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Event Notification Report for September 24, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
9/23/2019 - 9/24/2019

** EVENT NUMBERS **

!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Fuel Cycle Facility	Event Number: 54255
Facility: NUCLEAR FUEL SERVICES INC. RX Type: URANIUM FUEL FABRICATION Comments: HEU CONVERSION & SCRAP RECOVERY NAVAL REACTOR FUEL CYCLE LEU SCRAP RECOVERY Region: 2 City: ERWIN State: TN County: UNICOI License #: SNM-124 Docket: 07000143 NRC Notified By: RON RICE HQ OPS Officer: JEFFREY WHITED	Notification Date: 09/04/2019 Notification Time: 16:55 [ET] Event Date: 09/04/2019 Event Time: 03:46 [EDT] Last Update Date: 09/16/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 70.50(b)(1) - UNPLANNED CONTAMINATION	Person (Organization): SCOTT SHAEFFER (R2DO) NMSS_EVENTS_NOTIFICATION (EMAIL) - FUELS GROUP (EMAIL)

Event Text

UNPLANNED CONTAMINATION EVENT

The following was received via e-mail:

"On September 4, 2019, at approximately 0346 EDT, a glass component failed, resulting in an unplanned contamination event. The release was limited to an area inside of the Radiologically Controlled Area. This area is designed for radiological work. There has been no personnel contamination. Airborne radioactivity samples are below action levels. Cleanup and Decontamination activities were safely and promptly initiated, but due to the complexity and space constraints of the system components, normal access to the area is not likely be restored within 24 hours. There has been no exposures or releases to the environment or public.

"The licensee has notified the NRC Resident Inspector."

* * * RETRACTION ON 9/16/19 AT 1115 EDT FROM RON RICE TO BRIAN LIN * * *

The following retraction information was obtained from the licensee via email:

"The unplanned contamination event was decontaminated to levels that did not require access to be restricted by imposing additional radiological controls within 24 hours, so the event did not require a report per 10CFR70.50(b)(1)(i). The NRC resident inspector has been informed."

Notified R2DO (Ehrhardt), NMSS Events Notification (email), and Fuels Group (email).

Agreement State	Event Number: 54274
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY Licensee: AMERICAS STYRENCS LLC Region: 3 City: CHANNAHON State: IL County: WILL License #: IL-02375-01 Agreement: Y Docket: NRC Notified By: C GIBB VINSON HQ OPS Officer: BRIAN LIN	Notification Date: 09/13/2019 Notification Time: 09:36 [ET] Event Date: 09/10/2019 Event Time: 00:00 [CDT] Last Update Date: 09/13/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): DIANA BETANCOURT-ROLDAN (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTER

The following was received by the State of Illinois via email:

"The Radiation Safety Officer for Americas Styrencs, LLC, called to report that on September 10, 2019, they were conducting a routine six month shutter check on a Texas Nuclear Model 5180A device and determined that the shutter was stuck in the open position. The device is 40 years old, and it originally contained 2 Curies of Cs-137. The gauge is located on a vessel which is still in active use and is exposed to ambient weather conditions. The gauge is located approximately 10 feet overhead and the beam path is not a routine work location for day-to-day operations. They will contact Thermo MeasureTech to schedule service on the device and apprise the Illinois Emergency Management Agency (Agency) on the service date. Since this device operates continuously, it will continue to function and not interrupt their operations. An Agency inspector arrived on the scene on the same day to confirm that the device was in a safe configuration for continued operations."

Illinois Item Number: IL190028

Non-Agreement State	Event Number: 54275
Rep Org: MATERIALS TESTING, INC Licensee: MATERIALS TESTING, INC Region: 1 City: NEW HAVEN State: CT County: License #: 06-199-0901 Agreement: N Docket: NRC Notified By: WILLIAM SOUCY HQ OPS Officer: OSSY FONT	Notification Date: 09/13/2019 Notification Time: 11:32 [ET] Event Date: 09/12/2019 Event Time: 11:30 [EDT] Last Update Date: 09/13/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 30.50(b)(2) - SAFETY EQUIPMENT FAILURE	Person (Organization): DONNA JANDA (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

DAMAGED DENSITY GAUGE

The following is a synopsis of information received via phone:

On September 12, 2019, at approximately 1130 EDT, a Humboldt gauge (Model 5001C; S/N 3267), containing 10 mCi of Cs-137 and a 40 mCi Am-241/Be source, was damaged during a field inspection. The inspector notified the radiation safety officer (RSO) and informed him that the source was retracted at the time and the source was not damaged. The RSO instructed the inspector to place the device in the carrying case and return it to him at the office. No survey of the device was performed prior to removal from the job site.

Once the device was at the office, the RSO performed a swipe test and will be sending it to Humboldt. The RSO was also going to notify the device manufacturer of the damaged gauge. No exposure is expected but personnel dosimetry badge was sent for processing.

Fuel Cycle Facility	Event Number: 54279
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: OSSY FONT	Notification Date: 09/13/2019 Notification Time: 14:47 [ET] Event Date: 09/12/2019 Event Time: 16:40 [EDT] Last Update Date: 09/13/2019
Emergency Class: NON EMERGENCY 10 CFR Section: PART 70 APP A (c) - OFFSITE NOTIFICATION/NEWS REL	Person (Organization): FRANK EHRHARDT (R2DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

CONCURRENT REPORT FOR FIRE ALARM MAINTENANCE

"At 1640 (EDT) on September 12, 2019, the New Hanover County Deputy Fire Marshall was notified, per State code requirements, that the fire alarm system encompassing the Fuel Manufacturing Operation (FMO) will be taken offline for planned maintenance. The system was taken offline at approximately 0800 on September 13, 2019. Compensatory measures were enacted. The system was returned to service at approximately 1335 on September 13, 2019. 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 NRC Region, as well as the North Carolina Radioactive Materials Branch, will be notified.

Agreement State	Event Number: 54280
Rep Org: MA RADIATION CONTROL PROGRAM Licensee: MASSACHUSETTS GENERAL HOSPITAL Region: 1 City: BOSTON State: MA County: License #: 60-0055 Agreement: Y Docket: NRC Notified By: SZYMON MUDREWICZ HQ OPS Officer: OSSY FONT	Notification Date: 09/13/2019 Notification Time: 16:28 [ET] Event Date: 09/11/2019 Event Time: 00:00 [EDT] Last Update Date: 09/13/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): DONNA JANDA (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MISADMINISTRATION OF HIGH DOSE RATE THERAPY

The following was received via email from the Massachusetts Department of Public Health - Radiation Control Program (the Agency):

"On 09/13/19, a medical event was reported by Massachusetts General Hospital (MGH) (the licensee) involving the medical misadministration of HDR [high dose rate] therapy. The 59 year-old patient involved received dose to unintended tissue exceeding 50 percent of the prescribed dose defined in the written directive. The prescribed dose was 5.5 Gy over 5 fractions for a total of 27.5 Gy to the cervix. The therapy was performed using a Syeb-Neblett Template and 6 catheters including 1 tandem. The patient ultimately received the full intended dose to the tumor (high risk- CTV [clinical target volume]) and per the licensee there was no overdose to any critical structures including bladder, rectum, or bowel. A small region of the surface of the right vaginal wall (approximately 1 cm) did inadvertently receive 16.5 Gy due to the wrong treatment distances being entered into the treatment planning system for 2 of the 7 catheters by the physicist. The patient is not expected to be at an increased risk for toxicity due to this error. Both the patient and referring physician were immediately notified upon discovery. Licensee to submit written report within 15 days of discovery date. The Agency considers this event to be open and pending investigation."

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.

Part 21	Event Number: 54288
Rep Org: ROTORK CONTROLS Licensee: ROTORK CONTROLS Region: 1 City: ROCHESTER State: NY County: License #: Agreement: Y Docket: NRC Notified By: PATRICK A SHAW HQ OPS Officer: OSSY FONT	Notification Date: 09/23/2019 Notification Time: 12:35 [ET] Event Date: 06/17/2019 Event Time: 00:00 [EDT] Last Update Date: 09/23/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE	Person (Organization): CHRISTOPHER LALLY (R1DO) BRIAN BONSER (R2DO) ROBERT DALEY (R3DO) VINCENT GADDY (R4DO) - PART 21/50.55 REACTORS (EMAIL)

Event Text

PART 21 REPORT - NA - TYPE ACTUATOR OUTER CLUTCH RING ANOMALY

The following was received via fax:

"Rotork Controls Inc. has identified a potential concern as defined under 10 CFR Part 21 with model NA1 [nuclear A-range (inside containment)] and NA5 [seismic component] nuclear safety related actuators manufactured [and shipped] between January 1, 1979 and December 31, 1982. Switch mechanism in these actuators utilize an Outer Clutch Ring ([Part number =] N40039) made from beryllium copper. [Duke Energy] has reported (4) instances of Outer Clutch Ring failure between 2000 and 2019 [at Catawba and McGuire]. All failures occurred in Outer Clutch Rings made from beryllium copper.

"The number of affected actuators remaining installed is thought to be low and those still installed are approaching the end of their 40 year service life.

"Rotork cannot assess the risk further. Rotork recommends licensed operators assess this potential failure mode if actuators from this date range are still installed and should consider risk if affected actuators are to remain in service beyond 40 years.

"Failure of the Outer Clutch Ring results in:
1) lost travel limit switch operation in open and closed directions;
2) lost auxiliary switch operation for open and closed indication limits;
3) lost mechanical torque latch operation, if fitted.
Torque limit sensing is not affected. AOP [Add-On-Pack] operation is not affected."

"In 1982, Rotork changed the Outer Clutch Ring material to spring steel 'to improve setting and operation.'"

Rotork Controls, Inc.
675 Mile Crossing Blvd.
Rochester, New York 14624
tel: 1-585-247-2304
fax: 1-585-247-2308
www.rotork.com
info@rotork.com

Power Reactor	Event Number: 54289
Facility: BRAIDWOOD Region: 3 State: IL Unit: [1] [] [] RX Type: [1] W-4-LP,[2] W-4-LP NRC Notified By: RICHARD ROWE HQ OPS Officer: CATY NOLAN	Notification Date: 09/23/2019 Notification Time: 14:15 [ET] Event Date: 09/23/2019 Event Time: 11:06 [CDT] Last Update Date: 09/23/2019
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): ROBERT DALEY (R3DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

A/R

100

Power Operation

Hot Standby

Event Text

AUTOMATIC REACTOR TRIP DUE TO LOWERING STEAM GENERATOR LEVELS

"At 1106 CDT Braidwood Unit 1 experienced an automatic reactor trip due to lowering steam generator water levels following closure of the 1B steam generator feed water regulating valve.

"The cause of the 1B steam generator feedwater regulating valve failing closed is unknown at this time and is under investigation.

"Both trains of auxiliary feedwater started automatically following the reactor trip to maintain steam generator water levels.

"All systems responded as expected with the exception of intermediate range nuclear instrument N-36 which was identified as being undercompensated following the reactor trip. Both source range nuclear instruments were manually energized in accordance with station procedures. Steam generator power operated relief valves lifted momentarily and reseated as designed in response to the secondary transient due to the reactor trip. The main steam dump valves are in service to the main condenser to provide heat sink cooling. The plant is being maintained at normal operating pressure and temperature. AC power is being provided by offsite power with the diesel generators in stand by and all safety systems available. There is no impact to Unit 2.

"This report is being made per 10 CFR 50.72(b)(2)(iv)(B) for a RPS actuation, 4 hour notification, and per 10 CFR 50.72(b)(3)(iv)(A) for an automatic actuation of the auxiliary feedwater system, 8 hour notification.

"The NRC Resident Inspector has been informed."

Page Last Reviewed/Updated Wednesday, March 24, 2021