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Event Notification Report for July 21, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
7/20/2020 - 7/21/2020

** EVENT NUMBERS **


54757 54760 54774 54775 54792 54794 54795 54796

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Agreement State Event Number: 54757
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: OU Medicine, Inc.
Region: 4
City: Oklahoma City   State: OK
County:
License #: OK-21035-01
Agreement: Y
Docket:
NRC Notified By: Kevin Sampson
HQ OPS Officer: Bethany Cecere
Notification Date: 06/24/2020
Notification Time: 16:31 [ET]
Event Date: 06/23/2020
Event Time: 00:00 [CDT]
Last Update Date: 07/21/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
JEFFREY JOSEY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text



EN Revision Imported Date : 7/22/2020

EN Revision Text: AGREEMENT STATE REPORT - SUSPECTED DOSE TO WRONG ORGAN

The following is a summary of email received from the Oklahoma Department of Environmental Quality (OK DEQ):

OK DEQ was just informed that yesterday, June 23, 2020, a medical event may have occurred involving a patient undergoing radiation therapy to the vagina. The treatment plan called for three (3) fractions delivered by a High Dose Rate (HDR) afterloader. After the first fraction was administered, the therapist noted the presence of fecal matter on the applicator. The licensee is assuming that the applicator was placed in the patient's rectum instead of the vagina. The treatment plan estimated a dose of 0.85 Sv to the rectum due to the procedure. The licensee estimates the actual dose delivered, assuming the applicator was in the rectum, to be 1.5 Sv. The licensee is the University of Oklahoma Health Science Center, OK-03176-01. This is a Type A medical broadscope license. OK DEQ will provide more information as it becomes available.

* * * UPDATE ON 07/21/2020 AT 1549 EDT FROM LIBBY MCCASKILL TO OSSY FONT * * *

The following update was received from the OK DEQ via email:

OK DEQ is correcting the licensee name and license number. Initially, they were reported as the University of Oklahoma Health Science Center, OK-03176-01. The correct licensee is OU Medicine, Inc., License No. OK-21035-01.

Notified R4DO (Drake) and NMSS Event Notification via email.

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.

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Part 21 Event Number: 54760
Rep Org: PARAGON ENERGY SOLUTIONS
Licensee: Paragon Energy Solutions
Region: 4
City: Fort Worth   State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Tracy Bolt
HQ OPS Officer: Brian Lin
Notification Date: 06/30/2020
Notification Time: 17:41 [ET]
Event Date: 06/01/2020
Event Time: 00:00 [CDT]
Last Update Date: 07/21/2020
Emergency Class: Non Emergency
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
Person (Organization):
DAVE WERKHEISER (R1DO)
MARK MILLER (R2DO)
PATRICIA SILVA (R4DO)
- PART 21/50.55 REACTORS (EMAIL)

Event Text



EN Revision Imported Date : 7/22/2020

EN Revision Text: PART 21 - FAILURE OF SIZE 1 AND 2 FREEDOM SERIES AUXILIARY CONTACTS

The following is a summary of information received from Paragon Energy Solutions:

DUKE Harris Nuclear Plant (HNP) has identified instances where Size 1 and 2 Eaton Freedom Series starters have failed to function as expected in assemblies that were originally supplied by NLI. The auxiliary contacts have degraded prematurely and have failed to change state when the starter was energized which has affected indication and other controlling actions within the circuit.

The premature degradation of the auxiliary contacts with the old model NLI special coil, part number: 057018-COIL-1/2, has occurred on size 1 and 2 contactors that were continuously energized with significant run time after approximately 3 to 5 years of service time. HNP has provided information to manage the known degradation. The auxiliary contacts should be replaced at an increased frequency until new auxiliary contacts are installed along with the new design NLI special coil, part number: 057018-COIL-1/2-M.

The nature of the defect is the pre-mature aging of the component within the auxiliary contact mechanism that is adjacent to the operating coil. The starter coil is potentially being subjected to voltages of a nature that elevates the temperature within the starter adjacent to the auxiliary contacts.

It is recommended that the starters and coils be replaced in the applications where the units are being operated in a continuous duty application. It is also recommended that the control transformer be replaced with a true 4:1 ratio transformer. Paragon/NLI has developed a true 4:1 ratio transformer that will provide additional mitigation of this potential over-voltage condition. Replacing the transformer with a true 4:1 ratio reduces the control voltage that is being applied to the control circuit in a manner that will not prevent the unit from providing a sufficient voltage during a degraded voltage condition, and also will not subject the components to a voltage above the ratings when the supply voltage is operated above the nominal 480 VAC bus voltage.

Paragon has no other recommendations as the accelerated aging of the components and the expected life based on the additional heat the units have been subjected to is unknown.

Affected plants:
Sharon Harris
Oconee
Turkey Point
Columbia
North Anna
Waterford
River Bend
Beaver Valley

Should you have any questions regarding this matter, please contact:
Tracy Bolt
Chief Nuclear Officer
Paragon Energy Solutions
817-284-0077
tbolt@paragones.com

* * * UPDATE ON 7/21/20 AT 1241 EDT FROM TRACY BOLT TO ANDREW WAUGH * * *

The following is the summary of an email received from Paragon Energy Solutions:

The root cause of the degraded component is due to the increased voltage and the overall temperature of the starter coil at the elevated voltage. This elevated voltage and temperature has degraded the mechanism of the auxiliary contact operator to a point to which it has become separated from the parent component.

Paragon/NLI has developed a new version of the special coil (part number: 057018-COIL-1/2-M) that operates at a lower temperature than the original special coil that is currently in use at HNP. When the new version of the special coil is subjected to the same voltages, the temperature is lower.

The affected plants have been revised to:
Sharon Harris
Oconee
Turkey Point
Columbia
North Anna

Notified R1DO (Carfang), R2DO (Miller), R4DO (Drake), and Part 21 Reactors Group (email).

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Agreement State Event Number: 54774
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: ECS Mid-Atlantic, LLC
Region: 1
City: Manassas   State: VA
County: Prince William Co.
License #: 683-314-3
Agreement: Y
Docket:
NRC Notified By: Asfaw Fenta
HQ OPS Officer: Brian Lin
Notification Date: 07/10/2020
Notification Time: 11:12 [ET]
Event Date: 07/09/2020
Event Time: 00:00 [EDT]
Last Update Date: 07/10/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - PORTABLE MOISTURE DENSITY GAUGE DAMAGED

The following report was received from the Commonwealth of Virginia via email:

"On July 9, 2020, a representative of the Virginia Radioactive Materials Program (VRMP) received a report from a licensee through the Virginia Department of Emergency Management that a portable nuclear moisture /density gauge was damaged at a temporary jobsite in Manassas, Virginia. The VRMP contacted the licensee immediately and learned that a Bobcat V519 forklift struck the gauge (CPN MC1 Elite, Serial # 30950, containing 10 milliCuries of Cesium-137 and 50 milliCuries of Americium-241/Beryllium). The incident occurred while the gauge operator was running a gauge standardization count in front of the forklift. The guide tube of the gauge was bent and the case was scratched. However, the sources were in the shielded position and the shielding integrity was not damaged. The licensee performed a survey of the gauge and readings observed were less than 0.4 mR/hr at three (3) feet distance from the gauge. The gauge was put in its transport box and returned to the Manassas office. Wipe test samples were taken and results are pending. The VRMP is working with the licensee to obtain additional information and this report will be updated once the licensee's investigation is complete and the information is received."

Virginia report no.: VA-20-003

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Agreement State Event Number: 54775
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: Regents of the Univeristy of California, Los Angeles
Region: 4
City: Los Angeles   State: CA
County:
License #: 1335-19
Agreement: Y
Docket:
NRC Notified By: Andrew Taylor
HQ OPS Officer: Solomon Sahle
Notification Date: 07/10/2020
Notification Time: 20:18 [ET]
Event Date: 07/08/2020
Event Time: 00:00 [PDT]
Last Update Date: 07/10/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
GRETCHEN RIVERA-CAPELLA (NMSS DAY)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The following report was received from the State of California via email:

"On July 10, 2020, the Radiation Safety Officer for the University of California, Los Angeles, notified the Radiologic Health Branch of a Medical Event that occurred with a Varian High Dose Afterloader with an Ir-192 source during an ovarian cancer treatment. The prescribed dose to the intended organ was 24 Gray (2400 rad). Due to an incorrect entry of the catheter length into the treatment delivery system, an unintended dose of 21.8 Gray (2180 rad) was estimated to have been delivered to the large bowel. The dose delivered to the intended organ was initially estimated at 0 Gray (0 rad). The patient and the patient's physician were notified. The licensee's investigation into this medical event is ongoing and will be reviewed further by the California Department of Public Health"

California 5010 report no: 071020

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.

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Power Reactor Event Number: 54792
Facility: Davis Besse
Region: 3     State: OH
Unit: [1] [] []
RX Type: [1] B&W-R-LP
NRC Notified By: Alan Filipiak
HQ OPS Officer: Thomas Kendzia
Notification Date: 07/20/2020
Notification Time: 16:36 [ET]
Event Date: 07/19/2020
Event Time: 20:03 [EDT]
Last Update Date: 07/20/2020
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
Person (Organization):
HIRONORI PETERSON (R3DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION - EMERGENCY SIREN FAILURE

"In the evening of 7/19/20, a report was received from Ottawa County Sheriff Dispatch personnel that a single siren had sounded. Review of the siren system computer log determined Siren 202 in Carroll Township had malfunctioned and sounded at approximately 2003 EDT, and sounded a second time at approximately 2045 EDT while the siren was being polled for troubleshooting. Personnel were dispatched to Siren 202 to deenergize both the AC and DC power to prevent additional soundings. The cause of the siren sounding is under review, but it occurred following storms passing through the area.

"This notification is being made solely as a four-hour, non-emergency notification for a Notification of Other Government Agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi).

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

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Power Reactor Event Number: 54794
Facility: Browns Ferry
Region: 2     State: AL
Unit: [1] [2] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: Todd Christensen
HQ OPS Officer: Thomas Kendzia
Notification Date: 07/20/2020
Notification Time: 18:11 [ET]
Event Date: 07/20/2020
Event Time: 13:25 [CDT]
Last Update Date: 07/20/2020
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):
MARK MILLER (R2DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 43 Power Operation
2 M/R Y 100 Power Operation 0
3 N Y 100 Power Operation 76 Power Operation

Event Text

BIOFOULING OF INTAKE STRUCTURE LEADS TO MANUAL REACTOR SCRAM OF UNIT 2 AND DOWNPOWER OF UNITS 1 & 3

"On July 20, 2020, at 1325 hours Central Daylight Time, Brown's Ferry Unit 2 inserted a manual reactor scram due to degrading main condenser vacuum from marine biofouling at the intake structure. Brown's Ferry Unit 1 performed a down power to 43% and Unit 3 down powered to 76%. Conditions are stable on both Unit 1 and 3 following unit down power.

"Primary Containment Isolations Systems received an actuation signal for groups 2, 3, 6, and 8 on reactor water level below +2". All Primary Containment Isolations System groups that received an actuation signal performed as designed. Additionally, all other systems functioned as designed.

"This event is reportable within 4 hours per 10CFR50.72(b)(2)(iv)(B) - Any event or condition that results in actuation of the reactor protection system (RPS) when the reactor is critical except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation.

"This event also requires an 8 hour report per 10CFR 50.72(b)(3)(iv)(A), "Any event or condition that results in valid actuation of any of the systems listed in paragraph (b)(3)(iv)(B), (1) Reactor protection system (RPS) including: reactor scram or reactor trip, except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation and (2) General containment isolation signals affecting containment isolation valves in more than one system or multiple main steam isolation valves (MSIVs).

"The NRC Resident Inspector has been notified."

All control rods fully inserted and decay heat is being removed via normal feedwater and condenser.

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Power Reactor Event Number: 54795
Facility: Browns Ferry
Region: 2     State: AL
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: Todd Christensen
HQ OPS Officer: Thomas Herrity
Notification Date: 07/21/2020
Notification Time: 08:58 [ET]
Event Date: 07/21/2020
Event Time: 04:35 [CDT]
Last Update Date: 07/21/2020
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):
MARK MILLER (R2DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 40 Power Operation 0 Hot Shutdown

Event Text

BIOFOULING OF INTAKE STRUCTURE LEADS TO MANUAL REACTOR SCRAM OF UNIT 1

The following was received from TVA - Brown's Ferry at 0858, 21 July 20.

"On July 21, 2020, at 0435 hours Central Daylight Time, Browns Ferry Unit 1 inserted a manual reactor scram due to degrading main condenser vacuum from marine biofouling at the intake structure. Browns Ferry Unit 2 is in Mode 4 and Browns Ferry Unit 3 is at approximately 76% rated thermal power and stable.

"Primary Containment Isolation Systems received an actuation signal for groups 2, 3, 6, 8 on reactor water level below +2". All Primary Containment Isolation System groups that received an actuation signal performed as designed. Additionally, all other systems functioned as designed.

"This event is reportable within 4 hours per 10CFR50.72(b)(2)(iv)(B) - Any event or condition that results in actuation of the reactor protection system (RPS) when the reactor is critical except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation.

"This event also requires an 8 hour report per 10CFR50.72(b )(3)(iv)(A), Any event or condition that results in valid actuation of any of the systems listed in paragraph (b)(3)(iv)(B), (1) Reactor protection system (RPS) including: reactor scram or reactor trip, except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation and (2) General containment isolation signals affecting containment isolation valves in more than one system or multiple main steam isolation valves (MSIVs).

"The NRC Resident Inspector has been notified."

The plant is stable in Mode 3 and will remain shutdown until marine growth clogging the intake structure abates.

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Power Reactor Event Number: 54796
Facility: Robinson
Region: 2     State: SC
Unit: [2] [] []
RX Type: [2] W-3-LP
NRC Notified By: Kirk Schauer
HQ OPS Officer: Ossy Font
Notification Date: 07/21/2020
Notification Time: 12:42 [ET]
Event Date: 07/21/2020
Event Time: 08:51 [EDT]
Last Update Date: 07/21/2020
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(i) - Plant S/D Reqd By Ts
Person (Organization):
MARK MILLER (R2DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 99 Power Operation

Event Text

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN

"At 0851 EDT on July 21, 2020, a Technical Specification required shutdown was initiated at Robinson Unit 2. Technical Specification LCO 3.0.3 was entered due to LCO 3.1.7 not being met as a result of indication loss on Control Rod positions with more than one position indication inoperable for a group. LCO 3.0.3 was entered at 0752 EDT to initiate action within 1 hour to place the unit in MODE 3 within 7 hours. Since a Technical Specification required shutdown was initiated, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(i).

"Technical Specification LCO 3.0.3 was exited at 1003 EDT on July 21, 2020.

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

Shutdown was initiated and power was reduced approximately 3 percent. Reactor power was back to 98.5 percent at the time of notification.


Page Last Reviewed/Updated Wednesday, July 22, 2020
Wednesday, July 22, 2020