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

Event Notification Report for July 11, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
7/10/2019 - 7/11/2019

** EVENT NUMBERS **

Part 21	Event Number: 54095
Rep Org: PARAGON ENERGY SOLUTIONS LLC Licensee: ATC NUCLEAR Region: 1 City: OAK RIDGE State: TN County: License #: Agreement: Y Docket: NRC Notified By: RAY CHALIFOUX HQ OPS Officer: JOANNA BRIDGE	Notification Date: 05/31/2019 Notification Time: 14:27 [ET] Event Date: 05/29/2019 Event Time: 00:00 [EDT] Last Update Date: 07/11/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE	Person (Organization): GLENN DENTEL (R1DO) ALAN BLAMEY (R2DO) ROBERT DALEY (R3DO) JASON KOZAL (R4DO) - PART 21/50.55 REACTORS (EMAIL)

Event Text

PART 21 NOTIFICATION - INTROL POSITIONERS POTENTIAL LATENT DEFECT

The following is an excerpt of the Part 21 information received via email:

"Introl Positioners used by stations in G32 Terry Turbine control applicators have the potential to contain a latent defect. The defect is the result of internal corrosion which has been identified in Tl Operational Amplifiers Part No.TL084CN on the SL3EX Controller Boards of the turbine throttle valve positioner. It is believed the likely cause is associated with the ingress of solder flux into the IC Chip package on the controller board due to delamination caused by the soldering process during fabrication. The corrosion over time can result in intermittent open circuiting and high resistance in the aluminum metallization. Chlorine ionic contamination can also result in high leakage currents within the component circuitry. Failures may be manifested by a reduced valve position signal disproportional to the expected demand condition, no actuation signal (i.e. throttle valve remaining full open), or other anomalous unexpected behavior. There are three TL084CN chips on each SL3EX Controller Board within the positioner assembly. There have been two documented failures to date occurring in 2015 and 2019 in installed systems.

"Date determination was made: May 29, 2019

"Affected sites: Farley, SONGS, Cooper, Almaraz Trillo Nuclear Power Plant (Spain), Clinton, Harris, Wolf Creek, Point Beach, Hatch, Watts Bar, Sequoyah.

"Stations are advised to work directly with Curtiss-Wright SAS via the technical contacts below.

"Randy F. Iantorno Project Manager, T: 585.596.3831, M: 585.596.9248, email riantorno@curtisswright.com or Justin Pierce 585.596.3866."

* * * UPDATE FROM RANDY IANTORNO (CURTISS-WRIGHT) TO DONALD NORWOOD AT 1537 EDT ON 6/7/2019 * * *

The following is a synopsis of information received via E-mail:

Shearon Harris Nuclear Plant experienced an overspeed trip of the Turbine Driven Auxiliary Feedwater Pump (TDAFW) on January 18, 2019 during routine system testing. Upon receipt of the initial start signal, the valve remained in the fully open position causing the TDAFW to trip on overspeed. Investigation into the overspeed trip revealed the positioner was not controlling the actuator properly in response to the governor command signal. This situation and subsequent troubleshooting led to replacement with the site spare positioner. Once installed, the system responded as expected and the suspect positioner was sent to Curtiss-Wright SAS (CW SAS) for evaluation.

In a joint effort between CW SAS and Paragon Energy Solutions (PES), the positioner was tested and evaluated to determine the cause of the failure.

Corrective action which has been, is being, or will be taken:
- The three TI chips on the affected board have been successfully replaced at PES. The repaired positioner will be configured and returned to Shearon Harris.
- The evaluation of suspect chips has been limited to those removed from the failed positioner, along with some supplied to PES by CW SAS. Work is ongoing in this area.
- A complete list of potentially affected installations is listed in the PES Part 21 Report dated May 31, 2019.
- Although this defect has the potential of preventing the Electronic Governor Speed Control System (EGSCS) from performing its intended safety function, it does not prevent the Terry Steam Turbine from operating. If the EGSCS fails, the turbine can be operated manually using the Trip and Throttle Valve (TTV) to control speed by regulating steam flow to the turbine.
- Steps are being taken to develop a plan to replace chips on affected positioner boards. This is still in the preliminary stages and specific recommendations will follow.

Notified R1DO (Carfang), R2DO (Rose), R3DO (Kozak), R4DO (Kellar), Part 21 Reactors E-mail group, and Part 21 Materials E-mail group.

* * * 1058 EDT ON 7/11/2019, UPDATE FROM RANDY IANTORNO (CURTIS-WRIGHT) TO MICHAEL BLOODGOOD * * *

The following was received via e-mail.

"This is a follow up letter related to Curtiss-Wright SAS (CW SAS) Report no. 48 submitted on June 6, 2019 regarding the Introl positioner failure discovered at the Shearon Harris Nuclear Plant on January 18, 2019.

"As reported in the initial report, the failure has been isolated to internal corrosion discovered inside TL084N Operational Amplifier chips on the SL3EX Controller Board. The cause of the failure has yet to be determined; however CW SAS and Paragon Energy Solutions (PES) continue to investigate potential causes.

"CW SAS will continue working with affected sites to provide guidance on additional testing, along with developing solutions that include replacement of suspect chips on the Introl positioner control boards. To allow CW SAS to coordinate efforts on a site by site basis, this will be the final correspondence sent directly to the NRC on this matter."

Notified R2DO (Ehrhardt), R3DO (McCraw), R4DO (Azua), Part 21 Reactors E-mail group, and Part 21 Materials E-mail group.

Agreement State	Event Number: 54140
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY Licensee: ALEXIAN BROTHERS MEDICAL CENTER Region: 3 City: ELK GROVE VILLAGE State: IL County: License #: IL-01418-01 Agreement: Y Docket: NRC Notified By: GARY FORSEE HQ OPS Officer: RICHARD SMITH	Notification Date: 07/02/2019 Notification Time: 14:50 [ET] Event Date: 07/01/2019 Event Time: 00:00 [CDT] Last Update Date: 07/02/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): LAURA KOZAK (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

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

"The Agency [Illinois Bureau of Radiation Safety] was notified at approximately 1530 CDT on 7/1/19, that a medical event had occurred at Alexian Brothers Medical Center, in Elk Grove Village. The circumstances are near identical to those in an event reported by the licensee in February of this year (EN53859). An attempted intravascular brachytherapy procedure utilizing a Novoste BetaCath 3.5F System was aborted when the source train could not successfully reach the intended treatment site after three attempts. The source train was retracted without complication and there were no indications of kinks in the delivery catheter. Aborting the procedure resulted in an underdose exceeding 20 percent of the prescribed dose (prescribed dose was 18.4 Gy of Y-90 and delivered dose was 0.0 Gy). The three attempts also resulted in an exposure exceeding 50 rem to tissue other than the treatment site (treatment site was in the circumflex artery). The source train stopped each of three times 10mm proximal to the treatment site in the junction between the left coronary artery and the circumflex artery. The inadvertently exposed region received approximately 0.98 Gy or a dose equivalent of approximately 100 rem.

"A reactionary inspection was conducted by Agency staff on the morning of July 2, 2019. A written report was received by the licensee that same day in which tortuous patient anatomy was identified as the root cause. Agency inspectors will meet with the authorized user on the afternoon of July 3, 2019, to discuss each step of the intravascular brachytherapy procedure in an effort to further isolate the root cause. No adverse medical impact is expected to the patient as a result of this event, per the authorized user. Patient has been notified and referring physician was present. This report will be updated as additional information becomes available."

Illinois Item Number: IL190016

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: 54141
Rep Org: NE DIV OF RADIOACTIVE MATERIALS Licensee: MID-STATE ENGINEERING AND TESTING Region: 4 City: COLUMBUS State: NE County: License #: 09-07-01 Agreement: Y Docket: NRC Notified By: JULIA SCHMITT HQ OPS Officer: RICHARD SMITH	Notification Date: 07/02/2019 Notification Time: 18:17 [ET] Event Date: 07/02/2019 Event Time: 13:30 [CDT] Last Update Date: 07/03/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): MARK HAIRE (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 - LOST PORTABLE GAUGE

This is a summary of information received from the state of Nebraska via phone call:

On July 2, 2019, at approximately 1330 CDT, the licensee, Mid-State Engineering and Testing, lost a CPN-International MC Series Protaprobe gauge with 10 mCi Cs-137 and 50 mCi Am/Be-241 sources. This gauge is believed to be lost somewhere between Aurora and Columbus, Nebraska on the route that includes highways 14 and 30. The truck's tail gate was not closed causing the gauge to fall out of the truck. The licensee has attempted to locate the gauge but so far has been unsuccessful. The Nebraska State Patrol has been notified along with the Platte County Sheriff department. This was reported to the State of Nebraska Health and Human Services Agency at 1645 CDT. The State will be issuing a follow up written report later.

* * * UPDATE ON 7/3/2019 AT 1758 EDT FROM JULIA SCHMITT TO ANDREW WAUGH * * *

This is a summary of information received from the state of Nebraska via phone:

On July 3, 2019, the gauge was found by a member of the public and retrieved by the licensee. The gauge does not appear to be damaged.

Notified R4DO (Haire), NMSS Events (email), and ILTAB (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

Fuel Cycle Facility	Event Number: 54142
Facility: GLOBAL NUCLEAR FUEL - AMERICAS RX Type: URANIUM FUEL FABRICATION Comments: LEU CONVERSION (UF6 TO UO2) LEU FABRICATION LWR COMMERICAL FUEL Region: 2 City: WILMINGTON State: NC County: NEW HANOVER License #: SNM-1097 Docket: 07001113 NRC Notified By: PHILLIP OLLIS HQ OPS Officer: MICHAEL BLOODGOOD	Notification Date: 07/03/2019 Notification Time: 10:29 [ET] Event Date: 07/03/2019 Event Time: 09:15 [EDT] Last Update Date: 07/03/2019
Emergency Class: NON EMERGENCY 10 CFR Section: PART 70 APP A (c) - OFFSITE NOTIFICATION/NEWS REL	Person (Organization): ROBERT WILLIAMS (R2DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

OFFSITE NOTIFICATION DUE TO FIRE SPRINKLER MAINTENANCE

"At 0915 EST on July 3, 2019, the New Hanover County Deputy Fire Marshall was notified per State code requirements that the fire suppression system for the Fuel Manufacturing Operation Shop Support Areas was taken offline for planned maintenance to modify sprinkler piping. Compensatory measures were enacted. Because the New Hanover County Deputy Fire Marshall was notified, a concurrent notification to the NRC Operations Center is being made per 10 CFR 70, Appendix A(c)."

The licensee will be notifying the state of North Carolina and the NRC Regional Office.

Agreement State	Event Number: 54143
Rep Org: OHIO BUREAU OF RADIATION PROTECTION Licensee: NATIONWIDE CHILDREN'S HOSPITAL Region: 3 City: COLUMBUS State: OH County: License #: 02110250002 Agreement: Y Docket: NRC Notified By: MICHAEL RUBADUE HQ OPS Officer: ANDREW WAUGH	Notification Date: 07/03/2019 Notification Time: 11:48 [ET] Event Date: 07/01/2019 Event Time: 00:00 [EDT] Last Update Date: 07/03/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): LAURA KOZAK (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The following was received via email:

"On 7/2/2019, the Ohio Department of Health received a phone call from Nationwide Children's Hospital reporting a medical event. The licensee was treating acute myeloid leukemia (AML) with I-131 Iomab using a delivery system that is currently under research and development. The licensee stated the delivery system does not allow the dose vial to be seen and requires the manufacturer to set the infusion time. After the infusion, the technicians discovered the delivery system did not deliver the entire dose to the patient, resulting in an underdose of 42 percent.

"The patient and referring physician have been notified.

"An investigation of the event is pending."

Ohio Item Number: OH190010

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: 54146
Rep Org: WISCONSIN RADIATION PROTECTION Licensee: GE PRECISION HEALTHCARE, LLC Region: 3 City: WAUKESHA State: WI County: License #: 133-1107-01 Agreement: Y Docket: NRC Notified By: KYLE WALTON HQ OPS Officer: ANDREW WAUGH	Notification Date: 07/03/2019 Notification Time: 15:58 [ET] Event Date: 07/01/2019 Event Time: 00:00 [CDT] Last Update Date: 07/03/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): LAURA KOZAK (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - LEAKING SOURCE

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

"On July 3, 2019, the Department [Wisconsin Radiation Protection Section] received a letter sent and dated July 1, 2019, from GE Healthcare of a source that was discovered to be broken and leaking following it being dropped at the licensee's facility.

"The source (Sanders Medical Products, Germanium-68 Model PET-273/10 sealed source) was being transported in an open-topped lead shield on a cart within the licensee's restricted facility. While moving the cart, an employee lost their grip and the shield fell to the floor. The employee identified that a portion of the source had broken off.

"Using remote handling tongs, the broken portion was returned back into the shield. Surveys were immediately performed, and no contamination was identified on the floor or the employee's hands.

"Follow-up wipe tests were performed on the floor and the source. The source had removable contamination of 220 Bq. The source has been withdrawn from use and secured at the licensee's facility pending disposal.

"The licensee will be performing a review of the incident and their response procedures. A follow-up inspection will be performed by the Department."

Wisconsin Event Report ID No.: WI 190007

Non-Power Reactor	Event Number: 54157
Facility: GENERAL ELECTRIC HITACHI RX Type: 100 KW NTR (TANK) Comments: Region: 0 City: SUNOL State: CA County: ALAMEDA License #: R-33 Agreement: Y Docket: 05000073 NRC Notified By: JEFF SMYLY HQ OPS Officer: CATY NOLAN	Notification Date: 07/10/2019 Notification Time: 18:28 [ET] Event Date: 07/10/2019 Event Time: 14:59 [PDT] Last Update Date: 07/10/2019
Emergency Class: UNUSUAL EVENT 10 CFR Section: 50.72(a) (1) (i) - EMERGENCY DECLARED	Person (Organization): RAY AZUA (R4DO) WILLIAM GOTT (IRD) JIM WHITNEY (ILTAB) GREG BOWMAN (NRR EO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

NOTIFICATION OF UNUSUAL EVENT

On July 10, 2019, at 1459 PDT, GE Hitachi [test reactor in Sunol, California] declared an Unusual Event. Two individuals jumped a boundary fence. The individuals exited the area when approached by security. The licensee notified local law enforcement.

There was no offsite release. The licensee terminated the Unusual Event at 1553 PDT on July 10, 2019.

The licensee notified California Environmental Emergency Services and Alameda County law enforcement.

Notified DHS SWO, DHS NICC, FEMA Operations Center, FEMA NWC (email), and NuclearSSA (email).

Page Last Reviewed/Updated Wednesday, March 24, 2021