Event Notification Report for December 02, 2022

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
12/01/2022 - 12/02/2022

EVENT NUMBERS
56239 56240 56247 56252
Agreement State
Event Number: 56239
Rep Org: California Radiation Control Prgm
Licensee: Arrow Infrastructure Solutions Inc.
Region: 4
City: Mojave   State: CA
County:
License #: 3412-19
Agreement: Y
Docket:
NRC Notified By: Donald Oesterle
HQ OPS Officer: Ian Howard
Notification Date: 11/24/2022
Notification Time: 15:38 [ET]
Event Date: 11/23/2022
Event Time: 20:34 [PST]
Last Update Date: 11/24/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Werner, Greg (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - LOST THEN RECOVERED MOISTURE DENSITY GAUGE

The following information was provided by the California Department of Public Health - Radiation Health Branch (RHB) via email:

"On Wednesday night, November 24, 2022, Arrow Infrastructure Solutions Inc. [doing business as] dba Arrow Engineering [Radiation Safety Officer] RSO [redacted] reported to [California Office of Emergency Services] Cal OES the loss or possible theft of a CPN moisture density gauge, MC-1DR-P (MD70803845) containing sealed sources of Cs-137 (10 mCi) and Am-241:Be (50 mCi), Cal OES Control :22-6906. The loss or possible theft was noticed by the authorized user [AU] at a gas station in Mojave, CA as the user was returning from a jobsite. The AU noticed the truck tailgate down and the CPN gauge missing as they were leaving the gas station after a restroom break, the gauge possibly fell out of the truck on Highway 58 in between Tehachapi and Mojave. The AU retraced their route on the Highway but had not located the gauge so far, they will search again on 11/24/22 during the daylight. The licensee will gather additional information for the follow up investigation and provide additional information to the department as it becomes available.

"UPDATE: The FBI notified RHB Management that the gauge had been found by a member of the public and turned into the Kern County Law Enforcement Agency. The RSO was notified and provided with contact information so the gauge could be retrieved. The RSO was instructed to do a wipe/leak test, get it analyzed quickly, and secure the gauge in storage until a negative result was returned. If a leak is detected, they will coordinate with a service company for repair or disposal. RHB Brea staff will continue with the investigation."

California 5010 Number: 112322


Agreement State
Event Number: 56240
Rep Org: Georgia Radioactive Material Pgm
Licensee: Northeast Georgia Medical Center
Region: 1
City: Gainesville   State: GA
County:
License #: GA 199-1
Agreement: Y
Docket:
NRC Notified By: Stacy Allman
HQ OPS Officer: Brian Lin
Notification Date: 11/25/2022
Notification Time: 15:04 [ET]
Event Date: 11/16/2022
Event Time: 00:00 [EST]
Last Update Date: 12/01/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Carfang, Erin (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The following information was received from the Georgia Radioactive Materials Program via email:

"We received an emailed report of a misadministration, where there was over 50 percent deviation of the prescribed dose. The patient received only 10 percent of the [redacted] prescribed fractioned dose due to equipment malfunction. The patient is scheduled to receive the remainder of the dose at a later time. The licensee will conduct a thorough investigation and provide a formal report as soon as possible. We are still pending the source activity information and event date. We will update as more information comes in."

Georgia incident no.: 61

* * * UPDATE ON 12/01/2022 AT 0751 EST FROM THE GEORGIA RADIOACTIVE MATERIALS PROGRAM TO IAN HOWARD * * *

The following is a synopsis developed from information provided by the Georgia Radioactive Materials Program via email:

Was source able to be retracted to safe position? Yes
Manufacturer and Model number of HDR: Elekta's Flexitron
Serial number: 00625
Source activity (8.9 Ci); Prescribed dose (750 cGy); Delivered dose (12.7 cGy)

Root Cause: Equipment failure.
Assessment by Elekta's field service engineer determined that the Flexitron selector assembly should be recalibrated including lubrication of all brackets on the assembly.

Corrective Action: Recalibration.
Following recalibration of the Flexitron selector assembly, the treatment unit functions correctly. Spot checks performed by physics confirmed normal operation of the treatment unit. The treatment unit reentered clinical service the following day and this patient was successfully treated on 11/21/22 for their third fraction and they finished treatment on 11/23/22.


Notified: R1DO (Cahill). Notified via email: NMSS Event Notification.

A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.


Part 21
Event Number: 56247
Rep Org: Curtiss-Wright Nuclear Division
Licensee: QualTech NP, Curtiss-Wright Nuclear Division
Region: 3
City: Cincinnati   State: OH
County:
License #:
Agreement: Y
Docket:
NRC Notified By: QualTech NP
HQ OPS Officer: Howie Crouch
Notification Date: 11/30/2022
Notification Time: 13:53 [ET]
Event Date: 11/22/2022
Event Time: 00:00 [EST]
Last Update Date: 11/30/2022
Emergency Class: Non Emergency
10 CFR Section:
21.21(a)(2) - Interim Eval Of Deviation
Person (Organization):
Peterson, Hironori (R3DO)
Part 21/50.55 Reactors, - (EMAIL)
Event Text
PART 21 REPORT - INTERIM REPORT FOR EATON TRM5 TIMING RELAYS

The following is a summary of information provided by the Curtiss-Wright Nuclear Division via email:

QualTech NP discovered the presence of a programmable logic device (a flash-based CMOS (complementary metal-oxide-semiconductor) microcontroller) in the timing relays that was not previously identified for this family of relays. The only affected facility is Perry Nuclear Plant. This could potentially lead to unevaluated electromagnetic interference or radiofrequency interference issues when installed in the plant.

For questions concerning this potential 10 CFR 21 issue, please contact:
Tim Franchuk
Quality Assurance Director
QualTech NP, Curtiss-Wright Nuclear Division
(513) 528-7900, ext. 176


Part 21
Event Number: 56252
Rep Org: Flowserve
Licensee:
Region: 2
City: Lynchburg   State: VA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Chris Shaffer
HQ OPS Officer: Ernest West
Notification Date: 12/01/2022
Notification Time: 14:45 [ET]
Event Date: 10/05/2022
Event Time: 00:00 [EST]
Last Update Date: 12/01/2022
Emergency Class: Non Emergency
10 CFR Section:
21.21(a)(2) - Interim Eval Of Deviation
Person (Organization):
Part 21/50.55 Reactors, - (EMAIL)
Vossmar, Patricia (R4DO)
Event Text
PART 21 - DEVIATION TO QUALIFIED DESIGN

The following is a summary of information provided by Flowserve - Limitorque via email:

Entergy Waterford 3 informed Flowserve - Limitorque on 10/5/2022 that it discovered that a Peerless 125 volt, 25ft-lb, 56 frame direct current (DC) motor had two fasteners securing the brush holder ring assembly to the motor frame. However, the DC motor assembly used in the qualification test program was assembled with 4 fasteners. Therefore, the use of two fasteners is a deviation to the qualified design. Flowserve is submitting this report as an interim report and is evaluating this deviation to determine whether this condition could potentially affect the safety related function of DC powered Limitorque actuators.

Flowserve is continuing to work with the motor original equipment manufacturer (OEM) to refine the scope of potentially affected motors. Limitorque actuators equipped with Peerless - Winsmith DC electric motors with start torque ratings of 40 ft-lb and larger are not affected by this issue. Limitorque actuators equipped with alternating current (AC) powered electric motors are not affected by this issue.

The evaluation is expected to be completed by 01/27/2023. If there are questions, or addition information is required, please contact Chris Shaffer, Quality Assurance Manager, Flowserve Corporation, Ph: (434) 522-4136.

Known affected plant: Waterford 3 Nuclear Generating Station