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

Event Notification Report for February 25, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
2/22/2019 - 2/25/2019

** EVENT NUMBERS **

Non-Agreement State	Event Number: 53876
Rep Org: KINGSFORD MANUFACTURING COMPANY Licensee: KINGSFORD MANUFACTURING COMPANY Region: 3 City: BELLE State: MO County: License #: 24-20121-01 Agreement: N Docket: NRC Notified By: MARK NILGES HQ OPS Officer: BETHANY CECERE	Notification Date: 02/15/2019 Notification Time: 09:40 [ET] Event Date: 10/09/2018 Event Time: 00:00 [CST] Last Update Date: 02/15/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 30.50(b)(2) - SAFETY EQUIPMENT FAILURE	Person (Organization): ERIC DUNCAN (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

NUCLEAR GAUGE SHUTTER STUCK OPEN

The following is a summary from a phone call with the licensee:

The licensee decided to remove seven nuclear gauges from service. Ronan Engineering performed the removal. During the device removal on October 9, 2018, one device was found to have a stuck shutter in the open position. The gauge was removed and repaired.

Agreement State	Event Number: 53877
Rep Org: PA BUREAU OF RADIATION PROTECTION Licensee: ALBERT EINSTEIN HEALTHCARE NETWORK Region: 1 City: PHILADELPHIA State: PA County: License #: PA-0135 Agreement: Y Docket: NRC Notified By: JOSHUA MYERS HQ OPS Officer: THOMAS KENDZIA	Notification Date: 02/15/2019 Notification Time: 11:47 [ET] Event Date: 02/13/2019 Event Time: 00:00 [EST] Last Update Date: 02/15/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): MARC FERDAS (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL) EDWARD HARVEY (NMSS DAY) WILLIAM GOTT (IRD)

Event Text

AGREEMENT STATE REPORT - ADMINISTERED DOSE TO UNINTENDED ORGANS RESULTS OR WILL RESULT IN UNINTENDED PERMANENT DAMAGE

The following was received from the Pennsylvania Department of Environmental Protection (DEP) Bureau of Radiation Protection via email:

"On February 13, 2019, the patient was prescribed 31.3 milliCuries (mCi) Yttrium-90 (Y-90) Sirsphere for metastatic colorectal cancer and 31.69 mCi was delivered at time of treatment. From the post Y-90 Bremsstrahlung scan, performed on the day of treatment, it was discovered by the nuclear medicine physician, that some of the Y-90 microspheres also traveled to the stomach and left lobe of liver. The doctor has informed the patient and the patient is being monitored for potential complications. The doctor is working to determine the percentage of the Y-90 that went to stomach and left lobe of liver. No more information is available at this time from the licensee. The DEP will update this event as soon as more information is provided.

"The DEP will perform a reactive inspection."

The licensee reported this to the state per 10 CFR 35.3045 (b).

Pennsylvania Report: PA190004

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.

Agreement State	Event Number: 53878
Rep Org: MISSISSIPPI DIV OF RAD HEALTH Licensee: MISSISSIPPI DEPARTMENT OF TRANSPORTATION Region: 4 City: RED CREEK State: MS County: License #: MS-261-01 Agreement: Y Docket: NRC Notified By: JASON MOAK HQ OPS Officer: ANDREW WAUGH	Notification Date: 02/15/2019 Notification Time: 13:33 [ET] Event Date: 02/15/2019 Event Time: 00:00 [CST] Last Update Date: 02/15/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): VINCENT GADDY (R4DO) ILTAB (EMAIL) NMSS_EVENTS_NOTIFICATION (EMAIL)

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

Event Text

AGREEMENT STATE REPORT - THEFT OF A MOISTURE DENSITY GAUGE

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

"Mississippi Department of Transportation (MS-261-01) reported that a Troxler Model 3440 (serial number: 19297) portable gauge containing 10 milliCuries of cesium-137 and 44 milliCuries of americium-241/beryllium was stolen from the licensee's job site trailer closet in Red Creek, Mississippi. The gauge was padlocked in its original carrying case. Local law enforcement and the FBI have been notified. Follow-up information will be provided to the NRC on the recovery of the stolen gauge and entered into the Nuclear Material Events Database."

Mississippi Report Number: MS-190001

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	Event Number: 53879
Rep Org: ARKANSAS DEPARTMENT OF HEALTH Licensee: UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES Region: 4 City: LITTLE ROCK State: AR County: License #: ARK-0001-02110 Agreement: Y Docket: NRC Notified By: ANGIE HALL HQ OPS Officer: THOMAS KENDZIA	Notification Date: 02/15/2019 Notification Time: 17:07 [ET] Event Date: 02/13/2019 Event Time: 07:24 [CST] Last Update Date: 02/15/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): VINCENT GADDY (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DOSE DELIVERED WAS LESS THAN PRESCRIBED

The following was received from the Arkansas Department of Health, Radiation Control Program (the Department) via email:

"The treatment prescribed activity was for 0.54 GBq (14.5 mCi) on February 13, 2019. The calibrated activity at projected treatment time was 0.53 GBq (14.3 mCi). The patient received a dose of 0.204 GBq (5.51 mCi) due to 61.5 percent of the dose remaining in the connector of the manufacturer tubing and the catheter Terumo-Progreat Microcatheter (2.0 French Catheter). The Department performed an on-site review and investigation on February 15, 2019 at approximately 1215 [CST].

"The Department performed exposure surveys of the connector confirming activity stuck at the connector site. The connector site read the highest and in that concentrated area, reading 430 mR/hr, on February 15, 2019, at approximately 1415 [CST].

"There were no spills and/or contamination during this event.

"The licensee notified the manufacturer and the manufacturer will be performing an investigation on the tubing and radiopharmaceutical/sealed sources. The licensee is continuing to investigate the root cause and is preparing an initial fifteen day written report.

"The Department is waiting on information from the manufacturer(s) and licensee for further investigation. The Department will update this report when the licensee provides additional information."

Arkansas Event AR-2019-001

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.

Agreement State	Event Number: 53880
Rep Org: CALIFORNIA RADIATION CONTROL PRGM Licensee: GE HEALTHCARE Region: 4 City: SAN DIEGO State: CA County: License #: 5796-37 Agreement: Y Docket: NRC Notified By: L. ROBERT GREGER HQ OPS Officer: OSSY FONT	Notification Date: 02/17/2019 Notification Time: 08:25 [ET] Event Date: 02/14/2019 Event Time: 00:00 [PST] Last Update Date: 02/17/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): VINCENT GADDY (R4DO) ERIC DUNCAN (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL) DENNIS ALLSTON (ILTAB) - CNSNS (MEXICO) (EMAIL)

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

Event Text

AGREEMENT STATE REPORT - LOST MO-99/TC-99 GENERATOR

The following is a synopsis from information received from the state of California via email.

The California radiation protection program was notified by the licensee of a partially depleted, missing Mo-99/Tc-99m generator. The generator was shipped using a commercial carrier on October 31, 2018, from the licensee's California facility to their facility in Arlington Heights, Illinois. Near the beginning of February 2019, the licensee became aware that the generator did not arrive at its destination. The commercial carrier spent the last couple of weeks searching their facilities for the missing generator with no success and has suspended the search and considering the package lost.

At the time of shipment, the generator contained 10.35 GBq (280 mCi), greater than 1000 times the 10 CFR 20 Appendix C activity for Mo-99, making it reportable under 10 CFR 20.2201(a)(1)(i). It is housed in a 12.7 kg depleted uranium shield. The package was shipped as a label category Yellow II, with a TI [transportation index] of 0.2. By November 5, 2018, the activity of Mo-99 would have decayed below the 10 CFR 20.2201(a)(1)(i) reporting criteria. By November 23, 2018, the activity of Mo-99 would have decayed below the 10 CFR 20.2201(a)(1)(ii) reporting criteria.

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

Part 21	Event Number: 53891
Rep Org: FLOWSERVE Licensee: FLOWSERVE Region: 1 City: RALEIGH State: NC County: License #: Agreement: Y Docket: NRC Notified By: MARK RAIN HQ OPS Officer: MARK ABRAMOVITZ	Notification Date: 02/22/2019 Notification Time: 14:35 [ET] Event Date: 02/20/2019 Event Time: 00:00 [EST] Last Update Date: 02/22/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE	Person (Organization): ANNE DeFRANCISCO (R1DO) RANDY MUSSER (R2DO) ERIC DUNCAN (R3DO) RICK DEESE (R4DO) - PART 21/50.55 REACTORS (EMAIL)

Event Text

PART 21 REPORT - FLOWSERVE VALVE ASSIST SPRINGS MAY PREVENT FULL CLOSURE

The following report was received via fax:

"Description: GE BWXT, acting on behalf of Ontario Power sent five valves back to the Flowserve facility for evaluation of the spring which could spread apart when the flapper rotates open and wedge between the valve body and flapper, creating the potential for the valve flapper to stick open.

"Evaluation: Shop inspections of the returned valves confirmed the potential for the spring legs to rotate outwards and potentially wedge between the flapper and seat retainer. Of the five valves evaluated, two of the valves had the spring legs rotate outward and after repeated cycles got caught between the flapper and disc; on one of the instances the spring legs prevented full closure of the flapper.

"If the valves have a safety-related function to isolate flow and must transfer closed, then the springs could prevent the valve from performing its safety related function.

"The evaluation determined the cause is an inadequate spring design which allows the spring to deflect and permit the legs to move outward.

"Extent of Condition: In discussion with the customer, it is believed the problem did not exist with valves originally supplied from the Worcester, Scarborough Canada facility; although this cannot be confirmed by Flowserve. It is believed the extent of condition resides with valves and replacement springs supplied from the Flowserve Raleigh, NC facility when the product line was transferred and the spring vendors changed; even though it has been confirmed that the springs supplied out of the Raleigh, NC facility comply with the product drawing requirements. The springs were first sold in valve assemblies or as replacement parts from the Raleigh facility starting in 2008.

"Valve Scope: The scope of impacted valves is the Worcester series 44 swing check valves. (Please note Worcester also has a series 44 three piece ball valve, which is not in the scope.} The Raleigh facility has supplied parts or valves for four Worcester series 44 swing check valves assemblies which use these springs. The drawings numbers for these valve assemblies are listed below:

Drawing Valve Size Customer
KN44-0590 1.5 X 1 X 1.5 Bruce Power, GE BWXT & Ontario Power
KN44-0630 2 Comanche Peak
14-107362-001 1.5 X 1 X 1.5 GE BWXT
16-118733-001 1.5 X 1 X 1.5 GE BWXT

"Corrective Actions:
1) Owner's may remove the springs. The valves will check-off and seal under low pressure conditions without the assistance of the spring; this was demonstrated in shop tests using tap water pressure (approximately 60 psig) and will initiate closure when full open without the assistance of the spring.
2) Flowserve is evaluating alternate spring designs along with the possibility of adding guides to prevent the undesired spring movement. Any new design will be proof tested.

"Respectfully submitted,
Mark Rain, PE
Product/Design Engineering Specialist
Flowserve Corporation
Flow Control Division
1900 S. Saunders St.
Raleigh, NC 27603"

Fuel Cycle Facility	Event Number: 53892
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: RICARDO MEDINA HQ OPS Officer: MARK ABRAMOVITZ	Notification Date: 02/22/2019 Notification Time: 17:40 [ET] Event Date: 02/21/2019 Event Time: 18:45 [MST] Last Update Date: 02/22/2019
Emergency Class: NON EMERGENCY 10 CFR Section: PART 70 APP A (b)(1) - UNANALYZED CONDITION	Person (Organization): RANDY MUSSER (R2DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

IROFS SURVEILLANCE PERIODICITY ERROR

"It was discovered that the calculation which determines the periodicity for performing the IROFSC22 [Item Relied On For Safety] surveillance contains an error. IROFSC22 is a mass balance enrichment control.

"It is unclear if the calculation error causes the surveillance periodicity to fall outside of the minimum time to achieve a safe mass. UUSA [Urenco USA] has since changed the IROFS surveillance to a more frequent periodicity which has been determined to be sufficient.

"Although no event has occurred and the IROFS remain sufficient to meet the performance requirements of 10CFR70.61, as a conservative measure, UUSA is reporting this condition due to the facility being in a state that is different from that analyzed in the Integrated Safety Analysis and in accordance with 10 CFR 70 Appendix A(b)(1)

"The plant is in a safe condition."

The licensee will notify NRC Region 2 (Lopez).

Power Reactor	Event Number: 53893
Facility: HATCH Region: 2 State: GA Unit: [] [2] [] RX Type: [1] GE-4,[2] GE-4 NRC Notified By: ANDREW BELCHER HQ OPS Officer: ANDREW WAUGH	Notification Date: 02/23/2019 Notification Time: 09:13 [ET] Event Date: 02/23/2019 Event Time: 02:12 [EST] Last Update Date: 02/23/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION	Person (Organization): RANDY MUSSER (R2DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

Refueling

Event Text

AUTOMATIC ACTUATION OF 2C EMERGENCY DIESEL GENERATOR

"At 0212 EST on February 23, 2019, with Unit 2 in Mode 5, an actuation signal for the 2C Emergency Diesel Generator (EDG) was received during the Loss of Coolant Accident / Loss of Offsite Power logic system functional test. The 2C EDG was running and tied onto the 2G 4160 emergency bus when the alternate supply breaker was closed as required per the test procedure. Immediately upon closing the alternate supply breaker, both the alternate supply breaker and 2C EDG output breaker tripped open. The 2C EDG output breaker reclosed once the 2G 4160 bus undervoltage relays sensed a deenergized bus. When the 2C EDG tied to the 2G 4160 bus, the bus voltage was noted as being high, and the 2C EDG was secured. Investigation is ongoing to determine the cause of the initial bus undervoltage and the subsequent bus excessive voltage.

"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 emergency AC power system.

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

This event puts Unit 1 in a 72 hour Limiting Condition for Operation for the 1C Startup Transformer being out of service.

Power Reactor	Event Number: 53894
Facility: GRAND GULF Region: 4 State: MS Unit: [1] [] [] RX Type: [1] GE-6 NRC Notified By: GABRIEL HARGROVE HQ OPS Officer: MARK ABRAMOVITZ	Notification Date: 02/23/2019 Notification Time: 19:05 [ET] Event Date: 02/23/2019 Event Time: 14:58 [CST] Last Update Date: 02/23/2019
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): RICK DEESE (R4DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

A/R

100

Power Operation

Hot Shutdown

Event Text

AUTOMATIC REACTOR SCRAM AFTER TURBINE CONTROL VALVE FAST CLOSURE

"Actuation of RPS [Reactor Protection System] with the reactor critical. Reactor scram occurred at 1458 [CST] on 2/23/2019 from 100% power. The cause of the scram was due to Turbine Control Valve Fast Closure.

"All control rods are fully inserted. Currently reactor water level is being maintained by the Condensate Feedwater System in normal band and reactor pressure is being controlled via Main Turbine Bypass valves to the main condenser. No ECCS [Emergency Core Cooling System] initiation signals were reached and no ECCS or Diesel Generator initiation occurred.

"The Low-Low Set function of the Safety Relief Valves actuated upon turbine trip. This was reset when pressure was established on main turbine bypass valves.

"The cause of the turbine trip is still under investigation.

"There were no complications with scram response."

The licensee notified the NRC Resident Inspector.

There was no maintenance occurring on the main turbine at the time of the scram.

Power Reactor	Event Number: 53896
Facility: PERRY Region: 3 State: OH Unit: [1] [] [] RX Type: [1] GE-6 NRC Notified By: ALEX HALLMARK HQ OPS Officer: ANDREW WAUGH	Notification Date: 02/25/2019 Notification Time: 03:44 [ET] Event Date: 02/25/2019 Event Time: 00:24 [EST] Last Update Date: 02/25/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL	Person (Organization): ERIC DUNCAN (R3DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

A/R

Power Operation

Hot Shutdown

Event Text

AUTOMATIC REACTOR SCRAM DUE TO GENERATOR TRIP

"At 0024 EST on 2/25/19, with Unit 1 in Mode 1 at 74 percent power, the reactor automatically tripped due to a generator trip. The trip was not complex, with all systems responding normally post-trip.

"Operations responded and stabilized the plant. Reactor water level is being maintained via the feed system. Decay heat is being removed by discharging steam to the main condenser using the turbine bypass valves.

"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).

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

The generator trip is under investigation, but is believed to be due to grid perturbations.

Page Last Reviewed/Updated Wednesday, March 24, 2021