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Event Notification Report for February 12, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
2/11/2020 - 2/12/2020

** EVENT NUMBERS **


54510 54517 54519 54520

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Agreement State Event Number: 54510
Rep Org: SC DEPT OF HEALTH & ENV CONTROL
Licensee: PRISMA HEALTH BAPTIST HOSPITAL
Region: 1
City: Columbia   State: SC
County:
License #: 076
Agreement: Y
Docket:
NRC Notified By: ADAM GAUSE
HQ OPS Officer: KERBY SCALES
Notification Date: 02/03/2020
Notification Time: 13:42 [ET]
Event Date: 01/29/2020
Event Time: 00:00 [EST]
Last Update Date: 02/03/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MARK HENRION (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - INCORRECT ORGAN RECEIVED TREATMENT

The following was received from the South Carolina Department of Health and Environmental Control via email:

"The South Carolina Department of Health and Environmental Control was notified on 02/03/2020 of a potential medical event involving a prostate seed implant. The procedure occurred on 01/29/2020, and the licensee's radiation safety officer was notified of the potential medical event on 02/03/2020. The prescribed dose to the prostate was 145 Gray, with 76 seeds being implanted. Total activity of the seeds is being reported as 26.6 milliCuries. The licensee is reporting that the seeds were implanted into the bladder and not the prostate. As of 01/31/2020, 41 seeds of the implanted 76 seeds were still implanted in the patient. The licensee is also reporting the loss of 35 seeds. The prostate seed manufacturer is ISOAID, LLC ADVANTAGE I-125. The model of the seeds is IAI-125A. This event is still under investigation by the licensee and the South Carolina Department of Health and Environmental Control."

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.

Notified R1DO (Henrion) and NMSS Events (email)

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Power Reactor Event Number: 54517
Facility: SOUTH TEXAS
Region: 4     State: TX
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RONALD ROHAN
HQ OPS Officer: BETHANY CECERE
Notification Date: 02/11/2020
Notification Time: 14:45 [ET]
Event Date: 02/11/2020
Event Time: 10:07 [CST]
Last Update Date: 02/11/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
RAY AZUA (R4DO)
FFD GROUP (EMAIL)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

FITNESS-FOR-DUTY REPORT - POLICY VIOLATION

"On February 11, 2020, a licensed Senior Reactor Operator violated the station's fitness-for-duty policy. The employee's access to South Texas has been terminated.

"The NRC Resident Inspector has been notified."

The employee tested positive on a follow-up test for alcohol.

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Part 21 Event Number: 54519
Rep Org: C&D TECHNOLOGIES, INC.
Licensee: C&D TECHNOLOGIES, INC.
Region: 1
City: BLUE BELL   State: PA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: BOB MALLEY
HQ OPS Officer: BETHANY CECERE
Notification Date: 02/11/2020
Notification Time: 17:07 [ET]
Event Date: 02/03/2020
Event Time: 00:00 [EST]
Last Update Date: 02/11/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
BRICE BICKETT (R1DO)
ERIC MICHEL (R2DO)
ROBERT RUIZ (R3DO)
- PART 21/50.55 REACTORS (EMAIL)

Event Text

PART 21 REPORT - CONTAINER FAILURE IN KCR-07 BATTERIES

The following is a synopsis of a Part 21 report received by email:

"On December 6, 2019, Browns Ferry Nuclear Plant notified C&D of an issue with a KCR-07 battery where a crack had developed in the container wall, and electrolyte levels had dropped below the low-level line. C&D issued a Return Material Authorization to the customer, and the batteries were returned and analyzed. On February 3, 2020, this battery was analyzed, and the cause of the crack was determined to be caused by expansion of the post seals directly stressing the container walls. Although this unit passed capacity testing after return to C&D, undetected loss of electrolyte in field units could impact the operability of KCR-07 systems in the field. Accordingly, C&D is submitting this report to the NRC and notifying C&D's customers that use KCR-07 batteries[, manufactured prior to January 2012,] of this report.

"The battery manufacturing date is on the label.

"C&D implemented corrective actions to eliminate expansion of the positive post seal and to reinforce cover designs in 2011. Information from laboratory testing and field experience has shown that these corrective actions were effective at eliminating excessive stress in the post seal, cover, and container.

"If you have any questions or wish to discuss this matter or this report, please contact:
Robert Malley, VP Customer Experience, bmalley@cdtechno.com, (215) 619-7830 [or]
Kristen Jamison, Nuclear Applications Engineer, kjamison@cdtechno.com, (215) 775-1306."

The following Utilities/Plants are affected: Exelon Fitzpatrick, Exelon Limerick, First Energy Perry, TVA Browns Ferry, TVA Sequoyah, TVA Watts Bar.

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Part 21 Event Number: 54520
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: KERBY SCALES
Notification Date: 02/11/2020
Notification Time: 17:09 [ET]
Event Date: 02/11/2020
Event Time: 00:00 [EST]
Last Update Date: 02/11/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
Person (Organization):
BRICE BICKETT (R1DO)
ERIC MICHEL (R2DO)
ROBERT RUIZ (R3DO)
RAY AZUA (R4DO)
- PART 21/50.55 REACTORS (EMAIL)

Event Text

PART 21 REPORT - AMETEK 85-RP2675-01 POWER SUPPLY MOUNTING HARDWARE

The following is a synopsis of a Part 21 report received by email:

"SUMMARY - AMETEK Solidstate Controls recently discovered a concern with the structural integrity of the 85-RP2675-01 Rack Mounted Power supply. While qualifying a replacement part for an obsolete breaker, the left panel of the power supply came loose after the hardware had sheared during the seismic simulation testing of the qualification. The loss of structural integrity of the power supply led to internal shorting and a premature stoppage of the simulation testing.

"PROBLEM - During a seismic event, a structural failure of the power supply enclosure resulting in a loss of output could occur. At this point, it is suspected that the failure is related to a variation in the components that increased strain on the power supply enclosure, and it is indeterminate if there is a widespread deviation. It is also possible that the cause of the failure is attributed to inadequately sized hardware that supports the bottom panel of the power supply. In the current design, there are 3 #10-32 machine screws through each of the side panels that fasten to the bottom panel to support the transformer.

"AMETEK is unable to identify the actual structural support of power supplies in the field. In the recent testing performed, no support was provided under the power supply during the testing. If there is support in the end application from the bottom of the power supply, there may not be a structural concern as the connection screws would not be exposed to the same forces. In this instance, the power supply had been exposed to a peak acceleration of approximately 4.8 giga second. It should also be noted that acceptable results have been obtained in previous seismic tests and changes have not been made to the structure of the power supply since its initial design in 1996.

"ACTION RECOMMENDED - At this time, there are no actions to take as the evaluation is ongoing. The next step is to determine if the screws are likely to become overstrained with enough seismic force. To do this, AMETEK is repeating the test with two new power supplies. One power supply will not have any changes made to the structure while the second power supply will be enhanced to improve its seismic withstand capabilities.

"The enhancement is an increase in the size of the hardware to 1/4 inch bolts that connects the side panels to the bottom panel through 5/16 inch through holes with a nut and washers. In combination, these changes will increase the force required to shear the hardware [and] reduce the force on the bolt itself by allowing some movement to dampen the forces during a seismic event. While AMETEK believes this solution will be suitable, it has not been validated with a follow up seismic simulation test. Additionally, AMETEK is unable to determine the criticality of the applications the power supplies are installed in and if the safety function is required to be maintained during a seismic event, which will determine the need to take corrective actions.

"A report of the next seismic test results will follow upon completion as a final evaluation. The current expected date for completion is May, 2020. For questions or clarifications in the meantime, please contact Ethan Salsbury, Quality Director, at 1-614-410-6293."


Page Last Reviewed/Updated Wednesday, February 12, 2020
Wednesday, February 12, 2020