Event Notification Report for November 10, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/09/2022 - 11/10/2022
Agreement State
Event Number: 56180
Rep Org: Georgia Radioactive Material Pgm
Licensee: Northside Hospital Forsyth
Region: 1
City: Cumming State: GA
County:
License #: GA 748-1
Agreement: Y
Docket:
NRC Notified By: Drake Brookins
HQ OPS Officer: Ian Howard
Licensee: Northside Hospital Forsyth
Region: 1
City: Cumming State: GA
County:
License #: GA 748-1
Agreement: Y
Docket:
NRC Notified By: Drake Brookins
HQ OPS Officer: Ian Howard
Notification Date: 10/25/2022
Notification Time: 13:29 [ET]
Event Date: 10/18/2022
Event Time: 06:30 [EDT]
Last Update Date: 11/09/2022
Notification Time: 13:29 [ET]
Event Date: 10/18/2022
Event Time: 06:30 [EDT]
Last Update Date: 11/09/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Dentel, Glenn (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Dentel, Glenn (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 11/9/2022
EN Revision Text: AGREEMENT STATE REPORT - DAMAGED SEALED SOURCE
The following information was provided by the Georgia Radioactive Material Program via email:
"On 10/18/2022 at 0630 EDT, a Cs-137 vial source was being used to measure dose calibrator constancy. The nuclear medicine [NM] technologist noticed a crack in the bottom of the sealed source vial and possible contamination surrounding the vial.
"The sealed source was placed in a leak proof container, the Radiation Safety Officer (RSO) was notified, and decontamination protocol was followed. A leak test of the vial confirmed there was more than 0.005 microcuries of removable Cs-137 contamination.
"Post-decontamination surveys and wipe tests of the staff and department indicated that there was no contamination in the department, but there was detectable contamination on the hands of one staff member. The staff member is the individual who was handling the sealed source and discovered the crack in the source. He repeatedly scrubbed his hands - first with lukewarm soap and water, then with Bind-It brand radioactive decontamination hand soap until there was no improvement in the surveys of his hands.
"A final survey of the individuals hands hands showed there was no detectable contamination on his left hand. A small area on his right-hand thumb still measured 1000 [Counts Per Minute] CPM above background, and another small area on his right-hand index finger measured 700 CPM above background using a GM probe. Measurements of the contamination on his fingers using the on-site well counter indicated it was Cs-137 contamination.
"Both the Radiation Safety Officer and Medical Director were notified of the incident. The RSO came on-site to supervise decontamination efforts and to secure the leaking source and decontamination waste.
"Dose calibrator measurements of the source by the RSO indicated the source had leaked approximately 6 microcuries total. Since 6 microcuries of Cs-137 is less than 10 percent of the annual limits on intake (ALI) for Cs-137 (100 microcuries ALI for oral ingestion as defined in Appendix B of 10 CFR 20), [the Program's] understanding is no individual bioassay monitoring is required for the individual.
"The sealed source has been placed back within its shielded container, sealed with tape, and marked as leaking and out-of-service. The waste generated during the decontamination process was placed in a leakproof plastic bottle and marked as containing Cs-137. Both items are currently stored in [a secure area]. We are contacting waste disposal companies to arrange disposal of both the leaking sealed source and decontamination waste. The NM staff was re-educated on the requirement to wear disposable gloves at all times while handling radioactive materials, which includes sealed radioactive sources, per the Model Rules for Safe Use of Radiopharmaceuticals."
Georgia Incident Number: 60
* * * UPDATE ON 11/08/2022 AT 1323 EST FROM SHEREE BUTLER TO BRIAN LIN * * *
The following information is a summary of information received via email:
The licensee supplied an updated report to the state of Georgia. Georgia Radioactive Material Program employees will finalize and close out the report after disposal of the leaking source and contaminated waste.
Notified R1DO (Werkheiser) and NMSS Events Notification email group.
EN Revision Text: AGREEMENT STATE REPORT - DAMAGED SEALED SOURCE
The following information was provided by the Georgia Radioactive Material Program via email:
"On 10/18/2022 at 0630 EDT, a Cs-137 vial source was being used to measure dose calibrator constancy. The nuclear medicine [NM] technologist noticed a crack in the bottom of the sealed source vial and possible contamination surrounding the vial.
"The sealed source was placed in a leak proof container, the Radiation Safety Officer (RSO) was notified, and decontamination protocol was followed. A leak test of the vial confirmed there was more than 0.005 microcuries of removable Cs-137 contamination.
"Post-decontamination surveys and wipe tests of the staff and department indicated that there was no contamination in the department, but there was detectable contamination on the hands of one staff member. The staff member is the individual who was handling the sealed source and discovered the crack in the source. He repeatedly scrubbed his hands - first with lukewarm soap and water, then with Bind-It brand radioactive decontamination hand soap until there was no improvement in the surveys of his hands.
"A final survey of the individuals hands hands showed there was no detectable contamination on his left hand. A small area on his right-hand thumb still measured 1000 [Counts Per Minute] CPM above background, and another small area on his right-hand index finger measured 700 CPM above background using a GM probe. Measurements of the contamination on his fingers using the on-site well counter indicated it was Cs-137 contamination.
"Both the Radiation Safety Officer and Medical Director were notified of the incident. The RSO came on-site to supervise decontamination efforts and to secure the leaking source and decontamination waste.
"Dose calibrator measurements of the source by the RSO indicated the source had leaked approximately 6 microcuries total. Since 6 microcuries of Cs-137 is less than 10 percent of the annual limits on intake (ALI) for Cs-137 (100 microcuries ALI for oral ingestion as defined in Appendix B of 10 CFR 20), [the Program's] understanding is no individual bioassay monitoring is required for the individual.
"The sealed source has been placed back within its shielded container, sealed with tape, and marked as leaking and out-of-service. The waste generated during the decontamination process was placed in a leakproof plastic bottle and marked as containing Cs-137. Both items are currently stored in [a secure area]. We are contacting waste disposal companies to arrange disposal of both the leaking sealed source and decontamination waste. The NM staff was re-educated on the requirement to wear disposable gloves at all times while handling radioactive materials, which includes sealed radioactive sources, per the Model Rules for Safe Use of Radiopharmaceuticals."
Georgia Incident Number: 60
* * * UPDATE ON 11/08/2022 AT 1323 EST FROM SHEREE BUTLER TO BRIAN LIN * * *
The following information is a summary of information received via email:
The licensee supplied an updated report to the state of Georgia. Georgia Radioactive Material Program employees will finalize and close out the report after disposal of the leaking source and contaminated waste.
Notified R1DO (Werkheiser) and NMSS Events Notification email group.
Fuel Cycle Facility
Event Number: 56199
Facility: Westinghouse Electric Corporation
Region: 2 State: SC
Unit: [] [] []
RX Type: Uranium Fuel Fabrication
NRC Notified By: Patrick Donnelly
HQ OPS Officer: Eric Simpson
Region: 2 State: SC
Unit: [] [] []
RX Type: Uranium Fuel Fabrication
NRC Notified By: Patrick Donnelly
HQ OPS Officer: Eric Simpson
Notification Date: 11/02/2022
Notification Time: 11:12 [ET]
Event Date: 11/01/2022
Event Time: 11:29 [EDT]
Last Update Date: 11/02/2022
Notification Time: 11:12 [ET]
Event Date: 11/01/2022
Event Time: 11:29 [EDT]
Last Update Date: 11/02/2022
Emergency Class: Non Emergency
10 CFR Section:
PART 70 APP A (b)(1) - Unanalyzed Condition
10 CFR Section:
PART 70 APP A (b)(1) - Unanalyzed Condition
Person (Organization):
Miller, Mark (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Miller, Mark (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
UNANALYZED CONDITION - NUCLEAR MATERIAL RECEIVED IN EXCESS OF LICENSE LIMITS
The following is a synopsis of information provided by the licensee via email:
Uranium Recovery and Recycle Services (URRS) personnel were offloading ash on 11/1/22 that they had received in 2003 from the decommissioned Hematite site at Dock 3. The operators opened the Type A drum and from an inner canister pulled out the bag of Hematite ash. The bag had a tag indicating enrichment levels in excess of their license limits. Upon discovery, the operators contacted criticality safety engineering and the safeguards coordinator. The operators were instructed to replace the bag in the canister and drum and to segregate the drums that contained material potentially greater than license limits in accordance with generally accepted guidance for criticality safety. An extent of condition was performed using materials control and accounting records of the received material. It was discovered that several drums potentially contain material in excess of license enrichment limits. The plant is in a safe condition and the steps taken in response to this event are considered to be conservative.
This report is being made per 10 CFR 70 Appendix A (b)(1). This event resulted in the facility being in a state that was not analyzed in their Integrated Safety Analysis Report and resulted in a failure to meet the performance requirements of 10 CFR 70.61, specifically there were no controls in place due to it being an unanalyzed condition. Westinghouse is unable to open, sample, and test the ash to determine enrichment until the proposed process has been analyzed with documented controls in place.
This issue has been entered into the licensee's corrective action program as IR-2022-9728.
The following is a synopsis of information provided by the licensee via email:
Uranium Recovery and Recycle Services (URRS) personnel were offloading ash on 11/1/22 that they had received in 2003 from the decommissioned Hematite site at Dock 3. The operators opened the Type A drum and from an inner canister pulled out the bag of Hematite ash. The bag had a tag indicating enrichment levels in excess of their license limits. Upon discovery, the operators contacted criticality safety engineering and the safeguards coordinator. The operators were instructed to replace the bag in the canister and drum and to segregate the drums that contained material potentially greater than license limits in accordance with generally accepted guidance for criticality safety. An extent of condition was performed using materials control and accounting records of the received material. It was discovered that several drums potentially contain material in excess of license enrichment limits. The plant is in a safe condition and the steps taken in response to this event are considered to be conservative.
This report is being made per 10 CFR 70 Appendix A (b)(1). This event resulted in the facility being in a state that was not analyzed in their Integrated Safety Analysis Report and resulted in a failure to meet the performance requirements of 10 CFR 70.61, specifically there were no controls in place due to it being an unanalyzed condition. Westinghouse is unable to open, sample, and test the ash to determine enrichment until the proposed process has been analyzed with documented controls in place.
This issue has been entered into the licensee's corrective action program as IR-2022-9728.
Agreement State
Event Number: 56201
Rep Org: WA Office of Radiation Protection
Licensee: IsoRay Medical
Region: 4
City: Richland State: WA
County:
License #: WN-L0213-1
Agreement: Y
Docket:
NRC Notified By: Raj Maharjan
HQ OPS Officer: Donald Norwood
Licensee: IsoRay Medical
Region: 4
City: Richland State: WA
County:
License #: WN-L0213-1
Agreement: Y
Docket:
NRC Notified By: Raj Maharjan
HQ OPS Officer: Donald Norwood
Notification Date: 11/02/2022
Notification Time: 15:58 [ET]
Event Date: 09/29/2022
Event Time: 00:00 [PDT]
Last Update Date: 11/02/2022
Notification Time: 15:58 [ET]
Event Date: 09/29/2022
Event Time: 00:00 [PDT]
Last Update Date: 11/02/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Agrawal, Ami (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Agrawal, Ami (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - LEAKING CS-131 BRACHYTHERAPY SOURCE
The following information was received via email from the Washington Office of Radiation Protection:
"On 11/2/2022, a licensee, IsoRay Medical - License Number: WN-L0213-1 reported a Cs-131 Brachytherapy source, model CS-1, leaking at customer's facility. A customer detected contamination on equipment used during a procedure with Cs-131 seeds. The customer was not initially able to identify the isotope of the contamination using their equipment, however they were able to perform a half-life estimation using dose measurements on a collimated container loaded with all the contaminated items from the procedure. The decay rate was roughly in line with Cs-131. The customer indicated that as part of their own procedures, the order, which arrived as a non-sterile mick pig, was opened and surveyed. No contamination was found at that time. A thorough investigation is ongoing."
Washington Incident Number: WA-22-021
The following information was received via email from the Washington Office of Radiation Protection:
"On 11/2/2022, a licensee, IsoRay Medical - License Number: WN-L0213-1 reported a Cs-131 Brachytherapy source, model CS-1, leaking at customer's facility. A customer detected contamination on equipment used during a procedure with Cs-131 seeds. The customer was not initially able to identify the isotope of the contamination using their equipment, however they were able to perform a half-life estimation using dose measurements on a collimated container loaded with all the contaminated items from the procedure. The decay rate was roughly in line with Cs-131. The customer indicated that as part of their own procedures, the order, which arrived as a non-sterile mick pig, was opened and surveyed. No contamination was found at that time. A thorough investigation is ongoing."
Washington Incident Number: WA-22-021
Power Reactor
Event Number: 56214
Facility: Waterford
Region: 4 State: LA
Unit: [3] [] []
RX Type: [3] CE
NRC Notified By: Jeff Bradley
HQ OPS Officer: Brian Lin
Region: 4 State: LA
Unit: [3] [] []
RX Type: [3] CE
NRC Notified By: Jeff Bradley
HQ OPS Officer: Brian Lin
Notification Date: 11/09/2022
Notification Time: 15:37 [ET]
Event Date: 11/09/2022
Event Time: 08:46 [CST]
Last Update Date: 11/09/2022
Notification Time: 15:37 [ET]
Event Date: 11/09/2022
Event Time: 08:46 [CST]
Last Update Date: 11/09/2022
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Azua, Ray (R4DO)
FFD Group, (EMAIL)
Azua, Ray (R4DO)
FFD Group, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
FITNESS FOR DUTY REPORT
A non-licensed supervisor had a confirmed positive during a random fitness-for-duty test. The employee's access to the plant has been terminated.
The NRC Resident Inspector has been notified.
A non-licensed supervisor had a confirmed positive during a random fitness-for-duty test. The employee's access to the plant has been terminated.
The NRC Resident Inspector has been notified.
Hospital
Event Number: 56130
Rep Org: New Haven Hospital
Licensee: New Haven Hospital
Region: 1
City: New Haven State: CT
County: New Haven
License #: 06-00819-03
Agreement: N
Docket:
NRC Notified By: Bill Hinchcliffe
HQ OPS Officer: Adam Koziol
Licensee: New Haven Hospital
Region: 1
City: New Haven State: CT
County: New Haven
License #: 06-00819-03
Agreement: N
Docket:
NRC Notified By: Bill Hinchcliffe
HQ OPS Officer: Adam Koziol
Notification Date: 09/29/2022
Notification Time: 14:54 [ET]
Event Date: 09/28/2022
Event Time: 16:30 [EDT]
Last Update Date: 11/09/2022
Notification Time: 14:54 [ET]
Event Date: 09/28/2022
Event Time: 16:30 [EDT]
Last Update Date: 11/09/2022
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
Person (Organization):
Ambrosini, Josephine (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Ambrosini, Josephine (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MEDICAL EVENT - PATIENT UNDERDOSE
The following information was provided by the licensee via phone:
New Haven Hospital performed stereotactic radiosurgery treatment plan on brain lesions using a gamma knife. Following the procedure, it was determined that up to 6 of the 10 targets could have been missed resulting in up to a 50 percent underdose to the intended targets. There was no indication of unintended damage to neighboring tissues, organs, or structures.
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.
The following information was provided by the licensee via phone:
New Haven Hospital performed stereotactic radiosurgery treatment plan on brain lesions using a gamma knife. Following the procedure, it was determined that up to 6 of the 10 targets could have been missed resulting in up to a 50 percent underdose to the intended targets. There was no indication of unintended damage to neighboring tissues, organs, or structures.
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: 56128
Facility: Saint Lucie
Region: 2 State: FL
Unit: [1] [] []
RX Type: [1] CE,[2] CE
NRC Notified By: Ronald Cappillo
HQ OPS Officer: Ernest West
Region: 2 State: FL
Unit: [1] [] []
RX Type: [1] CE,[2] CE
NRC Notified By: Ronald Cappillo
HQ OPS Officer: Ernest West
Notification Date: 09/26/2022
Notification Time: 22:39 [ET]
Event Date: 09/26/2022
Event Time: 17:41 [EDT]
Last Update Date: 11/11/2022
Notification Time: 22:39 [ET]
Event Date: 09/26/2022
Event Time: 17:41 [EDT]
Last Update Date: 11/11/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
Miller, Mark (R2DO)
Miller, Mark (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Hot Standby | 0 | Hot Standby |
EN Revision Imported Date: 11/14/2022
EN Revision Text: SAFETY SYSTEM INOPERABILITY
The following information was provided by the licensee via email:
"At 1741 EDT on September 26, 2022, it was discovered that both trains of the chemical volume and control system were simultaneously inoperable due to an unisolable piping flaw detected during plant pressurization in preparation for startup following refueling outage.
"St. Lucie Unit 2 was not affected and remains at 100 percent power.
"This event is being reported pursuant to 10 CFR 50.72(b)(3)(v)(D).
"The NRC Resident Inspector has been notified."
* * * RETRACTION FROM RICHARD ROGERS TO DONALD NORWOOD AT 1155 EST ON 11/11/2022 * * *
The following information was provided by the licensee via email:
"The purpose of this notification is to retract a previous report made on 09/26/2022 at 2239 EDT (EN 56128).
"Notification of the event to the NRC was initially made as a result of declaring both trains of U1 Chemical and Volume Control System inoperable due to a piping flaw detected during plant pressurization in preparation for startup following a refueling outage.
"Subsequent to the initial report, FPL [Florida Power and Light] has concluded that the flaw identified in line 2"-CH[1]104 did not exceed (with sufficient margin) the allowable axial flaw size utilizing the ASME Code Case N-869 methodology, and the Chemical and Volume Control System was Operable but degraded for the period of concern.
"Therefore, this event is not considered a Safety System Functional Failure and is not reportable to the NRC as a Licensee Event Report (LER) per 10 CFR 50.73. The NRC Senior Resident Inspector has been notified."
Notified R2DO (Miller).
EN Revision Text: SAFETY SYSTEM INOPERABILITY
The following information was provided by the licensee via email:
"At 1741 EDT on September 26, 2022, it was discovered that both trains of the chemical volume and control system were simultaneously inoperable due to an unisolable piping flaw detected during plant pressurization in preparation for startup following refueling outage.
"St. Lucie Unit 2 was not affected and remains at 100 percent power.
"This event is being reported pursuant to 10 CFR 50.72(b)(3)(v)(D).
"The NRC Resident Inspector has been notified."
* * * RETRACTION FROM RICHARD ROGERS TO DONALD NORWOOD AT 1155 EST ON 11/11/2022 * * *
The following information was provided by the licensee via email:
"The purpose of this notification is to retract a previous report made on 09/26/2022 at 2239 EDT (EN 56128).
"Notification of the event to the NRC was initially made as a result of declaring both trains of U1 Chemical and Volume Control System inoperable due to a piping flaw detected during plant pressurization in preparation for startup following a refueling outage.
"Subsequent to the initial report, FPL [Florida Power and Light] has concluded that the flaw identified in line 2"-CH[1]104 did not exceed (with sufficient margin) the allowable axial flaw size utilizing the ASME Code Case N-869 methodology, and the Chemical and Volume Control System was Operable but degraded for the period of concern.
"Therefore, this event is not considered a Safety System Functional Failure and is not reportable to the NRC as a Licensee Event Report (LER) per 10 CFR 50.73. The NRC Senior Resident Inspector has been notified."
Notified R2DO (Miller).
Power Reactor
Event Number: 56135
Facility: Saint Lucie
Region: 2 State: FL
Unit: [1] [] []
RX Type: [1] CE,[2] CE
NRC Notified By: Michael Croteau
HQ OPS Officer: Mike Stafford
Region: 2 State: FL
Unit: [1] [] []
RX Type: [1] CE,[2] CE
NRC Notified By: Michael Croteau
HQ OPS Officer: Mike Stafford
Notification Date: 09/30/2022
Notification Time: 17:13 [ET]
Event Date: 09/30/2022
Event Time: 16:08 [EDT]
Last Update Date: 11/11/2022
Notification Time: 17:13 [ET]
Event Date: 09/30/2022
Event Time: 16:08 [EDT]
Last Update Date: 11/11/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
Miller, Mark (R2DO)
Miller, Mark (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Hot Standby | 0 | Hot Standby |
EN Revision Imported Date: 11/14/2022
EN Revision Text: SAFETY SYSTEM INOPERABILITY
The following information was provided by the licensee via email:
"At 1608 [EDT] on September 30, 2022, it was discovered that both trains of the chemical volume and control system were simultaneously inoperable due to an unisolable piping flaw inside containment detected during plant pressurization in preparation for startup following a refueling outage.
"St. Lucie Unit 2 was not affected and remains at 100 percent power.
"This event is being reported pursuant to 10CFR50.72(b)(3)(v)(D).
"The NRC Resident Inspector has been notified."
* * * RETRACTION FROM RICHARD ROGERS TO DONALD NORWOOD AT 1155 EDT ON 11/11/2022 * * *
The following information was provided by the licensee via email:
"The purpose of this notification is to retract a previous report made on 09/30/2022 at 1713 EDT (EN 56135).
"Notification of the event to the NRC was initially made as a result of declaring both trains of U1 Chemical and Volume Control System inoperable due to a piping flaw detected during plant pressurization in preparation for startup following a refueling outage.
"Subsequent to the initial report, FPL [Florida Power and Light] has concluded that the flaw identified in line 2"-CH-109 did not exceed (with sufficient margin) the allowable axial flaw size utilizing the ASME Code Case N-869 methodology, and the Chemical and Volume Control System was operable but degraded for the period of concern.
"Therefore, this event is not considered a Safety System Functional Failure and is not reportable to the NRC as a Licensee Event Report (LER) per 10 CFR 50.73. The NRC Senior Resident Inspector has been notified."
Notified R2DO (Miller).
EN Revision Text: SAFETY SYSTEM INOPERABILITY
The following information was provided by the licensee via email:
"At 1608 [EDT] on September 30, 2022, it was discovered that both trains of the chemical volume and control system were simultaneously inoperable due to an unisolable piping flaw inside containment detected during plant pressurization in preparation for startup following a refueling outage.
"St. Lucie Unit 2 was not affected and remains at 100 percent power.
"This event is being reported pursuant to 10CFR50.72(b)(3)(v)(D).
"The NRC Resident Inspector has been notified."
* * * RETRACTION FROM RICHARD ROGERS TO DONALD NORWOOD AT 1155 EDT ON 11/11/2022 * * *
The following information was provided by the licensee via email:
"The purpose of this notification is to retract a previous report made on 09/30/2022 at 1713 EDT (EN 56135).
"Notification of the event to the NRC was initially made as a result of declaring both trains of U1 Chemical and Volume Control System inoperable due to a piping flaw detected during plant pressurization in preparation for startup following a refueling outage.
"Subsequent to the initial report, FPL [Florida Power and Light] has concluded that the flaw identified in line 2"-CH-109 did not exceed (with sufficient margin) the allowable axial flaw size utilizing the ASME Code Case N-869 methodology, and the Chemical and Volume Control System was operable but degraded for the period of concern.
"Therefore, this event is not considered a Safety System Functional Failure and is not reportable to the NRC as a Licensee Event Report (LER) per 10 CFR 50.73. The NRC Senior Resident Inspector has been notified."
Notified R2DO (Miller).
Agreement State
Event Number: 56205
Rep Org: New York State Dept. of Health
Licensee: Universal Testing & Inspection
Region: 1
City: Manhasset State: NY
County:
License #: C2570
Agreement: Y
Docket:
NRC Notified By: Daniel Samson
HQ OPS Officer: Karen Cotton-Gross
Licensee: Universal Testing & Inspection
Region: 1
City: Manhasset State: NY
County:
License #: C2570
Agreement: Y
Docket:
NRC Notified By: Daniel Samson
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 11/04/2022
Notification Time: 12:33 [ET]
Event Date: 11/03/2022
Event Time: 14:30 [EDT]
Last Update Date: 11/04/2022
Notification Time: 12:33 [ET]
Event Date: 11/03/2022
Event Time: 14:30 [EDT]
Last Update Date: 11/04/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Lilliendahl, Jon (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MacDonald, Mark (ILTAB)
CNSC (Canada), - (EMAIL)
Lilliendahl, Jon (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MacDonald, Mark (ILTAB)
CNSC (Canada), - (EMAIL)
AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE
The following information was provided by the New York State Department of Health Bureau of Environmental Radiation Protection (NYSDOH BERP) via fax:
"On November 3, 2022, at approximately 1430 EDT, an authorized user for the licensee had finished conducting soils testing at a temporary job site located in Manhasset, NY and locked the moisture density device in the carrying case within the trunk of their vehicle. The authorized user was conducting concrete work while the gauge was locked in the trunk and returned to their vehicle later to find that the vehicle was stolen, with the gauge locked in the trunk. The authorized user contacted the Radiation Safety Officer (RSO) and Nassau Police immediately and the case was initiated by Nassau [Police] to track this vehicle. The RSO contacted NYSDOH BERP the following morning to report the missing device.
"The following, information is available on this device: Make/Model: Troxler 3430 Source 1: Cs-137 (10 millicurie); Source 2: Americium-241:Be (40 millicurie); Device S/N: 20136.
"New York State Department of Health is reaching out to the manufacturer and neighboring regulators to inform them of this event. NYSDOH will continue to monitor this event and provide updates as necessary.
"NY Event Report ID: NYDOH-22-07"
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
The following information was provided by the New York State Department of Health Bureau of Environmental Radiation Protection (NYSDOH BERP) via fax:
"On November 3, 2022, at approximately 1430 EDT, an authorized user for the licensee had finished conducting soils testing at a temporary job site located in Manhasset, NY and locked the moisture density device in the carrying case within the trunk of their vehicle. The authorized user was conducting concrete work while the gauge was locked in the trunk and returned to their vehicle later to find that the vehicle was stolen, with the gauge locked in the trunk. The authorized user contacted the Radiation Safety Officer (RSO) and Nassau Police immediately and the case was initiated by Nassau [Police] to track this vehicle. The RSO contacted NYSDOH BERP the following morning to report the missing device.
"The following, information is available on this device: Make/Model: Troxler 3430 Source 1: Cs-137 (10 millicurie); Source 2: Americium-241:Be (40 millicurie); Device S/N: 20136.
"New York State Department of Health is reaching out to the manufacturer and neighboring regulators to inform them of this event. NYSDOH will continue to monitor this event and provide updates as necessary.
"NY Event Report ID: NYDOH-22-07"
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: 56206
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: G.E. Healthcare DBA/ Medi+Physics
Region: 3
City: Arlington Heights State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: Zach Mengel
HQ OPS Officer: Karen Cotton-Gross
Licensee: G.E. Healthcare DBA/ Medi+Physics
Region: 3
City: Arlington Heights State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: Zach Mengel
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 11/04/2022
Notification Time: 13:04 [ET]
Event Date: 11/03/2022
Event Time: 00:00 [CDT]
Last Update Date: 11/04/2022
Notification Time: 13:04 [ET]
Event Date: 11/03/2022
Event Time: 00:00 [CDT]
Last Update Date: 11/04/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Ruiz, Robert (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MacDonald, Mark (ILTAB)
Lilliendahl, Jon (R1DO)
Ruiz, Robert (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MacDonald, Mark (ILTAB)
Lilliendahl, Jon (R1DO)
AGREEMENT STATE REPORT - RADIOPHARMACEUTICAL LOST IN TRANSIT
The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:
"The Agency was notified by Medi-Physics, Inc., doing business as GE Healthcare on the afternoon of 11/3/2022, that a radiopharmaceutical package containing 1.5 millicuries of In-111 was reported as lost while in the care of a common carrier. This does not represent a significant public safety hazard and there is no indication of intentional theft or diversion. Details on the package and shipment are provided below. The Georgia program will be notified along with the US NRC Operations Center.
"The package was shipped on 10/28/2022, from the licensee's facility in Arlington Heights, Illinois to Jubilant Radiopharma in Macon, Georgia. The package made it to the common carrier hub. Thereafter, it could not be accounted for and was declared lost on 11/3/2022. The package activity was 1.5 millicurie at the time of shipment but has decayed to approximately 1.147 millicurie at this time.
"IL Item Number: IL220042"
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
The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:
"The Agency was notified by Medi-Physics, Inc., doing business as GE Healthcare on the afternoon of 11/3/2022, that a radiopharmaceutical package containing 1.5 millicuries of In-111 was reported as lost while in the care of a common carrier. This does not represent a significant public safety hazard and there is no indication of intentional theft or diversion. Details on the package and shipment are provided below. The Georgia program will be notified along with the US NRC Operations Center.
"The package was shipped on 10/28/2022, from the licensee's facility in Arlington Heights, Illinois to Jubilant Radiopharma in Macon, Georgia. The package made it to the common carrier hub. Thereafter, it could not be accounted for and was declared lost on 11/3/2022. The package activity was 1.5 millicurie at the time of shipment but has decayed to approximately 1.147 millicurie at this time.
"IL Item Number: IL220042"
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: 56207
Rep Org: New York State Dept. of Health
Licensee:
Region: 1
City: State: NY
County:
License #: 0509
Agreement: Y
Docket:
NRC Notified By: Daniel Samson
HQ OPS Officer: Karen Cotton-Gross
Licensee:
Region: 1
City: State: NY
County:
License #: 0509
Agreement: Y
Docket:
NRC Notified By: Daniel Samson
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 11/04/2022
Notification Time: 13:26 [ET]
Event Date: 07/20/2022
Event Time: 00:00 [EDT]
Last Update Date: 11/04/2022
Notification Time: 13:26 [ET]
Event Date: 07/20/2022
Event Time: 00:00 [EDT]
Last Update Date: 11/04/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Lilliendahl, Jon (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MacDonald, Mark (ILTAB)
CNSC (Canada), - (EMAIL)
Lilliendahl, Jon (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MacDonald, Mark (ILTAB)
CNSC (Canada), - (EMAIL)
AGREEMENT STATE REPORT - LOST LICENSED MATERIAL (MEDICAL SEEDS)
The following information was provided by the New York State Department of Health (the Department) via fax:
"On August 16, 2022, the Department was notified of a missing I-125 localization seed (lsoAid I-125, Serial No. 78315 Activity: 0.025 millicurie) at a licensed medical facility in New York.
"On July 18, 2022, there were two patients, one seed in each of 2 patients was removed. Radiograph of the specimens showed seeds and biopsy clips were present. On July 20, 2022, the Nuclear Medicine technologist was called to retrieve the 2 seeds in a leaded container. Upon further survey, the technologist discovered there was only one seed, and the other was a biopsy clip. The Nuclear Medical Technologist surveyed the pathology lab, including benches, trash and floor but was then informed that the seeds were retrieved from the specimens the day before on July 19, 2022. The laboratory manager, radiology manager and nuclear medicine technologist tracked the path of seeds including the pathology lab, the operating room and hallways. Radioactive trash was also surveyed for radioactivity. The Radiation Safety Office and Medical Physicist were then notified of the missing seed.
"Corrective actions are in place including:
1. Nuclear Medicine will be notified immediately when a seed is retrieved from a specimen.
2. When retrieving the seed from the specimen, the survey meter must be used to ensure the seed is present.
3. Temporary pathology workers will not work with radioactive seeds.
"NY Event Report ID: NYDOH-22-06"
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
The following information was provided by the New York State Department of Health (the Department) via fax:
"On August 16, 2022, the Department was notified of a missing I-125 localization seed (lsoAid I-125, Serial No. 78315 Activity: 0.025 millicurie) at a licensed medical facility in New York.
"On July 18, 2022, there were two patients, one seed in each of 2 patients was removed. Radiograph of the specimens showed seeds and biopsy clips were present. On July 20, 2022, the Nuclear Medicine technologist was called to retrieve the 2 seeds in a leaded container. Upon further survey, the technologist discovered there was only one seed, and the other was a biopsy clip. The Nuclear Medical Technologist surveyed the pathology lab, including benches, trash and floor but was then informed that the seeds were retrieved from the specimens the day before on July 19, 2022. The laboratory manager, radiology manager and nuclear medicine technologist tracked the path of seeds including the pathology lab, the operating room and hallways. Radioactive trash was also surveyed for radioactivity. The Radiation Safety Office and Medical Physicist were then notified of the missing seed.
"Corrective actions are in place including:
1. Nuclear Medicine will be notified immediately when a seed is retrieved from a specimen.
2. When retrieving the seed from the specimen, the survey meter must be used to ensure the seed is present.
3. Temporary pathology workers will not work with radioactive seeds.
"NY Event Report ID: NYDOH-22-06"
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: 56208
Rep Org: SC Dept of Health & Env Control
Licensee: Mitsubishi Polyester Films
Region: 1
City: Greer State: SC
County:
License #: SC-036
Agreement: Y
Docket:
NRC Notified By: Leland Cave
HQ OPS Officer: Karen Cotton-Gross
Licensee: Mitsubishi Polyester Films
Region: 1
City: Greer State: SC
County:
License #: SC-036
Agreement: Y
Docket:
NRC Notified By: Leland Cave
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 11/04/2022
Notification Time: 16:30 [ET]
Event Date: 11/04/2022
Event Time: 02:00 [EDT]
Last Update Date: 11/04/2022
Notification Time: 16:30 [ET]
Event Date: 11/04/2022
Event Time: 02:00 [EDT]
Last Update Date: 11/04/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Lilliendahl, Jon (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Lilliendahl, Jon (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE - DAMAGED GAUGE
The following is a summary of the information received from the South Carolina Department of Health and Environmental Control (the Department) via email:
"On November 4, 2022, at approximately 0200 EDT, the Department received a call from Mitsubishi Polyester Films regarding a fixed gauge whose mylar film had torn on the source side. The Thermo ECS Gauging Systems model TFC-185 gauge contains 1250 millicuries of Kr-85. The gauge is used to measure film thickness and as film was moving through the unit, the edge folded over making it too thick to go through the gap cleanly and, in turn, tore the mylar film on the source side of the unit. The licensee's radiation safety officer (RSO) was notified regarding the situation.
"At approximately 0900 EDT, the RSO submitted a picture of the damaged mylar to the Department and stated that the gauge's mylar had already been replaced by the onsite field service engineer and that a full report will be submitted within thirty days."
SC Event: 56208
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
The following is a summary of the information received from the South Carolina Department of Health and Environmental Control (the Department) via email:
"On November 4, 2022, at approximately 0200 EDT, the Department received a call from Mitsubishi Polyester Films regarding a fixed gauge whose mylar film had torn on the source side. The Thermo ECS Gauging Systems model TFC-185 gauge contains 1250 millicuries of Kr-85. The gauge is used to measure film thickness and as film was moving through the unit, the edge folded over making it too thick to go through the gap cleanly and, in turn, tore the mylar film on the source side of the unit. The licensee's radiation safety officer (RSO) was notified regarding the situation.
"At approximately 0900 EDT, the RSO submitted a picture of the damaged mylar to the Department and stated that the gauge's mylar had already been replaced by the onsite field service engineer and that a full report will be submitted within thirty days."
SC Event: 56208
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: 56216
Facility: Cook
Region: 3 State: MI
Unit: [2] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Ted Dey
HQ OPS Officer: Adam Koziol
Region: 3 State: MI
Unit: [2] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Ted Dey
HQ OPS Officer: Adam Koziol
Notification Date: 11/10/2022
Notification Time: 10:12 [ET]
Event Date: 11/10/2022
Event Time: 07:44 [EST]
Last Update Date: 11/10/2022
Notification Time: 10:12 [ET]
Event Date: 11/10/2022
Event Time: 07:44 [EST]
Last Update Date: 11/10/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical 50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical 50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
Dickson, Billy (R3DO)
Dickson, Billy (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | A/R | Y | 44 | Power Operation | 0 | Hot Standby |
AUTOMATIC REACTOR TRIP AND AUXILIARY FEEDWATER SYSTEM ACTUATION
The following information was provided by the licensee via email:
"At 0744 EST on November 10, 2022, DC Cook Unit 2 tripped automatically on high-high level of number 23 steam generator (SG). The reason for the high-high level in SG 23 is under investigation.
"This notification is being made in accordance with 10 CFR 50.72(b)(2)(iv)(B), Reactor Protection System (RPS) actuation as a four (4) hour report, and under 10 CFR 50.72(b)(3)(iv)(A), specified system actuation of the Auxiliary Feedwater System, as an eight (8) hour report. The DC Cook NRC Resident Inspector has been notified.
"Unit 2 is being supplied by offsite power. All control rods fully inserted. All Auxiliary Feedwater Pumps started properly. Decay heat is being removed via the Steam Dump System. Preliminary evaluation indicates all plant systems functioned normally following the reactor trip. DC Cook Unit 2 remains stable in Mode 3 while conducting the post trip review. No radioactive release is in progress as a result of this event."
The following information was provided by the licensee via email:
"At 0744 EST on November 10, 2022, DC Cook Unit 2 tripped automatically on high-high level of number 23 steam generator (SG). The reason for the high-high level in SG 23 is under investigation.
"This notification is being made in accordance with 10 CFR 50.72(b)(2)(iv)(B), Reactor Protection System (RPS) actuation as a four (4) hour report, and under 10 CFR 50.72(b)(3)(iv)(A), specified system actuation of the Auxiliary Feedwater System, as an eight (8) hour report. The DC Cook NRC Resident Inspector has been notified.
"Unit 2 is being supplied by offsite power. All control rods fully inserted. All Auxiliary Feedwater Pumps started properly. Decay heat is being removed via the Steam Dump System. Preliminary evaluation indicates all plant systems functioned normally following the reactor trip. DC Cook Unit 2 remains stable in Mode 3 while conducting the post trip review. No radioactive release is in progress as a result of this event."
Part 21
Event Number: 56219
Rep Org: Flowserve
Licensee:
Region: 1
City: Raleigh State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Kayn Dills
HQ OPS Officer: Ian Howard
Licensee:
Region: 1
City: Raleigh State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Kayn Dills
HQ OPS Officer: Ian Howard
Notification Date: 11/11/2022
Notification Time: 14:00 [ET]
Event Date: 09/11/2022
Event Time: 00:00 [EDT]
Last Update Date: 11/11/2022
Notification Time: 14:00 [ET]
Event Date: 09/11/2022
Event Time: 00:00 [EDT]
Last Update Date: 11/11/2022
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):
Werkheiser, Dave (R1DO)
Miller, Mark (R2DO)
Dickson, Billy (R3DO)
Azua, Ray (R4DO)
Part 21/50.55 Reactors, - (EMAIL)
Werkheiser, Dave (R1DO)
Miller, Mark (R2DO)
Dickson, Billy (R3DO)
Azua, Ray (R4DO)
Part 21/50.55 Reactors, - (EMAIL)
PART 21 - FLOWSERVE SOLENOID VALVE DEFICIENCY REPORT
The following is a synopsis of information provided by Flowserve via fax:
Flowserve Corporation hereby submits the enclosed written notification of the identification of a defect, in accordance with the requirements of 10 CFR 21.21(d)(3)(ii). This notification pertains to the failure of a solenoid valve (model 38878-8) at Catawba Nuclear Station.
List of plants / customers potentially impacted:
Duke - Catawba
Luminant - Comanche Peak
Exelon - Byron
Exelon - Braidwood
NextEra Energy - Seabrook
The solenoid valve received by Duke Energy failed to shift position when the coil was initially energized. This solenoid valve is part of the feedwater isolation valve assembly and failure to shift will prevent the feedwater isolation valve from closing on demand.
Flowserve was initially notified on September 11, 2022. Flowserve provided response to Duke on September 15, 2022 to confirm that Flowserve would perform the evaluation within 45 days upon receipt of the solenoid valve. Flowserve received the solenoid valve for evaluation on October 5, 2022.
During Flowserve's investigation into the root cause of the solenoid valve failure, Flowserve was unable to replicate the failure. Based on examination of the solenoid valve components, excess thread lock compound had been applied to the set screw and nut on the coil cap. The excess thread lock compound then ran down the coil cap and wicked between the coil cap outside diameter and the end cap inside diameter. Once this excess thread lock compound cured, the coil cap was locked in the de-energized position, preventing the coil cap from shifting. After the customer left the solenoid valve energized for 10 minutes, the coil cap broke free from de-energized position and was able to shift freely. In the procedure for assembly and testing of this solenoid valve, the solenoid valve is not energized after application of the thread lock compound.
Flowserve will (1) revise the assembly and test procedure for the Model 38878 solenoid valve to add a final test after the thread lock component has been applied and been allowed to cure to verify the solenoid valve shifts when energized, and (2) provide training to assembly and test personnel on the importance of ensuring that excess thread lock compound has not been applied.
These actions will be completed by December 15, 2022.
Nuclear power plants with model 38878 solenoid valves that have not undergone acceptance testing should verify that these suspect solenoid valves will shift on demand when energized.
For additional information, please contact Kayn Dills, Flowserve Corp Quality Manager (800-225-6989)
The following is a synopsis of information provided by Flowserve via fax:
Flowserve Corporation hereby submits the enclosed written notification of the identification of a defect, in accordance with the requirements of 10 CFR 21.21(d)(3)(ii). This notification pertains to the failure of a solenoid valve (model 38878-8) at Catawba Nuclear Station.
List of plants / customers potentially impacted:
Duke - Catawba
Luminant - Comanche Peak
Exelon - Byron
Exelon - Braidwood
NextEra Energy - Seabrook
The solenoid valve received by Duke Energy failed to shift position when the coil was initially energized. This solenoid valve is part of the feedwater isolation valve assembly and failure to shift will prevent the feedwater isolation valve from closing on demand.
Flowserve was initially notified on September 11, 2022. Flowserve provided response to Duke on September 15, 2022 to confirm that Flowserve would perform the evaluation within 45 days upon receipt of the solenoid valve. Flowserve received the solenoid valve for evaluation on October 5, 2022.
During Flowserve's investigation into the root cause of the solenoid valve failure, Flowserve was unable to replicate the failure. Based on examination of the solenoid valve components, excess thread lock compound had been applied to the set screw and nut on the coil cap. The excess thread lock compound then ran down the coil cap and wicked between the coil cap outside diameter and the end cap inside diameter. Once this excess thread lock compound cured, the coil cap was locked in the de-energized position, preventing the coil cap from shifting. After the customer left the solenoid valve energized for 10 minutes, the coil cap broke free from de-energized position and was able to shift freely. In the procedure for assembly and testing of this solenoid valve, the solenoid valve is not energized after application of the thread lock compound.
Flowserve will (1) revise the assembly and test procedure for the Model 38878 solenoid valve to add a final test after the thread lock component has been applied and been allowed to cure to verify the solenoid valve shifts when energized, and (2) provide training to assembly and test personnel on the importance of ensuring that excess thread lock compound has not been applied.
These actions will be completed by December 15, 2022.
Nuclear power plants with model 38878 solenoid valves that have not undergone acceptance testing should verify that these suspect solenoid valves will shift on demand when energized.
For additional information, please contact Kayn Dills, Flowserve Corp Quality Manager (800-225-6989)
Power Reactor
Event Number: 56220
Facility: Cooper
Region: 4 State: NE
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: Scott Johnson
HQ OPS Officer: Lloyd Desotell
Region: 4 State: NE
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: Scott Johnson
HQ OPS Officer: Lloyd Desotell
Notification Date: 11/13/2022
Notification Time: 04:01 [ET]
Event Date: 11/12/2022
Event Time: 23:19 [CDT]
Last Update Date: 11/13/2022
Notification Time: 04:01 [ET]
Event Date: 11/12/2022
Event Time: 23:19 [CDT]
Last Update Date: 11/13/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical 50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical 50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
Azua, Ray (R4DO)
Azua, Ray (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | A/R | Y | 2 | Startup | 0 | Hot Standby |
AUTOMATIC REACTOR SCRAM
The following information was provided by the licensee email:
"On November 12, 2022, at 2319 CST, an actuation of the reactor protection system (RPS) initiated a full scram. The plant was in Mode 2, reactor pressure was 149 pounds. The high pressure coolant injection (HPCI) injection valve, HPCI-MOV-MO19, opened and injected cold water into the reactor vessel while HPCI system testing was in progress. The cause is still under investigation. All control rods inserted. Plant is currently in Mode 3 and stable. All systems operated as designed with no Primary Containment Isolation System group isolations. This event is being reported under two event classifications:
"50. 72(b)(2)(iv)(B) -- "Any event or condition that results in actuation of the reactor protection system (RPS) when the reactor is critical except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation."
"50. 72(b)(3)(iv)(A) -- "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."
"The NRC Resident has been informed."
The following information was provided by the licensee email:
"On November 12, 2022, at 2319 CST, an actuation of the reactor protection system (RPS) initiated a full scram. The plant was in Mode 2, reactor pressure was 149 pounds. The high pressure coolant injection (HPCI) injection valve, HPCI-MOV-MO19, opened and injected cold water into the reactor vessel while HPCI system testing was in progress. The cause is still under investigation. All control rods inserted. Plant is currently in Mode 3 and stable. All systems operated as designed with no Primary Containment Isolation System group isolations. This event is being reported under two event classifications:
"50. 72(b)(2)(iv)(B) -- "Any event or condition that results in actuation of the reactor protection system (RPS) when the reactor is critical except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation."
"50. 72(b)(3)(iv)(A) -- "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."
"The NRC Resident has been informed."