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Event Notification Report for September 17, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
9/14/2018 - 9/17/2018

** EVENT NUMBERS **


53464 53582 53583 53585 53587 53588 53591 53604 53605 53606 53608 53609

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Part 21 Event Number: 53464
Rep Org: AAF FLANDERS
Licensee: AAF FLANDERS
Region: 1
City: WASHINGTON   State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: SHAWN WINDLEY
HQ OPS Officer: RICHARD SMITH
Notification Date: 06/20/2018
Notification Time: 20:55 [ET]
Event Date: 05/02/2018
Event Time: 00:00 [EDT]
Last Update Date: 09/14/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
Person (Organization):
KENNETH RIEMER (R3DO)
PART 21/50.55 REACTORS ()

Event Text



EN Revision Imported Date : 9/17/2018

EN Revision Text: PART 21 - INTERIM REPORT NOTIFICATION

The following was received via phone call and email:

This report provides notification and interim information concerning an evaluation being performed by AAF Flanders for an unapproved design change in a High Efficiency Particulate Air Filter.

"An evaluation is underway for filters that underwent a non-approved design change. AAF Flanders has determined that an evaluation cannot be completed within the 60 day period. Discovery of the potential deviation was May 2, 2018.

"The information required for the 60-Day Interim Report Notification 21.21(a)(2) was provided. We anticipate that the evaluation will be completed by Sept 15, 2018.

"AAF Flanders is evaluating a potential nonconforming condition associated with filters (model number 0-007-C-42-03-NU-11-13-GG FU5) supplied to Prairie Island Nuclear Generating Plant (PINGP) / Xcel Energy."

AAF Flanders notified Prairie Island Nuclear Plant of this potential defect.

* * * UPDATE ON 9/14/2108 AT 1129 EDT FROM SHAWN WINDLEY TO ANDREW WAUGH * * *

The following information was received via email:

"A notification was submitted to the Commission with the subject matter of, 'Unapproved Design Change in a High Efficiency Particulate Air Filter.' At this time, the evaluation is pending third part qualification testing of the product. Information obtained from the qualification will be used in the determination of a defect. AAF Flanders had anticipated this process to have been completed by Sept 15, 2018 but because it is still on-going, we request an extension until October 31, 2018 to submit a final report to the Commission.

"The subject filters (model number 0-007-C-42-03-NU-11-13-GG FU5) supplied to Prairie Island Nuclear Generating Plant (PINGP)/ Xcel Energy had not been installed. AAF Flanders has recalled the subject filters and currently have them segregated and stored at our facility. They pose no threat public safety."

Notified R3DO (Hanna) and Part 21/50.55 Reactors Group (email).

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Non-Agreement State Event Number: 53582
Rep Org: TILDEN MINING COMPANY L.C.
Licensee: TILDEN MINING COMPANY L.C.
Region: 3
City: ISHPEMING   State: MI
County:
License #: 21-26748-01
Agreement: N
Docket:
NRC Notified By: LAWRENCE GRAY
HQ OPS Officer: ANDREW WAUGH
Notification Date: 09/06/2018
Notification Time: 12:45 [ET]
Event Date: 08/12/2017
Event Time: 00:00 [EDT]
Last Update Date: 09/14/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
ROBERT DALEY (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text



EN Revision Imported Date : 9/17/2018

EN Revision Text: GAUGE STUCK SHUTTER

On August 12, 2017, the Tilden Mining Company experienced a stuck open shutter on a gauge in the Tilden Unit 1 Cooler Chunk Tunnel. The licensee determined that the shutter lever was jammed with debris preventing the shutter from closing. The gauge was repaired on August 15, 2017. The Ronan RLL 1 source contains 0.9 milliCurie of Cesium-137 (serial number 317287A).

There were no overexposures as a result of this event.

* * * UPDATE FROM LAWRENCE GRAY TO HOWIE CROUCH AT 1151 EDT ON 9/14/18 * * *

The licensee reported that the gauge was not repaired on August 15, 2017 as previously reported but was repaired on September 13, 2017.

Notified R3DO (Hanna) and NMSS Events Notification (email).

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Agreement State Event Number: 53583
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: ADVANCED MEASUREMENT TECHNOLOGIES (AMETEK)
Region: 1
City: OAK RIDGE   State: TN
County:
License #: R-01003-J18
Agreement: Y
Docket:
NRC Notified By: ANTHONY HOGAN
HQ OPS Officer: ANDREW WAUGH
Notification Date: 09/06/2018
Notification Time: 16:46 [ET]
Event Date: 09/06/2018
Event Time: 00:00 [EDT]
Last Update Date: 09/06/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER LALLY (R1DO)
ILTAB (EMAIL)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST OR STOLEN SOURCES

The following was received state of Tennessee via email:

"AMETEK conducted an inventory of their sources and found 4 sealed sources that were unaccounted for and possibly lost or stolen. The total amount of all four of the sources was 8.76 microCi. They are as follows:

"Mixed gamma, 133 kBq, serial number 1249
Am-241, 2,200 Bq, serial number SS6712
Am-241, 3.873 kBq, serial number 1868
Sr-90, 5 microCuries"

State Event Report ID NO.: TN-18-151

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

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Agreement State Event Number: 53585
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: HARDIN MEMORIAL HOSPITAL
Region: 1
City: ELIZABETHTOWN   State: KY
County:
License #: 202-148-26
Agreement: Y
Docket:
NRC Notified By: ANGELA WILBERS
HQ OPS Officer: ANDREW WAUGH
Notification Date: 09/07/2018
Notification Time: 13:14 [ET]
Event Date: 09/07/2018
Event Time: 00:00 [EDT]
Last Update Date: 09/07/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER LALLY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - ADMINISTERED DOSE LOWER THAN PRESCRIBED DOSE

The following information was received from the Commonwealth of Kentucky via fax:

"At approximately 1045 [EDT] on September 7, 2018 an Authorized User at Hardin Memorial Hospital (HMH) called the RHB [Radiation Health Branch] supervisor to report a medical event. A HMH medical physicist determined a patient received 70 percent of an intended brachytherapy dose; the same Authorized User is adding seeds to bring the dose up to acceptable range. RHB staff have contacted the HMH Radiation Safety Officer and are awaiting further information on the possible medical event."

Kentucky Event Report ID No.: KY180003


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.

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Agreement State Event Number: 53587
Rep Org: UTAH DIVISION OF RADIATION CONTROL
Licensee: KLEINFELDER, INC.
Region: 4
City: WEST JORDAN   State: UT
County:
License #: UT 1800085
Agreement: Y
Docket:
NRC Notified By: PHILIP GRIFFIN
HQ OPS Officer: ANDREW WAUGH
Notification Date: 09/07/2018
Notification Time: 16:00 [ET]
Event Date: 09/07/2018
Event Time: 00:00 [MDT]
Last Update Date: 09/07/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JASON KOZAL (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DAMAGED GAUGE

The following was received from the State of Utah via fax:

"On September 5, 2018, a portable gauge user from Kleinfelder, Inc. (Radioactive Materials License UT 1800085) was performing compaction measurements at a field location in West Jordan, Utah. After performing a test, the operator placed the Troxler 3440 (s/n 19966) gauge on the tailgate of the licensee's vehicle to move to another location. The gauge fell off the tailgate of the truck, struck the pavement, and cracked the gauge case. The licensee performed exposure rate measurements of the gauge and incident site, and determined that the sealed sources were intact and that no contamination was present at the site. The licensee secured the damaged gauge in the transportation package, transported the gauge to the licensee's facility, and secured the gauge in the licensee's gauge storage cabinet. The licensee is conducting an investigation into the incident, and will submit a written report to the Division of Waste Management and Radiation Control (Division) within 30 days."

Utah Event Report ID No.: UT180007

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Agreement State Event Number: 53588
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: BRASKEM AMERICA INC
Region: 4
City: FREEPORT   State: TX
County:
License #: L06443
Agreement: Y
Docket:
NRC Notified By: ARTHUR TUCKER
HQ OPS Officer: ANDREW WAUGH
Notification Date: 09/07/2018
Notification Time: 17:11 [ET]
Event Date: 09/07/2018
Event Time: 00:00 [CDT]
Last Update Date: 09/07/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JASON KOZAL (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - GAUGE STUCK SHUTTER

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

"On September 7, 2018, the Agency [Texas Department of State Health Services] was notified by the licensee that during plant maintenance on a vessel, the handle on a Vega model SH-F2 nuclear gauge containing a 70 millicurie (original activity) Cesium-137 source was broken and the shutter was stuck in the half closed (half open) position. The license stated because of the location of the gauge on the vessel it does not create an exposure risk to any individual. The licensee has contacted a service provider to repair the gauge. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: 9611

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Agreement State Event Number: 53591
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: DUKE UNIVERSITY MEDICAL CENTER
Region: 1
City: DURHAM   State: NC
County:
License #: 0247-4
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: ANDREW WAUGH
Notification Date: 09/08/2018
Notification Time: 17:44 [ET]
Event Date: 09/07/2018
Event Time: 00:00 [EDT]
Last Update Date: 09/08/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER LALLY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - ADMINISTERED DOSE LOWER THAN PRESCRIBED DOSE

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

"A patient being treated for liver tumors was prescribed to receive 47.6 mCi of Y-90 microspheres, but instead received only 11.9 mCi (about 25 percent of prescribed). The remainder was in the vial as residual.

"Because this under-dosing was not due to stasis or emergent patient conditions, and the delivered dose was less than 20 percent of that prescribed, this constitutes a reportable medical event according to the 2016 version (9) of the NRC guidance for Y-90 microspheres.

"Source: Microspheres
Radionuclide: Y-90
Manufacturer: Sirtex Medical
Model: Sir-Spheres
S/N: Aggregate

"Investigation is pending for the Medical Event."

North Carolina Tracking Number: 180039


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.

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Fuel Cycle Facility Event Number: 53604
Facility: LOUISIANA ENERGY SERVICES
RX Type:
Comments: URANIUM ENRICHMENT FACILITY
GAS CENTRIFUGE FACILITY
Region: 2
City: EUNICE   State: NM
County: LEA
License #: SNM-2010
Docket: 70-3103
NRC Notified By: WYATT PADGETT
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 09/14/2018
Notification Time: 11:29 [ET]
Event Date: 09/15/2018
Event Time: 00:00 [MDT]
Last Update Date: 09/15/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
INFORMATION ONLY
70.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
MIKE ERNSTES (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

PREPLANNED OUTAGE OF A REQUIRED SAFETY MONITORING SYSTEM

"The UUSA [URENCO USA] facility CAAS [Criticality Accident and Alarm System] exists to detect and alarm in the unlikely event of a criticality accident, as required by 10 CFR 70.24, Criticality accident requirements. This monitoring system will be temporarily disabled during planned corrective maintenance activities for approximately thirty minutes, commencing at approximately 0730 MDT, on Saturday, September 15th, 2018. This activity will affect the CAAS in the Separations Building Module (SBM) 1001/1002 and the Cylinder Receipt and Dispatch Building (CRDB). The CAAS in the remaining portions of the facility will be unaffected.

"Essential personnel will remain inside the controlled access area during the maintenance activities. The populated areas of the facility will be limited to the Security Alarm Station, Operations Control Room, and the Maintenance Area housing the CAAS control cabinets in the Technical Services Building (TSB) where technicians will be needed for this work evolution. CAAS coverage of these populated areas will be provided during the maintenance activity by temporary criticality detection equipment.

"Compensatory measures will be implemented in accordance with section 3.1.5 of the UUSA Integrated Safety Analysis (ISA) Summary. These measures including evacuation of non-essential personnel from the areas of concern and the Immediate Evacuation Zone (IEZ) before removing the equipment from service, limiting access into facility, and restricting Special Nuclear Material (SNM) movement will be implemented until CAAS coverage is verified operational.

"UUSA will notify the NRC when CAAS coverage is returned to normal operation. Radiation surveys will be conducted prior to re-entry to confirm acceptable conditions in the area."

The licensee has notified the NRC Project Manager.

* * * UPDATE FROM WYATT PADGETT TO HOWIE CROUCH AT 1139 EDT ON 9/15/18 * * *

The Criticality Accident and Alarm System was returned to service at 0930 MDT after the completion of the scheduled maintenance. During the maintenance period, no abnormal radiation readings were observed.

Notified R2DO (Ernstes).

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Independent Spent Fuel Storage Installation Event Number: 53605
Rep Org: SAN ONOFRE
Licensee: SOUTHERN CALIFORNIA EDISON COMPANY
Region: 4
City: SAN CLEMENTE   State: CA
County: SAN DIEGO
License #: GL
Agreement: Y
Docket: 72-41
NRC Notified By: CHRIS DIMENTO
HQ OPS Officer: PHIL NATIVIDAD
Notification Date: 09/14/2018
Notification Time: 16:00 [ET]
Event Date: 08/03/2018
Event Time: 00:00 [PST]
Last Update Date: 09/14/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
72.75(d)(1) - SFTY EQUIP. DISABLED OR FAILS TO FUNCTION
Person (Organization):
MARK HAIRE (R4DO)
WILLIAM GOTT (IRD)

Event Text

SPENT FUEL CANISTER BECAME BOUND DURING DOWNLOAD INTO DRY STORAGE

"On Friday, August 3, [2018,] at approximately 1245 PST, Holtec International (a contractor for Southern California Edison (SCE)) was lowering a Multi-Purpose Canister (MPC) loaded with spent fuel into the Cavity Enclosure Container (CEC) of the SONGS Holtec UMAX Independent Spent Fuel Storage Installation (ISFSI) for purposes of dry storage. The canister was suspended from a Holtec Vertical Cask Transporter (VCT). During the download, the canister encountered an interference with the CEC divider shell and became bound in place. As a result, the downloader slings of the VCT became slack while the MPC was resting partially inside the CEC.

"Once Holtec became aware of the situation, the VCT towers were raised in order to restore tension in the rigging and to raise the MPC. The VCT was then adjusted, and the MPC was then safely lowered into the CEC and the rigging was disengaged.

"There was no effect on the integrity of the canister or release of radioactive material as a result of this event.

"This event meets the reporting criteria of 10CFR72.75(d)(1) in that the VCT, which is an important-to-safety component, was placed in a configuration which defeated its ability to perform its safety function. The VCT and associated rigging are described in Certificate of Compliance 1040, Technical Specification 5.2.c.3, which requires that lifting equipment shall have redundant drop protection features which prevent uncontrolled lowering of the load. By placing the VCT in the configuration of this event, the single-failure proof nature of the lifting devices was defeated. The VCT was no longer capable of mitigating the consequence of an accident, and there was no redundant equipment available and operable to perform the required safety function.

"SCE made an original determination that the event did not require a report. However, SCE contacted the NRC [Region IV] on Monday August 6th and again on Tuesday August 7th to provide details of the event.

"It has now been determined that the event is reportable under 10CFR72.75(d)(1) and this late report is being made."

Licensee notified RIV (Simpson).

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Power Reactor Event Number: 53606
Facility: SALEM
Region: 1     State: NJ
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JUSTIN HARGRAVE
HQ OPS Officer: BRIAN LIN
Notification Date: 09/14/2018
Notification Time: 16:28 [ET]
Event Date: 09/14/2018
Event Time: 00:00 [EDT]
Last Update Date: 09/14/2018
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
Person (Organization):
RAY MCKINLEY (R1DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 90 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP DUE TO A FAILURE OF THE STEAM GENERATOR FEED REGULATING VALVE

"At 1323 [EDT] on 9/14/18, with Unit 2 in Mode 1 at 90% power, the reactor automatically tripped due to a failure of 23BF19, 23 Steam Generator (SG) Feed Regulating Valve. The trip was not complex, with all systems responding normally post-trip. No equipment was inoperable prior to the event. An actuation of the auxiliary feedwater system occurred following the automatic reactor trip. The reason for the auxiliary feed water system auto-start was due to low level in the steam generator. Operations responded and stabilized the plant. Decay heat is being removed by the main steam dumps and auxiliary feedwater system. Unit 1 is not affected.

"Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour, non- emergency notification per 10 CFR 50.72(b)(2)(iv)(B). This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the auxiliary feed water system.

"There was no impact on the health and safety of the public or plant personnel.

"The NRC Resident Inspector has been notified. The Lower Alloways Creek Township will be notified."

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Power Reactor Event Number: 53608
Facility: GRAND GULF
Region: 4     State: MS
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: GERRY ELLIS
HQ OPS Officer: ANDREW WAUGH
Notification Date: 09/14/2018
Notification Time: 21:09 [ET]
Event Date: 09/14/2018
Event Time: 00:00 [CDT]
Last Update Date: 09/14/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
MARK HAIRE (R4DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 100 Power Operation 0 Hot Shutdown

Event Text

MANUAL REACTOR SCRAM

"At 1644 [CDT] a manual reactor scram was inserted by placing the Reactor Mode Switch to Shutdown. At 1643 [CDT] the Condensate Booster Pump A tripped on low suction pressure. At 1644 [CDT] the Reactor Feed Pump A tripped on low suction pressure. A Recirculation Flow Control Valve runback occurred as designed. Reactor Water level was approaching the Automatic Low Water Level 3 (11.4 inches) scram set point and manual actions were taken by placing the Mode Switch to Shutdown before the low level set point was reached. All systems responded as expected following the manual scram. The plant is stable in mode 3. This event is being reported under 10CFR 50.72(b)(2)(iv)(B), as any event or condition that results in actuation of the Reactor Protection System (RPS), when the reactor is critical.

"The NRC Senior Resident Inspector has been notified."

All control rods fully inserted, and decay heat is being removed through the turbine bypass valves to the main condenser. The licensee is investigating the cause of the event.

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Power Reactor Event Number: 53609
Facility: BRUNSWICK
Region: 2     State: NC
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: THOMAS SHERRILL
HQ OPS Officer: VINCE KLCO
Notification Date: 09/15/2018
Notification Time: 15:45 [ET]
Event Date: 09/15/2018
Event Time: 00:00 [EDT]
Last Update Date: 09/15/2018
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
MIKE ERNSTES (R2DO)
CATHERINE HANEY (R2)
HO NIEH (NRR)
WILLIAM GOTT (IRD)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Hot Shutdown 0 Hot Shutdown
2 N N 0 Hot Shutdown 0 Hot Shutdown

Event Text

UNUSUAL EVENT DUE TO SITE CONDITIONS PREVENTING PLANT ACCESS

"A hazardous event has resulted in on site conditions sufficient to prohibit the plant staff from accessing the site via personal vehicles due to flooding of local roads by Tropical Storm Florence."

Notified DHS SWO, FEMA OPS, and DHS NICC. Notified FEMA NWC, NuclearSSA, and FEMA NRCC via email.


Page Last Reviewed/Updated Monday, September 17, 2018
Monday, September 17, 2018