Event Notification Report for February 11, 2020

EN Revision Imported Date: 12/10/2020

EN Revision Text: PART 21 REPORT - AMETEK 85-RP2675-01 POWER SUPPLY MOUNTING HARDWARE

The following is a synopsis of a Part 21 report received by email:

"SUMMARY - AMETEK Solidstate Controls recently discovered a concern with the structural integrity of the 85-RP2675-01 Rack Mounted Power supply. While qualifying a replacement part for an obsolete breaker, the left panel of the power supply came loose after the hardware had sheared during the seismic simulation testing of the qualification. The loss of structural integrity of the power supply led to internal shorting and a premature stoppage of the simulation testing.

"PROBLEM - During a seismic event, a structural failure of the power supply enclosure resulting in a loss of output could occur. At this point, it is suspected that the failure is related to a variation in the components that increased strain on the power supply enclosure, and it is indeterminate if there is a widespread deviation. It is also possible that the cause of the failure is attributed to inadequately sized hardware that supports the bottom panel of the power supply. In the current design, there are 3 #10-32 machine screws through each of the side panels that fasten to the bottom panel to support the transformer.

"AMETEK is unable to identify the actual structural support of power supplies in the field. In the recent testing performed, no support was provided under the power supply during the testing. If there is support in the end application from the bottom of the power supply, there may not be a structural concern as the connection screws would not be exposed to the same forces. In this instance, the power supply had been exposed to a peak acceleration of approximately 4.8 giga second. It should also be noted that acceptable results have been obtained in previous seismic tests and changes have not been made to the structure of the power supply since its initial design in 1996.

"ACTION RECOMMENDED - At this time, there are no actions to take as the evaluation is ongoing. The next step is to determine if the screws are likely to become overstrained with enough seismic force. To do this, AMETEK is repeating the test with two new power supplies. One power supply will not have any changes made to the structure while the second power supply will be enhanced to improve its seismic withstand capabilities.

"The enhancement is an increase in the size of the hardware to 1/4 inch bolts that connects the side panels to the bottom panel through 5/16 inch through holes with a nut and washers. In combination, these changes will increase the force required to shear the hardware [and] reduce the force on the bolt itself by allowing some movement to dampen the forces during a seismic event. While AMETEK believes this solution will be suitable, it has not been validated with a follow up seismic simulation test. Additionally, AMETEK is unable to determine the criticality of the applications the power supplies are installed in and if the safety function is required to be maintained during a seismic event, which will determine the need to take corrective actions.

"A report of the next seismic test results will follow upon completion as a final evaluation. The current expected date for completion is May, 2020. For questions or clarifications in the meantime, please contact Ethan Salsbury, Quality Director, at 1-614-410-6293."

* * * UPDATE ON 12/09/2020 AT 0819 EST FROM ETHAN SALSBURY TO OSSY FONT * * *

The following is an update of a Part 21 report received by email:

"ACTION RECOMMENDED - AMETEK does not consider this to be a likely failure based on these test results. Additionally, AMETEK is unable to determine the criticality of the applications the power supplies are installed in and if the safety function is required to be maintained during a seismic event, which will determine the need to take corrective actions. The following enhancements can be applied to power supplies in operation:
- Add a #10-32 nut to each of the six (6) mounting screws to avoid any lateral movement of the sheet metal parts that would lead to potential elongation or striping of the fastener.
- Add support to the bottom of the transformer to prevent horizontal forces on the support screws

"Although recent testing did not result in a similar failure, AMETEK is taking actions to enhance the design of the power supply. On new power supplies, the mounting hardware will use ¬" bolts that connect the side panels to the bottom panel through 5/16" through holes with a nut and washers. In combination, these changes will increase the force required to shear the hardware reduce the force on the bolt itself by allowing some movement to dampen the forces during a seismic event."

Notified R1DO (Bower), R2DO (Miller), R3DO (Feliz-Adorno), and R4DO (Kellar) and Part 21/50.55 Reactors via email.

AGREEMENT STATE REPORT - QSA EXPOSURE DEVICE OPEN SHUTTER AND CAP

The following information was received from the state of Texas via email:

"On February 11, 2020, the Agency [Texas Department of State Health Services] was notified of an event by the licensee's consultant. The consultant stated the licensee had purchased a QSA 880 exposure device containing a 111 Curie iridium - 192 source from a licensee in Houston, Texas. The licensee's Radiation Safety Officer (RSO) picked up the shipment at the common carrier shipping building in Amarillo, Texas and placed [it] in the back of his pickup truck. The RSO then surveyed the package. The RSO found readings of 40 millirem per hour (mR/hr) on three sides, but 400 mR/hr of the fourth side. The RSO confirmed the reading with a second meter. The RSO contacted the consultant and the consultant had the RSO tape a self-reading dosimeter (SRD) to the side of the box with the highest reading and leave it there for 10 minutes. After ten minutes the RSO read the SRD and found it reading 50 millirem.

"The RSO contacted the company manager (CM) in Dumas, Texas. The CM brought two additional meters to the common carrier location. New readings were taken and the highest dose rate was now 700 mR/hr. The RSO moved the truck to a remote area at the common carrier facility and placed barriers up. The consultant stated they have contacted the licensee who shipped the device who has provided pictures on how the device was packed for shipment.

"The RSO is qualified for source retrieval. It was decided that they would get a power screw driver (to minimize time in the area) and remove the top of the box and inspect the exposure device.

"At 2116 CST, the Agency was notified by the licensee that they had open the transportation container and inspected the device. The RSO found that both the shutter and cap were opened. The RSO closed the shutter and cap using a remote handling tool. A dose rate taken after closing the shutter and cap was 40 mR/hr. The licensee is transporting the device to its storage location.

"The licensee was instructed to provide dose estimates for any individual who may have been exposed. Additional information will be provided as it is received in accordance with SA300."

Exposure received from closure of the door and cap was approximately 3 millirem.

Texas Incident Number: 9742

AGREEMENT STATE REPORT - LOST BRACHYTHERAPY SEED

The following was received from the state of Arizona via email:

"The Department [Arizona Department of Health Services] has received notification from the licensee (Scottsdale Healthcare dba Honorhealth Scottsdale Shea Medical Center) that one brachytherapy seed has been lost. It is assumed that the seed went down the drain of an autopsy table on 02/11/2020. All other seeds are accounted for and stored in the licensee's brachytherapy hot lab. The seed model is Civadot, and the isotope is Palladium-103. The Lot ID from which the seed originated is CSH-201. The calibrated activity of the seed on 12/10/2019 was 0.783 mCi (29.0 MBq). The calculated activity as of 02/12/2020 is 0.058 mCi (2.15 MBq). The Department has requested additional information and continues to investigate the event."

Arizona Incident Number: 20-003

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

FITNESS-FOR-DUTY REPORT - POLICY VIOLATION

"On February 11, 2020, a licensed Senior Reactor Operator violated the station's fitness-for-duty policy. The employee's access to South Texas has been terminated.

"The NRC Resident Inspector has been notified."

The employee tested positive on a follow-up test for alcohol.

AGREEMENT STATE REPORT - LOST CS-137 SHIPMENT

The following was received from the Commonwealth of Massachusetts by email:

"The licensee (QSA Global, Inc.) made [a] telephone notification at 1532 EST on February 11, 2020 to the Agency (Massachusetts Radiation Control Program) that it discovered on same day, February 11, 2020 at 1437 EST, that a shipment destined for Beijing, China, last known to be at the carrier's hub in Memphis, TN, is missing.

"The licensee reported that the missing shipment is a Type A, Yellow II labeled package, UN3332, containing a single 62.9 GBq (1.7 Curies), QSA Global, Inc. Model CDC.CY3 cesium-137 gamma gauging sealed source, serial number A3585.

"The licensee reported that the package was shipped for export from its facility in Burlington, Massachusetts on February 3, 2020 and that the carrier reported on February 6, 2020 that the package will stay at the carrier's Memphis, TN hub until further notice due to the coronavirus outbreak.

"The licensee reported that the shipment is missing in the common carrier's system and that there is the possibility that it went un-manifested to China. The licensee additionally reported that the customer will be contacted and sent a photo to see if they have received the package.

"The licensee reported that the consignee is Beijing Shucheng Science and Technology Development Co., Beijing, China under NRC export license PXB11a.03.

"The reporting requirement is immediate and is of 105 CMR 120.281(A)(1), missing licensed radioactive materials in aggregate quantity equal to or greater than 1,000 times quantity specified in 105 CMR 120.297, Appendix C.

"The Agency considers this event to be open."

* * * UPDATE ON 2/25/2020 AT 1406 EST FROM JOSHUA DAEHLER TO BETHANY CECERE * * *

The following was received from the Commonwealth of Massachusetts by email:

"On February 24, 2020, the Tennessee Division of Radiological Health informed the Agency (Massachusetts Radiation Control Program) that the package was found by the carrier to be at the carrier's hub in Memphis, TN."

Notified R1DO (Ferdas), ILTAB, and NMSS Events Notification Group (by 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

AGREEMENT STATE REPORT - TWO PERSONNEL EXCEEDED ANNUAL DOSE LIMIT

The following was received from the state of Louisiana via email:

"On February 11, 2020, Source Production & Equipment Company, Inc. (SPEC) contacted Louisiana Department of Environmental Quality, Emergency & Radiation Services Division, Radiation Section, by email to report that two employees had exceeded their annual five rem limit for the 2019 year. Both employees worked at SPEC in the hot cell room manufacturing Se-75, Ir-192, and Co-60 sources for industrial radiography. Hot Cell employee number 1 received an estimated TEDE of 5,028 mR and Hot Cell Employee number 2 received an estimated TEDE of 5,687 mR for 2019 year."

Event Report ID No.: LA20200003