delay in opening to a frozen closed condition. Eaton/Cutler Hammer determined that the silicone mold release was first introduced into the manufacturing facility in May 2008 and used periodically until October 2012. According to Eaton/Cutler Hammer, any starters manufactured after January 1, 2013 should be silicon mold release free. Following the failure of the 2014 starter at Susquehanna, Eaton Corporation performed an investigation and reconfirmed that silicon mold release was banned from molding production in October 2012 and has not been used since that time. Eaton concluded that the contamination does not appear to be systemic, but rather random and intermittent and that the contamination was most likely introduced either by operators and assemblers on the manufacturing lines, or by others who disassemble and inspect the product after shipment from their plant. Susquehanna does not take the components apart during receipt for testing or visual inspection. Eaton concluded that there is no evidence that the issue is systemic and considers it a random event. Susquehanna has evaluated the condition and has concluded that the condition could create a substantial safety hazard. The licensee notified the NRC Resident Inspector.
ENS 5285814 July 2017 11:13:00The following information was received from the State of Arizona via email: This First Notice constitutes EARLY notice of events of POSSIBLE safety or public interest significance. The information is as initially received WITHOUT verification or evaluation, and is basically all that is known by the Agency (Arizona Radiation Regulatory Agency) Staff at this time. During an inspection of the licensee on July 13, 2017, an inspector found one portable gauge where the radiation source exposure shutter would not close when moved to the closed position. The inspector's dose measurement at contact with the device was approximately 100 mR/hr. The gauge is a Troxler model 3430, Serial Number 30302, containing 8 milliCuries of Cesium-137 and 40 milliCuries of Americium-241. The licensee has contacted a repair company to fix the gauge as soon as possible. The Agency is investigating the event. The Governor's office and U.S. NRC are being notified of this event. Arizona First Notice: 17-009
ENS 5285113 July 2017 10:33:00The following information was received from the State of Colorado via email: This is an initial report regarding a misadministration event in Colorado. University of Colorado Hospital (License Number: CO 828-01) had a misadministration of Y-90 microspheres (SIRTex SIRSpheres) on Wednesday, July 12, 2017. At approximately 11 (MDT), the post administration measurements of the waste from the SIRSpheres Administration indicated that the activity administered to segment 2/3 of the patient's liver was only 68.7 percent of the prescribed activity. The written directive called for an activity of 0.24 GBq and residual waste activity measurements indicated that 0.165 GBq was delivered. The physician indicated that stasis was not reached during the administration to this segment. There was a separate administration to segment (four) of the liver in which stasis was reached. Follow-up information will be provided after they are 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.
ENS 5282926 June 2017 18:39:00On June 26, 2017, at 1531 (EDT), Indian Point Unit 2 inserted a manual reactor trip prior to Steam Generator levels reaching the automatic reactor trip setpoint. Steam Generator water level perturbation resulted from a loss of 22 Main Boiler Feed Pump. All Control Rods verified inserted. The Auxiliary Feedwater System started as designed and supplied feedwater to the Steam Generators. Heat removal is via the Main Condenser through the High Pressure Steam Dumps. Offsite power is being supplied through the normal 138kV feeder 95332. The cause of the 22 Main Boiler Feed Pump loss is currently under investigation. Entergy is issuing a press release/news release on this issue. Unit 2 is stable and in Mode 3. There was no impact on Unit 3. The licensee notified the State of New York and the NRC Resident Inspector.
ENS 5282624 June 2017 15:42:00On June 24, 2017 at 1028 (EDT), a loss of secondary containment occurred due to trip of 2V217A Zone III Filtered Exhaust Fan causing a reduction in D/P (differential pressure) to less than the required 0.25 WC (water column). 2V217B Zone III Filtered Exhaust Fan started on low flow in AUTO as designed and secondary containment D/P was restored to greater than 0.25 WC by 1029 hours. This event is being reported under 10 CFR 50.72(b)(3)(v)(c) and per the guidance of NUREG 1022, Rev. 3, section 3.2.7 as a loss of a safety function. There is no redundant Susquehanna secondary containment system. The licensee notified the NRC Resident Inspector.
ENS 5282223 June 2017 11:37:00

The following information was received from the State of North Carolina via email: On June 22, 2017 at (1130 EDT), North Carolina Radiation Protection Section (RPS) was informed by the Radiation Safety Officer for Hospira, Inc. (Pfizer), Rocky Mount, NC (License 064-0969-1) that they were experiencing an issue involving their Wet Shielded Irradiator (Nordion Model JS-8900, Serial Number IR-183, approved for 4,800,000.00 Ci of Co-60). RSO stated that during routine maintenance checks the Source 1 Rack of the irradiator would not trip the down switch to confirm the source rack was in the down position on the control panel and that they were following emergency procedures. Nordion was then contacted by the licensee to obtain assistance. RPS inspectors were immediately dispatched to the licensee's site. Once on site, RSO informed RPS that visual confirmation was made of source position via hydraulic cylinders that were fully extended, comparison of cable tightness on roof was observed, and that no indication of radiation in the vault was detected; all leading to the unconfirmed indication that the source rack had moved to the down position. With the assistance from Nordion, Hospira staff were able to initiate bypass procedures and gain access to the vault where confirmation was made that the source racks were in the down position. Nordion advised that a faulty down position switch was the cause for the failure. Switch was repaired on site by Hospira engineers, same day. Following repair, Hospira personnel cycled the sources which were brought up into position for one sterilization cycle and then the sources were brought down to test the position sensor. The test was successful, as indicated by the down position indicator lamps and screen on the operator's panel. Nordion staff was informed of the successful test and Hospira staff continued procedural tests to confirm full functionality. After confirming cycling up and down of the source racks, Hospira personnel performed full monthly QA check before resuming operations. 30-Day report is pending to RPS.

  • * * UPDATE ON 8/2/2017 AT 1042 EDT FROM TRAVIS CARTOSKI TO DONG PARK * * *

The following information was received from the State of North Carolina via email: We have completed our investigation and have no further information to provide in this event report. We would like to request (NMED) Event 170315 be Closed & Complete. Notified R1DO (Lilliendahl) and NMSS Events Notification via email.

ENS 5282323 June 2017 16:13:00The following information was received from the Commonwealth of Massachusetts via email: The licensee reported on June 23, 2017 that licensee learned from its licensed leak test service provider on June 21, 2017 that one 6 millicurie, cobalt-57 sealed source out of 25 sources received in a package on June 16, 2017 from the source manufacturer, Eckert & Ziegler Isotope Products, tested positive for leakage. The leakage was reported as being 4.2 times the limit of 0.005 microCuries (0.021 microCuries). The other 24 sources showed no contamination. The leaking sealed source is an Eckert & Ziegler Isotope Products Model 3901-2 source, serial number P6-883. The licensee reported that the leaking source was contained and secured in an individual zip lock type plastic bag; that there is no facility contamination based on area surveys performed; that the external surfaces of the package received, that had contained all of the 25 source, had been wipe tested and that the package was not contaminated; and that the sources were not used pending leak test results. The licensee reported that it notified the source manufacturer on June 21, 2017, received a return authorization number from the manufacturer, and shipped the source back to the manufacturer on June 22, 2017. The Agency (Massachusetts Radiation Control Program) considers this event to be open.
ENS 5282022 June 2017 20:33:00On June 20, 2017, at 1444 hours (EDT), with the reactor at 100% core thermal power and steady state conditions, plant personnel identified that both doors in one of the secondary containment airlocks (Door #58 and Door #85) were open briefly as part of normal passage of personnel. The Technical Specification definition of SECONDARY CONTAINMENT INTEGRITY states 'At least one door in each access opening is closed.' Actions were taken to immediately close both doors and restore operability of secondary containment. PNPS (Pilgrim Nuclear Power Station) is providing an 8-hour non-emergency notification in accordance with 10 CFR 50.72(b)(3)(v)(C), an event or condition that could have prevented fulfillment of a safety function needed to control the release of radioactive material. The NRC Resident Inspector has been notified. The licensee notified the Commonwealth of Massachusetts.
ENS 527927 June 2017 12:13:00

The following information was provided by the State of Arkansas via email: During routine shutter checks performed by the licensee on June 6, 2017, the licensee noted that the shutter would not close. The gauge is identified as Berthold Model LB 300 L source holder containing 0.189 milliCuries of Cobalt-60. The gauge remains operational in the normal use location and the RSO will place additional signs in the area. No maintenance is planned in the area that would require closing of the shutter. The RSO has performed a radiation survey to ensure that radiation exposure is maintained at less than 2 mR/hr in the vicinity of the gauge. The licensee has contacted the technical representative who was expected to be at the facility on July 6, 2017, for other maintenance and will examine this gauge. In accordance with RH-1502.f.2 (10 CFR 30.50(b)(2)) the malfunctioning shutter is reportable within 24 hours. The State of Arkansas is awaiting a written report from the licensee and final disposition information for the gauge. The State's event number is AR-2017-003.

  • * * UPDATE ON 3/20/2018 AT 1520 EDT FROM STEVE MACK TO DONG PARK * * *

The following was received via e-mail: A report submitted on July 3, 2017, indicated that the cause of the shutter failure was the exposure to alkaline pulp material and the carbon steel construction of the source holder. The source holder was replaced on January 9, 2018 with a comparable source holder constructed of stainless steel. The Department (Arkansas Department of Health) considers this event to be closed. Notified R4DO (Groom) and NMSS Events Notification via email.

ENS 5277024 May 2017 12:20:00The following information was received from the State of Texas by email: On October 16, 1998, the Agency (Texas Department of State Health Services) was notified that a Humboldt model 5001 moisture/density gauge containing a 10 millicurie cesium - 137 and a 40 millicurie americium - 241 source was lost during transport from San Antonio to Laredo, Texas. The gauge was to be delivered to the Texas Department of Transportation (TXDOT). A search of the transportation companies warehouses and delivery locations along the transportation route did not find the gauge. The investigation was placed in "Inactive" status. On May 17, 2017, the Agency received an email string showing that a moisture/density gauge was for sale on the internet site 'eBay'. A search of the eBay site found that the gauge serial number matched the serial number of the gauge reported missing in 1998. The Federal Bureau of Investigation (FBI) was contacted and a request was made for assistance in gathering information on the seller. Using the information gathered by the Agency and the FBI, the Agency was able to contact the seller. The seller removed the posting off of eBay immediately. The seller stated they purchase materials from companies who are going out of business and resell them. The seller stated they did not remember when or where the gauge was purchased. The seller stated they had just moved all the materials they store in a large warehouse into two smaller warehouses and that is when they discovered the gauge. They did some research on the use for the gauge online and decided to sell it. The seller turned the gauge over to TXDOT on May 24, 2017. Dose rates taken on the gauge by TXDOT were normal. The gauge will be leak tested and returned to the manufacturer. Additional information will be provided as it is received in accordance with SA-300. Event #35040 initially reported the event on 11/16/1998 as a lost source while in transit. Texas Incident: I-7394 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 5276016 May 2017 23:40:00

The Midwest Inspection Services building has been severely damaged by a tornado storm. All radiography cameras have been accounted for and are stored in a safe location. The vault is intact. Tornados are forecasted to continue throughout the evening.

  • * * UPDATE AT 1205 EDT ON 05/17/17 FROM MICHAEL BRODERICK TO JEFF HERRERA * * *

The following update was received from the Oklahoma Department of Environmental Quality via email: Shortly after 22:30 (CDT) on the evening of May 16th, Oklahoma DEQ (Department of Environmental Quality) verbally notified the HOO (NRC Headquarters Operations Officer) of an event affecting an Oklahoma radiography company. This is a follow-up report to confirm the verbal report and provide more details. Facility Name: Desert NDT, LLC dba Shawcor (note) the facility was historically known as Midwest Inspections, and was accidentally referred to by that name in the initial report. Facility license number: OK-32104-01 Because of concern generated by news reports, DEQ (Oklahoma Department of Environmental Quality) contacted the facility at about 22:00 (CDT) and over the following few minutes, we were able to reach the facility manager. (The facility manager) reported that their licensed facility at Elk City had been largely destroyed by the tornado reported in the media. He indicated that the vault was mostly intact, but had damage to the ceiling. All power at the facility was out. (The facility manager) indicated they (Desert NDT) had fifteen cameras in the vault, and others were out in trucks on jobs around the region. (The facility manager) reported that they (Desert NDT) had done an inventory on the fifteen cameras in the vault, and confirmed that they were accounted for. (The facility manager) had no reports of problems with any sources dispatched on jobs. (The facility manager) explained that they (Desert NDT) did not regard the damaged vault as suitable for secure storage, but they (Desert NDT) had one radiography truck that was largely intact, and they (Desert NDT) were storing the fifteen cameras in one truck, and keeping the truck under constant surveillance by an employee who was authorized unescorted access. Media reports indicated that another storm, weaker than the first, but still having potential tornadoes was headed for the area. In a second call, the facility manager reported that because of concerns about further storms, they had moved the cameras into a storm shelter in (a secure location). (The facility manager) indicated that the storm shelter was under surveillance, and was lockable, and would remain locked unless being directly accessed. In view of the remarkable circumstances, (Oklahoma) DEQ approved this arrangement as an interim measure. About 8:20 (CDT) on the morning of the 17th, (Oklahoma) DEQ contacted the manager again. (The facility manager) indicated that the fifteen cameras were still secured in the storm shelter. (The facility manager) reported that there was no known further damage during the night, and that the company would be conducting a confirmatory inventory of the fifteen cameras, and conducting an inventory to ensure that cameras out on jobs were safe and under control. (The facility manager) will report the results of this to (Oklahoma) DEQ when available. (The facility manager) explained that they were doing an assessment of undamaged trucks that were suitable for secure storage under Part 37, and that they planned to retain some sources at the Elk City facility using the trucks that were suitable. (The facility manager) indicated that excess sources would be moved to a licensed company facility out of state. (The facility manager) will follow up with (Oklahoma) DEQ later today. (Oklahoma) DEQ has used GIS (Geographic Information System) to identify seven other licensed facilities that are near the storm track, and are not considered as having as much concern. We (Oklahoma DEQ) contacted all of them by phone this morning and confirmed that all is well. Notified the R4DO (Miller) and NMSS via email.

ENS 5275314 May 2017 21:27:00On May 14, 2017 at time 1823 (CDT), Waterford 3 Steam Electric Station notified St. Charles Parish Emergency Services via 911 of a fire in the Generation Support Building (GSB), the Hahnville, Luling and Killona Fire Departments were dispatched. The GSB is an Administrative and Engineering Building outside the Protected Area and on the Owner Controlled Area. The fire was reported out at 1841. No personnel were injured due to the fire. The fire appeared to be from an external building exhaust fan. There was no internal or structural damage to the building. There was no radiological release. No Safety Related Systems were required to function. The licensee notified the NRC Resident Inspector.
ENS 5275214 May 2017 16:09:00At 0730 (CDT) on 5/14/2017, a visitor was working in the Protected Area (PA) on the turbine building roof and discovered a blue 12 ounce can of beer in their cooler. This was discovered when the visitor was removing items from their cooler into a larger community cooler. The visitor immediately notified their escort of the prohibited item. The escort then notified Security of the event. Security took possession of the item and the individual was escorted offsite. The individual stated when they packed their cooler at home they thought they had picked up a blue can of soda and did not notice it was a blue can of beer. This event is being reported per 10CFR26.719(b). The licensee notified the NRC Resident Inspector.
ENS 5274911 May 2017 18:11:00A can of alcohol (16.9 ounce foreign beer) was discovered unopened in an administration building refrigerator. Site security took possession of the can of alcohol. The owner of the can of alcohol is unknown. This licensee is making this 24 hour notification in accordance with 10CFR26.719(b)(1). The licensee notified the NRC Resident Inspector.
ENS 5274811 May 2017 15:24:00On Wednesday May 10, 2017 at approximately (1700 EDT), the Reactor Operator (RO) that was signed in on the reactor console logbook completed a ('key on') checklist in preparation for a routine reactor startup. The RO left the control room and brought the log book to the reactor bridge for the Designated Senior Reactor Operator (DSRO) to sign off for the ('key on') startup. The RO immediately realized his mistake concerning the procedural requirement for a reactor operator to be present in the control room at all times when the reactor is not secured (procedure OP-103), and returned to the control room. The DSRO followed the RO to the control room and observed that the reactor key was in the on position, the control rods were all fully inserted, and reactor power was at residual levels. The reactor was shutdown, but was not secured. The DSRO determined that this constituted a violation of procedure OP-103 and could be a Reportable Occurrence as defined under Technical Specification 1.2.24 h. The DSRO reviewed Technical Specification (TS) 6.6.2, Action to be Taken in the Event of a Reportable Occurrence. The DSRO determined that under TS 6.6.2a that reactor conditions had been returned to normal by the presence of the licensed operator in the control room. The DSRO then signed the Key On checklist authorization for reactor startup and the reactor was started. The DSRO spoke with the Manager of Engineering and Operations (MEO) by telephone about this matter at approximately 1800 on May 10, 2017. The MEO concurred that procedure OP-103 was violated and would be reportable to the Nuclear Regulatory Commission (NRC). The DSRO and MEO agreed to discuss this matter with the Director, Nuclear Reactor Program and the Reactor Health Physicist on May 11, 2017. The MEO stated on May 11, 2017 that TS 6.1.3a, the specification implemented by procedure OP-103, was not met. It was agreed that required notifications to NRC would be made by (1700) on May 11, 2017 to meet the 24 hour notification requirement.
ENS 5299326 September 2017 15:39:00

An endocrinologist specified a therapy dose of 20 milliCuries of I-131. An authorized dose directive was incorrectly written for 30 milliCuries of I-131. The patient was administered the initially determined dose of 20 milliCuries of I-131. Medical personnel determined that there was no impact on the patient. Hospital supervision notified the on-site Authorized User, the Radiation Safety Officer and the Medical Physicist. 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.

  • * * UPDATE AT 1345 EDT ON 9/27/17 FROM ANDRE VANTERPOOL TO RICHARD L. SMITH * * *

The actual event date was May 1, 2017, and the discovery date was September 25, 2017, at approximately 1500 MDT. Notified R4DO (Proulx) and NMSS Events Notification (via email).

ENS 527201 May 2017 11:30:00The following information was received from the Commonwealth of Kentucky via facsimile: KY RHB (Kentucky Radiation Health Branch) Inspector, Christopher Keffer, was performing a routine health and safety inspection of the licensee when the RSO (Radiation Safety Officer) discovered that a stored device was missing. According to the RSO, the laboratory where the device was stored was cleaned out the week before; it is currently believed that the device has been thrown away and is now in a landfill. The sealed source identification number is NR-536-D-808-B associated with a Perkins Elmer Clarus Model 500. The source is a Ni-63, 15 microCurie source. 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 5274611 May 2017 12:16:00The following information was received from the State of New Jersey via facsimile: Notifications: Phone call was made to the State of New Jersey Department of Environmental Protection (NJDEP) Bureau of Environmental Radiation on 5/10/17. The event occurred on 4/26/17. Event Description: PADEP (Pennsylvania Department of Environmental Protection) staff notified NJDEP staff of a package that was transported by a (New Jersey) pharmacy from a (Pennsylvania) nuclear medicine office. It appears that the package was accompanied by an inaccurate bill of lading and package label/(Transport Index). and brought to the licensee's (Somerset, New Jersey) facility. Investigation is ongoing.
ENS 5268618 April 2017 10:17:00The following information was received from the State of New Jersey via facsimile: The RSO (Radiation Safety Officer) for this cardiology office called to report a lost/missing Cs-137 dose calibrator vial source. Control of this facility was recently transferred to a medical center. When the new RSO visited the cardiology office to become familiar with it, it was discovered that the Cs-137 source was missing. The source, as listed on the cardiology office's inventory, contained 199.04 uCi (microCuries) of activity as of its calibration date of 9/1/2005. The decayed source would contain approximately 152.2 uCi (microCuries) of activity as of the date of this notification. The manufacturer and model # of the source were not immediately available. The RSO will follow-up with a written report within 30 days. 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 5267311 April 2017 14:28:00The following information was received from the State of Utah via email: (University) Radiological Health personnel responded to an incident involving a damaged tritium exit sign at the University Guest House. It was determined the damaged exit sign was leaking tritium and the licensee notified the (Utah) Division of Waste Management and Radiation Control. This incident report is the initial notification of the NRC Operations Center. Utah Event Report: UT170003
ENS 5277831 May 2017 07:50:00This 60-day optional telephone notification is being made in lieu of an LER submittal, as allowed by 10 CFR 50.73(a)(1). This notification is made pursuant to the reporting requirements specified in 10 CFR 50.73(a)(2)(iv)(A) for an invalid actuation of one of the systems listed in 10 CFR 50.73(a)(2)(iv)(B). On April 6, 2017, at 1212 Eastern Daylight Time (EDT), an invalid actuation of emergency diesel generators (EDGs) 1, 2. 3. and 4 occurred. In support of maintenance associated with the onsite electrical distribution system, activities were in progress to power the 2C balance-of-plant (BOP) bus from the startup auxiliary transformer (SAT) followed by de-energization of the 2D BOP bus. However, flexible links between the SAT and the 2D BOP bus had not been installed. As a result, under voltage sensing relay (27SX) was not energized and an invalid SAT secondary side under voltage EDG auto start signal was generated. There was no actual under voltage on the SAT, no loss of power, and all emergency buses continued to be powered by the unit auxiliary transformer (UAT). The EDGs responded properly to the auto-start signal. The actuation was complete, in that the EDGs successfully started and ran unloaded. The EDGs were returned to standby status by 1415 EDT. Since no actual under voltage condition existed which required the EDGs to start, and the start was not in response to actual plant conditions satisfying the requirements for initiation, this event has been determined to be an invalid actuation. This event did not result in any adverse impact to the health and safety of the public. The licensee notified the NRC Resident Inspector.
ENS 5265531 March 2017 19:14:00On March 31, 2017 at 1155 hours (EDT), with the reactor at 97% core thermal power and steady state conditions, operators inadvertently caused water level to rise in the Pressure Suppression Pool (TORUS). Pilgrim Nuclear Power Station (PNPS) was restoring normal system valve line-ups after performing flushing of the suction piping of the Core Spray system in accordance with station procedures. During the process of restoring the appropriate valve line-ups, water was inadvertently transferred to the TORUS from the Condensate Storage Tank. The cause of the event is understood. The Technical Specification (TS) Limiting Condition for Operation (LCO) Action Statement (AS) 3.7.A.5 was entered. The LCO AS was exited at 1540 when TORUS water level was restored to the limits specified in LCO's 3.7.A.1.b and 3.7.A.1.m. Because the TORUS was declared inoperable, PNPS is providing an 8-hour non-emergency notification in accordance with 10 CFR 50.72(b)(3)(v)(D), an event or condition that could have prevented fulfillment of a safety function needed to mitigate the consequences of an accident. This was a case of the water level in the TORUS being above the TS limit. The TORUS was potentially available to provide cooling to the reactor if required. The NRC Resident Inspector has been notified. The licensee notified the Commonwealth of Massachusetts and Plymouth County.
ENS 5265230 March 2017 21:58:00At 1630 PDT on March 30, 2017, a non-work related fatality occurred on the Diablo Canyon Power Plant property. The individual's work location was outside of the Protected Area. The fatality was not related to the health and safety of the public. Specifically, a contractor for Pacific Gas and Electric (PG&E) was found in the Security Training Building unresponsive. The individual was promptly attended to by Diablo Canyon personnel. The individual was subsequently pronounced dead by the San Luis Obispo County Paramedics. PG&E has not observed any heightened public, media, or government concerns as a result of the fatality. Because the fatality is unrelated to Diablo Canyon Power Plant industrial or radiological health and safety, no news release is planned. Because the fatality was not work related, nor the result of an accident, no notification to other government agencies was made at the time. However, PG&E will make a notification to the California Occupational Safety and Health Administration. Thus this ENS notification is in response to a notification to another government agency in accordance with 10 CFR 50.72(b)(2)(xi). The NRC Senior Resident Inspector and Resident Inspector have been notified.
ENS 5265431 March 2017 16:15:00The following information was received from the Commonwealth of Kentucky via facsimile: On 3/28/2017 the licensee left a Cs-137 brachytherapy sealed source at (address provided). On 3/30/2017 the licensee discovered the source was not in its shielded container and immediately determined the location of the source and took steps to retrieve and secure it. This event is actively being investigated by the licensee. Kentucky Event: KY170003 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 Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)
ENS 5255516 February 2017 13:03:00On February 15, 2017 at 1515, it was discovered by corporate Fitness for Duty (FFD) personnel that an unescorted access reactivation feature in the security database (Illuminate) does not reset the flag to include an individual in the random FFD pool due to a database coding error. The Illuminate database was implemented fleet-wide 1/3/17. Review by corporate FFD personnel found one individual currently badged at Clinton Power Station was affected by the coding error. The individual was not in the FFD random pool from 1/3/17 until 2/15/17. Corporate security personnel found no other individuals to be affected by this issue. Affected individual was added to the FFD random pool. Corporate security personnel notified all Exelon sites of the issue. Sites were notified that the ability to use the re-activation feature in Illuminate would be removed from use by site personnel. Pending removal, a daily query would be run in the database to assure the re-activation feature had not been used by site personnel. The licensee informed the NRC Resident Inspector.
ENS 5243715 December 2016 11:47:00

On December 15, 2016, at 1010 EST, the startup of the Reactor Building HVAC (Heating Ventilation and Air Conditioning) system resulted in the Technical Specification (TS) for secondary containment pressure boundary not being met for approximately 1 second. The maximum secondary containment pressure observed during that time was approximately 0.044 inches of vacuum water gauge. Secondary containment pressure was returned to within the TS operability limit of 0.125 inches of vacuum water gauge (TS SR 3.6.4. 1.1) by Reactor Building HVAC and Standby Gas Treatment System already in operation. There were no radiological releases associated with this event. Declaring secondary containment inoperable is reportable under 10CFR50.72(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.

  • * * RETRACTION AT 1922 EDT ON 3/17/2017 FROM DEREK ETUE TO BETHANY CECERE * * *

In this event notification, DTE Electric Company (DTE) reported conditions whereby the Fermi 2 secondary containment was believed to have exceeded Technical Specification Surveillance Requirements due to high winds. DTE hereby retracts this event notification as the Fermi 2 secondary containment has been determined to have been operable during this event as described below. The Fermi 2 secondary containment pressure is maintained at a pressure less than the external pressure to contain, dilute, hold up, and reduce the activity level of fission products prior to release to the environment, and to isolate and contain fission products that are released during a Design Basis Accident or certain operations. Secondary containment pressure is monitored by a number of differential pressure (dP) sensors. High wind gusts have resulted in momentary negative pressure on the leeward side of the building, causing a more positive pressure indication from one or more dP sensors. The secondary containment building pressure remains relatively constant during these 'wind events.' In December 2016, DTE implemented a software design change to display a 120-second rolling average for secondary containment dP indication. A 120-second rolling average recorded every second provides the operator a more accurate report of actual secondary containment conditions, while mitigating the signal noise and wind gust effects. The conditions associated with the subject event notification were re-reviewed in light of the improved secondary containment dP indication and it was determined that the Fermi 2 secondary containment was operable during this event. Specifically, the secondary containment pressure did not exceed Technical Specification Surveillance Requirements during this event. In summary, the above event notification is retracted because the Fermi 2 secondary containment was determined to have been fully operable during the conditions identified in the subject report. The licensee notified the NRC Resident Inspector. Notified R3DO (Stoedter).

ENS 5243214 December 2016 15:10:00

On December 14, 2016, at 1314 EST, the startup of the Reactor Building HVAC (Heating, Ventilation and Air Conditioning) system resulted in the Technical Specification (TS) for secondary containment pressure boundary not being met for approximately 1 second. The maximum secondary containment pressure observed during that time was approximately 0.07 inches of vacuum water gauge. Secondary containment pressure was returned to within the TS operability limit of 0.125 inches of vacuum water gauge (TS SR 3.6.4.1.1) by Reactor Building HVAC and Standby Gas Treatment System already in operation. There were no radiological releases associated with this event. Declaring secondary containment inoperable is reportable under 10CFR50.72(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.

  • * * RETRACTION AT 1922 EDT ON 3/17/2017 FROM DEREK ETUE TO BETHANY CECERE * * *

In this event notification, DTE Electric Company (DTE) reported conditions whereby the Fermi 2 secondary containment was believed to have exceeded Technical Specification Surveillance Requirements due to high winds. DTE hereby retracts this event notification as the Fermi 2 secondary containment has been determined to have been operable during this event as described below. The Fermi 2 secondary containment pressure is maintained at a pressure less than the external pressure to contain, dilute, hold up, and reduce the activity level of fission products prior to release to the environment, and to isolate and contain fission products that are released during a Design Basis Accident or certain operations. Secondary containment pressure is monitored by a number of differential pressure (dP) sensors. High wind gusts have resulted in momentary negative pressure on the leeward side of the building, causing a more positive pressure indication from one or more dP sensors. The secondary containment building pressure remains relatively constant during these 'wind events.' In December 2016, DTE implemented a software design change to display a 120-second rolling average for secondary containment dP indication. A 120-second rolling average recorded every second provides the operator a more accurate report of actual secondary containment conditions, while mitigating the signal noise and wind gust effects. The conditions associated with the subject event notification were re-reviewed in light of the improved secondary containment dP indication and it was determined that the Fermi 2 secondary containment was operable during this event. Specifically, the secondary containment pressure did not exceed Technical Specification Surveillance Requirements during this event. In summary, the above event notification is retracted because the Fermi 2 secondary containment was determined to have been fully operable during the conditions identified in the subject report. The licensee notified the NRC Resident Inspector. Notified R3DO (Stoedter)

ENS 5243314 December 2016 16:12:00On 12/13/2016 at approximately 1500 (PST), the AREVA Nuclear Criticality Safety Staff was notified that an administrative IROFS (Item Relied On For Safety) control had not been performed in the ELO raffinate treatment process. The ELO raffinate treatment process requires the sampling of a favorable geometry process tank (IROFS 306) that is discharged to one of two sets of favorable geometry quarantine tanks. When one of the two sets of quarantine tanks is full, the input is diverted to the other set of tanks and the set that is full is recirculated and sampled for U (Uranium) concentration (IROFS 307). When both sample results have been confirmed to be acceptable the discharge valve on the transfer line may be unlocked and the raffinate solution transferred to a filter press. Sampling of the process tank was completed as required, however; the quarantine tank transfer line was unlocked and contents were pumped to the filter press without completing the required independent sampling of the quarantine tank. AREVA is conservatively reporting this plant condition under 10CFR70 Appendix A, because an accident sequence that could result in accidental nuclear criticality may not have remained highly unlikely in the absence of IROFS 307. The licensee will notify NRC Region 2.
ENS 523568 November 2016 17:36:00At 1331 (CST) on November 8, 2016, Farley Nuclear Plant Unit 1 manually tripped from 32% reactor power. The plant was ramping down to remove the main generator from service due to an unrelated issue. 1A SGFP did not respond to control Steam Generator (SG) level as expected when the miniflow was opened per procedure. SG levels lowered due to lower feed flow and the reactor was manually tripped in accordance with plant procedures. All control rods fully inserted and Auxiliary feedwater (AFW) auto started as expected. The Main Steam Isolation Valves were closed to minimize the cool-down. Decay heat is being removed through the Atmospheric Relief Valves. All other systems responded as expected. The plant is currently stable in Mode 3 (Hot Standby). The failure of the 1A SGFP control is under investigation. Unit 2 was not affected. The NRC Resident Inspector has been notified. There is no primary to secondary leakage.
ENS 523517 November 2016 16:50:00

The following was excerpted from information received from the State of New Jersey by email: Event Narrative: On November 7, 2016, during the six-month shutter checks, the pneumatically operated shutter on the Vega source holder Phillips 66-Bayway Tag # PBL002 (source capsule S/N 0321CG) failed to close when tested. Several attempts were made wherein the shutter position indicator seemed to move slightly. It was concluded that the issue was not a failure of the air system controlling the pneumatic shutter actuator. The manufacturer was contacted to assess the problem. Root cause(s) and contributing factors: The source remained in the holder attached to the vessel in its normal operating position. The integrity of the source holder remains intact so there should be no exposures. Source/Radioactive Material/Devices: radioactive level gauge Isotope and activity; manufacturer, model and serial number, leak test results as applicable: The source is a 50 mCi Cs-137 solid sealed source, S/N 0321CG. The last leak test was 10/19/15. The equipment is an Ohmart/Vega model SH-F1A source holder mounted to a vessel. New Jersey Case Number: 161107162023

  • * * UPDATE FROM ED TRUSKOWSKI TO JOHN SHOEMAKER AT 1323 EST ON 12/1/2016 * * *

The following update was received from the State of New Jersey via email: Vega serviced the unit on November 11, 2016, with lubrication. It was considered to work properly after service. Phillips 66 notified NJDEP (New Jersey Department of Environmental Protection) on November 30, 2016, that a new unit will be purchased to replace the old unit. Event status is 'closed'. Notified R1DO (Bower) and NMSS_Events_Notification via email.

ENS 524107 December 2016 09:15:00

Agilent Technologies is a manufacturer of a part containing an electron capture detector (ECD) that fits into a gas chromatograph. The ECD contains an embedded sealed source (Ni-63; 15 milliCuries) and is manufactured in Shanghai, China and is transferred into the United States through the JFK Airport Worldwide Flight Services Warehouse. When the licensee's Philadelphia truck shipping service attempted to retrieve the two ECD sources at the JFK warehouse, the sources were discovered missing. The warehouse was searched without success. The ECD source serial numbers are U30355 and U30356. The model number is 62397AECD. Agilent Technologies holds an NRC license and is located at 2850 Centerville Road, Wilmington, DE 19808.

  • * * UPDATE ON 1/27/17 AT 1457 EST FROM DAVID BENNETT TO DONG PARK * * *

As a corrective action, the licensee has changed warehouse operations to a different warehouse used to receive devices manufactured in China. Notified R1DO (Welling) 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 523599 November 2016 17:50:00

The following information was excerpted from a facsimile received by SOR: Pursuant to the requirements of 10CFR Part 21, this letter notifies the NRC of a Part 21 condition. Irradiation testing performed since 1984 did not take into account all of the uncertainties associated with reported doses of gamma radiation to nuclear test specimens for qualification testing. SOR contracted services with lsomedix in 1992 for the radiation aging that was performed per SOR nuclear qualification report 9058-102 Revision 1. Although SOR imposed Part 21 reporting requirements, lsomedix did not include SOR as part of their Part 21 notification. The Part 21 was brought to SOR's attention through an inquiry by a nuclear power station. SOR requested a conference with Steris lsomedix which occurred on November 3, 2016. The teleconference confirmed that the subject radiation aging test results report would be affected by the Steris lsomedix Part 21. As a result, corrections are underway per qualification test report 9058-102 regarding the uncertainty calculations. SOR does not have the capability to perform further evaluations to determine if a safety hazard exists as the specific customer application is unknown. The end user must confirm for each application that the qualified life dose + accident dose + 10% of accident dose is less than or equal to the corrected values. SOR is currently identifying all customers potentially affected by this deviation. At the conclusion of this activity, SOR will notify the customers and the U.S. Nuclear Regulatory Commission in accordance with the requirements of 10 CFR Part 21.

  • * * UPDATE FROM MELANIE DIRKS TO JOHN SHOEMAKER AT 1455 EST ON 12/2/16 * * *

The following is an excerpt of an updated Part 21 received via email: Corrections are now complete to test report 9058-102 regarding the uncertainty calculations. The calculations changed from 8% uncertainty to 9.6% uncertainty for the minimum irradiation aging. SOR does not have the capability to perform further evaluations to determine if a safety hazard exists as the specific customer application is unknown. The end user must confirm for each application that the qualified life dose + accident dose + 10% of accident dose is less than or equal to the above noted values. Should you have any additional questions regarding this matter, please contact: Linda Coutts Inside Sales Representative Email: lcoutts@sorinc.com Tel 91.3�-956�-3071 Charles Lautner Customer Service Manager Email: clautner@sorinc.com Tel 913-956-3070 Notified R1DO (Bower), R2DO (McCoy), R3DO (Stoedter), R4DO (Haire), NMSS_Events_Notification, and Part 21/50.55 Reactors via email.