Event Notification Report for April 29, 2017
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/28/2017 - 04/29/2017
EVENT NUMBERS
52721527195271852716
Agreement State
Event Number: 52721
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: BAXTER HEALTHCARE CORPORATION
Region: 4
City: MOUNTAIN HOME State: AR
County:
License #: GL-0026
Agreement: Y
Docket:
NRC Notified By: ANGIE D. HALL
HQ OPS Officer: DONG HWA PARK
Licensee: BAXTER HEALTHCARE CORPORATION
Region: 4
City: MOUNTAIN HOME State: AR
County:
License #: GL-0026
Agreement: Y
Docket:
NRC Notified By: ANGIE D. HALL
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/02/2017
Notification Time: 14:16 [ET]
Event Date: 04/29/2017
Event Time: 18:30 [CDT]
Last Update Date: 06/21/2017
Notification Time: 14:16 [ET]
Event Date: 04/29/2017
Event Time: 18:30 [CDT]
Last Update Date: 06/21/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MARK HAIRE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
MARK HAIRE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - FIXED GAUGE WITH STUCK SHUTTER
The following report was received from the State of Arkansas via e-mail:
"The Arkansas Department of Health was notified via telephone and e-mail on Monday, May 1, 2017, at approximately 1337 [CDT] of the licensee's general licensed device stuck shutter and the failure of the shutter mechanism. The equipment failure appears to have occurred from strong thunderstorms. The lockout procedure was verbally verified with the licensee.
"The licensee's fixed gauge is a ThermoFisher Scientific, Model Number E-SFL10-XX, Serial Number SP9810, which contains approximately 1,178.42 mCi Kr-85 (approximately 43.60 GBq Kr-85).
"The original activity: 1,250 mCi Kr-85 (approximately 46.25 GBq Kr-85) as of June 1, 2016. The source's Model Number is TFC-185 and the Serial Number is QC00256.
"Licensee operations with the gauge are twenty-four hours a day. The gauge has a fail-safe closing shutter mechanism and the gauge immediately went into the safe mode electronically during the thunderstorm. The closed shutter position was verified by the visual colored indicators in place.
"There have been no known radiation exposures to personnel and/or members of the public. There have been no known radiological health and safety concerns.
"The shutter will be repaired by the manufacturer today, May 2, 2017, whom will perform a root cause analysis. The State of Arkansas is awaiting information from today's evaluation, repairs, and surveys.
"The State is awaiting a 30 day written report from the licensee."
State Event Number: ARK-2017-002
* * * UPDATE ON 6/9/17 AT 1507 EDT FROM ANGIE HALL TO BETHANY CECERE * * *
The following follow-up report was received from the State of Arkansas via e-mail:
"The [Arkansas] Department [of Health] has received the required thirty (30) day report from the licensee, along with the related exposure survey and service reports from the manufacturer.
"The licensee states, 'We have several of these gauges that have been operating normally for several years. Due to the nature of this repair and the fact that this is the only time we have ever had to do this repair, it is my belief that a component in the device failed to operate as intended. The technician scraped paint off the surface of the shutter/flag mechanism that would help the mechanism stick to the magnet. The technician also tightened and applied thread lock to the securing hardware for the magnet. Both items should have been done at the factory.'
"The manufacturer's Field Engineer (also known as Technician) stated, 'I believe the issue started with the holding magnet being loose. This may have caused the solenoid to work harder and fail, and that could have caused the board to fail.'
"The manufacturer's Radiation Safety Officer stated, 'Thermo EGS Gauging LLC. is aware of the shutter mechanism failing in the closed or failing to the closed position on the TFC-185 and the TFC-190 sensors. The R&D manufacturing team has been working on a engineering project to correct this issue. We are currently in the testing phase and will manufacture all future sensors with the updated materials and parts. There is also an upgrade retrofit kit in the works for existing sensors that are demonstrating/developing this shutter issue. Currently we are sending out Field Service engineers to the customer's site to offer temporary repairs on an as needed basis.'
"The Department is waiting on a response from the manufacturer concerning the above statement.
"There have been no known radiological health issues, radiological exposures, safety hazards, or concerns to personnel or members of the public during this event.
"Event Cause: Equipment failure/design, manufacturing, or installation error.
"Corrective Action by licensee: New equipment obtained and repairs made with engineering change to system.
"Reporting Requirement Information:
"Arkansas State Board of Health 'Rules and Regulations for Control of Sources of Ionizing Radiation' RH-1502.f.2 and RH-402.c.
"U.S. Nuclear Regulatory Commission (NRC) Regulations Title 10 CFR Section 30.50 (b) (2) - Equipment is disabled or fails to function as designed, and Title 10 CFR Section 21.21 - A failure to comply or a defect affecting a basic component that is supplied for a facility or an activity that is subject to licensing requirements.
"The licensee and manufacturer reports and surveys have been sent to Randy Erickson, Regional State Agreement Officer, U.S. NRC, Region IV Office, and the NRC Headquarters Operations Center.
"Note: Leak tests are not required for this type of gauge."
NMED Item Number 170231.
Notified R4DO (Rollins) and NMSS Events Notification by email.
* * * UPDATE ON 6/21/17 AT 1407 EDT FROM ANGIE HALL TO BETHANY CECERE * * *
The following follow-up report was received from the State of Arkansas via e-mail:
"The Department has received clarification from the manufacturer's Radiation Safety Officer, stating in part, 'Due to a manufacturing defect of some source housing parts, about 10% of our sensors sold in the past could be affect' (affected).
"He also stated, 'Our customer Baxter Healthcare is aware of this issue and unfortunately cannot provide a solution to them until their sensors develop this issue on a case by case basis.'
"The Department considers this event to be closed."
Notified R4DO (Gaddy) and NMSS Events Notification by email.
The following report was received from the State of Arkansas via e-mail:
"The Arkansas Department of Health was notified via telephone and e-mail on Monday, May 1, 2017, at approximately 1337 [CDT] of the licensee's general licensed device stuck shutter and the failure of the shutter mechanism. The equipment failure appears to have occurred from strong thunderstorms. The lockout procedure was verbally verified with the licensee.
"The licensee's fixed gauge is a ThermoFisher Scientific, Model Number E-SFL10-XX, Serial Number SP9810, which contains approximately 1,178.42 mCi Kr-85 (approximately 43.60 GBq Kr-85).
"The original activity: 1,250 mCi Kr-85 (approximately 46.25 GBq Kr-85) as of June 1, 2016. The source's Model Number is TFC-185 and the Serial Number is QC00256.
"Licensee operations with the gauge are twenty-four hours a day. The gauge has a fail-safe closing shutter mechanism and the gauge immediately went into the safe mode electronically during the thunderstorm. The closed shutter position was verified by the visual colored indicators in place.
"There have been no known radiation exposures to personnel and/or members of the public. There have been no known radiological health and safety concerns.
"The shutter will be repaired by the manufacturer today, May 2, 2017, whom will perform a root cause analysis. The State of Arkansas is awaiting information from today's evaluation, repairs, and surveys.
"The State is awaiting a 30 day written report from the licensee."
State Event Number: ARK-2017-002
* * * UPDATE ON 6/9/17 AT 1507 EDT FROM ANGIE HALL TO BETHANY CECERE * * *
The following follow-up report was received from the State of Arkansas via e-mail:
"The [Arkansas] Department [of Health] has received the required thirty (30) day report from the licensee, along with the related exposure survey and service reports from the manufacturer.
"The licensee states, 'We have several of these gauges that have been operating normally for several years. Due to the nature of this repair and the fact that this is the only time we have ever had to do this repair, it is my belief that a component in the device failed to operate as intended. The technician scraped paint off the surface of the shutter/flag mechanism that would help the mechanism stick to the magnet. The technician also tightened and applied thread lock to the securing hardware for the magnet. Both items should have been done at the factory.'
"The manufacturer's Field Engineer (also known as Technician) stated, 'I believe the issue started with the holding magnet being loose. This may have caused the solenoid to work harder and fail, and that could have caused the board to fail.'
"The manufacturer's Radiation Safety Officer stated, 'Thermo EGS Gauging LLC. is aware of the shutter mechanism failing in the closed or failing to the closed position on the TFC-185 and the TFC-190 sensors. The R&D manufacturing team has been working on a engineering project to correct this issue. We are currently in the testing phase and will manufacture all future sensors with the updated materials and parts. There is also an upgrade retrofit kit in the works for existing sensors that are demonstrating/developing this shutter issue. Currently we are sending out Field Service engineers to the customer's site to offer temporary repairs on an as needed basis.'
"The Department is waiting on a response from the manufacturer concerning the above statement.
"There have been no known radiological health issues, radiological exposures, safety hazards, or concerns to personnel or members of the public during this event.
"Event Cause: Equipment failure/design, manufacturing, or installation error.
"Corrective Action by licensee: New equipment obtained and repairs made with engineering change to system.
"Reporting Requirement Information:
"Arkansas State Board of Health 'Rules and Regulations for Control of Sources of Ionizing Radiation' RH-1502.f.2 and RH-402.c.
"U.S. Nuclear Regulatory Commission (NRC) Regulations Title 10 CFR Section 30.50 (b) (2) - Equipment is disabled or fails to function as designed, and Title 10 CFR Section 21.21 - A failure to comply or a defect affecting a basic component that is supplied for a facility or an activity that is subject to licensing requirements.
"The licensee and manufacturer reports and surveys have been sent to Randy Erickson, Regional State Agreement Officer, U.S. NRC, Region IV Office, and the NRC Headquarters Operations Center.
"Note: Leak tests are not required for this type of gauge."
NMED Item Number 170231.
Notified R4DO (Rollins) and NMSS Events Notification by email.
* * * UPDATE ON 6/21/17 AT 1407 EDT FROM ANGIE HALL TO BETHANY CECERE * * *
The following follow-up report was received from the State of Arkansas via e-mail:
"The Department has received clarification from the manufacturer's Radiation Safety Officer, stating in part, 'Due to a manufacturing defect of some source housing parts, about 10% of our sensors sold in the past could be affect' (affected).
"He also stated, 'Our customer Baxter Healthcare is aware of this issue and unfortunately cannot provide a solution to them until their sensors develop this issue on a case by case basis.'
"The Department considers this event to be closed."
Notified R4DO (Gaddy) and NMSS Events Notification by email.
Agreement State
Event Number: 52719
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: JANX
Region: 4
City: PARMA State: TX
County:
License #: 21-16560-01
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: BETHANY CECERE
Licensee: JANX
Region: 4
City: PARMA State: TX
County:
License #: 21-16560-01
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: BETHANY CECERE
Notification Date: 04/30/2017
Notification Time: 22:05 [ET]
Event Date: 04/29/2017
Event Time: 00:00 [CDT]
Last Update Date: 04/30/2017
Notification Time: 22:05 [ET]
Event Date: 04/29/2017
Event Time: 00:00 [CDT]
Last Update Date: 04/30/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE FAILED TO RETRACT
The following information was received from the state of Texas via email:
"On April 30, 2017, the Agency [Texas Department of State Health Services] was notified by the licensee's Radiation Safety Officer (RSO) that a radiography crew working at a temporary field site was unable to retract a 101 Curie iridium-192 source into a SPEC 150 exposure device (camera). The failure occurred after the radiography crew had moved the camera from one location to another at the same job site. The radiography crew notified the licensee of the event. The licensee sent an individual to the site to retrieve the source. The individual found that the guide tube had disconnected from the front of the camera and the flex in the cable was causing the connector to hang up on the camera inlet port. The recovery individual straightened the cable by pulling on the crank out cables and was able to fully retract the source. The RSO stated no over exposures occurred from this event. The RSO stated he believes sand had gotten into the guide tube to camera connection preventing the guide tube from fully latching on the camera outlet connection. The licensee possesses a license issued by the Nuclear Regulatory Commission and is operating under reciprocity in the State of Texas. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident No.: I-9483
The following information was received from the state of Texas via email:
"On April 30, 2017, the Agency [Texas Department of State Health Services] was notified by the licensee's Radiation Safety Officer (RSO) that a radiography crew working at a temporary field site was unable to retract a 101 Curie iridium-192 source into a SPEC 150 exposure device (camera). The failure occurred after the radiography crew had moved the camera from one location to another at the same job site. The radiography crew notified the licensee of the event. The licensee sent an individual to the site to retrieve the source. The individual found that the guide tube had disconnected from the front of the camera and the flex in the cable was causing the connector to hang up on the camera inlet port. The recovery individual straightened the cable by pulling on the crank out cables and was able to fully retract the source. The RSO stated no over exposures occurred from this event. The RSO stated he believes sand had gotten into the guide tube to camera connection preventing the guide tube from fully latching on the camera outlet connection. The licensee possesses a license issued by the Nuclear Regulatory Commission and is operating under reciprocity in the State of Texas. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident No.: I-9483
Power Reactor
Event Number: 52718
Facility: SEABROOK
Region: 1 State: NH
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: PAUL DUNDIN
HQ OPS Officer: BETHANY CECERE
Region: 1 State: NH
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: PAUL DUNDIN
HQ OPS Officer: BETHANY CECERE
Notification Date: 04/29/2017
Notification Time: 21:19 [ET]
Event Date: 04/29/2017
Event Time: 18:44 [EDT]
Last Update Date: 04/29/2017
Notification Time: 21:19 [ET]
Event Date: 04/29/2017
Event Time: 18:44 [EDT]
Last Update Date: 04/29/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
RAY MCKINLEY (R1DO)
RAY MCKINLEY (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | M/R | Y | 12 | Power Operation | 0 | Hot Standby |
MANUAL REACTOR TRIP DUE TO STEAM GENERATOR HI-HI LEVEL SIGNAL AND FEEDWATER ISOLATION
"At 1844 [EDT] on 04/29/2017, while the unit was in a low power condition exiting from a refueling outage, the reactor was manually tripped following a P-14 signal (Steam Generator Hi-Hi Level) and a resulting feedwater isolation signal. All control rods were verified to be fully inserted. The cause of the ['B'] steam generator high level is currently being investigated.
"Emergency feedwater actuated at 1845 due to a low-low water level in steam generator 'D'. Plant equipment response is being evaluated and the plant is stabilized in Mode 3 with decay heat removal through the steam dump system to the condensers. There was no release and the emergency feedwater system has been restored to standby.
"The 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 or under the reporting requirements of 10 CFR 50.73."
The licensee notified the NRC Resident Inspector.
"At 1844 [EDT] on 04/29/2017, while the unit was in a low power condition exiting from a refueling outage, the reactor was manually tripped following a P-14 signal (Steam Generator Hi-Hi Level) and a resulting feedwater isolation signal. All control rods were verified to be fully inserted. The cause of the ['B'] steam generator high level is currently being investigated.
"Emergency feedwater actuated at 1845 due to a low-low water level in steam generator 'D'. Plant equipment response is being evaluated and the plant is stabilized in Mode 3 with decay heat removal through the steam dump system to the condensers. There was no release and the emergency feedwater system has been restored to standby.
"The 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 or under the reporting requirements of 10 CFR 50.73."
The licensee notified the NRC Resident Inspector.
Power Reactor
Event Number: 52716
Facility: SOUTH TEXAS
Region: 4 State: TX
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BRAD HARDT
HQ OPS Officer: JEFF ROTTON
Region: 4 State: TX
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BRAD HARDT
HQ OPS Officer: JEFF ROTTON
Notification Date: 04/29/2017
Notification Time: 17:59 [ET]
Event Date: 04/29/2017
Event Time: 16:23 [CDT]
Last Update Date: 04/29/2017
Notification Time: 17:59 [ET]
Event Date: 04/29/2017
Event Time: 16:23 [CDT]
Last Update Date: 04/29/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
MICHAEL HAY (R4DO)
MICHAEL HAY (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 15 | Power Operation | 15 | Power Operation |
| 2 | N | Y | 90 | Power Operation | 90 | Power Operation |
OFFSITE NOTIFICATION DUE TO SMALL GRASS FIRE IN OWNER CONTROLLED AREA
"A grass fire was reported to the Unit 1 control room at 1102 CDT. The grass fire was reported to be in the owner controlled area 1/2 mile west of the protected area and switchyard. The local fire department was dispatched to fight the grass fire. The fire was reported to be out at 1155 CDT. No plant equipment was damaged and the operation of the plant was not affected. Region 12 (Houston) of the Texas Commission of Environmental Quality (TCEQ) was notified of the event at 1623 CDT for visible emissions resulting from the grass fire. No further actions are required by the TCEQ at this time and no press release is planned."
An insulator on a 345 kV line failed and the attached line separated and hit the ground. A spark was created when the 345 kV line hit the ground and started a fire that eventually grew to a 20 feet x 20 feet area.
The licensee notified the NRC Resident Inspector.
"A grass fire was reported to the Unit 1 control room at 1102 CDT. The grass fire was reported to be in the owner controlled area 1/2 mile west of the protected area and switchyard. The local fire department was dispatched to fight the grass fire. The fire was reported to be out at 1155 CDT. No plant equipment was damaged and the operation of the plant was not affected. Region 12 (Houston) of the Texas Commission of Environmental Quality (TCEQ) was notified of the event at 1623 CDT for visible emissions resulting from the grass fire. No further actions are required by the TCEQ at this time and no press release is planned."
An insulator on a 345 kV line failed and the attached line separated and hit the ground. A spark was created when the 345 kV line hit the ground and started a fire that eventually grew to a 20 feet x 20 feet area.
The licensee notified the NRC Resident Inspector.