Event Notification Report for April 11, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/10/2022 - 04/11/2022
Agreement State
Event Number: 55815
Rep Org: SC Dept of Health & Env Control
Licensee: Southern Felt Company Inc.
Region: 1
City: Bethune State: SC
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: Korina Koci
HQ OPS Officer: Brian Lin
Licensee: Southern Felt Company Inc.
Region: 1
City: Bethune State: SC
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: Korina Koci
HQ OPS Officer: Brian Lin
Notification Date: 04/01/2022
Notification Time: 09:42 [ET]
Event Date: 03/30/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/01/2022
Notification Time: 09:42 [ET]
Event Date: 03/30/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/01/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Werkheiser, Dave (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Werkheiser, Dave (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 4/11/2022
EN Revision Text: AGREEMENT STATE REPORT - FAILED INDICATOR
The following information was received from the South Carolina Department of Health and Environmental Control via email:
"During a routine inspection of a licensee's specific license on 03/23/22, the South Carolina Department of Health and Environmental Control was informed that a generally licensed fixed gauging device (80 milliCurie, Kr-85, Mahlo Model 6270, serial number PH847) had a failed indicator and had been repaired by the manufacturer on 01/11/22. Dose rate surveys of the fixed gauging device were performed by Department inspectors and indicated readings below the external radiation levels outlined in the sealed source and device registry certificate. The licensee submitted a written notification of the event to the Department on 03/30/22. This event is still under investigation by the South Carolina Department of Health and Environmental Control."
EN Revision Text: AGREEMENT STATE REPORT - FAILED INDICATOR
The following information was received from the South Carolina Department of Health and Environmental Control via email:
"During a routine inspection of a licensee's specific license on 03/23/22, the South Carolina Department of Health and Environmental Control was informed that a generally licensed fixed gauging device (80 milliCurie, Kr-85, Mahlo Model 6270, serial number PH847) had a failed indicator and had been repaired by the manufacturer on 01/11/22. Dose rate surveys of the fixed gauging device were performed by Department inspectors and indicated readings below the external radiation levels outlined in the sealed source and device registry certificate. The licensee submitted a written notification of the event to the Department on 03/30/22. This event is still under investigation by the South Carolina Department of Health and Environmental Control."
Agreement State
Event Number: 55816
Rep Org: Louisiana Radiation Protection Div
Licensee: Inspection Specialist Inc.
Region: 4
City: Marrero State: LA
County:
License #: LA-4266-L01
Agreement: Y
Docket:
NRC Notified By: James Pate
HQ OPS Officer: Brian Lin
Licensee: Inspection Specialist Inc.
Region: 4
City: Marrero State: LA
County:
License #: LA-4266-L01
Agreement: Y
Docket:
NRC Notified By: James Pate
HQ OPS Officer: Brian Lin
Notification Date: 04/01/2022
Notification Time: 11:07 [ET]
Event Date: 04/01/2022
Event Time: 00:00 [CDT]
Last Update Date: 04/01/2022
Notification Time: 11:07 [ET]
Event Date: 04/01/2022
Event Time: 00:00 [CDT]
Last Update Date: 04/01/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Deese, Rick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Deese, Rick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 4/11/2022
EN Revision Text: AGREEMENT STATE REPORT - SOURCE DISCONNECT OF AN INDUSTRIAL RADIOGRAPHY CAMERA
The following information was received from the Louisiana Department of Environmental Quality (LDEQ) via email:
"On April 1, 2022, LDEQ received this event notification. The licensee was working at Bayer Crop Science, LP performing industrial radiography work on March 28, 2022. At approximately 1051 CDT, the RSO [(Radiation Safety Officer)] was notified of a source disconnect. The event involved a QSA 880 Delta, serial number 7511, source serial number 4806514. The source was an Ir-192 with an activity of 59 Ci. The drive cable end connector had broken off from the drive cable. The source was retrieved back into a shielded condition.
"The person performing the source retrieval received 460 mR exposure.
"The radiographer involved had his pocket ion chamber go off scale and his badge was sent in. The badge read 337 mR which was at the end of the working month."
Louisiana Event Report ID No.: LA 20220004
EN Revision Text: AGREEMENT STATE REPORT - SOURCE DISCONNECT OF AN INDUSTRIAL RADIOGRAPHY CAMERA
The following information was received from the Louisiana Department of Environmental Quality (LDEQ) via email:
"On April 1, 2022, LDEQ received this event notification. The licensee was working at Bayer Crop Science, LP performing industrial radiography work on March 28, 2022. At approximately 1051 CDT, the RSO [(Radiation Safety Officer)] was notified of a source disconnect. The event involved a QSA 880 Delta, serial number 7511, source serial number 4806514. The source was an Ir-192 with an activity of 59 Ci. The drive cable end connector had broken off from the drive cable. The source was retrieved back into a shielded condition.
"The person performing the source retrieval received 460 mR exposure.
"The radiographer involved had his pocket ion chamber go off scale and his badge was sent in. The badge read 337 mR which was at the end of the working month."
Louisiana Event Report ID No.: LA 20220004
Non-Agreement State
Event Number: 55817
Rep Org: Ind Univ-IUPUI/IU Med Center Campus
Licensee: Ind Univ-IUPUI/IU Med Center Campus
Region: 3
City: Indianapolis State: IN
County:
License #: 13-02752-03
Agreement: N
Docket:
NRC Notified By: Michael Martin
HQ OPS Officer: Donald Norwood
Licensee: Ind Univ-IUPUI/IU Med Center Campus
Region: 3
City: Indianapolis State: IN
County:
License #: 13-02752-03
Agreement: N
Docket:
NRC Notified By: Michael Martin
HQ OPS Officer: Donald Norwood
Notification Date: 04/01/2022
Notification Time: 14:25 [ET]
Event Date: 03/31/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/01/2022
Notification Time: 14:25 [ET]
Event Date: 03/31/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/01/2022
Emergency Class: Non Emergency
10 CFR Section:
20.2201(a)(1)(i) - Lost/Stolen LNM>1000x
10 CFR Section:
20.2201(a)(1)(i) - Lost/Stolen LNM>1000x
Person (Organization):
Kozak, Laura (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Kozak, Laura (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 4/11/2022
EN Revision Text: NON-AGREEMENT STATE REPORT - LOST MEDICAL DOSE
The following information was provided by the licensee via telephone and email:
"Two clinical doses of Xofigo [(radium (Ra-223) dichloride, 119 microcuries)] were delivered to the Nuclear Medicine department on 3/31/2022. A patient scheduled for one of the doses on Thursday 3/31/2022 was successfully administered with the activity. A second patient was scheduled to receive the second dose on 4/1/2022 at 1300 EDT.
"At scheduled time, the Nuclear Medicine technologists could not locate the second dose. After a thorough search, the RSO [(Radiation Safety Officer)] was notified. It is suspected that the second dose was accidentally disposed of in the box in which both doses were received.
"The first dose was properly disposed of in a radioactive sharps container, and the second dose remained in the delivery box within the secured hot lab area. It is suspected that a nuclear medicine technologist threw the box away without realizing a second dose was inside, as it is an extremely rare occurrence for two doses to be delivered concurrently. The dose was not detected during the end of day survey nor by portal monitoring at the waste facility, due to the relatively low activity and low yield of x-rays/gamma-rays (Ra-223 is primarily an alpha emitter)."
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: NON-AGREEMENT STATE REPORT - LOST MEDICAL DOSE
The following information was provided by the licensee via telephone and email:
"Two clinical doses of Xofigo [(radium (Ra-223) dichloride, 119 microcuries)] were delivered to the Nuclear Medicine department on 3/31/2022. A patient scheduled for one of the doses on Thursday 3/31/2022 was successfully administered with the activity. A second patient was scheduled to receive the second dose on 4/1/2022 at 1300 EDT.
"At scheduled time, the Nuclear Medicine technologists could not locate the second dose. After a thorough search, the RSO [(Radiation Safety Officer)] was notified. It is suspected that the second dose was accidentally disposed of in the box in which both doses were received.
"The first dose was properly disposed of in a radioactive sharps container, and the second dose remained in the delivery box within the secured hot lab area. It is suspected that a nuclear medicine technologist threw the box away without realizing a second dose was inside, as it is an extremely rare occurrence for two doses to be delivered concurrently. The dose was not detected during the end of day survey nor by portal monitoring at the waste facility, due to the relatively low activity and low yield of x-rays/gamma-rays (Ra-223 is primarily an alpha emitter)."
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: 55819
Rep Org: Ohio Bureau of Radiation Protection
Licensee: Eurofins Environment Testing North Central, LLC
Region: 3
City: Barberton State: OH
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: Stephen James
HQ OPS Officer: Ossy Font
Licensee: Eurofins Environment Testing North Central, LLC
Region: 3
City: Barberton State: OH
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: Stephen James
HQ OPS Officer: Ossy Font
Notification Date: 04/04/2022
Notification Time: 10:57 [ET]
Event Date: 03/29/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/05/2022
Notification Time: 10:57 [ET]
Event Date: 03/29/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/05/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Kozak, Laura (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Kozak, Laura (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 4/12/2022
EN Revision Text: AGREEMENT STATE REPORT - ELECTRON CAPUTRE DETECTOR LEAKING SOURCE
The following information was received from the Ohio Bureau of Radiation Protection via email:
"Report of a leaking General License Ni-63 source (Model: G2397A, S/N: U3951) on an Electron Capture Detector. The source was returned to the manufacturer.
"Leak test result: 20 microcuries (740 kBq)"
NMED Item Number: OH220004
* * * UPDATE ON 4/5/22 AT 1413 EDT FROM S. JAMES TO T. HERRITY * * *
"UPDATES/CORRECTIONS ON LICENSEE NAME, ACTIVITY AND LEAK TEST RESULTS: Leak test was taken on Electron Capture Detector (ECD) in storage as part of 6-month cycle. ECD contained 15 mCi Ni-63 source. Results came back indicating leaking source at 2000 pCi. No contamination of the ECD was found. The ECD will be permanently taken out of service and returned to manufacturer."
Licensee name updated to full name: Eurofins Environment Testing North Central, LLC
Notified R3DO (McCraw) and NMSS Events via email.
EN Revision Text: AGREEMENT STATE REPORT - ELECTRON CAPUTRE DETECTOR LEAKING SOURCE
The following information was received from the Ohio Bureau of Radiation Protection via email:
"Report of a leaking General License Ni-63 source (Model: G2397A, S/N: U3951) on an Electron Capture Detector. The source was returned to the manufacturer.
"Leak test result: 20 microcuries (740 kBq)"
NMED Item Number: OH220004
* * * UPDATE ON 4/5/22 AT 1413 EDT FROM S. JAMES TO T. HERRITY * * *
"UPDATES/CORRECTIONS ON LICENSEE NAME, ACTIVITY AND LEAK TEST RESULTS: Leak test was taken on Electron Capture Detector (ECD) in storage as part of 6-month cycle. ECD contained 15 mCi Ni-63 source. Results came back indicating leaking source at 2000 pCi. No contamination of the ECD was found. The ECD will be permanently taken out of service and returned to manufacturer."
Licensee name updated to full name: Eurofins Environment Testing North Central, LLC
Notified R3DO (McCraw) and NMSS Events via email.
Agreement State
Event Number: 55820
Rep Org: California Radiation Control Prgm
Licensee: Miller Pacific Engineering Group
Region: 4
City: Novato State: CA
County:
License #: 5411-21
Agreement: Y
Docket:
NRC Notified By: Arunika Hewadikaram
HQ OPS Officer: Donald Norwood
Licensee: Miller Pacific Engineering Group
Region: 4
City: Novato State: CA
County:
License #: 5411-21
Agreement: Y
Docket:
NRC Notified By: Arunika Hewadikaram
HQ OPS Officer: Donald Norwood
Notification Date: 04/04/2022
Notification Time: 15:58 [ET]
Event Date: 04/01/2022
Event Time: 00:00 [PDT]
Last Update Date: 04/04/2022
Notification Time: 15:58 [ET]
Event Date: 04/01/2022
Event Time: 00:00 [PDT]
Last Update Date: 04/04/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 4/12/2022
EN Revision Text: AGREEMENT STATE REPORT - TWO STOLEN THEN RECOVERED MOISTURE DENSITY GAUGES
The following information was received via E-mail from the California Department of Public Health - Radiologic Health Branch (RHB):
"On 4/1/22, at 1934 PDT, California Office of Emergency Services (CalOES) contacted RHB to report two moisture density gauges stolen from a licensee's storage facility. The stolen gauges included a CPN Model MC1-DR, S/N MD 80709102 and a CPN Model MC1-Elite, S/N MD 70408697, each containing 10 mCi of Cs-137 and 40 mCi of Am-241. Both gauges were stolen between the hours of approximately 1700 PDT on 3/31/22 and 0900 PDT on Friday, 4/1/2022, from the locked storage shed located in the lower parking lot of the licensee's office [redacted] in Novato, CA. The licensee had notified the Novato Police Department of the theft immediately after it was discovered. On 4/2/22, RHB contacted the licensee and learned that both gauges had been recovered by the Novato PD. They were located on a paved walking trail south of the licensee's office building. Per the RSO [(Radiation Safety Officer)], the gauges did not have any evidence of tampering except minor damage to one of the Type A containers. On 4/4/22, both gauges will be taken to Instrotek for further evaluation and leak testing. "
California 5010 Number: 040122
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 STOLEN THEN RECOVERED MOISTURE DENSITY GAUGES
The following information was received via E-mail from the California Department of Public Health - Radiologic Health Branch (RHB):
"On 4/1/22, at 1934 PDT, California Office of Emergency Services (CalOES) contacted RHB to report two moisture density gauges stolen from a licensee's storage facility. The stolen gauges included a CPN Model MC1-DR, S/N MD 80709102 and a CPN Model MC1-Elite, S/N MD 70408697, each containing 10 mCi of Cs-137 and 40 mCi of Am-241. Both gauges were stolen between the hours of approximately 1700 PDT on 3/31/22 and 0900 PDT on Friday, 4/1/2022, from the locked storage shed located in the lower parking lot of the licensee's office [redacted] in Novato, CA. The licensee had notified the Novato Police Department of the theft immediately after it was discovered. On 4/2/22, RHB contacted the licensee and learned that both gauges had been recovered by the Novato PD. They were located on a paved walking trail south of the licensee's office building. Per the RSO [(Radiation Safety Officer)], the gauges did not have any evidence of tampering except minor damage to one of the Type A containers. On 4/4/22, both gauges will be taken to Instrotek for further evaluation and leak testing. "
California 5010 Number: 040122
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
Part 21
Event Number: 55827
Rep Org: Curtiss Wright Flow Control Co.
Licensee: Tennessee Valley Authority
Region: 3
City: Cincinnati State: OH
County:
License #:
Agreement: N
Docket:
NRC Notified By: Margie Hover
HQ OPS Officer: Brian Lin
Licensee: Tennessee Valley Authority
Region: 3
City: Cincinnati State: OH
County:
License #:
Agreement: N
Docket:
NRC Notified By: Margie Hover
HQ OPS Officer: Brian Lin
Notification Date: 04/07/2022
Notification Time: 15:15 [ET]
Event Date: 02/07/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/07/2022
Notification Time: 15:15 [ET]
Event Date: 02/07/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/07/2022
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)
McCraw, Aaron (R3DO)
Part 21/50.55 Reactors, - (EMAIL)
Miller, Mark (R2DO)
McCraw, Aaron (R3DO)
Part 21/50.55 Reactors, - (EMAIL)
EN Revision Imported Date: 4/11/2022
EN Revision Text: PART 21 - CURTISS-WRIGHT ACTUATOR BRAKE WIRING DEFICENCY REPORT
The following information was provided by Curtiss-Wright Nuclear Division via fax:
"The Tennessee Valley Authority (TVA) Browns Ferry Plant notified us (QualTech NP, Curtiss-Wright Nuclear Division) of two separate RCS/Dresser actuator failures which we had provided as safety related components. According to TVA, the first failure occurred on February 7, 2022, after being installed for approximately 167 days. The 2nd failure occurred on February 9, 2022, and was in service for approximately 24 hours when it failed.
"According to TVA in both cases the actuator's brake assembly wire harness shorted out to the frame, causing the on-board fuse to blow, disabling the actuator. The electrical short was caused by the wire harness laying against a sharp edge of the metal frame, which over time led to fraying of the wire insulation and subsequent bare wire to frame contact.
"Both units were returned to QualTech NP for evaluation and our findings confirmed TVA's assessment.
"The root cause of the issue is friction between the wires and the sharp metallic edge that over time cut through the insulation via vibration, which in turn shorted the power leads to the frame. This shorting effect was due to poor positioning and restraint of the wire harness/bundle by the manufacturer during assembly. It is not considered a design flaw, but a workmanship issue caused by the factory assembler.
"The corrective action taken with the two units was to install new brake assemblies and reposition the wire harness to prevent contact with the sharp edge. In addition, wire ties were added to restrain the wire's movement and keep it away from the sharp edge. As a follow up action, the associated dedication plan will be revised to inspect for this workmanship issue and correct as needed.
"Additional details are provided in the failure evaluation. QualTech NP has only sold this part to TVA (Browns Ferry) and could not find any additional failures of this type reported by the industry. Identification of the customer's orders and hardware involved are provided in the evaluation.
"Please phone (513) 528-7900 if you should have any questions."
EN Revision Text: PART 21 - CURTISS-WRIGHT ACTUATOR BRAKE WIRING DEFICENCY REPORT
The following information was provided by Curtiss-Wright Nuclear Division via fax:
"The Tennessee Valley Authority (TVA) Browns Ferry Plant notified us (QualTech NP, Curtiss-Wright Nuclear Division) of two separate RCS/Dresser actuator failures which we had provided as safety related components. According to TVA, the first failure occurred on February 7, 2022, after being installed for approximately 167 days. The 2nd failure occurred on February 9, 2022, and was in service for approximately 24 hours when it failed.
"According to TVA in both cases the actuator's brake assembly wire harness shorted out to the frame, causing the on-board fuse to blow, disabling the actuator. The electrical short was caused by the wire harness laying against a sharp edge of the metal frame, which over time led to fraying of the wire insulation and subsequent bare wire to frame contact.
"Both units were returned to QualTech NP for evaluation and our findings confirmed TVA's assessment.
"The root cause of the issue is friction between the wires and the sharp metallic edge that over time cut through the insulation via vibration, which in turn shorted the power leads to the frame. This shorting effect was due to poor positioning and restraint of the wire harness/bundle by the manufacturer during assembly. It is not considered a design flaw, but a workmanship issue caused by the factory assembler.
"The corrective action taken with the two units was to install new brake assemblies and reposition the wire harness to prevent contact with the sharp edge. In addition, wire ties were added to restrain the wire's movement and keep it away from the sharp edge. As a follow up action, the associated dedication plan will be revised to inspect for this workmanship issue and correct as needed.
"Additional details are provided in the failure evaluation. QualTech NP has only sold this part to TVA (Browns Ferry) and could not find any additional failures of this type reported by the industry. Identification of the customer's orders and hardware involved are provided in the evaluation.
"Please phone (513) 528-7900 if you should have any questions."
Power Reactor
Event Number: 55828
Facility: Surry
Region: 2 State: VA
Unit: [1] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: Alan Bidlowas
HQ OPS Officer: Thomas Herrity
Region: 2 State: VA
Unit: [1] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: Alan Bidlowas
HQ OPS Officer: Thomas Herrity
Notification Date: 04/07/2022
Notification Time: 16:12 [ET]
Event Date: 04/07/2022
Event Time: 09:09 [EDT]
Last Update Date: 04/07/2022
Notification Time: 16:12 [ET]
Event Date: 04/07/2022
Event Time: 09:09 [EDT]
Last Update Date: 04/07/2022
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Miller, Mark (R2DO)
FFD Group, (EMAIL)
Miller, Mark (R2DO)
FFD Group, (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 |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
EN Revision Imported Date: 4/11/2022
EN Revision Text: FITNESS-FOR-DUTY REPORT - FAILED FITNESS-FOR-DUTY TEST
The following information was provided by the licensee via phone call:
"At 0909 EDT on 4/7/2022, it was determined that a security officer tested positive during a random fitness-for-duty test. The individual's authorization for site access has been terminated.
"The NRC Resident Inspector has been notified."
EN Revision Text: FITNESS-FOR-DUTY REPORT - FAILED FITNESS-FOR-DUTY TEST
The following information was provided by the licensee via phone call:
"At 0909 EDT on 4/7/2022, it was determined that a security officer tested positive during a random fitness-for-duty test. The individual's authorization for site access has been terminated.
"The NRC Resident Inspector has been notified."
Power Reactor
Event Number: 55831
Facility: Turkey Point
Region: 2 State: FL
Unit: [4] [] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: Ryan Frank
HQ OPS Officer: Lloyd Desotell
Region: 2 State: FL
Unit: [4] [] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: Ryan Frank
HQ OPS Officer: Lloyd Desotell
Notification Date: 04/08/2022
Notification Time: 01:10 [ET]
Event Date: 04/07/2022
Event Time: 19:00 [EDT]
Last Update Date: 04/11/2022
Notification Time: 01:10 [ET]
Event Date: 04/07/2022
Event Time: 19:00 [EDT]
Last Update Date: 04/11/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(B) - Pot Rhr Inop
10 CFR Section:
50.72(b)(3)(v)(B) - Pot Rhr Inop
Person (Organization):
Miller, Mark (R2DO)
Miller, Mark (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 4 | N | N | 0 | Hot Shutdown | 0 | Hot Shutdown |
EN Revision Imported Date: 4/12/2022
EN Revision Text: BOTH TRAINS OF RESIDUAL HEAT REMOVAL INOPERABLE
The following information was provided by the licensee via fax or email:
"At 1900 EDT on 04/07/22, while Unit 4 was in Mode 4 following a refueling outage, it was discovered that both trains of residual heat removal (RHR) were simultaneously inoperable due to gas voiding. At 2032 EDT corrective actions were completed and both trains of RHR were declared operable. This condition is being reported pursuant to 10 CFR 50.72(b)(3)(v)(B).
"The NRC Resident Inspector has been notified."
* * * RETRACTION ON 04/11/22 AT 1022 EST FROM DAVID STOIA TO BRIAN SMITH * * *
The following information was provided by the licensee via email:
"On 4/8/2022 at 0110 EDT Turkey Point Unit 4 notified the [NRC Operations Center (NRCOC)] pursuant to 10 CFR 50.72(b)(3)(v)(B) that both trains of Residual Heat Removal (RHR) were simultaneously inoperable due to the presence of gas voids that were identified during scheduled system gas accumulation testing. Subsequent evaluation by [Florida Power & Light (FPL)] Engineering has concluded that both trains of RHR remained operable and capable of performing their specified safety function.
"This NRCOC notification is a retraction of EN# 55831."
The licensee notified the NRC Resident Inspector.
Notified R2DO (Miller)
EN Revision Text: BOTH TRAINS OF RESIDUAL HEAT REMOVAL INOPERABLE
The following information was provided by the licensee via fax or email:
"At 1900 EDT on 04/07/22, while Unit 4 was in Mode 4 following a refueling outage, it was discovered that both trains of residual heat removal (RHR) were simultaneously inoperable due to gas voiding. At 2032 EDT corrective actions were completed and both trains of RHR were declared operable. This condition is being reported pursuant to 10 CFR 50.72(b)(3)(v)(B).
"The NRC Resident Inspector has been notified."
* * * RETRACTION ON 04/11/22 AT 1022 EST FROM DAVID STOIA TO BRIAN SMITH * * *
The following information was provided by the licensee via email:
"On 4/8/2022 at 0110 EDT Turkey Point Unit 4 notified the [NRC Operations Center (NRCOC)] pursuant to 10 CFR 50.72(b)(3)(v)(B) that both trains of Residual Heat Removal (RHR) were simultaneously inoperable due to the presence of gas voids that were identified during scheduled system gas accumulation testing. Subsequent evaluation by [Florida Power & Light (FPL)] Engineering has concluded that both trains of RHR remained operable and capable of performing their specified safety function.
"This NRCOC notification is a retraction of EN# 55831."
The licensee notified the NRC Resident Inspector.
Notified R2DO (Miller)
Agreement State
Event Number: 55822
Rep Org: Ohio Bureau of Radiation Protection
Licensee: I. H. Schlezinger, Inc.
Region: 3
City: Columbus State: OH
County:
License #: N/A
Agreement: Y
Docket:
NRC Notified By: Stephen James
HQ OPS Officer: Thomas Herrity
Licensee: I. H. Schlezinger, Inc.
Region: 3
City: Columbus State: OH
County:
License #: N/A
Agreement: Y
Docket:
NRC Notified By: Stephen James
HQ OPS Officer: Thomas Herrity
Notification Date: 04/05/2022
Notification Time: 14:13 [ET]
Event Date: 03/30/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/05/2022
Notification Time: 14:13 [ET]
Event Date: 03/30/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/05/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
McCraw, Aaron (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
McCraw, Aaron (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 4/12/2022
EN Revision Text: AGREEMENT STATE REPORT - RADIOACTIVE GAUGE DISCOVERED IN SCRAP METAL
The following information was received from the Ohio Department of Health Bureau (ODH) of Environmental Health and Radiation Protection via email:
"On 3/30/22, ODH received notification of a load that tripped radiation detectors at a scrap facility in Marion, Ohio. The load returned to point of origin in Columbus, Ohio under DOT SP OH-OH-22-014. The Originator contacted ODH on 4/4/22 to report that they had surveyed the load and isolated a device that was box shaped, perhaps 8x4x4 inches. The item reportedly pegged the facility's Ludlum 19 (5 mR/hr), and was secured in a quarantine area.
"ODH staff responded to site on 4/5/22 and identified a Ronan Engineering Model RLL-1 gauge containing a 0.27 mCi Cs-137 source with a reading of 750 microR/hr on the side of the gauge. No contamination was detected. The facility will keep the device secure while disposal options are arranged. ODH will contact the manufacturer (Ronan Engineering) to attempt to identify the owner based on mode; and serial number on the device."
Ohio item number: OH220005
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 - RADIOACTIVE GAUGE DISCOVERED IN SCRAP METAL
The following information was received from the Ohio Department of Health Bureau (ODH) of Environmental Health and Radiation Protection via email:
"On 3/30/22, ODH received notification of a load that tripped radiation detectors at a scrap facility in Marion, Ohio. The load returned to point of origin in Columbus, Ohio under DOT SP OH-OH-22-014. The Originator contacted ODH on 4/4/22 to report that they had surveyed the load and isolated a device that was box shaped, perhaps 8x4x4 inches. The item reportedly pegged the facility's Ludlum 19 (5 mR/hr), and was secured in a quarantine area.
"ODH staff responded to site on 4/5/22 and identified a Ronan Engineering Model RLL-1 gauge containing a 0.27 mCi Cs-137 source with a reading of 750 microR/hr on the side of the gauge. No contamination was detected. The facility will keep the device secure while disposal options are arranged. ODH will contact the manufacturer (Ronan Engineering) to attempt to identify the owner based on mode; and serial number on the device."
Ohio item number: OH220005
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: 55823
Rep Org: Nevada Radiological Health
Licensee: Comprehensive Cancer Centers, NV
Region: 4
City: Las Vegas State: NV
County:
License #: 03-12-0491-01
Agreement: Y
Docket:
NRC Notified By: Corey Creveling
HQ OPS Officer: Thomas Herrity
Licensee: Comprehensive Cancer Centers, NV
Region: 4
City: Las Vegas State: NV
County:
License #: 03-12-0491-01
Agreement: Y
Docket:
NRC Notified By: Corey Creveling
HQ OPS Officer: Thomas Herrity
Notification Date: 04/05/2022
Notification Time: 18:37 [ET]
Event Date: 04/05/2022
Event Time: 00:00 [PDT]
Last Update Date: 04/05/2022
Notification Time: 18:37 [ET]
Event Date: 04/05/2022
Event Time: 00:00 [PDT]
Last Update Date: 04/05/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 4/12/2022
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT, EXCEEDED PRESCRIBED DOSE
The following was received from the State of Nevada via email:
"The patient was prescribed ten [High Dose Rate Brachytherapy] treatments [with a 9.0 curie Ir-192 source]. After four treatments, it was discovered that some of the catheters had been incorrectly labeled. This altered the dose distribution resulting in a higher skin dose than anticipated, however the target dose difference did NOT exceed 50 percent from the prescription. The remainder of the patient's treatment was re-planned to compensate for the dose already given. The total doses once complete will be within limits for the skin and the target dose will be within 20 percent of the prescription. All treatments were to the correct patient and correct site.
"The treatment area for this patient is adjacent to the skin, so the intended prescription would have given a skin max dose of nearly 100 percent of the prescribed treatment dose.
"For the four treatments given with the incorrectly labeled catheters, the dose to skin is estimated to be 3 times the initially expected dose, exceeding 50 rem.
"However, the patient's treatment was re-planned to provide additional skin sparing for the remaining treatments while maintaining minimum target coverage to compensate for the dose already given. We estimate the total skin dose from the entire treatment will exceed the initially anticipated skin dose by 41 percent. This total skin dose is still within standard protocol limits, and the written directive has been updated to be inclusive of the initial and new treatment plans and organ at risk (OAR) doses.
"The patient and referring physician were notified the day the event was discovered before the determination that a medical event took place."
Nevada Event Number: NV220002
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT, EXCEEDED PRESCRIBED DOSE
The following was received from the State of Nevada via email:
"The patient was prescribed ten [High Dose Rate Brachytherapy] treatments [with a 9.0 curie Ir-192 source]. After four treatments, it was discovered that some of the catheters had been incorrectly labeled. This altered the dose distribution resulting in a higher skin dose than anticipated, however the target dose difference did NOT exceed 50 percent from the prescription. The remainder of the patient's treatment was re-planned to compensate for the dose already given. The total doses once complete will be within limits for the skin and the target dose will be within 20 percent of the prescription. All treatments were to the correct patient and correct site.
"The treatment area for this patient is adjacent to the skin, so the intended prescription would have given a skin max dose of nearly 100 percent of the prescribed treatment dose.
"For the four treatments given with the incorrectly labeled catheters, the dose to skin is estimated to be 3 times the initially expected dose, exceeding 50 rem.
"However, the patient's treatment was re-planned to provide additional skin sparing for the remaining treatments while maintaining minimum target coverage to compensate for the dose already given. We estimate the total skin dose from the entire treatment will exceed the initially anticipated skin dose by 41 percent. This total skin dose is still within standard protocol limits, and the written directive has been updated to be inclusive of the initial and new treatment plans and organ at risk (OAR) doses.
"The patient and referring physician were notified the day the event was discovered before the determination that a medical event took place."
Nevada Event Number: NV220002
Part 21
Event Number: 55836
Rep Org: Westinghouse Electric Company
Licensee: Westinghouse Electric Company
Region: 1
City: Cranberry Township State: PA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Camille Zozula
HQ OPS Officer: Mike Stafford
Licensee: Westinghouse Electric Company
Region: 1
City: Cranberry Township State: PA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Camille Zozula
HQ OPS Officer: Mike Stafford
Notification Date: 04/11/2022
Notification Time: 21:01 [ET]
Event Date: 04/06/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/11/2022
Notification Time: 21:01 [ET]
Event Date: 04/06/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/11/2022
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):
Cahill, Christopher (R1DO)
McCraw, Aaron (R3DO)
Part 21/50.55 Reactors, - (EMAIL)
Cahill, Christopher (R1DO)
McCraw, Aaron (R3DO)
Part 21/50.55 Reactors, - (EMAIL)
PART 21 - WESTINGHOUSE ACTUATOR FULL VOLTAGE REVERSING CONTACTORS DEFICENCY REPORT
The following information was provided by the licensee via email:
"The following information is provided pursuant to the requirements of 10 CFR Part 21 to report a defect that could lead to a substantial safety hazard.
"Name and address of the individual informing the Commission:
Camille T. Zozula
Westinghouse Electric Company
1000 Westinghouse Drive
Cranberry Township, Pennsylvania 16066
(412) 374-2577
zozulact@westinghouse.com
"Commercially dedicated Eaton Freedom Series NEMA Size 1 and 2 full voltage reversing (FVR) contactors with mechanical interlocks that were manufactured between April 2014 until June 2018.
"The [FVRs] are designed and qualified to open and close on demand. The FVRs sporadically failed to electrically close on demand because the mechanical interlock is not returning to the de-energized position.
"Westinghouse sold LaSalle County Station Units 1 and 2 a quantity of 206 safety related [FVRs] that are potentially affected between 2014 and 2022.
"Westinghouse developed an alignment tool intended to increase the effectiveness of the installed mechanical interlocks and prevent them from binding. Westinghouse provided the alignment tool and associated procedure to LaSalle on February 17, 2022.
"Effective March 11, 2022, Westinghouse updated the commercial dedication instruction to include additional critical characteristics of the mechanical interlock assembly based on the results of the causal analysis. It was determined that the pawl contained within the mechanical interlock assembly was the cause of the mechanical binding.
"Westinghouse purchased the latest revision mechanical interlocks that contain Revision 3 pawls from Eaton. They are being dedicated by Westinghouse and installed by LaSalle Station in conjunction with the alignment tool, as they become available.
"Westinghouse has been in daily communication with LaSalle Station since January 2022 and provides real-time updates on the Westinghouse testing efforts.
"Westinghouse provided an on-site expert to LaSalle between February 23-25, 2022.
"The overall failure rate of the installed components has been low and is related to a tolerance stack-up among the mechanical interlock, mechanical interlock pawl, and the two reversing contactors. Additionally, the failures only occur after some time in service which cannot be correlated to a specific installed time or number of cycles. It is a random event.
"Westinghouse analyzed, reviewed, and regression tested mechanical interlocks that contain the Revision 3 pawls to confirm they are functional and meet the LaSalle environmental requirements."
The following information was provided by the licensee via email:
"The following information is provided pursuant to the requirements of 10 CFR Part 21 to report a defect that could lead to a substantial safety hazard.
"Name and address of the individual informing the Commission:
Camille T. Zozula
Westinghouse Electric Company
1000 Westinghouse Drive
Cranberry Township, Pennsylvania 16066
(412) 374-2577
zozulact@westinghouse.com
"Commercially dedicated Eaton Freedom Series NEMA Size 1 and 2 full voltage reversing (FVR) contactors with mechanical interlocks that were manufactured between April 2014 until June 2018.
"The [FVRs] are designed and qualified to open and close on demand. The FVRs sporadically failed to electrically close on demand because the mechanical interlock is not returning to the de-energized position.
"Westinghouse sold LaSalle County Station Units 1 and 2 a quantity of 206 safety related [FVRs] that are potentially affected between 2014 and 2022.
"Westinghouse developed an alignment tool intended to increase the effectiveness of the installed mechanical interlocks and prevent them from binding. Westinghouse provided the alignment tool and associated procedure to LaSalle on February 17, 2022.
"Effective March 11, 2022, Westinghouse updated the commercial dedication instruction to include additional critical characteristics of the mechanical interlock assembly based on the results of the causal analysis. It was determined that the pawl contained within the mechanical interlock assembly was the cause of the mechanical binding.
"Westinghouse purchased the latest revision mechanical interlocks that contain Revision 3 pawls from Eaton. They are being dedicated by Westinghouse and installed by LaSalle Station in conjunction with the alignment tool, as they become available.
"Westinghouse has been in daily communication with LaSalle Station since January 2022 and provides real-time updates on the Westinghouse testing efforts.
"Westinghouse provided an on-site expert to LaSalle between February 23-25, 2022.
"The overall failure rate of the installed components has been low and is related to a tolerance stack-up among the mechanical interlock, mechanical interlock pawl, and the two reversing contactors. Additionally, the failures only occur after some time in service which cannot be correlated to a specific installed time or number of cycles. It is a random event.
"Westinghouse analyzed, reviewed, and regression tested mechanical interlocks that contain the Revision 3 pawls to confirm they are functional and meet the LaSalle environmental requirements."