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Home NRC Library Document Collections Events, Reports Associated with Event Notification Reports 2019

Event Notification Report for February 01, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
1/31/2019 - 2/1/2019

** EVENT NUMBERS **

Part 21	Event Number: 53816
Rep Org: AMETEK SOLIDSTATE CONTROLS Licensee: AMETEK SOLIDSTATE CONTROLS Region: 3 City: COLUMBUS State: OH County: License #: Agreement: Y Docket: NRC Notified By: ETHAN SALSBURY HQ OPS Officer: DONALD NORWOOD	Notification Date: 01/07/2019 Notification Time: 12:48 [ET] Event Date: 01/07/2019 Event Time: 00:00 [EST] Last Update Date: 01/31/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE	Person (Organization): FRANK EHRHARDT (R2DO) DAVID HILLS (R3DO) - PART 21/50.55 REACTORS (EMAIL)

Event Text

EN Revision Imported Date : 2/1/2019

EN Revision Text: PART 21 - COMPONENTS PROVIDED AS SAFETY-RELATED SPARE PARTS WITHOUT BEING DEDICATED

"AMETEK Solidstate Controls (SCI) is providing this report in accordance with 10CFR Part 21 as notice of a process defect that resulted in components being provided as safety-related spare parts without being dedicated.

"PROBLEM DESCRIPTION: Lack of evidence of dedication testing for AMETEK Solidstate Controls Safety-Related Operational Spare Parts Kits provided with SCI equipment

"CAUSE: In October 2018, NextEra Seabrook notified SCI of a part number discrepancy with a safety-related fuse that was provided with an operational spare parts kit with an equipment order. After further investigation, it was determined that dedication testing was not performed on the operational spare parts kits provided with the equipment on various jobs in recent years.

"Generally, spare parts are ordered separately from equipment and a process is in place to direct the parts to quality for commercial grade dedication testing. In this instance, the parts were ordered as a line item on the sale and the parts in question were selected from inventory without being routed through quality for commercial grade dedication.

"PROBLEM YOU COULD SEE: Evidence of dedication testing is not available for operational spare parts kits which were provided with equipment orders, however, there are no functional concerns with the components provided on these orders. The parts would have been selected at the same time as the parts that were installed in the systems. Additionally, for the commercial grade items provided, there is no history of failure during
dedication testing performed by AMETEK either in equipment or during bench testing.

"ACTION REQUIRED: Aside from printed circuit boards, the parts supplied as operational spare parts will need to be dedicated. AMETEK SCI recommends returning the untested items and will work with [the customer] to arrange returns and retesting. Please contact Mr. Mark Shreve of AMETEK SCI's Client Services group at 1-800-222-9079, 1-614-846-7500 ext. 6332, or mark.shreve@ametek.com."

The non-dedicated parts were supplied to Brunswick Steam Electric Plant, Seabrook Station, and North Anna Power Station. In addition, non-dedicated parts were also supplied to the Krsko Nuclear Power Plant in Slovenia and the Maanshan Nuclear Power Plant in Taiwan.

* * * UPDATE ON 1/31/19 AT 1304 EST FROM ETHAN SALSBURY TO OSSY FONT * * *

The following was received via email from Ametek:

"After further evaluation, [Ametek] has determined that additional kits are impacted by this issue, but the same customer list and POs apply. No additional customers are impacted and a corrected notification will be provided to customers that have been previously identified."

R1DO (Bickett) and R2DO (Lopez) were notified. Part 21 Reactors Group was notified via email.

Agreement State	Event Number: 53843
Rep Org: NEW YORK STATE DEPT. OF HEALTH Licensee: ROSWELL PARK CANCER INSTITUTE CORP Region: 1 City: BUFFALO State: NY County: License #: 2923 Agreement: Y Docket: NRC Notified By: DANIEL SAMSON HQ OPS Officer: MARK ABRAMOVITZ	Notification Date: 01/23/2019 Notification Time: 13:49 [ET] Event Date: 10/05/2018 Event Time: 00:00 [EST] Last Update Date: 01/23/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): MEL GRAY (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - MISSING I-125 SEED

The following report was received via fax:

"On 11/28/2018 the Department [New York State Department of Health] was notified of a missing I-125 localization seed (Best Medical International, Inc., Model 2301, Activity: 186 microCuries) at Roswell Park Cancer Institute in Buffalo, New York.

"Two lodine-125 breast localization seeds were placed into a patient on September 20, 2018 and removed on September 28, 2018. One seed was placed in a specimen container with the specimen, and the other seed was placed into a separate specimen container. Surgery has documentation that both seeds were sent to Pathology in separate containers; however, only one was returned to the Nuclear Medicine Department on October 4, 2018. The RSO was informed on October 5, 2018. The facility conducted searches and surveys of the Surgery, Pathology, Nuclear Medicine and Environmental Services areas, but could not locate the missing seed. Trash and regulated medical waste were also surveyed and inspected. Searches and surveys were repeated, but the seed was not found. It is believed that the seed was disposed of as regulated medical waste or in regular trash."

New York State ID: NYSDOH - 18-04

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

Non-Agreement State	Event Number: 53844
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: DONALD NORWOOD	Notification Date: 01/24/2019 Notification Time: 11:14 [ET] Event Date: 01/24/2019 Event Time: 00:00 [EST] Last Update Date: 01/24/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 30.50(b)(2) - SAFETY EQUIPMENT FAILURE	Person (Organization): HIRONORI PETERSON (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

FAILURE TO CLOSE AND LOCK NUCLEAR GAUGE SHUTTER

The following was received via e-mail:

"Between 2200 EST on January 23, 2019 and 0000 EST on January 24, 2019 a Ronan RLL1 [Density Scale Source] was unbolted from the frame on which it was mounted and placed on the floor. (Source was a Cs-137 0.54 milliCurie decayed to 0.45 milliCurie, Serial #212785A)

"No permit was pulled to remove the scale source, and the shutter wasn't closed and locked out.

"After it was unbolted, and was placed on the floor with the beam pointed towards a conveyor belt and the ceiling.

"Balling line 10, Conveyor 21 was approximately 6 feet above the placed source, and the ceiling is at 60 feet.

"No employees worked in front of the beam once placed on the floor.

"No one noticed the scale sitting on the floor unlocked until January 24, 2019 around 1500 EST.

"Once the source was found, trained personnel put the shutter block in place and locked out the source.

"The RSO then authorized a permit.

"Once the source was secured, and permit posted, the RSO did a full investigation.

"Basic cause - The maintenance employee that unbolted the source entered the area from a direction that could only be accessed during a maintenance down. There was a radiation label on the scale itself, but no sign from his access point."

Non-Agreement State	Event Number: 53845
Rep Org: NUCOR STEEL Licensee: NUCOR STEEL Region: 3 City: Crawfordsville State: IN County: License #: 13-25975-01 Agreement: N Docket: NRC Notified By: SHAWN AKER HQ OPS Officer: JEFFREY WHITED	Notification Date: 01/24/2019 Notification Time: 15:36 [ET] Event Date: 01/24/2019 Event Time: 07:00 [EST] Last Update Date: 01/24/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 30.50(b)(2) - SAFETY EQUIPMENT FAILURE	Person (Organization): HIRONORI PETERSON (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

GAUGE NOT OPERATING DUE TO POWER LOSS TO UNIT

The following was received via e-mail:

"[The Nucor Steel] Electrician received a call this morning at approximately 0700 EST by the slitter line operator notifying him that the slitter line gauge was not operating and had no power to the entire unit. The electrician did a survey to ensure the shutter was closed on the device. He measured 12 microR/hr on contact, at 1 foot and at 3 feet. At that time he trouble shot the electrical and determined that it was something that was not going to be resolved quickly so he locked out the device and did another survey to confirm that the shutter was closed. He used a Fluke 451 meter serial# 2194 Calibration date 5/30/2018.

"[The Nucor Engineer] went over this afternoon to confirm the survey with another meter and got 18 microR/hr on contact, 8 microR/hr at 1 foot with a background of 5 microR/hr, [using] a fluke 451P serial #6064 meter with calibration date 5/30/2018.

"[Nucor] maintenance personnel are planning on continuing to troubleshoot the electrical issue and determine whether they can fix it or they will need to call in an outside vendor tomorrow. Only electrical work on power to the system will be performed by Nucor personnel.

"[The Nucor] radioactive materials registration is XF7000385, expires 12/9/19. The gauge is a DMC AM-5A Serial# BS957911 with a Am-241 source 1 Curie activity Serial# 5135LV."

No personnel radiation exposure occurred due to this event.

No additional notifications were performed by the licensee.

Power Reactor	Event Number: 53852
Facility: SALEM Region: 1 State: NJ Unit: [] [2] [] RX Type: [1] W-4-LP,[2] W-4-LP NRC Notified By: JASON MORGAN HQ OPS Officer: MARK ABRAMOVITZ	Notification Date: 01/31/2019 Notification Time: 04:23 [ET] Event Date: 01/31/2019 Event Time: 03:01 [EST] Last Update Date: 01/31/2019
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): BRICE BICKETT (R1DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

M/R

100

Power Operation

Hot Standby

Event Text

MANUAL REACTOR TRIP - CIRCULATING WATER ICING CONDITIONS

"At 0301 [EST] on 1/31/19, with Unit 2 in Mode 1 at 100% power, the reactor was manually tripped due to icing conditions requiring the removal of 4 Circulating Water Pumps from service. The trip was not complex, with all systems responding normally post-trip. 21 CFCU [Containment Fan Cooler Unit] was inoperable prior to the event for a planned maintenance window and did not contribute to the cause of the event and did not adversely impact the plant response to the trip. An actuation of the Auxiliary Feedwater System occurred following the manual reactor trip. The reason for the Auxiliary Feed Water System auto-start was due to low level in a steam generator. Operations responded and stabilized the plant. Decay heat is being removed by the Main Steam Dumps and Auxiliary Feedwater System.

"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 also being reported as an eight hour non-emergency notification 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 icing condition was described as frazil ice.

Unit-1 reduced power to 88% because one circulating water pump was shutdown.

Power Reactor	Event Number: 53853
Facility: PRAIRIE ISLAND Region: 3 State: MN Unit: [] [2] [] RX Type: [1] W-2-LP,[2] W-2-LP NRC Notified By: DOUG LARSON HQ OPS Officer: MARK ABRAMOVITZ	Notification Date: 01/31/2019 Notification Time: 10:48 [ET] Event Date: 01/31/2019 Event Time: 07:43 [CST] Last Update Date: 01/31/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION	Person (Organization): JAMNES CAMERON (R3DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

100

Power Operation

Event Text

BOTH EMERGENCY DIESEL GENERATORS INOPERABLE DUE TO LOW AIR TEMPERATURE

"At 0743 [CST] on 1/31/2019, both trains of Unit 2 Diesel Generators were declared INOPERABLE due to outside air temperature exceeding the low temperature design limit for the diesel engines; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v) for an event or condition that could have prevented the fulfillment of a safety function. The Unit 2 Diesel Generators are still able to start if necessary to provide power. Additionally, multiple layers of defense in depth measures are in place to ensure safety. Prairie Island has five sources of offsite power; all of which are currently available. The Unit 1 Diesel Generators are OPERABLE and capable of being cross-connected to Unit 2. Additional equipment capable of responding to beyond design basis events is available on site providing another layer of defense in depth.

"Both Unit 2 Diesel Generators were returned to an OPERABLE status at 0810 on 1/31/2019 based on outside air temperature rising above the low temperature design limit with forecasted temperatures to remain above the low temperature design limit.

"There is no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

The air temperature limit was -30 degrees Fahrenheit.

Unit 1 was not affected. The EDGs were supplied by a different manufacturer with different air temperature limits.

Power Reactor	Event Number: 53854
Facility: SEABROOK Region: 1 State: NH Unit: [1] [] [] RX Type: [1] W-4-LP NRC Notified By: BRUCE FIELDING HQ OPS Officer: OSSY FONT	Notification Date: 01/31/2019 Notification Time: 17:06 [ET] Event Date: 01/31/2019 Event Time: 10:30 [EST] Last Update Date: 01/31/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 26.719 - FITNESS FOR DUTY	Person (Organization): BRICE BICKETT (R1DO) FFD GROUP (EMAIL)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

100

Power Operation

Event Text

FALSE NEGATIVE INDICATED ON A FITNESS FOR DUTY BLIND QUALITY ASSURANCE TEST

"On 1/31/2019, the Medical Review Officer for Seabrook was notified of an error made by the HHS [Health and Human Services] certified lab resulting in a false negative Fitness for Duty quality assurance test result. The test lab, Quest Diagnostics-Norristown, was provided an adulterated sample specimen that was part of a blind performance test, which tested negative. This false negative test result will be investigated and the results reported as required.

"This event is being reported in accordance with 10 CFR 26.719(c)(3).

"NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Wednesday, March 24, 2021