Event Notification Report for March 10, 2020

U.S. Nuclear Regulatory Commission Operations Center Event Reports For 3/9/2020 - 3/10/2020 ** EVENT NUMBERS **

 

54471

54549

54550

54551

54552

54553

54554

54555

54557

Part 21	Event Number: 54471
Rep Org: CARRIER CORPORATION Licensee: CARRIER CORPORATION Region: 1 City: SYRACUSE   State: NY County: License #: Agreement: Y Docket: NRC Notified By: DAVID KWASIGROCH HQ OPS Officer: BRIAN P. SMITH	Notification Date: 01/10/2020 Notification Time: 13:44 [ET] Event Date: 01/10/2020 Event Time: 00:00 [EST] Last Update Date: 03/09/2020
Emergency Class: NON EMERGENCY 10 CFR Section: 21.21(a)(2) - INTERIM EVAL OF DEVIATION	Person (Organization): STEVEN RUDISAIL (R2DO) - PART 21/50.55 REACTORS (EMAIL)

Event Text

PART 21 - FAILED OIL PUMP DUE TO IMPROPER MOTOR ASSEMBLY The following was received via facsimile: "Duke Energy via Mr. James M. Smith issued a letter to Carrier Corporation's Customer Service Organization on November 21, 2019 reporting that on November 4, 2019, a Carrier 17FA999-1200-107 Oil Pump (Duke Energy UTC Number 30110654) failed rendering one train of the Control Room Area Chilled Water System inoperable. A failure investigation by Duke Energy representatives determined that the oil pump, which had been in service for less than two months, had a broken shaft and failed due to improperly assembled oil pump motor assembly. The failed oil pump and a replacement (spare) oil pump in the warehouse (Duke Energy UTC Number 30078287) both had loose fasteners and unstaked alignment pins. "Prior to Duke Energy's November 21, 2019 notice, Carrier issued a corrective action to their supplier on April 28, 2017 to address failures with a different non-safety related oil pump (Carrier Model 17FA512- 968) at a non-nuclear facility. The corrective action applied to all 17FA oil pump assemblies supplied to Carrier after April 28, 2017, including both safety and non-safety related oil pumps. The corrective action consisted of cleaning of threaded holes and application of red Loctite, ensuring specified torque requirements are met using a calibrated digital torque wrench, and verifying the staking operation. Both oil pump issues described by Duke Energy in the November 21, 2019 notice concerned oil pumps built prior to the April 28, 2017 corrective action. Carrier is not aware of reports of any other defects in pumps in the same series in either nuclear or non-nuclear applications built since the corrective action. "Carrier will provide a final report to the U.S. Nuclear Regulatory Commission no later than March 11, 2020. If you have questions regarding this matter, please contact the undersigned." David Kwasigroch, Associate Director of Engineering, (315) 432-3461, dave.kwasigroch@carrier.com. This issue affects McGuire Nuclear Station. * * * UPDATE ON 3/9/20 AT 1102 EDT FROM DAVID KWASIGROCH TO BETHANY CECERE * * * The following is a synopsis of the additional information in the final report, as received via fax: "Carrier issued a corrective action to our supplier on April 28, 2017 to address failures with a different non-safety related oil pump (Carrier Model 17FA5l2-968) at a non-nuclear facility. The corrective action was applied to all 17FA oil pump assemblies supplied to Carrier after April 28, 2017, including both safety and non-safety related oil pumps. The corrective action consisted of cleaning of threaded holes and application of red Loctite, ensuring specified torque requirements are met using a calibrated digital torque wrench, and verifying the staking operation. "Additional design modifications are being implemented, which consist of: adding an additional set screw with Nylok Patch into the motor housing to secure the stator, installing pressed in dowel pins to hold the pump cover and pump housing together, and the addition of lock tab washers with TorQ-Patch cover bolts to keep the bolts more secure. "Carrier's records indicate that four affected pumps were supplied to three nuclear facilities: the two pumps that were the subject of Duke Energy's notice; one pump supplied to Dominion Energy, Inc.; and one pump supplied to Susquehanna Nuclear, LLC. Carrier mailed letters to the three nuclear facilities on March 5, 2020, to coordinate replacement of the affected pumps. It is not known whether the pumps supplied to Dominion Energy, Inc., or Susquehanna Nuclear, LLC were improperly assembled." Notified R1DO (Finney), R2DO (Davis), and Part 21/50.55 Reactors Group (by email).

Agreement State	Event Number: 54549
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM Licensee: INTERNATIONAL PAPER Region: 1 City: SAVANNAH   State: GA County: License #: GA 143-1 Agreement: Y Docket: NRC Notified By: GREGORY REESE HQ OPS Officer: OSSY FONT	Notification Date: 02/28/2020 Notification Time: 06:54 [ET] Event Date: 05/02/2019 Event Time: 00:00 [EST] Last Update Date: 02/28/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): MARC FERDAS (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - BROKEN DENSITY GAUGE SHUTTER The following is a summary of emails received from the Georgia Department of Natural Resources (the state): On 05/02/2019, the licensee discovered a broken shutter on an Ohmart DSGX GEN2000 fixed density gauge during semi-annual leak testing. The gauge is roughly 15 to 20 feet in the air and contained a 20 mCi Cs-137 source (A-2102 source/SN 61798). The source was barricaded and warnings posted. The source was determined not to be leaking. At the time a reactive inspection was performed. On 08/01/2019, an update was sent to the state. An offsite authorized technician attempted to repair the shutter but was unsuccessful. The radiation source remained in service and barricaded and the RSO continued to actively monitor the source with no leakage detected. The licensee was obtaining a quote for removal/proper disposal and the purchase of a new radiation source for replacement, but the source continues to be operational with no additional risk to workers. The incident was closed on 08/01/2019. Incident Report No.: GA-2019-15 * * * UPDATE ON 2/28/2020 AT 1406 EST FROM GREG REESE TO THOMAS KENDZIA * * * Gauge was replaced and sent to QSA Global for disposal. Source was received at QSA Global on 01/13/2020 and verified to not be leaking. Notified R1DO (Ferdas) and NMSS Event Notification (email).

Agreement State	Event Number: 54550
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM Licensee: PIEDMONT FAYETTE HOSPITAL Region: 1 City: FAYETTEVILLE   State: GA County: License #: GA 1340-1 Agreement: Y Docket: NRC Notified By: GREGORY REESE HQ OPS Officer: OSSY FONT	Notification Date: 02/28/2020 Notification Time: 06:54 [ET] Event Date: 01/18/2019 Event Time: 00:00 [EST] Last Update Date: 02/28/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): MARC FERDAS (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

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

Event Text

AGREEMENT STATE REPORT - IMPROPER DISPOSAL OF I-125 SEED The following is a summary of emails received from the Georgia Department of Natural Resources (the state): On 01/18/2019, the licensee performed a Radioactive Seed Localization (RSL) using 81 microCi of I-125. The tissue and seed were transported to pathology where the pathologist misidentified the seed as a straight clip-non-radioactive and the material was designated for disposal. The Nuclear Technologist realized on 02/06/2019, through paperwork, that the seed could not be accounted for and had improperly gone out through the ordinary waste process at the hospital. On 03/04/2019, the state's reactive inspection report found that the RSL procedure was a two seed implantation. A documentation problem occurred when two separate I-125 seed tracking documents were used instead of one. When the tissue containing the seeds was excised and taken to pathology in a cup, only a single document showing one seed implant made it to pathology. The second document did not arrive, so pathology was unaware that there were two seed implants. This led to one of the seeds being mistaken for a clip. The cup that the tissue was transported in was surveyed at pathology and there was the expected readout, which was attributed to a single seed. Corrective actions include to document seeds acquired for implantation on a single sheet of paper. Efforts were being made to discontinue the RSL program and replace it with a radiofrequency seed localization system that involves no radioactivity. The incident was closed on 03/04 2019. Incident Report No.: GA-2019-10 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: 54551
Rep Org: TENNESSEE DIV OF RAD HEALTH Licensee: BLUES CITY BREWERY, LLC Region: 1 City: Memphis   State: TN County: License #: GL-125 Agreement: Y Docket: NRC Notified By: ANDREW HOLCOMB HQ OPS Officer: OSSY FONT	Notification Date: 02/28/2020 Notification Time: 10:17 [ET] Event Date: 02/19/2020 Event Time: 00:00 [EST] Last Update Date: 02/28/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): MARC FERDAS (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL) ILTAB (EMAIL)

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

Event Text

AGREEMENT STATE REPORT - LOSS OF DEVICES CONTAINING AM-241 The following was received from the Tennessee Division of Radiological Health via email: "During a recent inventory at Blues City Brewery, the environmental health and safety manager discovered that two devices [Industrial Dynamics CI-2GV/3] were missing. Devices had been out of use for 1 - 2 years. Actual activity [of the Am-241 sources] are unknown at this point. The activity will be reported during the follow-up report." Incident Report No.: TN-20-038 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: 54552
Rep Org: LOUISIANA RADIATION PROTECTION DIV Licensee: SOURCE PRODUCTION & EQUIPMENT COMPANY, INC Region: 4 City: SAINT ROSE   State: LA County: License #: LA-2966-L01 Agreement: Y Docket: NRC Notified By: JAMES PATE HQ OPS Officer: THOMAS KENDZIA	Notification Date: 02/28/2020 Notification Time: 15:54 [ET] Event Date: 02/11/2020 Event Time: 00:00 [CST] Last Update Date: 02/28/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JASON KOZAL (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - TWO PERSONNEL EXCEEDED ANNUAL DOSE LIMIT The following was received from the state of Louisiana via email: "On February 11, 2020, Source Production & Equipment Company, Inc. (SPEC) contacted Louisiana Department of Environmental Quality, Emergency & Radiation Services Division, Radiation Section, by email to report that two employees had exceeded their annual five rem limit for the 2019 year. Both employees worked at SPEC in the hot cell room manufacturing Se-75, Ir-192, and Co-60 sources for industrial radiography. Hot Cell employee number 1 received an estimated TEDE of 5,028 mR and Hot Cell Employee number 2 received an estimated TEDE of 5,687 mR for 2019 year." Event Report ID No.: LA20200003

Agreement State	Event Number: 54553
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES Licensee: DESERT NDT LLC dba SHAWCOR Region: 4 City: ABILENE   State: TX County: License #: LO6462 Agreement: Y Docket: NRC Notified By: KAREN BLANCHARD HQ OPS Officer: DONALD NORWOOD	Notification Date: 03/01/2020 Notification Time: 13:52 [ET] Event Date: 03/01/2020 Event Time: 00:00 [CST] Last Update Date: 03/01/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JASON KOZAL (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - LOSS OF CONTROL OF RADIOACTIVE MATERIAL The following information was received via E-mail: This event occurred in Austin, Texas. "On March 1, 2020, one of the licensee's technicians had pulled off the road and was parked in a parking area, sleeping, when local law enforcement pulled up. Local law enforcement wanted to take the technician in for suspicion of DWI. At approximately 0800 CST the technician called the site radiation safety officer and told him of the situation. "Law enforcement stayed with the technician until the tow truck came and took the vehicle to impound at approximately 0830 CST. The vehicle was locked, the alarm on the dark room was activated and the technician took all the keys to the dark room and camera with him. The vehicle was carrying a radiography camera (Spec 150) containing an 80 Curie Iridium-192 source. "The licensee dispatched employees to the impound yard and they arrived at approximately 1015 CST and provided surveillance of the vehicle until it was released to them. They verified that the alarm system on the dark room was still armed and that the camera was present. The truck is being returned to the licensee's facility. "At last report from the licensee, law enforcement had not performed any testing to determine if the technician was under-the-influence. More information will be provided as it is obtained in accordance with SA-300." Texas Incident Number: Not Yet Assigned

Agreement State	Event Number: 54554
Rep Org: MAGRUDER PAVING, LLC Licensee: MAGRUDER PAVING, LLC Region: 3 City: TROY   State: MO County: PHELPS License #: 24-32782-01 Agreement: N Docket: NRC Notified By: DWAYNE MULLER HQ OPS Officer: DONALD NORWOOD	Notification Date: 03/02/2020 Notification Time: 12:45 [ET] Event Date: 02/29/2020 Event Time: 00:00 [CST] Last Update Date: 03/02/2020
Emergency Class: NON EMERGENCY 10 CFR Section: 20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X	Person (Organization): KARLA STOEDTER (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL) ILTAB (EMAIL)

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

Event Text

STOLEN PORTABLE DENSITY MOISTURE GAUGE The licensee left a locked trailer at a job site in Rolla, Missouri Friday evening, 2/28/2020. The trailer contained a locked case, which was chained and locked to the trailer. The case contained a Seaman's portable density moisture gauge, Model Number C300, Serial Number 21274, with a 4.5 mCi Radium-226 source. The trailer, with the gauge inside, was stolen from the job site sometime between Friday evening 2/28/2020 and mid-day Saturday 2/29/2020 when employees of the licensee returned to the job site. The trailer is an enclosed trailer, approximately 14 feet in length, white in color, with no lettering or other readily distinguishable markings on the outside. The licensee notified the Phelps' county sheriff's office. The sheriff's office issued report number 20200263 for this event. 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: 54555
Rep Org: COLORADO DEPT OF HEALTH Licensee: CINEMARK - #346 - GREELEY Region: 4 City: GREELEY   State: CO County: License #: GL001289 Agreement: Y Docket: NRC Notified By: KATHRYN MOTE HQ OPS Officer: DONALD NORWOOD	Notification Date: 03/02/2020 Notification Time: 16:28 [ET] Event Date: 06/08/2019 Event Time: 00:00 [MST] Last Update Date: 03/02/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): RICK DEESE (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL) ILTAB (EMAIL)

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

Event Text

AGREEMENT STATE REPORT - 90 LOST TRITIUM EXIT SIGNS The following information was received via E-mail: "The Cinemark - Number 346 - Greeley Manager reported 90 lost tritium exit signs when conducting the annual reconciliation." According to the Colorado General License Coordinator, the licensee says that the signs were not installed during construction and believes that the signs were never delivered. 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

Non-Agreement State	Event Number: 54557
Rep Org: OCEANEERING INTERNATIONAL Licensee: OCEANEERING INTERNATIONAL Region: 4 City: MORGAN CITY   State: LA County: License #: LA-7396-LO1 Agreement: Y Docket: NRC Notified By: TOMMY JACOBS HQ OPS Officer: OSSY FONT	Notification Date: 03/02/2020 Notification Time: 22:31 [ET] Event Date: 03/02/2020 Event Time: 17:50 [CST] Last Update Date: 03/02/2020
Emergency Class: NON EMERGENCY 10 CFR Section: 20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X	Person (Organization): RICK DEESE (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL) ILTAB (EMAIL)

This material event contains a "Category 3" level of radioactive material.

Event Text

RADIOGRAPHY CAMERA LOST OVERBOARD The licensee reported that a SPEC 150 Model G-60 (s/n: 1507) camera was lost when it fell overboard in the WD73-A area of the Gulf of Mexico. The device contained an 18 Ci iridium-192 source (s/n: 2604). The licensee stated that they will not attempt to retrieve the device. They will also notify the Louisiana Department of Environmental Quality. THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)