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Event Notification Report for June 07, 2021

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
06/06/2021 - 06/07/2021

Part 21
Event Number: 55174
Rep Org: Meggitt Safety Systems Inc.
Licensee: Meggitt Safety Systems Inc.
Region: 4
City: Simi Valley   State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Ayelet Cohen-Tucker
HQ OPS Officer: Jeffrey Whited
Notification Date: 04/06/2021
Notification Time: 12:31 [ET]
Event Date: 02/05/2021
Event Time: 00:00 [PDT]
Last Update Date: 06/04/2021
Emergency Class: Non Emergency
10 CFR Section:
21.21(a)(2) - Interim Eval Of Deviation
Person (Organization):
MILLER, MARK (R1DO)
MILLER, MARK (R2DO)
PELKE, PATRICIA (R3DO)
KOZAL, JASON (R4DO)
PART 21/50.55 REACTORS, - (EMAIL)
Event Text
EN Revision Imported Date: 6/7/2021

EN Revision Text: PART 21 INTERIM REPORT OF DEVIATION

"Meggitt Safety Systems, Inc. (Meggitt) has recently identified situations where the appropriate amount of testing was not performed to verify the acceptability of critical characteristics for commercially procured materials for use in safety related products in the Nuclear Cable Product Line. On February 5, 2021 during an internal audit, it was discovered that material verification for critical characteristics for several components had not been performed in accordance with Meggitt Engineering Document (ER94113 Rev T). These components are used on Meggitt nuclear safety related cables for in-containment instrumentation and control cables. These are also used on fire-resistant (Appendix R) power and control cables. The safety function of the in-containment and Appendix R cables is to reliably interconnect the detection/sensing device to the plant instrumentation during normal and [Loss of Coolant Accident] LOCA conditions and to interconnect the remote control location to critical devices during normal and abnormal/fire conditions respectively. Without the material verification there is a potential that the cables would not perform their Safety function properly.

"Meggitt is revalidating materials and engaging suppliers to satisfy critical characteristics verification requirements. Meggitt's preliminary assessment is that there is no impact to the safety function, however the COVID-19 pandemic has impacted our ability to complete our investigation. As a result, Meggitt is unable to meet the 60 day requirement and requests an additional 60 days to complete the Part 21 Safety Evaluation. The expected completion date is June 4, 2021."

Contact Information:
Jim Healy
Senior Vice-President and General Manager
Meggitt Safety Systems, Inc.
1785 Voyager Ave Simi Valley, CA 93063
(805) 581-8608

* * * UPDATE ON 6/4/21 AT 1641 EST FROM LINA PADEN TO BETHANY CECERE * * *

"Meggitt's evaluation has been concluded with satisfactory results. There is no safety hazard on delivered nuclear cables as a result of inadequate constituent component material verification, nor does the failure to comply potentially cause a substantial safety hazard. These conditions are not reportable under Meggitt Airframe Systems procedure SOP 6045 and regulation 10CFR Part 21 and 10 CFR 50.55(e)."

Notified R1DO (Bickett), R2DO (Miller), R3DO (Dickson), R4DO (Groom), and Part 21 Reactors Group (by email).


Agreement State
Event Number: 55283
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: Raba-Kistner Consultants
Region: 4
City: San Antonio   State: TX
County:
License #: L-01571
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Kerby Scales
Notification Date: 05/30/2021
Notification Time: 14:39 [ET]
Event Date: 05/30/2021
Event Time: 00:00 [CDT]
Last Update Date: 05/30/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
GEPFORD, HEATHER (R4)
ILTAB, (EMAIL)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
CNSNS (MEXICO), - (EMAIL)
Event Text
EN Revision Imported Date: 6/7/2021

EN Revision Text: AGREEMENT STATE REPORT - STOLEN GUAGE

The following was received from the Texas Department of State Health Services (the Agency) via email:

"On May 30, 2021, the Agency was notified by the licensee's radiation safety officer (RSO) that a Humboldt model 5001 EZ was stolen from a truck parked overnight at a technician's home. The gauge contains a 40 millicurie americium - 241 source and an 10 millicurie cesium - 137 source. The technician had taken the gauge home on May 29, 2021. The gauge was locked in the truck with two independent chains and locks. The technician went to their truck at 0900 [CDT] on May 30, 2021 and found both were cut and the transport case and the gauge were stolen. The RSO stated the operating arm was locked in the shielded position. The RSO stated the technician drove around in the immediate area in an attempt to find the gauge. The RSO stated local law enforcement had been notified. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: 9852


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: 55284
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: IRIS NDT
Region: 4
City: Houston   State: TX
County:
License #: L-06435
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Kerby Scales
Notification Date: 05/30/2021
Notification Time: 18:43 [ET]
Event Date: 05/28/2021
Event Time: 15:00 [CDT]
Last Update Date: 05/30/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
GEPFORD, HEATHER (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
WILLIAMS, KEVIN (DIR MSST)
Event Text
EN Revision Imported Date: 6/7/2021

EN Revision Text: AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE TO RADIOGRAPHER

The following was received from the Texas Department of State Health Services via email:

"On May 30, 2021, at approximately [1500] CDT one of the licensee's radiographers reported to the radiation safety officer that on May 28, 2021, he had handled a collimator while the source was in it. The radiographer was using a SPEC 150 camera with a 22 curie Iridium-192 source. The radiographer had taken a shot on top of a 2-inch pipe on a pipe stand. He then set up for the next shot by taking hold of the collimator (back, shielded side) and slid it down to the side of the pipe (90 degree). The beam was always facing the pipe. When he walked back to the camera to crank out the source, he found he had not cranked it back in after the first shot. The radiographer was not wearing an alarming rate meter, a pocket dosimeter, or a dosimetry badge, and he was not carrying/using a survey meter at the time of the incident. The licensee's initial, rough calculations indicate the dose will be lower than the reporting criteria used for this report, but until they can get more information, this report is being made as an immediate report. The radiographer was seen by a physician today and the licensee reported white blood cell counts were normal. The licensee is investigating the event and also why the radiographer did not report the incident when it occurred. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident number not assigned as of the time of the report.


Fuel Cycle Facility
Event Number: 55288
Facility: American Centrifuge Plant
Region: 2     State: OH
Unit: [] [] []
RX Type: Uranium Enrichment Facility
NRC Notified By: Brian Summers
HQ OPS Officer: Donald Norwood
Notification Date: 06/03/2021
Notification Time: 10:04 [ET]
Event Date: 06/03/2021
Event Time: 08:36 [EDT]
Last Update Date: 06/03/2021
Emergency Class: Non Emergency
10 CFR Section:
PART 70 APP A (c) - Offsite Notification/News Rel
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
MILLER, MARK (R2DO)
Event Text
EN Revision Imported Date: 6/7/2021

EN Revision Text: REPORT OF OFFSITE NOTIFICATIONS

"Event meets ACD2-RG-044 App. B N.1 'The licensee shall notify the NRC Operations Center of any event or situation, related to the health and safety of the public or onsite personnel, or protection of the environment, for which a news release is planned or notification to other government agencies has been or will be made. Such an event may include an on-site fatality or inadvertent release of radioactively contaminated materials.'"

"Received preliminary notification from TestAmerica Colorado that there was an exceedance of the Total Suspended Solids NPDES permit limit at Outfall 013. This was not unexpected with the current state of the settling pond above Outfall 013. An Ohio EPA [OEPA] 24 hour non-compliance notification form was filled out and sent to OEPA NPDES inspector.

"Notification [to NRC] concurrent to the OEPA notification."


Agreement State
Event Number: 55286
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH
Licensee: Spencer Municipal Hospital
Region: 3
City: Spencer   State: IA
County:
License #: 0164121M1
Agreement: Y
Docket:
NRC Notified By: Randal S. Dahlin
HQ OPS Officer: Joanna Bridge
Notification Date: 06/01/2021
Notification Time: 14:40 [ET]
Event Date: 04/07/2021
Event Time: 00:00 [CDT]
Last Update Date: 06/07/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
FELIZ-ADORNO, NESTOR (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
RIVERA-CAPELLA, GRETCHEN (NMSS DAY)
Event Text
EN Revision Imported Date: 6/8/2021

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT

The following was received from the state of Iowa via e-mail:

"The licensee reported a potential medical event involving a prostate seed implant therapy. The procedure was performed on April 7, 2021 and the post plan CT scan was conducted on May 27, 2021. The CT scan revealed that a number of seeds were implanted outside of the treatment site. The licensee called and emailed Iowa Department of Public Health (IDPH) Radioactive Materials (RAM) staff on Friday, May 28, 2021. RAM staff, who were out on extended memorial day holiday, did not receive the email or phone message until June 1, 2021 when returning to the office. RAM staff has reached out to the licensee for additional information. RAM staff is intending to conduct a reactive inspection of the licensee [the first week in June]. The licensee will be providing the 15 day written report as required by rule. This event will be updated once the additional information requested from the licensee is received.

"Item Number: IA210002"

* * * UPDATE ON 06/04/2021 AT 1036 EDT FROM RANDAL DAHLIN TO JEFFREY WHITED * * *

The following was received from the Iowa Department of Public Health (IDPH) via e-mail:

"IDPH conducted an onsite investigation on June 3, 2021. This event is being updated based on that investigation.

"It appears that the iodine-125 seeds were implanted correctly on the day of the procedure, but due to swelling of the prostate and the 50 days until the post plan CT when the prostate swelling had reduced, the plan showed 16 seeds outside of the target volume. IDPH staff found no procedural problems with the licensees implant procedure. This possible event will be updated once again when the written report is received from the licensee."

Notified R3DO (Dickson), NMSS EO (Sida) and NMSS Event Notifications (email).

* * * RETRACTION ON 06/07/2021 AT 1527 EDT FROM RANDAL DAHLIN TO LLOYD DESOTELL * * *

The following was received from the Iowa Department of Public Health (IDPH) via e-mail:

"On June 1, 2021 Iowa reported a potential medical event at Spencer Municipal Hospital (License number 0164-1-21-M1) involving Iodine-125 prostate implant seeds. This potential medical event occurred on April 7, 2021 and was discovered by the licensee on May 27, 2021 during their post procedure review. This event was reported to the State on May 28, 2021 and Iowa Department of Public Health (IDPH) Radioactive Materials Program (RAM) staff became aware of the event on June 1, 2021 after the long Memorial Day weekend.

"IDPH RAM staff conducted a reactive inspection at Spencer Municipal Hospital on June 3, 2021 to interview staff involved in the prostate treatment therapy procedure. IDPH staff determined that all seventy-one Iodine-125 seeds were implanted in the correct location of the prostate based on the treatment pre-plan and that when the post procedure CT scan was evaluated it was determined that sixteen seeds had migrated outside of the target volume. Therefore, this does not meet the definition of a reportable medical event per Iowa Administrative Code 641-38.2(136C).

"IDPH program staff had a meeting with NRC Region III staff (Darren Piccirillo and Geoff Warren) via Microsoft Teams on Monday, June 7, 2021 to discuss this potential medical event. Region III staff agreed with IDPH that this seed migration is not a reportable medical event.

"Therefore Iowa is retracting event number 55286 (IA210002)."

Notified R3DO (Kunowski) and NMSS Event Notifications (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.


Power Reactor
Event Number: 55295
Facility: Comanche Peak
Region: 4     State: TX
Unit: [2] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Kris Brigman
HQ OPS Officer: Howie Crouch
Notification Date: 06/07/2021
Notification Time: 18:31 [ET]
Event Date: 06/07/2021
Event Time: 15:27 [CDT]
Last Update Date: 06/07/2021
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):
DRAKE, JAMES (R4)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 100 Power Operation 0 Hot Standby
Event Text
AUTOMATIC REACTOR TRIP ON TURBINE TRIP DUE TO FAULT AND FIRE IN THE MAIN TRANSFORMER

"At 1527 (Central Standard Time) Unit 2 Reactor tripped caused by a turbine trip due to a fault and fire on Unit 2 Main Transformer #1. All Aux Feedwater Pumps started due to steam generator Lo-Lo levels.

"Unit 2 is being maintained in Hot Standby (Mode 3) in accordance with Integrated Plant Operating Procedure IPO-007B. The Emergency Response Guideline Network has been exited. Decay heat is being rejected to the Main Condenser via the steam dump valves.

"Fire was extinguished at 1546 without offsite assistance. No major injuries reported and no personnel transported offsite for medical attention. Cause of the fault and fire are under investigation.

"NRC Resident Inspector has been notified."

All rods inserted into the core during the trip. There were no relief valves or safety valves lifted during the transient. The plant is stable in its normal shutdown electrical lineup via the auxiliary transformer with all safety equipment available. Unit 1 was not affected by the transient.