Event Notification Report for November 14, 2022

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
11/10/2022 - 11/14/2022

!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
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
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
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
Miller, Mark (R2DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Hot Standby 0 Hot Standby
Event Text
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).


!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
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
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
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
Miller, Mark (R2DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Hot Standby 0 Hot Standby
Event Text
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).


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
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
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Lilliendahl, Jon (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MacDonald, Mark (ILTAB)
CNSC (Canada), - (EMAIL)
Event Text
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


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
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
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Ruiz, Robert (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MacDonald, Mark (ILTAB)
Lilliendahl, Jon (R1DO)
Event Text
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


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
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
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Lilliendahl, Jon (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MacDonald, Mark (ILTAB)
CNSC (Canada), - (EMAIL)
Event Text
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


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
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
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Lilliendahl, Jon (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
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


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
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
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Azua, Ray (R4DO)
FFD Group, (EMAIL)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 100 Power Operation 100 Power Operation
Event Text
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.


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
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
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical
50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
Dickson, Billy (R3DO)
Power Reactor Unit Info
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
Event Text
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."


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
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
Emergency Class: Non Emergency
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)
Event Text
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)


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
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
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical
50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
Azua, Ray (R4DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 2 Startup 0 Hot Standby
Event Text
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."

Page Last Reviewed/Updated Monday, November 14, 2022