Event Notification Report for October 20, 2020

THERMAL EVENT RESULTING IN LOSS OF INTEGRITY OF LICENSED CONTAINER

At 1000 EDT on October 20, 2020, a thermal event occurred inside a hot cell at the Curium facility in Noblesville, Indiana. The thermal event did not result in a chemical or radioactive material release. Prior to the incident, technicians were processing materials containing strontium 82 and 85 (quantities are unknown at this time). The pressure created by the reaction caused the rear door of the hot cell to open approximately eight inches and was immediately shut by the technicians. There is no contamination outside of the hot cell and there were no injured or contaminated personnel. The vessel containing the strontium material was observed to be intact and the resultant fire was extinguished by the hot cell's suppression system. No offsite fire assistance was required. Personnel have not accessed the hot cell due to elevated dose rates. Dose rates outside of the hot cell are within the facility's normal limits and historical averages.

EN Revision Imported Date: 12/8/2020

EN Revision Text: AGREEMENT STATE REPORT - DAMAGED GAUGE

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

"On October 20, 2020, a representative of the Virginia Radioactive Materials Program (VRMP) received a report from a licensee via email that a portable nuclear moisture/density gauge was damaged in a vehicle accident at the intersection of Airport Road and Hwy 156 in Sandston, Virginia. The report indicated that a Troxler soil density gauge (Model 3430, Serial # 36803, containing 8 milliCuries of Cesium-137 and 40 milliCuries of Americium-241/Beryllium) was being transported in its case in the bed of a truck. During the accident, the case was damaged and the gauge housing was cracked, but there appeared to be no significant damage to the baseplate, rod, shielding or sources. The licensee's survey of the gauge yielded readings of 8-10 mR/hr at a 6 inch distance from the gauge. The gauge was returned to the Ashland office then transferred to an intact case and transported to North East Technical Services [(NETS)] for further evaluation. 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."

VA incident no.: VA20005

* * * RETRACTION ON 12/08/20 AT 0922 EST FROM ASFAW FENTA TO SOLOMON SAHLE * * *

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

"On November 4, 2020, VRMP performed a reactive inspection. The inspector noted that on October 20, 2020, the licensee sent the gauge to NETS for leak testing and evaluation. The record from NETS indicated that no removable contamination was detected. It also concluded that every component of the gauge is functioning as it should and the gauge was deemed serviceable for field use. The licensee, however, reported this initially as a damaged gauge because of the small crack observed on the plastic case of the gauge. Since the gauge still functioned properly with no damage to any shielding components, the incident does not meet the reporting requirements of 12VAC5-481-1110 B. 2.(10 CFR 30.50 b.2). Thus, VRMP requests the NRC Operation Center retract this event report. "

Notified R1DO (Bower) and NMSS Event Notification via email.

CONCURRENT REPORT DUE TO NON-RADIATION WORKER INJURY

"A carpenter working in a clean area (not a radiological controlled area) injured his hand and required medical treatment.

"The nature of the hand injury requires reporting to the State of Washington Department of Labor and Industry. This concurrent report is being made in compliance with 10 CFR 70 Appendix A criteria c) which requires the reporting of any event or situation, related to health and safety for which notification to other government agencies has been or will be made."

The licensee also notified the NRC Region 2 office.

AGREEMENT STATE REPORT - MISSING LICENSED MATERIAL

The following information was received from the Commonwealth of Pennsylvania via email:

"On October 20, 2020 the licensee discovered a lost gadolinium-153 source. This source, Eckert and Ziegler Model NES8412, is an attenuation correction source in a SPECT camera. These sources are sold in pairs, and the serial numbers for the pair are R3-129 and R3-130. Only one is missing and it is unknown which it is currently. The licensee believes the sources were present in mid-June when the source holders were removed from the gamma camera in preparation for scrapping. The licensee is investigating to confirm that is true. The sources were nominally 250 mCi (+20%/-10%) each on March 1, 2019. The activity on June 15, 2020 was calculated to be 64 mCi, and on the date of discovery 44 mCi. The licensee has notified its facility and safety staff and is actively searching for the source. The DEP [Department of Environmental Protection] has been in contact with the licensee and will update this event as soon as more information is provided."

PA incident no.: PA200022

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 REPORT - EQUIPMENT FAILED TO FUNCTION AS DESIGNED

The following information was received from the State of Wisconsin, Department of Health Service (DHS) via email:

"On October 20, 2020, the licensee's high dose-rate remote afterloader experienced multiple abnormalities during the administration of a fraction to a patient. Prior to exposure, the device failed to retract its check cable when performing the pre-administration routine. Following the manufacturer's advice, the licensee restarted, and performed a system restore on the device. The routine was then re-initiated and went as expected, with the exception of "Status - Terminated" appearing on the console during the administration. All indications were that the fraction was delivered successfully to the patient. Following the fraction, no information was saved indicating that any fraction had been delivered. The licensee was able to replicate circumstances using radiographic film, and verified that while dose is being delivered as intended, no record is being retained by the software. The licensee worked with a manufacturer's service technician on October 21 to address the issue. They believe they have resolved the immediate hardware and software issues. The manufacturer will continue to follow up on the event. DHS will follow up with the licensee."

WI Incident No.: WI200007

PART 21 REPORT - CAMSHAFT KEY WITH INCORRECT STAMPING

The following is a summary of the report provided by the supplier:

ESI supplied stepped camshaft keys with an incorrect stamping. The keys are stamped "AFT" on one end to identify orientation during installation. Keys supplied by ESI have ''AFT" stamped on the opposite end of where they should be stamped. If installed incorrectly and the condition goes undetected during post-maintenance inspection activities, engine performance could suffer resulting in inability of the emergency diesel generator set to perform its safety-related function. This issue is therefore considered to be a reportable defect as defined by 10CFR-part 21.

The key is used in early Cooper-Bessemer model KSV diesel engines to locate the fuel pump cam on the engine's camshaft. This design has a stepped arrangement to provide 4-1/2 degree timing retard. The key is stamped "AFT" to designate the end facing the generator end of the engine. An additional "CAM" tamping designates the cam (up) surface. In the event the key is stamped incorrectly, it is feasible the key could be installed backward which would advance the timing by 9 degree from the desired position.

Date which the information of the defect or failure was obtained is October 20, 2020.

The extent of condition is limited to the part number supplied on the following two orders:

Part Number (KSV-16-6E#1)
Customer (Nebraska Public Power District (NPPD) - Cooper Nuclear Station)
Purchase Orders:
1. NPPD Purchase Order Number (4500106009), ESI Sales Order Number (3006001), Quantity - 5
2. NPPD Purchase Order Number (4500106222), ESI Sales Order Number (3006017), Quantity - 5

Corrective Actions

For affected users:
Camshaft keys installed on engines: No action is required provided post-maintenance injection timing was verified and subsequent engine performance was successful. An incorrectly installed key would be evident by a shift in fuel injection timing. If injection timing and/or engine performance has not been verified, then additional inspections should be performed to verify installed keys from the above referenced orders are oriented properly.

Camshaft keys in inventory (not-installed) on engines: Cooper Nuclear may elect to correct the mislabeled condition or return to ESI for rework. To correct the condition, surface grind to remove the existing "AFT" stamping. Stamp opposite end with "AFT" designation.

For affected ESI:
The dedication report will be revised to add clarification of the correct end for the "AFT" stamping. This will be completed by December 18, 2020.

Points of Contact: John Kriesel, Engineering Manager and Dan Roberts, Quality Manager at Engine Systems Inc. 175 Freight Rd. Rocky Mount, NC 27804. Office number: 252-977-2720