Event Notification Report for October 07, 2021

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
10/06/2021 - 10/07/2021

EVENT NUMBERS
55403 55498 55499 55500 55507 55509
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 55403
Facility: Fermi
Region: 3     State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: Levi Smith
HQ OPS Officer: Lloyd Desotell
Notification Date: 08/11/2021
Notification Time: 11:32 [ET]
Event Date: 08/11/2021
Event Time: 06:34 [EDT]
Last Update Date: 10/06/2021
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
SKOKOWSKI, RICHARD (R3)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation
Event Text
EN Revision Imported Date: 10/7/2021

EN Revision Text: HPCI INOPERABILITY

"At 0634 EDT on August 11, 2021 [high pressure coolant injection] HPCI was declared inoperable due to a pump flow controller problem. The cause of the controller problem is unknown at this time and is under investigation.

"[Reactor core isolation cooling] RCIC was verified operable per Tech Spec 3.5.1 E.1.

"This report is being made pursuant to 10CFR50.72(b)(3)(v)(D) based on an unplanned HPCI inoperability.

"There was no impact on the health and safety of the public or plant personnel.

"The NRC Resident Inspector has been notified."

* * * RETRACTION FROM WHITNEY HEMMINGWAY TO KAREN COTTON ON 10/6/2021 AT 1036 EDT * * *
"The purpose of this notification is to retract a previous report made on August 11, 2021 (EN 55403). At 0634 EDT on August 11, 2021, an unplanned inoperability of the High Pressure Coolant Injection system (HPCI) was reported pursuant to 10 CFR 50.72(b)(3)(v)(D) by EN 55403. HPCI was declared inoperable due to receipt of an alarm associated with the pump flow controller. The HPCI system operating procedure states that HPCI should be declared inoperable when this alarm is received. The cause of the alarm, a loose transmitter connection, was identified and corrected. Following clearance of the alarm, HPCI was declared operable at approximately 1930 EDT on August 11, 2021.

"This alarm indicated a fault in the signal from the transmitter to the HPCI flow controller; in this case, the HPCI flow controller would have continuously called for maximum HPCI flow. The controller is configured with a high limiter to prevent an overspeed trip. An engineering evaluation of the event identified that HPCI was capable of performing its required safety functions while this alarm was present. The condition was that the HPCI flow controller would have continuously called for maximum HPCI flow upon HPCI initiation, however operators would be able to manually control HPCI flow upon HPCI initiation. Additionally HPCI would have run until Reactor Pressure Vessel (RPV) level reached Level 8 where it would trip until RPV level decreased to Level 2 then automatically restart."

The licensee notified the NRC Resident Inspector.
Notified R3DO (Peterson).


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: 10/7/2021

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: 10/7/2021

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.


Agreement State
Event Number: 55500
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: Professional Services Industries
Region: 4
City: Walla Walla   State: WA
County:
License #: WN-IR021-1
Agreement: Y
Docket:
NRC Notified By: James Killingbeck
HQ OPS Officer: Kerby Scales
Notification Date: 09/30/2021
Notification Time: 13:59 [ET]
Event Date: 09/30/2021
Event Time: 05:00 [PDT]
Last Update Date: 09/30/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
PROULX, DAVID (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
CNSC (CANADA), - (EMAIL)
Event Text
EN Revision Imported Date: 10/7/2021

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

The following report was received from the state of Washington via email:

"A pickup truck containing a InstroTek, Inc. Model 3500 Xplorer portable moisture density gauge in the cab was parked overnight at a hotel in Walla Walla, WA. The shipping case was locked and chained to the steering wheel of the pickup truck, and the cab of the pickup truck was locked. During the night, the portable moisture density gauge was stolen. The technician noticed that it was missing at about [0500 PDT]. The theft has been reported to the Walla Walla Police Department."

Gauge Serial Number: 4233
Radionuclides and Activities:
Gamma Source: Cesium-137, 10 millicuries. Source Model Number: Eckert & Ziegler HEG-137. Source Code: HEG-0085. Source Serial Number: BG1234.
Neutron Source: Americium-241:Be, 40 millicuries. Source Model Number: Eckert & Ziegler AM1.N02. Source Code: PHI-0161. Source Serial Number K433/20.
Date of Latest Leak Test of Sealed Sources: February 24, 2021.

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: 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
EN Revision Imported Date: 10/7/2021

EN Revision 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
EN Revision Imported Date: 10/7/2021

EN Revision 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 Thursday, October 07, 2021