Event Notification Report for July 21, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/20/2021 - 07/21/2021
Power Reactor
Event Number: 55370
Facility: Susquehanna
Region: 1 State: PA
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Robert DiPietro
HQ OPS Officer: Ossy Font
Region: 1 State: PA
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Robert DiPietro
HQ OPS Officer: Ossy Font
Notification Date: 07/21/2021
Notification Time: 20:50 [ET]
Event Date: 07/21/2021
Event Time: 18:26 [EDT]
Last Update Date: 07/21/2021
Notification Time: 20:50 [ET]
Event Date: 07/21/2021
Event Time: 18:26 [EDT]
Last Update Date: 07/21/2021
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):
GRAY, MEL (R1)
GRAY, MEL (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | A/R | Y | 100 | Power Operation | 0 | Hot Standby |
EN Revision Imported Date: 8/20/2021
EN Revision Text: AUTOMATIC REACTOR SCRAM
"At 1826 EDT on July 21, 2021, Susquehanna Steam Electric Station Unit 1 reactor automatically scrammed due to a trip of the Main Turbine.
"Unit 1 reactor was operating at 100 percent reactor power with no evolutions in progress. The Control Room received indication of a Main Turbine trip with both divisions of RPS [Reactor Protection System] actuated and all control rods inserted. The Reactor Recirculation Pumps tripped on EOC-RPT [end of cycle recirculation pump trip]. Reactor water level lowered to +8 inches causing Level 3 (+13 inches) isolations. No ECCS [Emergency Core Cooling Systems] or RCIC [Reactor Core Isolation Cooling system] actuations occurred. The Operations crew subsequently maintained reactor water level at the normal operating band using Reactor Feed Water.
"The reactor is currently stable in Mode 3 with main condenser available. Investigation into the trip of the Main Turbine is in progress.
"The NRC Resident Inspector was notified. A voluntary notification to PEMA will be made.
"This event requires a 4 hour ENS notification in accordance with 10CFR50.72(b)(2)(iv)(B) and an 8 hour ENS notification in accordance with 10CFR50.72(b)(3)(iv)(A) and 10CFR50.72(b)(3)(iv)(B)."
EN Revision Text: AUTOMATIC REACTOR SCRAM
"At 1826 EDT on July 21, 2021, Susquehanna Steam Electric Station Unit 1 reactor automatically scrammed due to a trip of the Main Turbine.
"Unit 1 reactor was operating at 100 percent reactor power with no evolutions in progress. The Control Room received indication of a Main Turbine trip with both divisions of RPS [Reactor Protection System] actuated and all control rods inserted. The Reactor Recirculation Pumps tripped on EOC-RPT [end of cycle recirculation pump trip]. Reactor water level lowered to +8 inches causing Level 3 (+13 inches) isolations. No ECCS [Emergency Core Cooling Systems] or RCIC [Reactor Core Isolation Cooling system] actuations occurred. The Operations crew subsequently maintained reactor water level at the normal operating band using Reactor Feed Water.
"The reactor is currently stable in Mode 3 with main condenser available. Investigation into the trip of the Main Turbine is in progress.
"The NRC Resident Inspector was notified. A voluntary notification to PEMA will be made.
"This event requires a 4 hour ENS notification in accordance with 10CFR50.72(b)(2)(iv)(B) and an 8 hour ENS notification in accordance with 10CFR50.72(b)(3)(iv)(A) and 10CFR50.72(b)(3)(iv)(B)."
Agreement State
Event Number: 55371
Rep Org: COLORADO DEPT OF HEALTH
Licensee: UCHealth Greeley Hospital
Region: 4
City: Greenley State: CO
County:
License #: CO 1276-01
Agreement: Y
Docket:
NRC Notified By: Timothy Thorvaldson
HQ OPS Officer: Thomas Herrity
Licensee: UCHealth Greeley Hospital
Region: 4
City: Greenley State: CO
County:
License #: CO 1276-01
Agreement: Y
Docket:
NRC Notified By: Timothy Thorvaldson
HQ OPS Officer: Thomas Herrity
Notification Date: 07/22/2021
Notification Time: 10:25 [ET]
Event Date: 07/21/2021
Event Time: 00:00 [MDT]
Last Update Date: 07/22/2021
Notification Time: 10:25 [ET]
Event Date: 07/21/2021
Event Time: 00:00 [MDT]
Last Update Date: 07/22/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
O'KEEFE, NEIL (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
O'KEEFE, NEIL (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 8/20/2021
EN Revision Text: AGREEMENT STATE REPORT - Y-90 MICROSPHERE UNDERDOSE
The following was received from the Colorado Department of Public Health and Environment via email:
"Y-90 TheraSphere procedure misadministration: 60.8 mCi was the prescribed dose and 0 mCi was the administered dose."
Colorado Event Report ID No.: CO 210017
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 - Y-90 MICROSPHERE UNDERDOSE
The following was received from the Colorado Department of Public Health and Environment via email:
"Y-90 TheraSphere procedure misadministration: 60.8 mCi was the prescribed dose and 0 mCi was the administered dose."
Colorado Event Report ID No.: CO 210017
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.
Agreement State
Event Number: 55372
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: Titan Inspection, Inc.
Region: 1
City: Williamsport State: PA
County:
License #: PA-1559
Agreement: Y
Docket:
NRC Notified By: John S. Chippo
HQ OPS Officer: Joanna Bridge
Licensee: Titan Inspection, Inc.
Region: 1
City: Williamsport State: PA
County:
License #: PA-1559
Agreement: Y
Docket:
NRC Notified By: John S. Chippo
HQ OPS Officer: Joanna Bridge
Notification Date: 07/22/2021
Notification Time: 13:58 [ET]
Event Date: 07/21/2021
Event Time: 00:00 [EDT]
Last Update Date: 07/23/2021
Notification Time: 13:58 [ET]
Event Date: 07/21/2021
Event Time: 00:00 [EDT]
Last Update Date: 07/23/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
GRAY, MEL (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
GRAY, MEL (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 8/23/2021
EN Revision Text: AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE FAILED TO RETRACT
The following was received via an email from the Pennsylvania Bureau of Radiation:
"The licensee reported that on July 21, 2021, while using a QSA Global Model 880 containing a 135.5 curie source of iridium-192, the source failed to fully retract and lock. The source serial number is 32578M and the camera serial number is D9477. The technicians secured the area by adjusting their 2 mR/hr boundaries to an unshielded source distance and immediately contacted their company [Radiation Safety Officer] (RSO). The licensee then contacted QSA Global who will be onsite on July 22, 2021, to retrieve the source and take the camera and entire crank and assembly mechanism with them for evaluation. The licensee will remain onsite to secure the boundary until QSA arrives. No overexposures have occurred and all proper procedures were followed. The cause of the malfunction remains unknown. More information will be provided when received."
Pennsylvania Event Report ID No.: PA210007
* * * UPDATE ON 7/23/2021 AT 0738 EDT FROM JOHN CHIPPO TO JEFFREY WHITED * * *
The following update was received via an email from the Pennsylvania Bureau of Radiation:
"QSA arrived on site at approximately 2000 EDT on July 22, 2021, and the source was moved to a locked position in the camera at 2155 EDT. At this time the drive cable is suspected to be the problem. The camera and drive system will be evaluated."
Notified R1DO (Gray) and NMSS Events Notification via email.
EN Revision Text: AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE FAILED TO RETRACT
The following was received via an email from the Pennsylvania Bureau of Radiation:
"The licensee reported that on July 21, 2021, while using a QSA Global Model 880 containing a 135.5 curie source of iridium-192, the source failed to fully retract and lock. The source serial number is 32578M and the camera serial number is D9477. The technicians secured the area by adjusting their 2 mR/hr boundaries to an unshielded source distance and immediately contacted their company [Radiation Safety Officer] (RSO). The licensee then contacted QSA Global who will be onsite on July 22, 2021, to retrieve the source and take the camera and entire crank and assembly mechanism with them for evaluation. The licensee will remain onsite to secure the boundary until QSA arrives. No overexposures have occurred and all proper procedures were followed. The cause of the malfunction remains unknown. More information will be provided when received."
Pennsylvania Event Report ID No.: PA210007
* * * UPDATE ON 7/23/2021 AT 0738 EDT FROM JOHN CHIPPO TO JEFFREY WHITED * * *
The following update was received via an email from the Pennsylvania Bureau of Radiation:
"QSA arrived on site at approximately 2000 EDT on July 22, 2021, and the source was moved to a locked position in the camera at 2155 EDT. At this time the drive cable is suspected to be the problem. The camera and drive system will be evaluated."
Notified R1DO (Gray) and NMSS Events Notification via email.
Part 21
Event Number: 56178
Rep Org: Tioga Pipe Inc.
Licensee: Tioga Pipe Inc.
Region: 1
City: Easton State: PA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Bryan Nichols
HQ OPS Officer: Ian Howard
Licensee: Tioga Pipe Inc.
Region: 1
City: Easton State: PA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Bryan Nichols
HQ OPS Officer: Ian Howard
Notification Date: 10/24/2022
Notification Time: 16:21 [ET]
Event Date: 07/21/2021
Event Time: 00:00 [EDT]
Last Update Date: 10/25/2022
Notification Time: 16:21 [ET]
Event Date: 07/21/2021
Event Time: 00:00 [EDT]
Last Update Date: 10/25/2022
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)
Dentel, Glenn (R1DO)
Part 21/50.55 Reactors, - (EMAIL)
Miller, Mark (R2DO)
Dentel, Glenn (R1DO)
Part 21/50.55 Reactors, - (EMAIL)
EN Revision Imported Date: 10/26/2022
EN Revision Text: PART 21 - TIOGA PIPE PURCHASED AND SUPPLIED UNQUALIFIED PIPING
The following information was provided by Tioga Pipe via email:
"Tioga Pipe Inc. purchased unqualified [piping] from Maxim Tubes Company PVT. LTD. The unqualified [piping] passed all required tests and examinations in accordance with the requirements of ASME NCA-4255.5, however, the material was identified with multiple linear indications located on the inside diameter [surface] of the pipe. The indications were discovered by Duke Energy during their pre-fabrication inspection at the Catawba Nuclear Station. The indications ranged from one quarter of an inch to well over an inch in length. This material along with the material with the same heat number at McGuire Nuclear Station was returned to Tioga Pipe for further evaluation. The evaluation found these indications to be lap-like and thus, rejectable in accordance with ASME SA999 paragraph 28.12.
"All material supplied from Maxim Tubes Company PVT. LTD. has been identified by Duke, found not to be installed, and returned to Tioga Pipe. At this time, all of the defective material is in Tioga's possession and there is no risk of this defective material being installed into a nuclear facility."
* * * UPDATE ON 10/25/2022 AT 1657 EDT FROM SHANNON ECHOLS TO IAN HOWARD * * *
Mackson Nuclear, a Tioga Company, submitted the Tioga report referenced above via email.
Notified Part 21/50.55 Reactors group via email.
EN Revision Text: PART 21 - TIOGA PIPE PURCHASED AND SUPPLIED UNQUALIFIED PIPING
The following information was provided by Tioga Pipe via email:
"Tioga Pipe Inc. purchased unqualified [piping] from Maxim Tubes Company PVT. LTD. The unqualified [piping] passed all required tests and examinations in accordance with the requirements of ASME NCA-4255.5, however, the material was identified with multiple linear indications located on the inside diameter [surface] of the pipe. The indications were discovered by Duke Energy during their pre-fabrication inspection at the Catawba Nuclear Station. The indications ranged from one quarter of an inch to well over an inch in length. This material along with the material with the same heat number at McGuire Nuclear Station was returned to Tioga Pipe for further evaluation. The evaluation found these indications to be lap-like and thus, rejectable in accordance with ASME SA999 paragraph 28.12.
"All material supplied from Maxim Tubes Company PVT. LTD. has been identified by Duke, found not to be installed, and returned to Tioga Pipe. At this time, all of the defective material is in Tioga's possession and there is no risk of this defective material being installed into a nuclear facility."
* * * UPDATE ON 10/25/2022 AT 1657 EDT FROM SHANNON ECHOLS TO IAN HOWARD * * *
Mackson Nuclear, a Tioga Company, submitted the Tioga report referenced above via email.
Notified Part 21/50.55 Reactors group via email.
Agreement State
Event Number: 55855
Rep Org: Kansas Dept of Health & Environment
Licensee: Kansas State University
Region: 4
City: Hutchinson State: KS
County:
License #: 38-C011-01
Agreement: Y
Docket:
NRC Notified By: Kimberly Steves
HQ OPS Officer: Kerby Scales
Licensee: Kansas State University
Region: 4
City: Hutchinson State: KS
County:
License #: 38-C011-01
Agreement: Y
Docket:
NRC Notified By: Kimberly Steves
HQ OPS Officer: Kerby Scales
Notification Date: 04/22/2022
Notification Time: 17:03 [ET]
Event Date: 07/21/2021
Event Time: 00:00 [CDT]
Last Update Date: 04/22/2022
Notification Time: 17:03 [ET]
Event Date: 07/21/2021
Event Time: 00:00 [CDT]
Last Update Date: 04/22/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
Proulx, David (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Proulx, David (R4DO)
AGREEMENT STATE REPORT - DAMAGED PORTABLE GAUGE
The following was received from the state of Kansas via email:
"On 4/21/22 during the course of an inspection of the facility, the State of Kansas discovered that an incident involving one of their portable gauges occurred on 7/21/2021. This incident was never reported to Kansas and was discovered through the inspection process.
"Licensee Kansas State University (# 38-C011-01) had a Campbell Pacific Nuclear model 503 portable gauge (serial number 50505) damaged while being used in a field at the Hutchinson, Kansas field research station. The gauge contained 50 mCi of AmBe. The gauge was run over when the student who was using the gauge under the oversight of the local RSO [Radiation Safety Officer] (unknown at this time if the local RSO was present at the site) backed a vehicle over it. At this time Kansas has not been able to determine if the student left the gauge unattended for a brief time or if the student did not properly secure the gauge into the vehicle and it fell out. The gauge was inspected immediately after the incident, and it was found that, though the gauge shielding appeared to be intact, the shipping case was damaged. Immediately following the incident, the student contacted their Primary Investigator (PI), who is a university instructor overseeing the student's project, to inform him of the incident, but it was reported that the PI asked if it was urgent and the student said no. The gauge was discovered damaged by the PI a week later on 7/28/2021.
"Upon discovery, the PI reported that he ordered a new shipping case and ordered leak tests. The leak tests were performed on 7/29/2021 and did not show damage to the source. The damage to the gauge housing was on the opposite side of the machine from the source and did not interfere with the source's insertion or retraction. Because of this, the licensee stated that they decided it was not reportable to Kansas. An investigation is underway to determine what steps were taken by the licensee, including possible repairs to the unit. Follow-up information will be provided as it is obtained."
The following was received from the state of Kansas via email:
"On 4/21/22 during the course of an inspection of the facility, the State of Kansas discovered that an incident involving one of their portable gauges occurred on 7/21/2021. This incident was never reported to Kansas and was discovered through the inspection process.
"Licensee Kansas State University (# 38-C011-01) had a Campbell Pacific Nuclear model 503 portable gauge (serial number 50505) damaged while being used in a field at the Hutchinson, Kansas field research station. The gauge contained 50 mCi of AmBe. The gauge was run over when the student who was using the gauge under the oversight of the local RSO [Radiation Safety Officer] (unknown at this time if the local RSO was present at the site) backed a vehicle over it. At this time Kansas has not been able to determine if the student left the gauge unattended for a brief time or if the student did not properly secure the gauge into the vehicle and it fell out. The gauge was inspected immediately after the incident, and it was found that, though the gauge shielding appeared to be intact, the shipping case was damaged. Immediately following the incident, the student contacted their Primary Investigator (PI), who is a university instructor overseeing the student's project, to inform him of the incident, but it was reported that the PI asked if it was urgent and the student said no. The gauge was discovered damaged by the PI a week later on 7/28/2021.
"Upon discovery, the PI reported that he ordered a new shipping case and ordered leak tests. The leak tests were performed on 7/29/2021 and did not show damage to the source. The damage to the gauge housing was on the opposite side of the machine from the source and did not interfere with the source's insertion or retraction. Because of this, the licensee stated that they decided it was not reportable to Kansas. An investigation is underway to determine what steps were taken by the licensee, including possible repairs to the unit. Follow-up information will be provided as it is obtained."