Home NRC Library Document Collections Events, Reports Associated with Event Notification Reports 2019

Event Notification Report for November 25, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/22/2019 - 11/25/2019

** EVENT NUMBERS **

!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor	Event Number: 54293
Facility: FERMI Region: 3 State: MI Unit: [2] [] [] RX Type: [2] GE-4 NRC Notified By: GREG MILLER HQ OPS Officer: OSSY FONT	Notification Date: 09/25/2019 Notification Time: 15:30 [ET] Event Date: 09/25/2019 Event Time: 12:03 [EDT] Last Update Date: 11/22/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION	Person (Organization): JAMNES CAMERON (R3DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

100

Power Operation

Event Text

HIGH PRESSURE COOLANT INJECTION DECLARED INOPERABLE

"At 1203 EDT, on September 25, 2019, during a Division 2 Emergency Equipment Service Water (EESW) pump and valve surveillance test, the Division 2 Emergency Equipment Cooling Water (EECW) Temperature Control Valve was found to be approximately 80 percent open rather than in its required full open position during fail safe testing. The Division 2 EESW system is required to support operability of the Division 2 EECW system. The Division 2 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. An investigation is underway into the cause of the failure. This report is being made pursuant to 10 CFR 50.72(b)(3)(v)(D) based on an unplanned HPCI inoperability.

"The NRC Senior Resident Inspector has been notified."

The licensee is in 72-hour shutdown action statement.

* * * RETRACTION ON 11/21/19 AT 1547 EST FROM PAUL ANGOVE TO BRIAN LIN * * *

"Subsequent engineering evaluation has determined that the EECW TCV was capable of passing sufficient flow to perform its design basis functions, including supporting the HPCI room cooler, while approximately 80% open. Therefore, HPCI remained operable and there was no loss of safety function. The event did not involve a condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident under 10 CFR 50.72(b)(3)(v)(D).

"EN 54293 is retracted and no Licensee Event Report under 10 CFR 50.73(a)(2)(v)(D) is required to be submitted.

"The NRC Resident Inspector has been notified. "

Notified R3DO (Cameron).

!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor	Event Number: 54330
Facility: PEACH BOTTOM Region: 1 State: PA Unit: [] [3] [] RX Type: [2] GE-4,[3] GE-4 NRC Notified By: JEREMY PETERS HQ OPS Officer: BRIAN LIN	Notification Date: 10/15/2019 Notification Time: 19:14 [ET] Event Date: 10/15/2019 Event Time: 12:10 [EDT] Last Update Date: 11/22/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION	Person (Organization): DON JACKSON (R1DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

Power Operation

Event Text

HIGH PRESSURE COOLANT INJECTION (HPCI) SYSTEM INOPERABLE

"On 10/15/19 at 1210 [EDT] Peach Bottom discovered a degraded spring hanger (23DBN-H39) associated with Unit 3 High Pressure Coolant Injection (HPCI) system. The hanger is located downstream of MO-3-23-14 HPCI Steam Supply Valve before the HO-3-23-4513 Turbine Stop Valve. A review of the piping and support design analysis were performed and concluded the U3 HPCI turbine inlet nozzle would potentially exceed its allowable stresses. Following Engineering review, U3 HPCI was declared inoperable at 1743 [EDT].

"This report is being submitted pursuant to 10 CFR 50.72(b)(3)(v)(D).

"The NRC Resident Inspector has been notified."

* * * RETRACTION ON 11/22/19 AT 0851 EST FROM DAN DULLUM TO BETHANY CECERE * * *

"Additional evaluation by Engineering personnel determined that the degraded spring hanger would have no adverse effect on the subject piping or HPCI turbine nozzle structural integrity. Pressure, deadweight, and seismic stresses were within allowable limits. Non-destructive examination (NDE) of the piping and nozzle was performed to identify any signs of cracking, yielding, or defects. NDE results were satisfactory. The degraded spring hanger did not effect the Unit 3 HPCI system operability and this call is being retracted.

"The NRC Resident Inspector has been notified."

Notified R1DO (Cahill).

Agreement State	Event Number: 54385
Rep Org: PA BUREAU OF RADIATION PROTECTION Licensee: WEST PENN ALLEGHENY HEALTH SYSTEM INC Region: 1 City: PITTSBURG State: PA County: License #: PA-0031 Agreement: Y Docket: NRC Notified By: JOHN CHIPPO HQ OPS Officer: OSSY FONT	Notification Date: 11/14/2019 Notification Time: 10:40 [ET] Event Date: 11/08/2019 Event Time: 00:00 [EST] Last Update Date: 11/15/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): FRANK ARNER (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DOSE DELIVERED DIFFERS BY MORE THAN 20 PERCENT

The following was received from the Pennsylvania Department of Environmental Protection (DEP; the Department) via email:

"The Department received initial verbal notification from a licensee on November 8, 2019 of a possible reportable event with a detailed report on November 13, 2019 that on November 8, 2019 a reportable event occurred during an eye plaque implant (Theragenics model AgX100) containing 13 lodine-125 seeds. The seed activity was 3.728 mCi per seed for a total activity of 48.46 mCi. The prescribed dose was 8,500 rad with a planned treatment time of 101 hours. The implant was placed at 0745 [EDT] on 11/8/19. At approximately 0815 the patient complained of excessive pain. It is believed that the eye plaque had become dislodged from its proper position. It was removed at 1731 the same day. The licensee initial worst-case dose estimate to the normal sclera, conjunctiva and cornea is 1,899 rad at a depth of 1 mm for an 8.5 hour exposure. The dose at 2mm for this same time period is 1,425 rad. Both the patient and surgeon were notified. The effects on the patient are currently being evaluated. The DEP will update this event as soon as more information is provided."

Event Report ID No: PA190027

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.

Agreement State	Event Number: 54387
Rep Org: ARIZONA DEPT OF HEALTH SERVICES Licensee: UNIVERSITY OF ARIZONA Region: 4 City: TUCSON State: AZ County: License #: 10-024 Agreement: Y Docket: NRC Notified By: BRIAN D. GORETZKI HQ OPS Officer: JEFF HERRERA	Notification Date: 11/15/2019 Notification Time: 13:30 [ET] Event Date: 11/15/2019 Event Time: 00:00 [MST] Last Update Date: 11/15/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): GREG WERNER (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST/STOLEN TRITIUM EXIT SIGN

The following report was received from the Arizona Department of Health Services via email:

"The Department received notification that one (1) tritium exit sign has been lost/stolen. The Department has requested additional information and continues to investigate the event."

Arizona Incident Number: 19-027

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

Agreement State	Event Number: 54388
Rep Org: MAINE RADIATION CONTROL PROGRAM Licensee: NETCO, INC. Region: 1 City: WINDSOR State: ME County: License #: ME 11613 #11 Agreement: Y Docket: NRC Notified By: THOMAS HILLMAN HQ OPS Officer: CATY NOLAN	Notification Date: 11/15/2019 Notification Time: 13:56 [ET] Event Date: 11/15/2019 Event Time: 08:57 [EST] Last Update Date: 11/15/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): FRANK ARNER (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - LEAKING SEALED SOURCE

The following was received from the Maine Radiation Control Program via fax:

"At 0857 [EST on November 15, 2019,] NETCo, Inc. notified the State of Maine Radiation Control Program that they had received leak test results from their vendor [Radiation Safety & Control Services] RSCS. One the test results indicated the Ni-63 source in a replacement component to a SAFRAN Morpho Detection Trace device was leaking. Two additional tests on components with Ni-63 sources reported detectable activity but less than 0.0005 microCi. The source contains 10.0 mCi of Ni-63 and the leak test result was 0.1968 microCi on the leaking source.

"The RSO at NETCo has surveyed the work area where the leak tests were performed along with the storage container and bag that they arrived in. No detectable activity was found. NETCo will be also performing smear tests of all the areas that came in contact with the sources. The sources (components) in question will be put in a one gallon paint can awaiting proper disposal in our locked cabinet.

"The State has sent an inspector to perform additional surveys. Licensee will be providing a full report to the State as information becomes available."

Maine Event Report ID No. ME 19-002

Agreement State	Event Number: 54389
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT Licensee: GEOTECHNOLOGY, INC. Region: 4 City: LENEXA State: KS County: License #: 22-B845 Agreement: Y Docket: NRC Notified By: KIMBERLY STEVES HQ OPS Officer: JEFF HERRERA	Notification Date: 11/15/2019 Notification Time: 19:17 [ET] Event Date: 11/15/2019 Event Time: 00:00 [CST] Last Update Date: 11/15/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): GREG WERNER (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DAMAGED TROXLER MOISTURE DENSITY GAUGE

The following report was received from the Kansas Department of Health and Environmental Services via email:

"The gauge operator stepped approximately 15 feet away from the gauge to observe fill material being placed and a bulldozer backed over the gauge, clipping the corner of it. The gauge was not in use at the time and the source was not out. The only damage is to the yellow housing and a crack in the grey battery housing.

"The RSO [Radiation Safety Officer] conducted radiological surveys using a SE International Radiation Alert Monitor 4 and obtained background readings only.

"The gauge will be returned to the office and put into secure storage until it can be returned to the manufacturer for repair.

"Follow-up information will be provided to NRC."

The density gauge was a Troxler model 3430, serial number 25943, containing 333 MBq of Cs-137 and 1,628 GBq of Am-241/Be.

Agreement State	Event Number: 54392
Rep Org: NC DIV OF RADIATION PROTECTION Licensee: NUCOR CORPORATION D/B/A/ NUCOR STEEL Region: 1 City: COFIELD State: NC County: License #: 046-1152-1 Agreement: Y Docket: NRC Notified By: TRAVIS CARTOSKI HQ OPS Officer: JEFF HERRERA	Notification Date: 11/16/2019 Notification Time: 21:06 [ET] Event Date: 11/15/2019 Event Time: 00:00 [EST] Last Update Date: 11/16/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): FRANK ARNER (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - STUCK OPEN SHUTTER ON NUCLEAR PROCESS GAUGE

The following summary report was received from the North Carolina Radioactive Materials Branch via email:

"This happened 11/15/19 and [the Nucor Environmental Manager] was made aware of the incident around [1400 EST], yesterday.

"Nucor Steel has a 2015 fixed nuclear gauge in a c-frame that was due for maintenance. The gauge was deemed offline and they rolled the c-frame to a locked location where they were to perform scheduled maintenance. It was at this time that they discovered the shutter was stuck open. They tried to close the shutter (with air) but it would not close. [The Nucor Environmental Manager] explained that they roll the gauge by motor, and that during this time the shutter was opened. No employee was exposed to radiation. This gauge is exposed to the elements and [the Nucor Environmental Manager] believes there is dirt inhibiting the shutter from closing. Since they could not get it to close, they rolled the gauge back to its normal online position where it can be open and not at risk to employees. [The Nucor Environmental Manager] stated there is no damage to the source and there [are] not any leaks.

"[The Nucor Environmental Manager] called the manufacturer to come perform maintenance yesterday. They arrived at his facility around [1400] today and are currently working on the gauge."

Page Last Reviewed/Updated Thursday, March 25, 2021