Event Notification Report for March 07, 2023

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
03/06/2023 - 03/07/2023

EVENT NUMBERS
56252 56295 56368 56383 56390
Part 21
Event Number: 56252
Rep Org: Flowserve
Licensee:
Region: 2
City: Lynchburg   State: VA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Chris Shaffer
HQ OPS Officer: Ernest West
Notification Date: 12/01/2022
Notification Time: 14:45 [ET]
Event Date: 10/05/2022
Event Time: 00:00 [EST]
Last Update Date: 03/06/2023
Emergency Class: Non Emergency
10 CFR Section:
21.21(a)(2) - Interim Eval Of Deviation
Person (Organization):
Part 21/50.55 Reactors, - (EMAIL)
Vossmar, Patricia (R4DO)
Event Text
EN Revision Imported Date: 3/6/2023

EN Revision Text: PART 21 - DEVIATION TO QUALIFIED DESIGN

The following is a summary of information provided by Flowserve - Limitorque via email:

Entergy Waterford 3 informed Flowserve - Limitorque on 10/5/2022 that it discovered that a Peerless 125 volt, 25ft-lb, 56 frame direct current (DC) motor had two fasteners securing the brush holder ring assembly to the motor frame. However, the DC motor assembly used in the qualification test program was assembled with 4 fasteners. Therefore, the use of two fasteners is a deviation to the qualified design. Flowserve is submitting this report as an interim report and is evaluating this deviation to determine whether this condition could potentially affect the safety related function of DC powered Limitorque actuators.

Flowserve is continuing to work with the motor original equipment manufacturer (OEM) to refine the scope of potentially affected motors. Limitorque actuators equipped with Peerless - Winsmith DC electric motors with start torque ratings of 40 ft-lb and larger are not affected by this issue. Limitorque actuators equipped with alternating current (AC) powered electric motors are not affected by this issue.

The evaluation is expected to be completed by 01/27/2023. If there are questions, or addition information is required, please contact Chris Shaffer, Quality Assurance Manager, Flowserve Corporation, Ph: (434) 522-4136.

Known affected plant: Waterford 3 Nuclear Generating Station

* * * UPDATE ON 01/27/2023 AT 1011 EST FROM FLOWSERVE TO JOHN RUSSELL* * *

Flowserve provided an update to notify that the final evaluation of the safety consequence and reportability, primarily involving seismic qualification, will be delayed until 02/24/2023.

Notified R4DO (Agrawal) via phone and the Part 21 group via email.

* * * UPDATE ON 03/03/2023 AT 0952 EST FROM CHRIS SHAFFER (FLOWSERVE) TO JOHN RUSSELL* * *

Flowserve has completed the evaluation of the deviation described in the initial notification. Flowserve has concluded that the deviation has no substantial impact to the safety function of the component and/or the associated actuator.

Notified R4DO (Vossmar) via phone and the Part 21 group via email.


Power Reactor
Event Number: 56295
Facility: Fermi
Region: 3     State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: Whitney Hemingway
HQ OPS Officer: Ian Howard
Notification Date: 01/04/2023
Notification Time: 08:28 [ET]
Event Date: 01/04/2023
Event Time: 01:48 [EST]
Last Update Date: 03/06/2023
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
Edwards, Rhex (R3DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation
Event Text
EN Revision Imported Date: 3/7/2023

EN Revision Text: HIGH PRESSURE COOLANT INJECTION INOPERABLE

The following information was provided by the licensee via email:

"At 0148 EST on January 4, 2023 it was identified that P4400F603B, Division 2 Emergency Equipment Cooling Water (EECW) Supply Isolation Valve, lost position indication. Division 2 EECW System was declared inoperable due to the potential that this valve may not be capable of performing its safety function to automatically isolate the safety related Division 2 EECW system from the non-safety related Reactor Building Closed Cooling Water (RBCCW) system. Because the Division 2 EECW system provides cooling to the High Pressure Coolant Injection (HPCI) room cooler, HPCI was also declared inoperable; therefore, this condition is being reported as an eight-hour, non--emergency notification per 10 CFR 50.72(b)(3)(v)(D).

"At 0240 EST, position indication was restored and Division 2 EECW and HPCI was returned to operable following inspection of the associated motor control center (MCC) and testing of the associated fuses. The cause of the loss of indication is under investigation.

"The Senior NRC resident inspector has been notified."

* * * RETRACTION ON 3/6/23 AT 1740 EST FROM GREGORY MILLER TO KERBY SCALES * * *

The following retraction was received from the licensee via email:

"The purpose of this notification is to retract a previous Event Notification, EN 56295, reported on 1/4/2023.

"Following the initial EN, further analysis of the condition was performed utilizing a gothic analysis model to perform HPCI room heat-up calculations. Based on the initial conditions at the time of the indication loss, specifically HPCI room and Suppression Pool temperature, it was determined that the resulting worst case post-accident room temperature was sufficiently low enough to provide margin to HPCI operability without the room cooler in service for the required mission time.

"No other concerns were noted during the event. Therefore, HPCI remained operable and there was no loss of safety function. The event did not involve a condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident under 10 CFR 50.72(b)(3)(v)(D).

"Therefore, the NRC non-emergency 10 CFR 50.72(b)(3)(v)(D) report was not required and the NRC report 56295 can be retracted and no Licensee Event Report under 10 CFR 50.73(a)(2)(v)(D) is required to be submitted.

"The NRC Senior Resident Inspector has been notified."

Notified R3DO (Ruiz).


Agreement State
Event Number: 56368
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Sofie
Region: 3
City: Romeoville   State: IL
County:
License #: IL-02074-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Adam Koziol
Notification Date: 02/16/2023
Notification Time: 15:55 [ET]
Event Date: 01/17/2023
Event Time: 00:00 [CST]
Last Update Date: 03/06/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Dickson, Billy (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
EN Revision Imported Date: 3/7/2023

EN Revision Text: AGREEMENT STATE REPORT - OCCUPATIONAL DOSE LIMIT EXCEEDED

The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:

"The Agency received written correspondence on February 16, 2023, indicating a worker at a Romeoville, IL nuclear pharmacy (Sofie, RML IL-02074-01) received a whole body dose that exceeded the occupational limits in 32 Ill. Adm. Code 340.210. The exposure occurred over the course of 2022 and no adverse health impacts are anticipated. Specifically, the information provided indicates a quality control production associate received 5,090 millirem over the course of 2022, exceeding the occupational limit of 5,000 millirem.

"The licensee has conducted an investigation and believes the cause is related to both a management deficiency and equipment issues. New duties assigned in July of 2022 resulted in increased exposure which was apparently not reviewed and/or assessed at a frequency sufficient to limit occupational dose. Additionally, dose delivery equipment reportedly failed at some point in 2022, resulting in the use of equipment with insufficient shielding. The licensee identified corrective action as more frequent dosimetry exchange, repair of equipment (timeline unspecified) and reassignment of duties.

"This is a reportable incident under 32 Ill. Adm. Code 340.1230 and was reported to NRC the same day (2/16/23). The licensee provided timely notification. In the next week, IEMA inspectors will perform a reactionary inspection to assess the adequacy of the licensee's investigation and corrective action, compliance with Agency regulations and root cause determination."

Illinois Event Number: IL230004

* * * UPDATE FROM GARY FORSEE TO DONALD NORWOOD ON 3/6/2023 AT 1059 EDT * * *

The following information was received via email:

"On March 3, 2023, Agency inspectors performed a reactionary inspection. The root cause of failing to provide adequate monitoring of occupational exposures was confirmed. This was compounded when delivery equipment failed and alternate procedures were utilized.

"The subject employee who exceeded the annual occupational dose of 5,000 mrem (5 rem) was reported as having received 5,090 mrem. However, during the inspection, inspectors discovered that from February 14, 2022, through April 25, 2022, the employee was wearing visitor dosimetry, which wasn't added to the individuals dosimetry report. It was added to her Form 5 by the RSO which was completed on February 20, 2023. The total exposure was 5,781 mrem for this individual.

"It was also noted that as a result of not adding the visitor badges to the individuals report the employee first exceeded the annual occupational dose at the end of October, 2022, having reached 5,057 mrem. Additional violations regarding employee dosimetry were noted and are being assessed at this time. However, they are not expected to result in another occupational exposure. The Agency has requested dosimetry records for all licensee staff working under the alternate procedures. Updates will be provided as they become available."

otified the R3DO (Havertape) and the NMSS Events Notification email group.


Agreement State
Event Number: 56383
Rep Org: Texas Dept of State Health Services
Licensee: Citizens Medical Center
Region: 4
City: Victoria   State: TX
County:
License #: L 00283
Agreement: Y
Docket:
NRC Notified By: Chris Moore
HQ OPS Officer: Adam Koziol
Notification Date: 02/28/2023
Notification Time: 07:02 [ET]
Event Date: 02/27/2023
Event Time: 00:00 [CST]
Last Update Date: 02/28/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Vossmar, Patricia (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - STUCK SOURCE

The following information was provided by the Texas Department of State Health Services (the Agency) via email:

"On February 27, 2023, the Agency was sent a reciprocity notice that a service company was going to work in a hospital to repair a Elekta model 136146 Flexitron high dose rate remote afterloader unit (HDR) containing 10 Ci of Ir-192. The report indicated the source was stuck. The Agency contacted the hospital and determined that the source became stuck outside the HDR unit during the conduct of a dwell position accuracy check using the source position check ruler. This was conducted as a daily Quality Assurance (QA) check. The QA device transfer tube for the test was connected upside down, the connector was inverted, by error, which allowed the source to travel outside the tube and get stuck outside the vault below the ruler. The source could not be retrieved. There is no report of excess exposure to hospital staff and no medical procedure was being conducted. The unit was repaired and a report was issued by the service technician to determine if there is a design issue with the test equipment. Additional details will be sent in accordance with SA 300."

Texas Incident Number: I-9994

Texas NMED Number: TX23007


Power Reactor
Event Number: 56390
Facility: River Bend
Region: 4     State: LA
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: Jessie Hoda
HQ OPS Officer: Donald Norwood
Notification Date: 03/05/2023
Notification Time: 03:02 [ET]
Event Date: 03/04/2023
Event Time: 23:00 [CST]
Last Update Date: 03/05/2023
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(xii) - Offsite Medical
Person (Organization):
Vossmar, Patricia (R4DO)
Crouch, Howard (IR)
Felts, Russell (NRR EO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 0 Power Operation 0 Power Operation
Event Text
TRANSPORT OF A POTENTIALLY CONTAMINATED PERSON OFFSITE

The following information was provided by the licensee via email:

"At 2300 CST on March 4, 2023, River Bend Station (RBS) was shut down in Mode 5 when an individual was transported offsite for treatment at an offsite medical facility. Due to the nature of the medical condition, the individual was not thoroughly surveyed prior to being transported offsite. Follow-up surveys performed by radiation protection technicians identified no contamination of the worker or of the ambulance and response personnel.

"This is an eight-hour notification, non-emergency for the transportation of a contaminated person offsite. This event is reportable in accordance with 10 CFR 50.72(b)(3)(xii).

"The NRC Resident Inspector has been notified."