Event Notification Report for April 12, 2022

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
04/11/2022 - 04/12/2022

EVENT NUMBERS
55819 55820 55822 55823 55831 55836
Agreement State
Event Number: 55819
Rep Org: Ohio Bureau of Radiation Protection
Licensee: Eurofins Environment Testing North Central, LLC
Region: 3
City: Barberton   State: OH
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: Stephen James
HQ OPS Officer: Ossy Font
Notification Date: 04/04/2022
Notification Time: 10:57 [ET]
Event Date: 03/29/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/05/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Kozak, Laura (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
EN Revision Imported Date: 4/12/2022

EN Revision Text: AGREEMENT STATE REPORT - ELECTRON CAPUTRE DETECTOR LEAKING SOURCE

The following information was received from the Ohio Bureau of Radiation Protection via email:

"Report of a leaking General License Ni-63 source (Model: G2397A, S/N: U3951) on an Electron Capture Detector. The source was returned to the manufacturer.

"Leak test result: 20 microcuries (740 kBq)"

NMED Item Number: OH220004

* * * UPDATE ON 4/5/22 AT 1413 EDT FROM S. JAMES TO T. HERRITY * * *

"UPDATES/CORRECTIONS ON LICENSEE NAME, ACTIVITY AND LEAK TEST RESULTS: Leak test was taken on Electron Capture Detector (ECD) in storage as part of 6-month cycle. ECD contained 15 mCi Ni-63 source. Results came back indicating leaking source at 2000 pCi. No contamination of the ECD was found. The ECD will be permanently taken out of service and returned to manufacturer."

Licensee name updated to full name: Eurofins Environment Testing North Central, LLC

Notified R3DO (McCraw) and NMSS Events via email.


Agreement State
Event Number: 55820
Rep Org: California Radiation Control Prgm
Licensee: Miller Pacific Engineering Group
Region: 4
City: Novato   State: CA
County:
License #: 5411-21
Agreement: Y
Docket:
NRC Notified By: Arunika Hewadikaram
HQ OPS Officer: Donald Norwood
Notification Date: 04/04/2022
Notification Time: 15:58 [ET]
Event Date: 04/01/2022
Event Time: 00:00 [PDT]
Last Update Date: 04/04/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
EN Revision Imported Date: 4/12/2022

EN Revision Text: AGREEMENT STATE REPORT - TWO STOLEN THEN RECOVERED MOISTURE DENSITY GAUGES

The following information was received via E-mail from the California Department of Public Health - Radiologic Health Branch (RHB):

"On 4/1/22, at 1934 PDT, California Office of Emergency Services (CalOES) contacted RHB to report two moisture density gauges stolen from a licensee's storage facility. The stolen gauges included a CPN Model MC1-DR, S/N MD 80709102 and a CPN Model MC1-Elite, S/N MD 70408697, each containing 10 mCi of Cs-137 and 40 mCi of Am-241. Both gauges were stolen between the hours of approximately 1700 PDT on 3/31/22 and 0900 PDT on Friday, 4/1/2022, from the locked storage shed located in the lower parking lot of the licensee's office [redacted] in Novato, CA. The licensee had notified the Novato Police Department of the theft immediately after it was discovered. On 4/2/22, RHB contacted the licensee and learned that both gauges had been recovered by the Novato PD. They were located on a paved walking trail south of the licensee's office building. Per the RSO [(Radiation Safety Officer)], the gauges did not have any evidence of tampering except minor damage to one of the Type A containers. On 4/4/22, both gauges will be taken to Instrotek for further evaluation and leak testing. "

California 5010 Number: 040122

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: 55822
Rep Org: Ohio Bureau of Radiation Protection
Licensee: I. H. Schlezinger, Inc.
Region: 3
City: Columbus   State: OH
County:
License #: N/A
Agreement: Y
Docket:
NRC Notified By: Stephen James
HQ OPS Officer: Thomas Herrity
Notification Date: 04/05/2022
Notification Time: 14:13 [ET]
Event Date: 03/30/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/05/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
McCraw, Aaron (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
EN Revision Imported Date: 4/12/2022

EN Revision Text: AGREEMENT STATE REPORT - RADIOACTIVE GAUGE DISCOVERED IN SCRAP METAL

The following information was received from the Ohio Department of Health Bureau (ODH) of Environmental Health and Radiation Protection via email:

"On 3/30/22, ODH received notification of a load that tripped radiation detectors at a scrap facility in Marion, Ohio. The load returned to point of origin in Columbus, Ohio under DOT SP OH-OH-22-014. The Originator contacted ODH on 4/4/22 to report that they had surveyed the load and isolated a device that was box shaped, perhaps 8x4x4 inches. The item reportedly pegged the facility's Ludlum 19 (5 mR/hr), and was secured in a quarantine area.

"ODH staff responded to site on 4/5/22 and identified a Ronan Engineering Model RLL-1 gauge containing a 0.27 mCi Cs-137 source with a reading of 750 microR/hr on the side of the gauge. No contamination was detected. The facility will keep the device secure while disposal options are arranged. ODH will contact the manufacturer (Ronan Engineering) to attempt to identify the owner based on mode; and serial number on the device."

Ohio item number: OH220005



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: 55823
Rep Org: Nevada Radiological Health
Licensee: Comprehensive Cancer Centers, NV
Region: 4
City: Las Vegas   State: NV
County:
License #: 03-12-0491-01
Agreement: Y
Docket:
NRC Notified By: Corey Creveling
HQ OPS Officer: Thomas Herrity
Notification Date: 04/05/2022
Notification Time: 18:37 [ET]
Event Date: 04/05/2022
Event Time: 00:00 [PDT]
Last Update Date: 04/05/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
EN Revision Imported Date: 4/12/2022

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT, EXCEEDED PRESCRIBED DOSE

The following was received from the State of Nevada via email:

"The patient was prescribed ten [High Dose Rate Brachytherapy] treatments [with a 9.0 curie Ir-192 source]. After four treatments, it was discovered that some of the catheters had been incorrectly labeled. This altered the dose distribution resulting in a higher skin dose than anticipated, however the target dose difference did NOT exceed 50 percent from the prescription. The remainder of the patient's treatment was re-planned to compensate for the dose already given. The total doses once complete will be within limits for the skin and the target dose will be within 20 percent of the prescription. All treatments were to the correct patient and correct site.

"The treatment area for this patient is adjacent to the skin, so the intended prescription would have given a skin max dose of nearly 100 percent of the prescribed treatment dose.

"For the four treatments given with the incorrectly labeled catheters, the dose to skin is estimated to be 3 times the initially expected dose, exceeding 50 rem.

"However, the patient's treatment was re-planned to provide additional skin sparing for the remaining treatments while maintaining minimum target coverage to compensate for the dose already given. We estimate the total skin dose from the entire treatment will exceed the initially anticipated skin dose by 41 percent. This total skin dose is still within standard protocol limits, and the written directive has been updated to be inclusive of the initial and new treatment plans and organ at risk (OAR) doses.

"The patient and referring physician were notified the day the event was discovered before the determination that a medical event took place."

Nevada Event Number: NV220002


!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 55831
Facility: Turkey Point
Region: 2     State: FL
Unit: [4] [] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: Ryan Frank
HQ OPS Officer: Lloyd Desotell
Notification Date: 04/08/2022
Notification Time: 01:10 [ET]
Event Date: 04/07/2022
Event Time: 19:00 [EDT]
Last Update Date: 04/11/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(B) - Pot Rhr Inop
Person (Organization):
Miller, Mark (R2DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
4 N N 0 Hot Shutdown 0 Hot Shutdown
Event Text
EN Revision Imported Date: 4/12/2022

EN Revision Text: BOTH TRAINS OF RESIDUAL HEAT REMOVAL INOPERABLE

The following information was provided by the licensee via fax or email:

"At 1900 EDT on 04/07/22, while Unit 4 was in Mode 4 following a refueling outage, it was discovered that both trains of residual heat removal (RHR) were simultaneously inoperable due to gas voiding. At 2032 EDT corrective actions were completed and both trains of RHR were declared operable. This condition is being reported pursuant to 10 CFR 50.72(b)(3)(v)(B).

"The NRC Resident Inspector has been notified."

* * * RETRACTION ON 04/11/22 AT 1022 EST FROM DAVID STOIA TO BRIAN SMITH * * *

The following information was provided by the licensee via email:

"On 4/8/2022 at 0110 EDT Turkey Point Unit 4 notified the [NRC Operations Center (NRCOC)] pursuant to 10 CFR 50.72(b)(3)(v)(B) that both trains of Residual Heat Removal (RHR) were simultaneously inoperable due to the presence of gas voids that were identified during scheduled system gas accumulation testing. Subsequent evaluation by [Florida Power & Light (FPL)] Engineering has concluded that both trains of RHR remained operable and capable of performing their specified safety function.

"This NRCOC notification is a retraction of EN# 55831."

The licensee notified the NRC Resident Inspector.

Notified R2DO (Miller)


Part 21
Event Number: 55836
Rep Org: Westinghouse Electric Company
Licensee: Westinghouse Electric Company
Region: 1
City: Cranberry Township   State: PA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Camille Zozula
HQ OPS Officer: Mike Stafford
Notification Date: 04/11/2022
Notification Time: 21:01 [ET]
Event Date: 04/06/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/11/2022
Emergency Class: Non Emergency
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
Person (Organization):
Cahill, Christopher (R1DO)
McCraw, Aaron (R3DO)
Part 21/50.55 Reactors, - (EMAIL)
Event Text
PART 21 - WESTINGHOUSE ACTUATOR FULL VOLTAGE REVERSING CONTACTORS DEFICENCY REPORT

The following information was provided by the licensee via email:

"The following information is provided pursuant to the requirements of 10 CFR Part 21 to report a defect that could lead to a substantial safety hazard.

"Name and address of the individual informing the Commission:
Camille T. Zozula
Westinghouse Electric Company
1000 Westinghouse Drive
Cranberry Township, Pennsylvania 16066
(412) 374-2577
zozulact@westinghouse.com

"Commercially dedicated Eaton Freedom Series NEMA Size 1 and 2 full voltage reversing (FVR) contactors with mechanical interlocks that were manufactured between April 2014 until June 2018.

"The [FVRs] are designed and qualified to open and close on demand. The FVRs sporadically failed to electrically close on demand because the mechanical interlock is not returning to the de-energized position.

"Westinghouse sold LaSalle County Station Units 1 and 2 a quantity of 206 safety related [FVRs] that are potentially affected between 2014 and 2022.

"Westinghouse developed an alignment tool intended to increase the effectiveness of the installed mechanical interlocks and prevent them from binding. Westinghouse provided the alignment tool and associated procedure to LaSalle on February 17, 2022.

"Effective March 11, 2022, Westinghouse updated the commercial dedication instruction to include additional critical characteristics of the mechanical interlock assembly based on the results of the causal analysis. It was determined that the pawl contained within the mechanical interlock assembly was the cause of the mechanical binding.

"Westinghouse purchased the latest revision mechanical interlocks that contain Revision 3 pawls from Eaton. They are being dedicated by Westinghouse and installed by LaSalle Station in conjunction with the alignment tool, as they become available.

"Westinghouse has been in daily communication with LaSalle Station since January 2022 and provides real-time updates on the Westinghouse testing efforts.

"Westinghouse provided an on-site expert to LaSalle between February 23-25, 2022.

"The overall failure rate of the installed components has been low and is related to a tolerance stack-up among the mechanical interlock, mechanical interlock pawl, and the two reversing contactors. Additionally, the failures only occur after some time in service which cannot be correlated to a specific installed time or number of cycles. It is a random event.

"Westinghouse analyzed, reviewed, and regression tested mechanical interlocks that contain the Revision 3 pawls to confirm they are functional and meet the LaSalle environmental requirements."