Event Notification Report for May 26, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/25/2023 - 05/26/2023
Agreement State
Event Number: 56524
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Flexsys America, L.P.
Region: 3
City: Sauget State: IL
County:
License #: IL-01229-01
Agreement: Y
Docket:
NRC Notified By: Whitney Cox
HQ OPS Officer: Sam Colvard
Licensee: Flexsys America, L.P.
Region: 3
City: Sauget State: IL
County:
License #: IL-01229-01
Agreement: Y
Docket:
NRC Notified By: Whitney Cox
HQ OPS Officer: Sam Colvard
Notification Date: 05/18/2023
Notification Time: 15:44 [ET]
Event Date: 02/23/2023
Event Time: 00:00 [CDT]
Last Update Date: 05/18/2023
Notification Time: 15:44 [ET]
Event Date: 02/23/2023
Event Time: 00:00 [CDT]
Last Update Date: 05/18/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Feliz-Adorno, Nestor (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Feliz-Adorno, Nestor (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - FAILED SHUTTER
The following information is a summary provided by the Illinois Emergency Management Agency via email:
During a routine inspection on May 17, 2023 at Flexsys America, L.P. in Sauget, IL, an inspector identified a February 2022 equipment failure involving a fixed gauge that resulted in a stuck-open condition of the shutter (300mCi Cs-137 sealed source, model A-2102, serial number 3654CP). This incident was reportable to ONS-RAM within 24 hours under 32 Ill. Adm. Code 340.1220(c)(2). No personnel exposures occurred as a result. Corrective action was taken with repairs to the mechanism performed by the manufacturer and the gauge was returned to operable condition. The initial reporting requirement was not met by the licensee and will be addressed through inspection correspondence. This matter was reported to the NRC within the required timeframe.
Illinois report number: IL230010
The following information is a summary provided by the Illinois Emergency Management Agency via email:
During a routine inspection on May 17, 2023 at Flexsys America, L.P. in Sauget, IL, an inspector identified a February 2022 equipment failure involving a fixed gauge that resulted in a stuck-open condition of the shutter (300mCi Cs-137 sealed source, model A-2102, serial number 3654CP). This incident was reportable to ONS-RAM within 24 hours under 32 Ill. Adm. Code 340.1220(c)(2). No personnel exposures occurred as a result. Corrective action was taken with repairs to the mechanism performed by the manufacturer and the gauge was returned to operable condition. The initial reporting requirement was not met by the licensee and will be addressed through inspection correspondence. This matter was reported to the NRC within the required timeframe.
Illinois report number: IL230010
Agreement State
Event Number: 56525
Rep Org: Texas Dept of State Health Services
Licensee: Univ. TX MD Anderson Cancer Center
Region: 4
City: Houston State: TX
County:
License #: L00466
Agreement: Y
Docket:
NRC Notified By: Randall Redd
HQ OPS Officer: Sam Colvard
Licensee: Univ. TX MD Anderson Cancer Center
Region: 4
City: Houston State: TX
County:
License #: L00466
Agreement: Y
Docket:
NRC Notified By: Randall Redd
HQ OPS Officer: Sam Colvard
Notification Date: 05/18/2023
Notification Time: 19:11 [ET]
Event Date: 05/18/2023
Event Time: 00:00 [CDT]
Last Update Date: 05/18/2023
Notification Time: 19:11 [ET]
Event Date: 05/18/2023
Event Time: 00:00 [CDT]
Last Update Date: 05/18/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Azua, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Azua, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - CONTAMINATED WORKER
The following information was provided by Texas Department of State Health Services (the Department) via email:
"On May 18, 2023, The University of Texas MD Anderson Cancer Center (the licensee) reported to this Department that they had discovered a technician and package with contamination of around 12,000 dpm [disintegrations per minute]. The licensee's technician picked up the bag (package) with their bare hands. They then did a wipe test of the bag and found that it was contaminated. They also discovered that both their hands were contaminated. They washed repeatedly which reduced the contamination on their hands but did not eliminate it. The licensee believes that the remaining contamination has been absorbed into their skin and that it is no longer removable. The technician has gone home with instructions to continue wearing gloves. The technician is pregnant, and the licensee plans to perform a thyroid check tomorrow.
"The bag had elevated readings at the handle, but the contamination seemed to mostly be at the top right of the bag where the zipper handle was located. The licensee has not found contamination in any other areas of their facility. The licensee used a well counter to try to determine the isotope and believes it is either 5 microcuries of technetium-99m or 2 microcuries of iodine-123. A comparison of activities of the following day will determine which isotope it is since there is a significant difference in half-lives. The container with the ordered 10 millicuries of iodine-123, which was inside the bag, was wiped and found to not be contaminated.
"The nuclear pharmacy that supplied the bag and material inside the bag did wipe tests of the driver's hands, the steering wheel, pedals, the rack the bag would sit on, and the hand truck that the package would have been placed on. They did not find any radiation above background. They also performed wipes and surveys within their facility and again did not find any contamination.
"The worker who prepared the material at the pharmacy in the morning only drew iodine-123 for this single package. All other iodine-123 packages were pre-prepared. The pharmacy sent around 45 packages out in the morning to many medical facilities. None have reported contamination. The truck only carries packages from this single pharmacy.
"The Department has asked both facilities to continue to look for contamination and has recommended that the technician wear cotton gloves inside of the other gloves to hopefully get the hands to sweat the material out into the cotton."
Texas incident number: 10020.
The following information was provided by Texas Department of State Health Services (the Department) via email:
"On May 18, 2023, The University of Texas MD Anderson Cancer Center (the licensee) reported to this Department that they had discovered a technician and package with contamination of around 12,000 dpm [disintegrations per minute]. The licensee's technician picked up the bag (package) with their bare hands. They then did a wipe test of the bag and found that it was contaminated. They also discovered that both their hands were contaminated. They washed repeatedly which reduced the contamination on their hands but did not eliminate it. The licensee believes that the remaining contamination has been absorbed into their skin and that it is no longer removable. The technician has gone home with instructions to continue wearing gloves. The technician is pregnant, and the licensee plans to perform a thyroid check tomorrow.
"The bag had elevated readings at the handle, but the contamination seemed to mostly be at the top right of the bag where the zipper handle was located. The licensee has not found contamination in any other areas of their facility. The licensee used a well counter to try to determine the isotope and believes it is either 5 microcuries of technetium-99m or 2 microcuries of iodine-123. A comparison of activities of the following day will determine which isotope it is since there is a significant difference in half-lives. The container with the ordered 10 millicuries of iodine-123, which was inside the bag, was wiped and found to not be contaminated.
"The nuclear pharmacy that supplied the bag and material inside the bag did wipe tests of the driver's hands, the steering wheel, pedals, the rack the bag would sit on, and the hand truck that the package would have been placed on. They did not find any radiation above background. They also performed wipes and surveys within their facility and again did not find any contamination.
"The worker who prepared the material at the pharmacy in the morning only drew iodine-123 for this single package. All other iodine-123 packages were pre-prepared. The pharmacy sent around 45 packages out in the morning to many medical facilities. None have reported contamination. The truck only carries packages from this single pharmacy.
"The Department has asked both facilities to continue to look for contamination and has recommended that the technician wear cotton gloves inside of the other gloves to hopefully get the hands to sweat the material out into the cotton."
Texas incident number: 10020.
Agreement State
Event Number: 56526
Rep Org: PA Bureau of Radiation Protection
Licensee: Thomas Jefferson Univ. Hospital
Region: 1
City: Philadelphia State: PA
County:
License #: PA-0130
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Kerby Scales
Licensee: Thomas Jefferson Univ. Hospital
Region: 1
City: Philadelphia State: PA
County:
License #: PA-0130
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Kerby Scales
Notification Date: 05/19/2023
Notification Time: 12:03 [ET]
Event Date: 04/11/2023
Event Time: 00:00 [EDT]
Last Update Date: 05/19/2023
Notification Time: 12:03 [ET]
Event Date: 04/11/2023
Event Time: 00:00 [EDT]
Last Update Date: 05/19/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Defrancisco, Anne (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Defrancisco, Anne (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL EVENT (PATIENT UNDERDOSE)
The following information was received from the Pennsylvania Department of Radiation Protection via email:
"On March 28, 2023, a patient was treated with a permanent Cs-131 implant with a prescribed dose of 60 Gy. On April 11, 2023, the patient presented with a serious medical condition which necessitated the immediate removal of the implant. The seeds were all accounted for and placed into storage for decay to background. The actual dose delivered is calculated to be 37 Gy. The referring physician and the patient have been informed."
Event Report Identification Number: PA230015
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 received from the Pennsylvania Department of Radiation Protection via email:
"On March 28, 2023, a patient was treated with a permanent Cs-131 implant with a prescribed dose of 60 Gy. On April 11, 2023, the patient presented with a serious medical condition which necessitated the immediate removal of the implant. The seeds were all accounted for and placed into storage for decay to background. The actual dose delivered is calculated to be 37 Gy. The referring physician and the patient have been informed."
Event Report Identification Number: PA230015
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
Agreement State
Event Number: 56528
Rep Org: Georgia Radioactive Material Pgm
Licensee: Cardiac Consultants of Central GA
Region: 1
City: Macon State: GA
County:
License #: GA 1629-1
Agreement: Y
Docket:
NRC Notified By: Stacy Allman
HQ OPS Officer: Bill Gott
Licensee: Cardiac Consultants of Central GA
Region: 1
City: Macon State: GA
County:
License #: GA 1629-1
Agreement: Y
Docket:
NRC Notified By: Stacy Allman
HQ OPS Officer: Bill Gott
Notification Date: 05/19/2023
Notification Time: 12:23 [ET]
Event Date: 05/11/2023
Event Time: 00:00 [EDT]
Last Update Date: 05/19/2023
Notification Time: 12:23 [ET]
Event Date: 05/11/2023
Event Time: 00:00 [EDT]
Last Update Date: 05/19/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Defrancisco, Anne (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Defrancisco, Anne (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - LEAKING SOURCE
The information below was provided by the Georgia Department of Natural Resources via email:
"During a routine sealed source inventory check, Cardiac Consultants of Central Georgia, LLC, license GA 1629-1 discovered that one of their Cs-137 vials (S/N 1615-4-2) appeared to display signs of moisture within. This source's current activity is 0.15078 mCi. A wipe test was then performed. Results of the wipe test confirmed that this source was leaking. The area surrounding the source was surveyed and wipe tested as well. No sign of contamination was discovered. The leaking source has been contained and is secured in the licensee's hot lab in an appropriate shielded container. The licensee waits for a hazardous waste disposal quote before properly disposing. This incident occurred on May 11, 2023, and the licensee reported to the State on May 15, 2023. The State is waiting for the licensee to provide a copy of leak test results for the source of concern and confirmation of source disposal."
GA Incident Number: 65
The information below was provided by the Georgia Department of Natural Resources via email:
"During a routine sealed source inventory check, Cardiac Consultants of Central Georgia, LLC, license GA 1629-1 discovered that one of their Cs-137 vials (S/N 1615-4-2) appeared to display signs of moisture within. This source's current activity is 0.15078 mCi. A wipe test was then performed. Results of the wipe test confirmed that this source was leaking. The area surrounding the source was surveyed and wipe tested as well. No sign of contamination was discovered. The leaking source has been contained and is secured in the licensee's hot lab in an appropriate shielded container. The licensee waits for a hazardous waste disposal quote before properly disposing. This incident occurred on May 11, 2023, and the licensee reported to the State on May 15, 2023. The State is waiting for the licensee to provide a copy of leak test results for the source of concern and confirmation of source disposal."
GA Incident Number: 65
Agreement State
Event Number: 56529
Rep Org: Colorado Dept of Health
Licensee: University of Colorado Hospital
Region: 4
City: Aurora State: CO
County:
License #: CO 828-01
Agreement: Y
Docket:
NRC Notified By: Matt Gift
HQ OPS Officer: Kerby Scales
Licensee: University of Colorado Hospital
Region: 4
City: Aurora State: CO
County:
License #: CO 828-01
Agreement: Y
Docket:
NRC Notified By: Matt Gift
HQ OPS Officer: Kerby Scales
Notification Date: 05/19/2023
Notification Time: 13:49 [ET]
Event Date: 05/18/2023
Event Time: 00:00 [MDT]
Last Update Date: 05/19/2023
Notification Time: 13:49 [ET]
Event Date: 05/18/2023
Event Time: 00:00 [MDT]
Last Update Date: 05/19/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Azua, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Azua, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL EVENT (PATIENT UNDERDOSE)
The following was received from the Colorado Department of Public Health and Environment via email:
"On May 19, 2023, the associate radiation safety officer at the University of Colorado Hospital reported a medical event. The event occurred on May 18, 2023, during a Y-90 TheraSphere administration. The licensee reported that during the administration, there was an obstruction in a line/catheter causing the target to only receive 4.6 percent of the intended dose. The authorized user does not believe the obstruction was due to stasis. The prescribed dose for the treatment was 300 Gy (20.06 mCi) and the administered dose was calculated to be 13.87 Gy (0.93 mCi). The licensee is working with the manufacturer, and the exact cause of the obstruction resulting in the medical event is still under investigation."
Colorado Event Report Number: CO230012
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 was received from the Colorado Department of Public Health and Environment via email:
"On May 19, 2023, the associate radiation safety officer at the University of Colorado Hospital reported a medical event. The event occurred on May 18, 2023, during a Y-90 TheraSphere administration. The licensee reported that during the administration, there was an obstruction in a line/catheter causing the target to only receive 4.6 percent of the intended dose. The authorized user does not believe the obstruction was due to stasis. The prescribed dose for the treatment was 300 Gy (20.06 mCi) and the administered dose was calculated to be 13.87 Gy (0.93 mCi). The licensee is working with the manufacturer, and the exact cause of the obstruction resulting in the medical event is still under investigation."
Colorado Event Report Number: CO230012
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
Agreement State
Event Number: 56530
Rep Org: MA Radiation Control Program
Licensee: Invicro LLC
Region: 1
City: Needham State: MA
County:
License #: 55-0692
Agreement: Y
Docket:
NRC Notified By: Kenath Traegde
HQ OPS Officer: Kerby Scales
Licensee: Invicro LLC
Region: 1
City: Needham State: MA
County:
License #: 55-0692
Agreement: Y
Docket:
NRC Notified By: Kenath Traegde
HQ OPS Officer: Kerby Scales
Notification Date: 05/19/2023
Notification Time: 16:11 [ET]
Event Date: 05/19/2023
Event Time: 10:00 [EDT]
Last Update Date: 05/19/2023
Notification Time: 16:11 [ET]
Event Date: 05/19/2023
Event Time: 10:00 [EDT]
Last Update Date: 05/19/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Defrancisco, Anne (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Defrancisco, Anne (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - PACKAGE EXCEEDED RADIATION LIMITS
The following information was received from the Massachusetts Radiation Control Program (the Agency) via email:
"A telephone call received by the Agency from the [Radiation Safety Officer] RSO of Invicro, LLC, at 1054 EDT on 5/19/2023. A package was received on 5/19/2023 at approximately 1000 EDT at the licensee's site that exceeded the dose rate limit of 200 mrem/hr on the external surface of the package. The radionuclide was fluorine-18 (F-18) in liquid form enclosed in a glass vial. The assayed dose was 499 mCi at 0930 at PETNET Solutions, Inc. in Woburn, MA, the distributor of the F-18.
"The package was labeled Yellow II and the maximum surface dose rate should therefore not exceed 50 mrem/hour for a Yellow II labeled package. The package upon shipment was measured by the shipper to have a surface dose rate of 7 mrem/hour and a transport index (TI) of 0.4.
"The licensee reported that 5 wipe samples were taken on the external surface of the package with no resultant removable contamination observed. It was reported that the glass vial contained approximately 350 mCi of F-18 at the time the package was opened. The external dose rates on all external surfaces continued to exceed 200 mR/hr, even with the vial removed from the package.
"Surveys of areas where the package was opened, and where the vial was transported, are undergoing. The vial is currently stored in a hot cell. The external package is being stored in a shielded location. Personnel are being surveyed for contamination. At this time there is no indication of external contamination of the shipping package.
"The Agency, Invicro LLC, and PETNET Solutions, Inc. are in communication working the details of the scenario and potential personnel exposer.
"The Massachusetts Radiation Control Program considers this to be an open reportable event."
The following information was received from the Massachusetts Radiation Control Program (the Agency) via email:
"A telephone call received by the Agency from the [Radiation Safety Officer] RSO of Invicro, LLC, at 1054 EDT on 5/19/2023. A package was received on 5/19/2023 at approximately 1000 EDT at the licensee's site that exceeded the dose rate limit of 200 mrem/hr on the external surface of the package. The radionuclide was fluorine-18 (F-18) in liquid form enclosed in a glass vial. The assayed dose was 499 mCi at 0930 at PETNET Solutions, Inc. in Woburn, MA, the distributor of the F-18.
"The package was labeled Yellow II and the maximum surface dose rate should therefore not exceed 50 mrem/hour for a Yellow II labeled package. The package upon shipment was measured by the shipper to have a surface dose rate of 7 mrem/hour and a transport index (TI) of 0.4.
"The licensee reported that 5 wipe samples were taken on the external surface of the package with no resultant removable contamination observed. It was reported that the glass vial contained approximately 350 mCi of F-18 at the time the package was opened. The external dose rates on all external surfaces continued to exceed 200 mR/hr, even with the vial removed from the package.
"Surveys of areas where the package was opened, and where the vial was transported, are undergoing. The vial is currently stored in a hot cell. The external package is being stored in a shielded location. Personnel are being surveyed for contamination. At this time there is no indication of external contamination of the shipping package.
"The Agency, Invicro LLC, and PETNET Solutions, Inc. are in communication working the details of the scenario and potential personnel exposer.
"The Massachusetts Radiation Control Program considers this to be an open reportable event."
Part 21
Event Number: 56538
Rep Org: Engine Systems, Inc
Licensee: Engine Systems, Inc
Region: 1
City: Rocky Mount State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Dan Roberts
HQ OPS Officer: Ian Howard
Licensee: Engine Systems, Inc
Region: 1
City: Rocky Mount State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Dan Roberts
HQ OPS Officer: Ian Howard
Notification Date: 05/24/2023
Notification Time: 15:32 [ET]
Event Date: 03/28/2023
Event Time: 00:00 [EDT]
Last Update Date: 05/24/2023
Notification Time: 15:32 [ET]
Event Date: 03/28/2023
Event Time: 00:00 [EDT]
Last Update Date: 05/24/2023
Emergency Class: Non Emergency
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
Person (Organization):
Miller, Mark (R2DO)
Part 21/50.55 Reactors, - (EMAIL)
Miller, Mark (R2DO)
Part 21/50.55 Reactors, - (EMAIL)
PART 21 - DEFECT IDENTIFIED IN EMERGENCY DIESEL GENERATOR GOVERNOR
The following is a synopsis of information provided by the Engine Systems, Inc (ESI) via fax:
Component Description: Woodward Governor, Part No. 9903-722, Serial No. 18847017
Problem Description: An EGB-35P governor/actuator (governor) installed on a customer's emergency diesel generator failed soon after installation. Investigation revealed a piece of foreign material, a loose buffer plug, inside the governor that caused the failure. Since the governor is used to maintain fuel rack position of the diesel engine, failure of the governor would prevent the emergency diesel generator from performing its safety-related function during an event.
Affected Plants: Brunswick Nuclear Plant
Corrective Actions for Brunswick Nuclear Plant: No action required. The affected governor has been returned to ESI.
Corrective Actions for ESI: The governor will be refurbished under ESI's 10 CFR 50 Appendix B program and certified for continued use at Brunswick Nuclear Plant. To prevent reoccurrence, ESI will revise the dedication requirements to enhance existing foreign material inspection practices to include a visual inspection where the buffer plug was located within the governor. The revisions are expected to be complete within 30 days but in all cases prior to future shipments.
The following is a synopsis of information provided by the Engine Systems, Inc (ESI) via fax:
Component Description: Woodward Governor, Part No. 9903-722, Serial No. 18847017
Problem Description: An EGB-35P governor/actuator (governor) installed on a customer's emergency diesel generator failed soon after installation. Investigation revealed a piece of foreign material, a loose buffer plug, inside the governor that caused the failure. Since the governor is used to maintain fuel rack position of the diesel engine, failure of the governor would prevent the emergency diesel generator from performing its safety-related function during an event.
Affected Plants: Brunswick Nuclear Plant
Corrective Actions for Brunswick Nuclear Plant: No action required. The affected governor has been returned to ESI.
Corrective Actions for ESI: The governor will be refurbished under ESI's 10 CFR 50 Appendix B program and certified for continued use at Brunswick Nuclear Plant. To prevent reoccurrence, ESI will revise the dedication requirements to enhance existing foreign material inspection practices to include a visual inspection where the buffer plug was located within the governor. The revisions are expected to be complete within 30 days but in all cases prior to future shipments.
Power Reactor
Event Number: 56539
Facility: Palo Verde
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: Lorraine Weaver
HQ OPS Officer: Ian Howard
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: Lorraine Weaver
HQ OPS Officer: Ian Howard
Notification Date: 05/24/2023
Notification Time: 19:58 [ET]
Event Date: 05/24/2023
Event Time: 07:10 [MST]
Last Update Date: 05/24/2023
Notification Time: 19:58 [ET]
Event Date: 05/24/2023
Event Time: 07:10 [MST]
Last Update Date: 05/24/2023
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Vossmar, Patricia (R4DO)
FFD Group, (EMAIL)
Vossmar, Patricia (R4DO)
FFD Group, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 2 | N | N | 0 | Cold Shutdown | 0 | Cold Shutdown |
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
FITNESS-FOR-DUTY REPORT
The following information was provided by the licensee via phone and email:
"On May 24th, 2023, at approximately 0710 MDT, a non-licensed contract supervisor had a confirmed positive for alcohol during a for-cause fitness-for-duty test. The individual's plant access has been terminated in accordance with station procedures.
"The NRC Resident Inspector has been notified."
The following information was provided by the licensee via phone and email:
"On May 24th, 2023, at approximately 0710 MDT, a non-licensed contract supervisor had a confirmed positive for alcohol during a for-cause fitness-for-duty test. The individual's plant access has been terminated in accordance with station procedures.
"The NRC Resident Inspector has been notified."
Power Reactor
Event Number: 56541
Facility: Watts Bar
Region: 2 State: TN
Unit: [2] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Joanne Dehay
HQ OPS Officer: Ian Howard
Region: 2 State: TN
Unit: [2] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Joanne Dehay
HQ OPS Officer: Ian Howard
Notification Date: 05/25/2023
Notification Time: 17:02 [ET]
Event Date: 05/25/2023
Event Time: 13:45 [EDT]
Last Update Date: 05/25/2023
Notification Time: 17:02 [ET]
Event Date: 05/25/2023
Event Time: 13:45 [EDT]
Last Update Date: 05/25/2023
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(ii)(B) - Unanalyzed Condition
10 CFR Section:
50.72(b)(3)(ii)(B) - Unanalyzed Condition
Person (Organization):
Miller, Mark (R2DO)
Miller, Mark (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
UNANALYZED CONDITION OF EMERGENCY DIESEL GENERATOR
The following information was provided by the licensee via phone and email:
"At 1345 EDT on May 25, 2023, it was determined that a fire barrier for area 737-A1B was not installed, and would render the 2A Emergency Diesel Generator (EDG) not operable in the event of a fire on the Unit 2 side of elevation 737 in the Auxiliary Building. The 2A EDG is the credited power source for fire safe shutdown for a fire located in this area. Without the credited source of power, this places WBN U2 [Watts Bar Nuclear Unit 2] in an unanalyzed condition. A fire watch has been established in the area until the issue is resolved. Therefore, this event is being reported as an eight-hour non-emergency notification per 10 CFR 50.72(b)(3)(ii)(B).
"The NRC Resident Inspector has been notified."
The following information was provided by the licensee via phone and email:
"At 1345 EDT on May 25, 2023, it was determined that a fire barrier for area 737-A1B was not installed, and would render the 2A Emergency Diesel Generator (EDG) not operable in the event of a fire on the Unit 2 side of elevation 737 in the Auxiliary Building. The 2A EDG is the credited power source for fire safe shutdown for a fire located in this area. Without the credited source of power, this places WBN U2 [Watts Bar Nuclear Unit 2] in an unanalyzed condition. A fire watch has been established in the area until the issue is resolved. Therefore, this event is being reported as an eight-hour non-emergency notification per 10 CFR 50.72(b)(3)(ii)(B).
"The NRC Resident Inspector has been notified."
Agreement State
Event Number: 56533
Rep Org: Texas Dept of State Health Services
Licensee: Nextier Completion Solutions, Inc
Region: 4
City: Pleasanton State: TX
County:
License #: L 06712
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Ian Howard
Licensee: Nextier Completion Solutions, Inc
Region: 4
City: Pleasanton State: TX
County:
License #: L 06712
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Ian Howard
Notification Date: 05/23/2023
Notification Time: 15:00 [ET]
Event Date: 05/23/2023
Event Time: 00:00 [CDT]
Last Update Date: 05/23/2023
Notification Time: 15:00 [ET]
Event Date: 05/23/2023
Event Time: 00:00 [CDT]
Last Update Date: 05/23/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Vossmar, Patricia (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Vossmar, Patricia (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - SHUTTER MISSING
The following information was provided by the Texas Department of State Health Services (the Agency) via phone and email:
"On May 23, 2023, the Agency was notified by the licensee's radiation safety officer (RSO) that while conducting routine shutter checks, the shutter for a Thermo Fisher model 5190 gauge was missing. The shutter is a block of lead that slides across the radiation beam. The RSO stated they believe the lead block (shutter) must have vibrated off the slide. The gauge has been removed and placed in storage and will be disposed of. The gauge contains a 200 millicurie (original activity) [Cs-137] source. No individual received an exposure that exceeded any limit. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident No.: 10022
Texas NMED No.: TX230025
The following information was provided by the Texas Department of State Health Services (the Agency) via phone and email:
"On May 23, 2023, the Agency was notified by the licensee's radiation safety officer (RSO) that while conducting routine shutter checks, the shutter for a Thermo Fisher model 5190 gauge was missing. The shutter is a block of lead that slides across the radiation beam. The RSO stated they believe the lead block (shutter) must have vibrated off the slide. The gauge has been removed and placed in storage and will be disposed of. The gauge contains a 200 millicurie (original activity) [Cs-137] source. No individual received an exposure that exceeded any limit. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident No.: 10022
Texas NMED No.: TX230025
Power Reactor
Event Number: 56542
Facility: Fermi
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: Eric Frank
HQ OPS Officer: Donald Norwood
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: Eric Frank
HQ OPS Officer: Donald Norwood
Notification Date: 05/26/2023
Notification Time: 14:16 [ET]
Event Date: 05/25/2023
Event Time: 00:00 [EDT]
Last Update Date: 05/26/2023
Notification Time: 14:16 [ET]
Event Date: 05/25/2023
Event Time: 00:00 [EDT]
Last Update Date: 05/26/2023
Emergency Class: Non Emergency
10 CFR Section:
21.21(a)(2) - Interim Eval Of Deviation
10 CFR Section:
21.21(a)(2) - Interim Eval Of Deviation
Person (Organization):
Benjamin, Jamie (R3DO)
Part 21/50.55 Reactors, - (EMAIL)
Benjamin, Jamie (R3DO)
Part 21/50.55 Reactors, - (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
PART 21 INTERIM EVALUATION - MECHANICAL DRAFT COOLING TOWER FAN BRAKES DESIGN FLAW
The following is a summary of the information provided by the licensee via email:
"As previously reported under Fermi LER 2023-001-00, submitted on May 22, 2023, at 1145 EDT on March 23, 2023, it was determined that all mechanical draft cooling tower (MDCT) fan brakes would not perform their design function during a tornado due to the speed switch not functioning over its published voltage and frequency ranges. The MDCT fan brakes are required to prevent fan overspeed from a design basis tornado. On May 25, 2023, Fermi completed its 10 CFR Part 21 discovery process and determined the need to perform a 10 CFR Part 21 evaluation. The vendor (Engine Systems Inc. (ESI)) was contacted and the purchaser (Fermi) assumed responsibility for performing the Part 21 evaluation for the supplied mechanism. This Part 21 evaluation is being tracked by Fermi CARD 23-20075.
"It has been determined the direct cause of the event was due to the Dynalco speed switch model SST-2400A-1, supplied by ESI, not functioning over its published voltage and frequency ranges. Corrective actions were taken to develop a design change to correct MDCT fan speed control system returning the MDCT fans, ultimate heat sink, and the service water subsystems to service on March 24, 2023. The root cause evaluation is ongoing, and written follow-up will be provided in 30 days by providing a supplement to the original LER by June 24, 2023.
"No new commitments are being made in this submittal."
The following is a summary of the information provided by the licensee via email:
"As previously reported under Fermi LER 2023-001-00, submitted on May 22, 2023, at 1145 EDT on March 23, 2023, it was determined that all mechanical draft cooling tower (MDCT) fan brakes would not perform their design function during a tornado due to the speed switch not functioning over its published voltage and frequency ranges. The MDCT fan brakes are required to prevent fan overspeed from a design basis tornado. On May 25, 2023, Fermi completed its 10 CFR Part 21 discovery process and determined the need to perform a 10 CFR Part 21 evaluation. The vendor (Engine Systems Inc. (ESI)) was contacted and the purchaser (Fermi) assumed responsibility for performing the Part 21 evaluation for the supplied mechanism. This Part 21 evaluation is being tracked by Fermi CARD 23-20075.
"It has been determined the direct cause of the event was due to the Dynalco speed switch model SST-2400A-1, supplied by ESI, not functioning over its published voltage and frequency ranges. Corrective actions were taken to develop a design change to correct MDCT fan speed control system returning the MDCT fans, ultimate heat sink, and the service water subsystems to service on March 24, 2023. The root cause evaluation is ongoing, and written follow-up will be provided in 30 days by providing a supplement to the original LER by June 24, 2023.
"No new commitments are being made in this submittal."
Power Reactor
Event Number: 56543
Facility: Prairie Island
Region: 3 State: MN
Unit: [2] [] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: Chris Baartman
HQ OPS Officer: Donald Norwood
Region: 3 State: MN
Unit: [2] [] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: Chris Baartman
HQ OPS Officer: Donald Norwood
Notification Date: 05/27/2023
Notification Time: 20:28 [ET]
Event Date: 05/27/2023
Event Time: 18:34 [CDT]
Last Update Date: 05/28/2023
Notification Time: 20:28 [ET]
Event Date: 05/27/2023
Event Time: 18:34 [CDT]
Last Update Date: 05/28/2023
Emergency Class: Non Emergency
10 CFR Section:
50.72(a) (1) (i) - Emergency Declared 50.72(b)(2)(iv)(B) - RPS Actuation - Critical 50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
10 CFR Section:
50.72(a) (1) (i) - Emergency Declared 50.72(b)(2)(iv)(B) - RPS Actuation - Critical 50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
Benjamin, Jamie (R3DO)
Geissner, John (R3RA)
Veil, Andrea (DNRR)
Grant, Jeffery (IRMOC)
Gavrilas, Mirela (DNSIR)
Benjamin, Jamie (R3DO)
Geissner, John (R3RA)
Veil, Andrea (DNRR)
Grant, Jeffery (IRMOC)
Gavrilas, Mirela (DNSIR)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | A/R | Y | 100 | Power Operation | 0 | Hot Standby |
NOTIFICATION OF UNUSUAL EVENT DUE TO MULTIPLE FIRE ALARMS IN CONTAINMENT NOT VERIFIED WITHIN 15 MINUTES
The following information was provided by the licensee via email:
"Notification of Unusual Event, HU4.1 declared based on multiple fire alarms in the containment building not verified within 15 minutes.
"Turbine trip causing reactor trip due to fault on 2GT transformer.
"At 1845 CDT, verification of no fire in the containment building."
Notified DHS Senior Watch Officer, FEMA Operations Center, CISA Central watch officer, DOE Operations Center (email), HHS Operations Center (email), EPA Emergency Operations Center (email), USDA Operations Center (email), FDA EOC (email), FEMA NWC (email) and DHS Nuclear SSA (email), FEMA NRCC (email) and CWMD watch desk (email).
* * * UPDATE AT 0148 EDT ON 5/28/23 FROM CHRIS BAARTMAN TO BILL GOTT * * *
The following information was provided by the licensee via email:
"This update is being made to report the actuation of the auxiliary feedwater system following the reactor trip at 1819 CDT. This event is being reported as a specified system actuation in accordance with the reporting criteria of 10 CFR 50.72(b)(3)(iv)(A).
"This update is also being made for the termination of the notification of unusual event at 2304 CDT on 5/27/2023. The basis for the termination was that there was no indication of a fire.
"Upon lockout of 2GT transformer, main to reserve power transfer did not occur on 3 of 4 non-safeguards buses. Subsequently, operator action successfully restored power to all non-safeguards buses at 1925 CDT.
"There was no impact to the health and safety of the public or plant personnel.
"The NRC resident inspector has been notified of the update."
Notified R3DO (Benjam¡n), NRR EO (Walker), IRMOC (Grant), DHS Senior Watch Officer, FEMA Operations Center, CISA Central watch officer, DOE Operations Center (email), HHS Operations Center (email), EPA Emergency Operations Center (email), USDA Operations Center (email), FDA EOC (email), FEMA NWC (email) and DHS Nuclear SSA (email), FEMA NRCC (email) and CWMD watch desk (email).
The following information was provided by the licensee via email:
"Notification of Unusual Event, HU4.1 declared based on multiple fire alarms in the containment building not verified within 15 minutes.
"Turbine trip causing reactor trip due to fault on 2GT transformer.
"At 1845 CDT, verification of no fire in the containment building."
Notified DHS Senior Watch Officer, FEMA Operations Center, CISA Central watch officer, DOE Operations Center (email), HHS Operations Center (email), EPA Emergency Operations Center (email), USDA Operations Center (email), FDA EOC (email), FEMA NWC (email) and DHS Nuclear SSA (email), FEMA NRCC (email) and CWMD watch desk (email).
* * * UPDATE AT 0148 EDT ON 5/28/23 FROM CHRIS BAARTMAN TO BILL GOTT * * *
The following information was provided by the licensee via email:
"This update is being made to report the actuation of the auxiliary feedwater system following the reactor trip at 1819 CDT. This event is being reported as a specified system actuation in accordance with the reporting criteria of 10 CFR 50.72(b)(3)(iv)(A).
"This update is also being made for the termination of the notification of unusual event at 2304 CDT on 5/27/2023. The basis for the termination was that there was no indication of a fire.
"Upon lockout of 2GT transformer, main to reserve power transfer did not occur on 3 of 4 non-safeguards buses. Subsequently, operator action successfully restored power to all non-safeguards buses at 1925 CDT.
"There was no impact to the health and safety of the public or plant personnel.
"The NRC resident inspector has been notified of the update."
Notified R3DO (Benjam¡n), NRR EO (Walker), IRMOC (Grant), DHS Senior Watch Officer, FEMA Operations Center, CISA Central watch officer, DOE Operations Center (email), HHS Operations Center (email), EPA Emergency Operations Center (email), USDA Operations Center (email), FDA EOC (email), FEMA NWC (email) and DHS Nuclear SSA (email), FEMA NRCC (email) and CWMD watch desk (email).