Event Notification Report for September 24, 2021

EN Revision Imported Date: 9/24/2021

EN Revision Text: PART 21 REPORT - VACUUM BREAKERS FAILURE TO CLOSE

The following is a summary of the report provided by Framatome Inc.:

Identification of Component: Siemens 5kV 1200A Vacuum Breakers - 5-DPU-350-1200-78

Nature of Defect:
Framtome reported during dedication testing / inspection that a batch of 5-DPU-350-1200-78 MV vacuum breakers exhibited sporadic failure to close upon both electrical and mechanical closure signals. This was entered in their Corrective Action Program and troubleshooting / testing was completed at the Siemens manufacturing facility. Using a high speed camera to troubleshoot, they determined the close latch does not have sufficient torsional force to consistently maintain the breaker close latch in the closed position during the closing cycle. In some instances the breaker will receive a close signal and the close latch will not maintain the breaker in a closed position and the breaker will fail to close. It has been observed in testing that this condition is sporadic and that subsequent attempts to close the breaker will result in a closed breaker. The issue has no impact on the breakers staying closed once they have successfully closed. The issue has no impact on the ability for the breakers to open.

Number and Location of Basic Components:
The reportable defect is similar to design on the 22 breakers delivered and 19 installed at St. Lucie Unit 1, during refueling cycle 30. St. Lucie was notified on May 28, 2021 by Framatome Inc. via telephone and email.

Corrective Actions to Date:
Preliminary evaluation determined a modification of the breakers is required to increase the torsion spring force acting on the close latch. Framatome is working with Siemens to develop a long-term solution to increase the torsional spring force acting on the close latch. An interim solution utilizing a revised spring retaining bracket could be deployed near-term.

Gayle Elliott
Deputy Director, Licensing & Regulatory Affairs
Framatome Inc.
3315 Old Forest Road
Lynchburg, Va. 24501
Office (434-832-3347)
Mobile (434-841-0306)

* * * UPDATE FROM GAYLE ELLIOT TO HOWIE CROUCH AT 1538 EDT ON 9/23/21 * * *

The following information was received from Framatome via email:

"The preliminary evaluation determined a modification of the breakers was required to increase the torsion spring force acting on the close latch. Framatome worked with Siemens to develop an interim and long-term solution. The interim solution utilized a revised spring retaining bracket that could be deployed near-term. The original long-term solution was a new torsion spring design which applied approximately 40 percent more torsional force on the trip latch.

"Following a reoccurrence of the failure-to-close issue, Framatome and Siemens identified the root cause of the trip latch bounce and [determined] the associated corrective actions. The solution developed will mitigate all main failure to close causes (low power to the closing mechanism, insufficient time for the trip latch to drop, and improper trip latch to jackshaft interaction) for the 5kV replacement circuit breakers. The solution consists of the following:
1) Circuit breakers comply with the following revised design performance parameters:
a. Jackshaft rotational speed (C speed #2)
b. Jackshaft overtravel
c. Jackshaft overtravel duration
2) Circuit breakers have the new torsion spring installed
3) Circuit breakers meet the revised bump stop gap

"By increasing the bump stop gap, the jackshaft is now able to rotate further before it hits the bump stop. This reduces the amount of force transferred to the bump stop and in turn the operating mechanism. This reduction significantly reduces the amount of latch bounce for this breaker design.

"St. Lucie was first notified of this 10CFR21 reportable defect on May 28, 2021 by Framatome Inc. via telephone and email."

Notified R2DO (Miller) and Part 21 group via email.

EN Revision Imported Date: 9/24/2021

EN Revision Text: AGREEMENT STATE REPORT - DAMAGED TROXLER MOISTURE DENSITY GAUGE

The following information was received from the state of Oklahoma via email:

"We [Oklahoma Department of Environmental Quality] have been informed that earlier today a Troxler Model 3440 gauge was struck by a truck in Oklahoma City. The gauge belonged to CEC Corp. (OK-31047-01). Surveys of the gauge indicated that the shielding was intact. [The State] will provide more information as it becomes available."

Troxler Model 3440 gauges contain 40 mCi Am241:Be and 8 mCi Cs-137 sources.

EN Revision Imported Date: 9/24/2021

EN Revision Text: AGREEMENT STATE REPORT - RADIOGRAPHY DEVICE MALFUNCTION

The following information was received from the state of California via email:

"On 9/14/2021, the licensee contacted the Radiation Health Branch (RHB) to report an incident that occurred on 9/13/2021 in which a radiography exposure device failed to retract to the fully shielded position. The licensee reported that after completing their second exposure shot, the radiography crew cranked the source to the fully shielded position which actuated the fully shielded source position indicator. The crew reverse cranked the source to confirm that the source was locked into the fully shielded position and discovered that the source was still exposed. The radiographers were able to lock the source into the final position after manipulating the locking mechanism manually. The licensee reported an exposure maximum of 33 millirem to one of the radiographers due to this incident. At this time, the licensee does not expect an overexposure to either radiographers nor members of the public. RHB will be investigating this incident further."

EN Revision Imported Date: 9/24/2021

EN Revision Text: AGREEMENT STATE REPORT - MISSING RADIOACTIVE SOURCE

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

"On September 16, 2021, at 1020 [EDT], the licensee notified the Massachusetts Radiation Control Program (RCP) via telephone of a missing 5 millicurie Cs-137 sealed source. The source has been missing since the last inventory performed by the licensee on August 16, 2021. Upon discovery, the licensee subsequently searched for the source with survey meters on their licensed premises and could not locate it. Personnel involved with the use of the source were immediately interviewed and later all employees were interviewed. To the date of this report the licensee has not found the source.

"The only item related to the source that was discovered was the top cover to the lead shielding container. The shielding cylinder and the sealed Cs-137 source are still missing.

"The licensee written report and RCP on-site inspection are pending. The Agency considers this matter still OPEN."

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 Imported Date: 9/24/2021

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 7.09 Ci of tritium each, were reported as lost during annual registration. The owner recalled that the signs had been removed many years ago."

NMED No.: CO210020

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 Imported Date: 9/24/2021

EN Revision Text: AGREEMENT STATE REPORT - FOUR LOST TRITIUM EXIT SIGNS

The following was received from the Colorado Department of Health via email:

"Four exit signs, each containing 6.2 Ci of tritium, were reported as lost during annual registration. New owner as of 04/01/2021. Upon inspecting the property, unable to locate signs registered with the State."

NMED No.: CO210029

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 Imported Date: 9/24/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

The following was received from the Colorado Department of Health via email:

"One exit sign, containing 7.5 Ci of tritium, was reported as lost during annual registration."

NMED No.: CO210028

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 Imported Date: 9/24/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

The following was received from the Colorado Department of Health via email:

"One exit sign, containing 17.5 Ci of tritium, was reported as lost during annual registration. An exhaustive search resulted in the belief that the contractor never installed the sign."

NMED No.: CO210027

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 Imported Date: 9/24/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

The following was received from the Colorado Department of Health via email:

"One exit sign, containing 9.2 Ci of Tritium, was reported as lost during annual registration. The owner was not able to locate the sign on the property and the owner was unsure of when the sign was removed."

NMED No.: CO210026

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 Imported Date: 9/24/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

The following was received from the Colorado Department of Health via email:

"One exit sign, containing 7.5 Ci of tritium, was reported as lost during annual registration. There was a change of ownership in 2019. The sign was lost or replaced prior to new ownership."

NMED No.: CO210025

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 Imported Date: 9/24/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

The following was received from the Colorado Department of Health via email:

"One exit sign, containing 7.03 Ci of tritium, reported as lost during annual registration. The business moved to a new location. It was most likely disposed of with other demolition debris when vacated."

NMED No.: CO210021

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 Imported Date: 9/24/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

The following information was received via email:

"One exit sign, containing 12.57 Ci of tritium, was reported as lost during annual registration. The location of the sign is unknown."

NMED No.: CO210024


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 Imported Date: 9/24/2021

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 Imported Date: 9/24/2021

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 6.2 Ci of tritium each, reported as lost during the annual registration. Licensee is unable to locate."

NMED No.: CO210023

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 Imported Date: 9/24/2021

EN Revision Text: CAAS ALARM NOT CLEARLY AUDIBLE

During routine Criticality Accident Alarm System (CAAS) maintenance on July 20, 2021, UUSA [(URENCO USA)] staff identified an area in which the CAAS alarm was not clearly audible. The alarm was (and is) functioning, but not at an adequate level of sound pressure to meet the acceptance criteria. UUSA arranged compensatory measures which achieve an equivalent safety function within 24 hours in the affected area. The affected area was in the Immediate Evacuation Zone (IEZ), outside of the area in which licensed special nuclear material is handled, used, or stored.

On September 16, 2021, an NRC inspector conducting an onsite inspection informed UUSA staff that given the potential that the alarm had not been clearly audible for a period of time between surveillances, this event should have been reported within 24 hours to the NRC in accordance with 10 CFR 70.50(b)(2) in which equipment is disabled or fails to function as designed when required by regulation (10 CFR 70.24).

The licensee will notify the NRC Region 2.

EN Revision Imported Date: 9/24/2021

EN Revision Text: AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

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

"On September 17, 2021, the Agency was notified by the licensee that a Troxler 3411 moisture density gauge containing a 40 milliCurie americium - 241 source and an 8 milliCurie cesium - 137 source was damaged at a temporary job site. The licensee reported that while the gauge was sitting on the ground and not being used it was run over by a bulldozer, snapping the operating arm of the cesium source. The source was in the shielded position when the event occurred and a radiation survey of the gauge after the event verified it was still fully shielded. The licensee stated the gauge would be returned to its storage location and arrangements would be made to have the gauge disposed of. No individual received an exposure that exceeded any limit. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident No.: 9885

* * * UPDATE FROM ART TUCKER TO THOMAS HERRITY AT 11:23 ON 09/20/21 * * *
The following information was received via e-mail:

"Received pictures of the gauge. Pictures show the rod for the cesium source was bent. The dose rate meter appears to be reading 0.8 millirem per hour."

Notified R4DO (YOUNG) and NMSS Events Notification group.

EN Revision Imported Date: 9/24/2021

EN Revision Text: HIGH PRESSURE COOLANT INJECTION SYSTEM DECLARED INOPERABLE

"During planned testing of the Unit 1 HPCI [high pressure coolant injection] system, flow controller oscillations occurred which prevented successful completion of the surveillance test. Operators secured Unit 1 HPCI and declared the system inoperable."

HPCI inoperable placed the licensee in a 14-day limiting condition for operation that was extended to 30 days after their risk-informed completion time evaluation was done.

The licensee has notified the NRC Resident Inspector.