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Event Notification Report for February 04, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
2/1/2019 - 2/4/2019

** EVENT NUMBERS **


53844 53845 53847 53848 53856 53858

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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."

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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.

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Agreement State Event Number: 53847
Rep Org: NJ RAD PROT AND REL PREVENTION PGM
Licensee: INSPIRA MEDICAL CENTERS, INC.
Region: 1
City: VINELAND   State: NJ
County:
License #: 450632
Agreement: Y
Docket:
NRC Notified By: RICHARD PEROS
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 01/25/2019
Notification Time: 10:37 [ET]
Event Date: 01/24/2019
Event Time: 00:00 [EST]
Last Update Date: 01/25/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - PATIENT UNDERDOSED BY GREATER THAN 20 PERCENT

The following was received from the State of New Jersey via email:

"While a dosage of samarium-153 Quadramet was being administered to a patient, no one noticed that there was a crack in the locking assembly of the IV tubing connection. As a result, when the material was being administered, most of it leaked out of the assembly, rather than being administered to the patient. This resulted in the patient receiving only 2.35 mCi of the prescribed dosage of 58 mCi. This caused a reportable underdosage. The physician has been informed and all the necessary involved persons involved have been supplied with this information. The licensee will follow-up with a full report."

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: 53848
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: SAGEBRUSH PIPELINE AND EQUIPMENT COMPANY, INC.
Region: 4
City: TULSA   State: OK
County:
License #: OK-32109-01
Agreement: Y
Docket:
NRC Notified By: JENNIFER MCALLISTER
HQ OPS Officer: ANDREW WAUGH
Notification Date: 01/25/2019
Notification Time: 16:27 [ET]
Event Date: 01/25/2019
Event Time: 14:30 [CST]
Last Update Date: 01/25/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA MALFUNCTION

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

"On January 25, 2019, at approximately 1430 CST, [Oklahoma Department of Environmental Quality (DEQ)] received a call from Sagebrush Pipeline Equipment Company, Inc., Oklahoma License No. OK-32109-01. [The licensee] experienced a guide tube disconnect, while the source was cranked out. They were using a SPEC 150 with 48 Ci of Ir-192. The carded radiographer explained that when cranking out the source, there was a small catch, so he attempted to crank the source back into the camera. That was when they realized the guide tube was disconnected from the camera, and the source while still connected to the guidewire, was still in the guide tube. They were able to return the source back to its shielded position. [Oklahoma DEQ] will provide updates when they receive the licensee's report."

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Part 21 Event Number: 53856
Rep Org: SOR
Licensee: SOR
Region: 4
City: LENEXA   State: KS
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MELANIE DIRKS
HQ OPS Officer: OSSY FONT
Notification Date: 02/01/2019
Notification Time: 13:53 [ET]
Event Date: 12/08/2018
Event Time: 00:00 [CST]
Last Update Date: 02/01/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
BRICE BICKETT (R1DO)
OMAR LOPEZ (R2DO)
JAMNES CAMERON (R3DO)
RAY AZUA (R4DO)
- PART 21/50.55 REACTORS (EMAIL)

Event Text

PART 21 - NOTIFICATION OF DEVIATION OF SWITCHES WITH TERMINAL BLOCKS

The following was received via fax and email from SOR:

"Exelon Limerick generating station notified SOR on December 8, 2018 via email regarding corrective action needed for the R-series housing on two of their emergency diesel engines. Limerick reported that the field wire lugs were in close contact with the switch cover gasket and had degraded the EPR (Ethylene Propylene Rubber) housing cover material enough to short to the cover which, in turn, tripped the 1A control fuse. Limerick reported that the uninsulated terminals and wiring were already available at the switch location during installation and used without modification. Limerick's immediate corrective action was to land the field wiring on the bottom tier of the terminal block and insulate the lugs.

"EPR is known to be an effective electrical insulator, and is used as insulation for many electrical cables. For this reason, the EPR cover gasket was used on the SOR R-series nuclear housing to offer sufficient electrical insulation. Due to the failure at the Limerick generating station and subsequent evaluation at SOR, the EPR gasket alone does not provide sufficient electrical insulation between the terminal block connections and the metallic housing cover when uninsulated terminals are installed. This direct connection will cause heating of the gasket and eventual direct short through the EPR material.

"SOR does not have the capability to perform further evaluations to determine if a safety hazard exists as the specific customer installation practices is unknown. The end user must confirm for each application the wire installation applied with this specific model string."

The plants who are potentially affected by this deviation are in the process of being notified by email and/or postal letter and are:
- Callaway
- Braidwood
- Byron
- Limerick
- Quad Cities
- Davis Besse
- St. Lucie
- H.B. Robinson

"SOR has completed or is implementing the following corrective actions:
- Completed the identification of the customers potentially affected by this deviation within this notification
- Initiated customer complaint 21 and corrective action (CAR) 1003
- Released ECO 5443 to add 3.5" wide Nomex insulation paper to the terminal block units
- Created a modified cover gasket with a Kapton insulation piece for field units
- Revision to SOR General Instruction to require customers to use insulated terminal connections targeting completion by February 28, 2019
- Investigate modification to SOR insulation resistance and dielectric tests targeting completion by February 28, 2019"

Should you have any additional questions regarding this matter, please contact:

For general inquiries:
Linda Coutts
Inside Sales Representative
Email: lcoutts@sorinc.com
Tel 913-956-3071

For technical inquiries:
Mike Bequette
Vice President of Engineering
Email: mbeguette@sorinc.com
Tel 913-956-3040

Sara Roos
Senior Engineer
Email: sroos@sorinc.com
Tel 913-956-3049

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Independent Spent Fuel Storage Installation Event Number: 53858
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: MICHAEL JOHNSON
HQ OPS Officer: OSSY FONT
Notification Date: 02/02/2019
Notification Time: 13:44 [ET]
Event Date: 02/01/2019
Event Time: 14:05 [PST]
Last Update Date: 02/02/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
72.75(d)(1) - SFTY EQUIP. DISABLED OR FAILS TO FUNCTION
Person (Organization):
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
JEFFERY GRANT (IRD)

Event Text

NO SEISMIC ANALYSIS FOR CANISTER TRANSPORT PROCESS

"During follow-up reviews resulting from the Aug. 3, 2018 canister downloading event (EN#53605), Southern California Edison [SCE] became aware of a condition where, during short periods of the canister transport process, the Vertical Cask Transporter (VCT) could have been operated without a supporting seismic analysis while transporting loaded canisters for storage. SCE has decided to conservatively report this issue.

"The VCT is a mobile gantry crane that is used to transport and download fuel canisters into an Independent Spent Fuel Storage Installation (ISFSI) enclosure. Twenty-nine canisters have been downloaded into the San Onofre nuclear plant ISFSI in this manner since January 2018. The Holtec UMAX Certificate of Compliance requires that lifting of a loaded spent fuel canister must be performed with redundant (i.e., single-failure-proof) load drop protection features. Inherent in the definition is the ability to withstand seismic loading. SCE identified that although applicable rigging and downloading procedures were followed, a supporting seismic analysis should be developed for the short duration periods in the process where the canisters are transitioned to rigging.

"Southern California Edison has directed its vendor, Holtec, to perform this further seismic analysis. While the additional analysis may conclude that the VCT is stable and functional during these transitioning periods, SCE will work with the vendor should modifications to the canister transport process become necessary.

"SCE is making this notification in accordance with the requirements of 10 CFR 72.75(d)(1). There was no seismic event that resulted in damage to the VCT or a spent fuel canister during the fuel transfer campaign. All 29 spent fuel canisters are currently in safe storage within the ISFSI."


Page Last Reviewed/Updated Monday, February 04, 2019
Monday, February 04, 2019