Event Notification Report for June 22, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/21/2021 - 06/22/2021
Agreement State
Event Number: 55478
Rep Org: COLORADO DEPT OF HEALTH
Licensee: Rocky Mountain Bottling Co.
Region: 4
City: Wheat Ridge State: CO
County:
License #: GL000979
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Ossy Font
Licensee: Rocky Mountain Bottling Co.
Region: 4
City: Wheat Ridge State: CO
County:
License #: GL000979
Agreement: Y
Docket:
NRC Notified By: Kathryn Mote
HQ OPS Officer: Ossy Font
Notification Date: 09/17/2021
Notification Time: 13:46 [ET]
Event Date: 06/22/2021
Event Time: 00:00 [MDT]
Last Update Date: 09/17/2021
Notification Time: 13:46 [ET]
Event Date: 06/22/2021
Event Time: 00:00 [MDT]
Last Update Date: 09/17/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
AZUA, RAY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
AZUA, RAY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 10/15/2021
EN Revision Text: AGREEMENT STATE REPORT - TWO LOST TRITIUM EXIT SIGNS
The following was received from the Colorado Department of Health via email:
"Two exit signs, containing 9.2 Ci and 10 Ci of tritium, reported as lost during the annual registration. The timeframe of removal is unknown."
NMED No.: CO210022
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
EN Revision Text: AGREEMENT STATE REPORT - TWO LOST TRITIUM EXIT SIGNS
The following was received from the Colorado Department of Health via email:
"Two exit signs, containing 9.2 Ci and 10 Ci of tritium, reported as lost during the annual registration. The timeframe of removal is unknown."
NMED No.: CO210022
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
Power Reactor
Event Number: 55321
Facility: Davis Besse
Region: 3 State: OH
Unit: [1] [] []
RX Type: [1] B&W-R-LP
NRC Notified By: Andrew Miller
HQ OPS Officer: Joanna Bridge
Region: 3 State: OH
Unit: [1] [] []
RX Type: [1] B&W-R-LP
NRC Notified By: Andrew Miller
HQ OPS Officer: Joanna Bridge
Notification Date: 06/22/2021
Notification Time: 16:55 [ET]
Event Date: 06/22/2021
Event Time: 12:08 [EDT]
Last Update Date: 06/22/2021
Notification Time: 16:55 [ET]
Event Date: 06/22/2021
Event Time: 12:08 [EDT]
Last Update Date: 06/22/2021
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(ii)(B) - Unanalyzed Condition
10 CFR Section:
50.72(b)(3)(ii)(B) - Unanalyzed Condition
Person (Organization):
STONE, ANN MARIE (R3)
STONE, ANN MARIE (R3)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
EN Revision Imported Date: 7/22/2021
EN Revision Text: HIGH-ENERGY LINE BREAK DOOR UNABLE TO BE LATCHED
"At 1208 [EDT] on 6/22/2021, the high-energy line break door separating Auxiliary Feedwater Train Rooms 1 and 2 was not able to be latched following normal usage. The door was able to be closed, protecting Train 1 equipment from a break in Room 2. However, it is assumed a break in Room 1 would push the unlatched door open and allow high-energy fluids to enter Room 2. This condition is not bounded by existing design and licensing documents; however, it poses no impact to the health and safety of the public or plant personnel. The door was able to be latched at 1215 [EDT] on 6/22/2021 following repairs to the door latch interlocking mechanism. Therefore, this event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(B). No other equipment was inoperable during this event.
"The NRC Resident Inspector has been notified."
EN Revision Text: HIGH-ENERGY LINE BREAK DOOR UNABLE TO BE LATCHED
"At 1208 [EDT] on 6/22/2021, the high-energy line break door separating Auxiliary Feedwater Train Rooms 1 and 2 was not able to be latched following normal usage. The door was able to be closed, protecting Train 1 equipment from a break in Room 2. However, it is assumed a break in Room 1 would push the unlatched door open and allow high-energy fluids to enter Room 2. This condition is not bounded by existing design and licensing documents; however, it poses no impact to the health and safety of the public or plant personnel. The door was able to be latched at 1215 [EDT] on 6/22/2021 following repairs to the door latch interlocking mechanism. Therefore, this event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(B). No other equipment was inoperable during this event.
"The NRC Resident Inspector has been notified."
Power Reactor
Event Number: 55322
Facility: Cook
Region: 3 State: MI
Unit: [2] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Richard Harris
HQ OPS Officer: Thomas Herrity
Region: 3 State: MI
Unit: [2] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Richard Harris
HQ OPS Officer: Thomas Herrity
Notification Date: 06/23/2021
Notification Time: 01:55 [ET]
Event Date: 06/22/2021
Event Time: 23:31 [EDT]
Last Update Date: 06/23/2021
Notification Time: 01:55 [ET]
Event Date: 06/22/2021
Event Time: 23:31 [EDT]
Last Update Date: 06/23/2021
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
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical 50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
STONE, ANN MARIE (R3)
STONE, ANN MARIE (R3)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | M/R | Y | 100 | Power Operation | 0 | Hot Standby |
EN Revision Imported Date: 7/22/2021
EN Revision Text: MANUAL RX TRIP DUE TO STEAM LEAK IN MOISTURE SEPARATOR RE-HEATER CROSSOVER PIPE
"On June 22, 2021, at 2331 EDT, DC Cook Unit 2 Reactor was manually tripped due to a large steam leak in a crossover pipe of the Moisture Separator Re-heater (MSR) to the low pressure turbine.
"This notification is being made in accordance with 10 CFR 50.72(b)(2)(iv)(B), Reactor Protection System (RPS) actuation as a four (4) hour report, and under 10 CFR 50.72(b)(3)(iv)(A), specified system actuation of the Auxiliary Feedwater System, as an eight (8) hour report.
"The DC Cook Resident NRC Inspector has been notified.
"Unit 2 is being supplied by offsite power. All control rods fully inserted. All Auxiliary Feedwater Pumps started properly. Decay heat is being removed via the Steam Dump System. Preliminary evaluation indicates all plant systems functioned normally following the Reactor Trip. DC Cook Unit 2 remains stable in Mode 3 while conducting the Post Trip Review. No radioactive release is in progress as a result of this event."
Unit 1 was not affected.
EN Revision Text: MANUAL RX TRIP DUE TO STEAM LEAK IN MOISTURE SEPARATOR RE-HEATER CROSSOVER PIPE
"On June 22, 2021, at 2331 EDT, DC Cook Unit 2 Reactor was manually tripped due to a large steam leak in a crossover pipe of the Moisture Separator Re-heater (MSR) to the low pressure turbine.
"This notification is being made in accordance with 10 CFR 50.72(b)(2)(iv)(B), Reactor Protection System (RPS) actuation as a four (4) hour report, and under 10 CFR 50.72(b)(3)(iv)(A), specified system actuation of the Auxiliary Feedwater System, as an eight (8) hour report.
"The DC Cook Resident NRC Inspector has been notified.
"Unit 2 is being supplied by offsite power. All control rods fully inserted. All Auxiliary Feedwater Pumps started properly. Decay heat is being removed via the Steam Dump System. Preliminary evaluation indicates all plant systems functioned normally following the Reactor Trip. DC Cook Unit 2 remains stable in Mode 3 while conducting the Post Trip Review. No radioactive release is in progress as a result of this event."
Unit 1 was not affected.
Agreement State
Event Number: 55323
Rep Org: NORTH CAROLINA DIV OF RAD PROTECTIO
Licensee: Daimler Trucks
Region: 1
City: Cleveland State: NC
County:
License #: TBD
Agreement: Y
Docket:
NRC Notified By: Travis Cartoski
HQ OPS Officer: Thomas Kendzia
Licensee: Daimler Trucks
Region: 1
City: Cleveland State: NC
County:
License #: TBD
Agreement: Y
Docket:
NRC Notified By: Travis Cartoski
HQ OPS Officer: Thomas Kendzia
Notification Date: 06/23/2021
Notification Time: 11:28 [ET]
Event Date: 06/22/2021
Event Time: 00:00 [EDT]
Last Update Date: 06/23/2021
Notification Time: 11:28 [ET]
Event Date: 06/22/2021
Event Time: 00:00 [EDT]
Last Update Date: 06/23/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
DEBOER, JOSEPH (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
DEBOER, JOSEPH (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 7/23/2021
EN Revision Text: AGREEMENT STATE REPORT - LOSS OF RADIOACTIVE MATERIAL
The following report was received from the North Carolina (NC) Division of Health Service Regulation via email:
"A NC General Licensee reports the loss of 8 NRD Advanced Static Control devices. Each device contained Po-210 with an activity of 10 mCi, each. General License: TBD as at the time of this report our General License Coordinator is currently unavailable. The licensee reports that the devices may have been inadvertently disposed of and their search continues at this time. This report remains incomplete but shall be updated to complete and close the record."
Advanced Static Control Device:
Manufacturer: NRD Inc.; Model: P-2021-Z705; S/N's: A2MB768, A2MB770, A2MB771, A2MB775, A2MB777, A2MB731, A2MB736, A2MB738
Sources Information:
Po-210 Activity .01 Ci each
NC Item Number: NC210010
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
EN Revision Text: AGREEMENT STATE REPORT - LOSS OF RADIOACTIVE MATERIAL
The following report was received from the North Carolina (NC) Division of Health Service Regulation via email:
"A NC General Licensee reports the loss of 8 NRD Advanced Static Control devices. Each device contained Po-210 with an activity of 10 mCi, each. General License: TBD as at the time of this report our General License Coordinator is currently unavailable. The licensee reports that the devices may have been inadvertently disposed of and their search continues at this time. This report remains incomplete but shall be updated to complete and close the record."
Advanced Static Control Device:
Manufacturer: NRD Inc.; Model: P-2021-Z705; S/N's: A2MB768, A2MB770, A2MB771, A2MB775, A2MB777, A2MB731, A2MB736, A2MB738
Sources Information:
Po-210 Activity .01 Ci each
NC Item Number: NC210010
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: 55324
Rep Org: Ohio Department of Health
Licensee: Christ Hospital, Cincinnati
Region: 3
City: Cincinnati State: OH
County:
License #: 02120310008
Agreement: Y
Docket:
NRC Notified By: Micheal Snee
HQ OPS Officer: Thomas Herrity
Licensee: Christ Hospital, Cincinnati
Region: 3
City: Cincinnati State: OH
County:
License #: 02120310008
Agreement: Y
Docket:
NRC Notified By: Micheal Snee
HQ OPS Officer: Thomas Herrity
Notification Date: 06/24/2021
Notification Time: 09:29 [ET]
Event Date: 06/22/2021
Event Time: 00:00 [EDT]
Last Update Date: 06/24/2021
Notification Time: 09:29 [ET]
Event Date: 06/22/2021
Event Time: 00:00 [EDT]
Last Update Date: 06/24/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
STONE, ANN MARIE (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
STONE, ANN MARIE (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 7/23/2021
EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT
The following was received from the state of Ohio via email:
"Event occurred on 6/22/21. The patient was scheduled for therapy with Y-90 Sir-Spheres. The prescribed dose was 4389 rem. [However, they] administered only 3336 rem, or 76 percent (-24 percent) of the prescribed dose. During the infusion of the Sir-Sphere particles, the infusion catheter became clogged due to the high volume of particles. The catheter was removed, a new catheter placed and used for the infusion of the remaining particles. Stasis was not reached, there was not a patient event, and the estimated difference in dose to the patient exceeds 50 rem to the liver. There were no negative effect to the individual patient, no additional treatment is necessary as a result of this occurrence (administered therapy is sufficient), and no further actions are necessary to prevent recurrence. The physician notified the patient and [their] personal representative of the event, post therapy on 6/22/2021."
Ohio Item Number: OH210005
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.
EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT
The following was received from the state of Ohio via email:
"Event occurred on 6/22/21. The patient was scheduled for therapy with Y-90 Sir-Spheres. The prescribed dose was 4389 rem. [However, they] administered only 3336 rem, or 76 percent (-24 percent) of the prescribed dose. During the infusion of the Sir-Sphere particles, the infusion catheter became clogged due to the high volume of particles. The catheter was removed, a new catheter placed and used for the infusion of the remaining particles. Stasis was not reached, there was not a patient event, and the estimated difference in dose to the patient exceeds 50 rem to the liver. There were no negative effect to the individual patient, no additional treatment is necessary as a result of this occurrence (administered therapy is sufficient), and no further actions are necessary to prevent recurrence. The physician notified the patient and [their] personal representative of the event, post therapy on 6/22/2021."
Ohio Item Number: OH210005
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: 55808
Facility: Summer
Region: 2 State: SC
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-AP1000,[3] W-AP1000
NRC Notified By: Justin Bouknight
HQ OPS Officer: Brian Lin
Region: 2 State: SC
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-AP1000,[3] W-AP1000
NRC Notified By: Justin Bouknight
HQ OPS Officer: Brian Lin
Notification Date: 03/30/2022
Notification Time: 09:43 [ET]
Event Date: 06/22/2021
Event Time: 00:00 [EDT]
Last Update Date: 03/30/2022
Notification Time: 09:43 [ET]
Event Date: 06/22/2021
Event Time: 00:00 [EDT]
Last Update Date: 03/30/2022
Emergency Class: Non Emergency
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
Person (Organization):
Miller, Mark (R2DO)
Part 21/50.55 Reactors, - (EMAIL)
Miller, Mark (R2DO)
Part 21/50.55 Reactors, - (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 |
EN Revision Imported Date: 4/15/2022
EN Revision Text: PART 21 - POPPET SEAL FAILURE
The following information was provided by the licensee via fax or email:
"This is a non-emergency notification required by 10 CFR 21.21(d)(3)(i). A written notification in accordance with 10 CFR 21.21(d)(3)(ii) will be provided within 30 days.
"On June 22, 2021, VC Summer Nuclear Station (VCSNS) received information indicating that a poppet seal failure in the Feedwater Isolation Valve (FWIV) 'B' control block was due to laminations in the Viton material. The failure occurred on May 12, 2021 and was captured in the corrective action program as CR-21-01263.
"VCSNS completed a Substantial Safety Hazard Evaluation and determined that the laminations in VCSNS poppet seal lots 7064051 and 7081558 constituted a substantial safety hazard. The FWIV poppet seals are responsible for retaining and directing pressurized air to each side of the FWIV actuator for repositioning and maintaining FWIV position in both the open and closed positions.
"The NRC Senior Resident Inspector has been notified."
EN Revision Text: PART 21 - POPPET SEAL FAILURE
The following information was provided by the licensee via fax or email:
"This is a non-emergency notification required by 10 CFR 21.21(d)(3)(i). A written notification in accordance with 10 CFR 21.21(d)(3)(ii) will be provided within 30 days.
"On June 22, 2021, VC Summer Nuclear Station (VCSNS) received information indicating that a poppet seal failure in the Feedwater Isolation Valve (FWIV) 'B' control block was due to laminations in the Viton material. The failure occurred on May 12, 2021 and was captured in the corrective action program as CR-21-01263.
"VCSNS completed a Substantial Safety Hazard Evaluation and determined that the laminations in VCSNS poppet seal lots 7064051 and 7081558 constituted a substantial safety hazard. The FWIV poppet seals are responsible for retaining and directing pressurized air to each side of the FWIV actuator for repositioning and maintaining FWIV position in both the open and closed positions.
"The NRC Senior Resident Inspector has been notified."