Event Notification Report for October 06, 2021

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
10/05/2021 - 10/06/2021

Agreement State
Event Number: 55495
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: Turner Specialty Services
Region: 4
City: Nederland   State: TX
County:
License #: L 05417
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Kerby Scales
Notification Date: 09/28/2021
Notification Time: 13:50 [ET]
Event Date: 09/27/2021
Event Time: 00:00 [CDT]
Last Update Date: 09/28/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
PROULX, DAVID (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
Event Text
EN Revision Imported Date: 10/6/2021

EN Revision Text: AGREEMENT STATE REPORT - UNRETRACTABLE SOURCE

The following was received from the state of Texas (the Agency) via email:

"On September 27, 2021, the licensee notified the Agency that one of its industrial radiography crews working at a temporary job site had been unable to retract the source. The crew was using a QSA 880D exposure device, containing a 35 curie iridium-192 source, and they had placed it on pipe approximately two feet off the ground so the guide tube/collimator would reach where the shot was to be taken. After cranking out the source, they recognized the drive cable was not straight and when they pulled back to straighten it, the device fell and bent the guide tube and the source could not be retracted. The source was cranked into the collimator and the radiographers stayed outside their barricade until an authorized person arrived to retrieve the source. The authorized person pulled back on the camera and the guide tube straightened enough so they could retract the source into the fully shielded/locked position. No one received an overexposure as a result of this event. The camera was taken to the manufacturer and the inspection found no issues. The guide tube was removed from service and will be disposed. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident Number: 9887


Agreement State
Event Number: 55496
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: Jacksonville Cardiovascular Center, P.L.
Region: 1
City: Jacksonville   State: FL
County:
License #: 3725-2
Agreement: Y
Docket:
NRC Notified By: Paul Norman
HQ OPS Officer: Kerby Scales
Notification Date: 09/28/2021
Notification Time: 13:45 [ET]
Event Date: 09/28/2021
Event Time: 00:00 [EDT]
Last Update Date: 09/28/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
SCHROEDER, DAN (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
Event Text
EN Revision Imported Date: 10/6/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST SOURCE

The following is summary of an event received from the state of Florida via email:

A Cs-137 source (184.3 microcuries) was discovered missing at the Reception and Medical Center (RMC) of the Lake Butler Nuclear Medicine Department, at the Lake Butler Department of Corrections (DOC). The medical center is contracted to operate under Jacksonville Cardiovascular Center. The building is a modular trailer. The missing source was noted during a scheduled inventory. The source is believed to have been moved or relocated by the DOC during construction to repair a collapsed floor. The source is believed to be somewhere in the trailer.

Florida Incident Number: FL21-122

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: 55498
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: Universal Engineering Sciences
Region: 1
City: Tampa   State: FL
County:
License #: 2884-1
Agreement: Y
Docket:
NRC Notified By: David Pieski
HQ OPS Officer: Kerby Scales
Notification Date: 09/29/2021
Notification Time: 17:28 [ET]
Event Date: 09/29/2021
Event Time: 09:10 [EDT]
Last Update Date: 09/29/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
SCHROEDER, DAN (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
Event Text
EN Revision Imported Date: 10/6/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST TROXLER GAUGE

The following is a summary of an email received from the state of Florida:

At approximately 1645 EDT on 9/29/21, the Universal Engineering Sciences (UES) Radiation Safety Officer (RSO) called to report a lost Troxler gauge (Model 3440 with a 8 milliCurie Cs-137 and 40 milliCurie Am-241:Be source) that fell off a company truck. The loss occurred at approximately 0910 EDT, 9/29/21. The driver/operator failed to place the gauge in its case, departed job site in company truck, and later realized the loss. Several UES employees unsuccessfully searched the truck route for the gauge. The RSO contacted the Tampa and the Tampa International Airport Police Department to appraise the situation.

FL incident no.:21-124

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: 55499
Rep Org: NEVADA RADIOLOGICAL HEALTH
Licensee: GenesisCare USA, LLC
Region: 4
City: Las Vegas   State: NV
County:
License #: 03-12-13639-01
Agreement: Y
Docket:
NRC Notified By: John Follette
HQ OPS Officer: Kerby Scales
Notification Date: 09/29/2021
Notification Time: 18:41 [ET]
Event Date: 09/28/2021
Event Time: 00:00 [PDT]
Last Update Date: 09/29/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
PROULX, DAVID (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
Event Text
EN Revision Imported Date: 10/6/2021

EN Revision Text: AGREEMENT STATE REPORT - DOSE ADMINISTERED WRONG PATIENT

The following is a summary of a report received from the state of Nevada via telephone and email:

During an inspection on 9/28/21 at Genesis Care, the State discovered that a patient incorrectly received radiation treatment for breast cancer in 2001. Pathology results were accidentally switched resulting in the wrong patient receiving treatment. A patient was treated with a mamosite breast applicator that didn't have breast cancer. The dose received by the patient is unknown at this time. The patient with breast cancer was not treated. The State is following up with the licensee and will provide updated information.

Nevada Item Number: NV210017

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: 55504
Facility: Ginna
Region: 1     State: NY
Unit: [1] [] []
RX Type: [1] W-2-LP
NRC Notified By: Eric Matz
HQ OPS Officer: Jeffrey Whited
Notification Date: 10/04/2021
Notification Time: 08:05 [ET]
Event Date: 10/04/2021
Event Time: 00:31 [EDT]
Last Update Date: 10/04/2021
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
CARFANG, ERIN (R1)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Hot Standby 0 Hot Shutdown
Event Text
EN Revision Imported Date: 10/6/2021

EN Revision Text: VALID SYSTEM ACTUATION

"The 'A' Steam Generator Narrow Range Water Level went less than 17 percent causing an Auxiliary Feed Water System valid actuation signal.

"The Auxiliary Feed Water System was in service at the time of the event providing decay heat removal. There was no adverse effect on plant systems. The Steam Generator Narrow Range Water Level was restored to normal operating band.

"This is being reported per 10 CFR 50.72(b)(3)(iv)(A), which states, 'Any event or condition that results in valid actuation of any of the systems listed in paragraph (b)(3)(iv)(B) of this section, except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation.'

"[Reactor Coolant System] RCS Pressure 340 pounds and RCS Temperature 340 Degrees F."

The NRC Resident Inspector was notified.


Part 21
Event Number: 55505
Rep Org: FLOWSERVE
Licensee:
Region: 1
City: Lynchburg   State: VA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Chris Shaffer
HQ OPS Officer: Brian Lin
Notification Date: 10/04/2021
Notification Time: 12:04 [ET]
Event Date: 08/04/2021
Event Time: 00:00 [EDT]
Last Update Date: 10/04/2021
Emergency Class: Non Emergency
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
Person (Organization):
MILLER, MARK (R2DO)
PART 21/50.55 REACTORS, - (EMAIL)
Event Text
EN Revision Imported Date: 10/6/2021

EN Revision Text: PART 21 - ACTUATOR FAILURE

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

Flowserve - Limitorque was notified by Framatome Nuclear Parts Center that TVA Browns Ferry Nuclear (BFN) plant reported that a Limitorque SMB actuator had failed to operate electrically. It was noted by TVA that the actuator failure was discovered following a recent steam leak in the vicinity of the actuator. Investigation at BFN identified the failed component as the DC electric motor. The motor was removed from the actuator and disassembled by BFN personnel. Subsequently the motor was returned to Flowserve - Limitorque for evaluation. The subject motor is designated as a safety related basic component. Flowserve' s investigation, in conjunction with the motor original equipment manufacturer (OEM), has concluded that during manufacture, the subject motor sustained mechanical damage to the stator assembly field coil which led to the failure. As the dedicating entity, Flowserve is reporting this deviation in the assembly of the motor as a defect per the requirements of 10 CFR 21. Flowserve's investigation has concluded that this manufacturing defect is an isolated occurrence. No other instances of similar mechanical damage to the stator field coil insulation of Peerless DC motors have been observed or reported. The defect is specific to a quantity of one motor originally supplied to Framatome NPC on Limitorque Order Number 164879.001. This motor was subsequently supplied to the TVA Browns Ferry Nuclear Plant.

Identification of Component: Limitorque part # P-140-851-18F0
Description: Peerless 7.5 ft-lb, 250 volt DC motor
Serial Number: E18-99091-2 manufactured in August 2018

Corrective Actions to Date: The motor OEM is implementing additional assembly controls and quality control verification concerning the installation and final appearance of the coil support rod that damaged the stator field coil. This action, to be completed by October 15, 2021 will supplement the existing inspection checks on fully assembled motors, which includes insulation resistance tests and high potential tests which verify the integrity of the motor insulation system.

Technical questions concerning this notification can be directed to Kyle Ramsey, Engineering Specialist, Flowserve - Limitorque Actuation Systems: kramsey@flowserve.com


Power Reactor
Event Number: 55506
Facility: Arkansas Nuclear
Region: 4     State: AR
Unit: [2] [] []
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: Derek Mosher
HQ OPS Officer: Howie Crouch
Notification Date: 10/04/2021
Notification Time: 19:59 [ET]
Event Date: 10/04/2021
Event Time: 14:33 [CDT]
Last Update Date: 10/04/2021
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(ii)(A) - Degraded Condition
Person (Organization):
DIXON, JOHN (R4)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling
Event Text
EN Revision Imported Date: 10/6/2021

EN Revision Text: DEGRADED CONDITION DISCOVERED ON REACTOR VESSEL HEAD PENETRATION

"At 1433 CDT, on October 4, 2021, Arkansas Nuclear One, Unit 2 (ANO-2) completed the analysis related to an indication revealed on head penetration 46 during Reactor Vessel Closure Head inspections. It was determined the indication is not acceptable under ASME code requirements. The indication displays characteristics consistent with primary water stress corrosion cracking. No leak path signal was identified during ultrasonic testing.

"The plant was in cold shutdown at 0 percent power and in Mode 6 for a refueling outage at the time of discovery. Repair actions will be completed prior to plant startup from the outage. This condition has no impact to the health and safety of the public.

"This report is being made in accordance with 10 CFR 50.72(b)(3)(ii)(A) for degradation of a principal safety barrier. This is the only indication that is currently present, however, if additional indications are found, they will also be repaired prior to the plant startup.

"The NRC Senior Resident Inspector has been notified."


Power Reactor
Event Number: 55507
Facility: Beaver Valley
Region: 1     State: PA
Unit: [2] [] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: James Schwer
HQ OPS Officer: Donald Norwood
Notification Date: 10/05/2021
Notification Time: 10:07 [ET]
Event Date: 10/05/2021
Event Time: 06:32 [EDT]
Last Update Date: 10/05/2021
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):
CARFANG, ERIN (R1)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R N 90 Power Operation 0 Hot Standby
Event Text
AUTOMATIC REACTOR TRIP AND AUXILIARY FEEDWATER ACTUATION

"At 0632 EDT on October 5, 2021, with Unit 2 in Mode 1 at approximately 90 percent power for an end of cycle coastdown, the reactor automatically tripped due to an unexpected unblocking of the low power trip logic. The trip was not complex, with all systems responding normally post-trip. There was no equipment inoperable prior to the event that contributed to the reactor trip or adversely impacted plant response. The Auxiliary Feedwater System automatically started as designed in response to the reactor trip. Operations responded and stabilized the plant. Decay heat is being removed by discharging steam to the main condenser using the condenser steam dump valves.

"Beaver Valley Power Station Unit 1 is unaffected and remains at 100 percent power in Mode 1.

"Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). Additionally, the automatic actuation of the Auxiliary Feedwater System is being reported as an eight hour, non-emergency Specific System Actuation per 10 CFR 50.72(b)(3)(iv)(A).

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."


Non-Power Reactor
Event Number: 55509
Facility: Missouri U of Science & Tech (MIST)
RX Type: 200 Kwpool Reactor
Comments:
Region: 0
City: Rolla   State: MO
County: Phelps
License #: R-79
Agreement: Y
Docket: 0500123
NRC Notified By: Ethan Taber
HQ OPS Officer: Brian Lin
Notification Date: 10/05/2021
Notification Time: 13:20 [ET]
Event Date: 10/04/2021
Event Time: 00:00 [CDT]
Last Update Date: 10/05/2021
Emergency Class: Non Emergency
10 CFR Section:
Non-Power Reactor Event
Person (Organization):
TAKAS, MICHAEL (NPR)
TORRES, PAULETTE (PM)
Event Text
TECHNICAL SPECIFICATION VIOLATION

"The Missouri University of Science and Technology Reactor (MSTR) is required by facility Technical Specification 3.3.2 to maintain pool water resistivity above 0.2 MOhm-cm so long as fuel elements are in the pool. TS 3.3.2 continues that 'This requirement may be waived for a period of up to 3 weeks once every 3 years.' On September 13, 2021, pool resistivity dropped below the 0.2 MOhm-cm threshold, triggering the three-week waiver to support water deionization system maintenance. Ion exchange resins for this system were replaced, but the system was not able to be restored to an operational status prior to exceeding the three-week waiver. It is noted that pool resistivity recovered above 0.2 MOhm-cm by September 14, 2021 and was maintained until the system was removed from service to replace the resins (September 28, 2021).

"This report is being made under the provisions of MSTR Technical Specification 6.7.2, requiring a report by telephone to the NRC Headquarters Operations Center no later than the following working day. Under the provisions of MSTR Technical Specification 6.7.2, a written follow-up report will be submitted to the Commission within 14 days. Additional replacement parts will need to be secured and repairs performed to restore operability. It is anticipated that full compliance with TS 3.3.2 will be restored within two weeks (by October 19, 2021)."

Page Last Reviewed/Updated Wednesday, October 06, 2021