Event Notification Report for October 05, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/04/2023 - 10/05/2023
Agreement State
Event Number: 56760
Rep Org: Utah Division of Radiation Control
Licensee: Kleinfelder, Inc.
Region: 4
City: Spanish Fork State: UT
County:
License #: UT 1800085
Agreement: Y
Docket:
NRC Notified By: Ryan Johnson
HQ OPS Officer: Ernest West
Licensee: Kleinfelder, Inc.
Region: 4
City: Spanish Fork State: UT
County:
License #: UT 1800085
Agreement: Y
Docket:
NRC Notified By: Ryan Johnson
HQ OPS Officer: Ernest West
Notification Date: 09/27/2023
Notification Time: 18:23 [ET]
Event Date: 09/27/2023
Event Time: 14:00 [MDT]
Last Update Date: 09/27/2023
Notification Time: 18:23 [ET]
Event Date: 09/27/2023
Event Time: 14:00 [MDT]
Last Update Date: 09/27/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Young, Cale (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Young, Cale (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE - DAMAGED TROXLER GAUGE
The following information was provided by the Utah Division of Waste Management and Radiation Control via email:
"At approximately 1400 [CDT] on September 27, 2023, a Troxler 3440 portable gauge (serial number 37345) was run over by a water truck. The Troxler 3440 gauge has an 8 mCi Cs-137 source and a 40 mCi [Am-241/Be] source. The Utah radiation safety officer inspected the gauge at the job site and determined that the sources appeared to be undamaged and remained in the shielded position.
"The licensee took the gauge to another Utah licensee, Construction Materials Technologies (doing business as Precision Calibration) [with license number] UT1800143, for evaluation and repair."
Utah Event Report ID: UT23-0008
The following information was provided by the Utah Division of Waste Management and Radiation Control via email:
"At approximately 1400 [CDT] on September 27, 2023, a Troxler 3440 portable gauge (serial number 37345) was run over by a water truck. The Troxler 3440 gauge has an 8 mCi Cs-137 source and a 40 mCi [Am-241/Be] source. The Utah radiation safety officer inspected the gauge at the job site and determined that the sources appeared to be undamaged and remained in the shielded position.
"The licensee took the gauge to another Utah licensee, Construction Materials Technologies (doing business as Precision Calibration) [with license number] UT1800143, for evaluation and repair."
Utah Event Report ID: UT23-0008
Agreement State
Event Number: 56761
Rep Org: Texas Dept of State Health Services
Licensee: PRO INSPECTION INCORPORATED
Region: 4
City: Odessa State: TX
County:
License #: L06666
Agreement: Y
Docket:
NRC Notified By: Randall Redd
HQ OPS Officer: Ernest West
Licensee: PRO INSPECTION INCORPORATED
Region: 4
City: Odessa State: TX
County:
License #: L06666
Agreement: Y
Docket:
NRC Notified By: Randall Redd
HQ OPS Officer: Ernest West
Notification Date: 09/27/2023
Notification Time: 18:40 [ET]
Event Date: 09/26/2023
Event Time: 10:00 [CDT]
Last Update Date: 09/28/2023
Notification Time: 18:40 [ET]
Event Date: 09/26/2023
Event Time: 10:00 [CDT]
Last Update Date: 09/28/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Young, Cale (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Fisher, Jennifer (NMSS DAY)
Young, Cale (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Fisher, Jennifer (NMSS DAY)
AGREEMENT STATE - RADIOGRAPHY SOURCE DISCONNECTED
The following information was provided by the Radiation Control Program Texas Department of State Health Services (the Department) via email:
"On September 27, 2023, the Department received a report of a source disconnect incident from a licensee that occurred on September 26, 2023, at around 1000 [CDT]. The source is 63.6 curies of iridium-192 in an Industrial Nuclear Corporation (INC) IR-100 camera. The licensee could not give a narrative or a dose estimate for the trainee who was working the source. They did report that the drive cable was not broken, and it seems that this may be a misconnect. They were not able to provide a time estimate for the exposure to the trainee, but they were talking about minutes. They have taken the trainee to a medical facility for blood tests with no results yet. This Department recommended that they send bloodwork to [Radiation Emergency Assistance Center/Training Site] (REAC/TS) and provided contact information for REAC/TS. The Department has also asked that the licensee take daily pictures of the trainee's hands. His dosimetry badge has been sent in overnight for processing. The trainer was reportedly not close to the source and his dose was reported as not significant.
"An experienced consultant has been hired by the licensee and will begin work in the morning reconstructing what happened. A meeting with the Department is set up for 1100 [CDT] to discuss a dose estimate as well as get a narrative.
"The source retrieval was performed by the associate radiation safety officer and another individual. Licensee has reported that both are trained to retrieve sources. Each person received about 90 mR. An update will be provided to the [NRC] Headquarters Operations Center (HOC) tomorrow afternoon. Further information after that will be provided per SA-300."
Texas Incident Number: I-10055
Texas NMED Number: TX230046
* * * UPDATE ON 9/28/2023 AT 1832 EDT FROM RANDALL REDD TO BETHANY CECERE * * *
The following information was provided by the Radiation Control Program Texas Department of State Health Services (the Department) via email:
"On September 28, 2023, the Department received additional information from both the licensee and the consultant hired by the licensee following a reenactment of the incident.
"It was reported that, after setting up and taking two shots, the trainee noticed that the source got stuck in the guide tube. The trainee did not have his alarming dosimeter turned on, and he did not have his survey meter close by. The trainee believed the source was back in shielding, and he continued to work. He replaced the film, repositioned the tip of the guide tube, and cranked the source back out although it was already out. He repeated this a total of four times before he noticed that the source lock indicator was not in the shielded position. The trainee then checked his dosimeter and found it off scale. He immediately reported this to the trainer which began the source retrieval event wherein they expanded the boundary, maintained security, and waited for the associate radiation safety officer to arrive.
"The film for the first two shots came out as expected, but the film for the last four shots came out black indicating that the source was near the film long enough to overexpose those four. This would indicate the source did become disconnected after the second shot.
"Based upon measured times and distances during the re-enactment, a whole-body dose of 38 R to the trainee has been reported TO this Department. The estimate for dose to each hand was reported to be 18 R. The trainee had left his badge in the truck so it will not be helpful in verifying these values. Dose to the trainer was 5 mrem. The trainer was 50 feet away during this event.
"Based upon this information, this Department is adding the following reporting criteria to this event: 20.2202(a)(1)(i) - Overexposure event involving byproduct, source, or special nuclear material possessed by the licensee that may have caused or threatens to cause an individual to receive a total effective dose equivalent greater than or equal to 25 rems (0.25 Sv).
"This Department will be reviewing the dose calculations and will provide an assessment with the final NMED report."
Notified Young (R4DO), Einberg (NMSS), and NMSS Events by email.
The following information was provided by the Radiation Control Program Texas Department of State Health Services (the Department) via email:
"On September 27, 2023, the Department received a report of a source disconnect incident from a licensee that occurred on September 26, 2023, at around 1000 [CDT]. The source is 63.6 curies of iridium-192 in an Industrial Nuclear Corporation (INC) IR-100 camera. The licensee could not give a narrative or a dose estimate for the trainee who was working the source. They did report that the drive cable was not broken, and it seems that this may be a misconnect. They were not able to provide a time estimate for the exposure to the trainee, but they were talking about minutes. They have taken the trainee to a medical facility for blood tests with no results yet. This Department recommended that they send bloodwork to [Radiation Emergency Assistance Center/Training Site] (REAC/TS) and provided contact information for REAC/TS. The Department has also asked that the licensee take daily pictures of the trainee's hands. His dosimetry badge has been sent in overnight for processing. The trainer was reportedly not close to the source and his dose was reported as not significant.
"An experienced consultant has been hired by the licensee and will begin work in the morning reconstructing what happened. A meeting with the Department is set up for 1100 [CDT] to discuss a dose estimate as well as get a narrative.
"The source retrieval was performed by the associate radiation safety officer and another individual. Licensee has reported that both are trained to retrieve sources. Each person received about 90 mR. An update will be provided to the [NRC] Headquarters Operations Center (HOC) tomorrow afternoon. Further information after that will be provided per SA-300."
Texas Incident Number: I-10055
Texas NMED Number: TX230046
* * * UPDATE ON 9/28/2023 AT 1832 EDT FROM RANDALL REDD TO BETHANY CECERE * * *
The following information was provided by the Radiation Control Program Texas Department of State Health Services (the Department) via email:
"On September 28, 2023, the Department received additional information from both the licensee and the consultant hired by the licensee following a reenactment of the incident.
"It was reported that, after setting up and taking two shots, the trainee noticed that the source got stuck in the guide tube. The trainee did not have his alarming dosimeter turned on, and he did not have his survey meter close by. The trainee believed the source was back in shielding, and he continued to work. He replaced the film, repositioned the tip of the guide tube, and cranked the source back out although it was already out. He repeated this a total of four times before he noticed that the source lock indicator was not in the shielded position. The trainee then checked his dosimeter and found it off scale. He immediately reported this to the trainer which began the source retrieval event wherein they expanded the boundary, maintained security, and waited for the associate radiation safety officer to arrive.
"The film for the first two shots came out as expected, but the film for the last four shots came out black indicating that the source was near the film long enough to overexpose those four. This would indicate the source did become disconnected after the second shot.
"Based upon measured times and distances during the re-enactment, a whole-body dose of 38 R to the trainee has been reported TO this Department. The estimate for dose to each hand was reported to be 18 R. The trainee had left his badge in the truck so it will not be helpful in verifying these values. Dose to the trainer was 5 mrem. The trainer was 50 feet away during this event.
"Based upon this information, this Department is adding the following reporting criteria to this event: 20.2202(a)(1)(i) - Overexposure event involving byproduct, source, or special nuclear material possessed by the licensee that may have caused or threatens to cause an individual to receive a total effective dose equivalent greater than or equal to 25 rems (0.25 Sv).
"This Department will be reviewing the dose calculations and will provide an assessment with the final NMED report."
Notified Young (R4DO), Einberg (NMSS), and NMSS Events by email.
Agreement State
Event Number: 56762
Rep Org: Utah Division of Radiation Control
Licensee: Construction Materials Technologies, LLC
Region: 4
City: Unknown State: UT
County:
License #: UT 1800143
Agreement: Y
Docket:
NRC Notified By: Spencer Wickham
HQ OPS Officer: Ernest West
Licensee: Construction Materials Technologies, LLC
Region: 4
City: Unknown State: UT
County:
License #: UT 1800143
Agreement: Y
Docket:
NRC Notified By: Spencer Wickham
HQ OPS Officer: Ernest West
Notification Date: 09/27/2023
Notification Time: 19:33 [ET]
Event Date: 05/08/2023
Event Time: 00:00 [MDT]
Last Update Date: 10/04/2023
Notification Time: 19:33 [ET]
Event Date: 05/08/2023
Event Time: 00:00 [MDT]
Last Update Date: 10/04/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Young, Cale (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Young, Cale (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 10/5/2023
EN Revision Text: AGREEMENT STATE - DAMAGED GAUGE
The following information was provided by the Utah Division of Waste Management and Radiation Control (the Division) via email:
"During a routine radioactive materials inspection on September 27, 2023, the Division was informed that a gauge was damaged by a piece of equipment which cracked the gauge's casing in May of 2023. The incident was not reported to the Division by the licensee as they believed the event was not reportable. The Division is waiting for additional information pertaining to the incident and will provide an update once the information is received."
Utah Event Report ID number: UT 230007
The following additional information was obtained from the Utah Division of Waste Management and Radiation Control in accordance with Headquarters Operations Officers Report Guidance:
The location is listed as 'Unknown' since the location where the portable gauge was in use when it was damaged is currently unknown but will be provided once that information is received.
* * * RETRACTION ON OCTOBER 4, 2023 AT 1809 EDT FROM SPENCER WICKHAM TO KAREN COTTON * * *
The following information is a summary of an email provided by the Utah Division of Waste Management and Radiation Control (the Division):
After review of additional information provided to the Division by the licensee, it was determined that the gauge only received minor damage to the gauge casing. All equipment of the gauge necessary for safety worked as intended. Therefore the event was not reportable and requested by the Division to be withdrawn.
Notified R4DO (Kellar), NMSS Events (email).
EN Revision Text: AGREEMENT STATE - DAMAGED GAUGE
The following information was provided by the Utah Division of Waste Management and Radiation Control (the Division) via email:
"During a routine radioactive materials inspection on September 27, 2023, the Division was informed that a gauge was damaged by a piece of equipment which cracked the gauge's casing in May of 2023. The incident was not reported to the Division by the licensee as they believed the event was not reportable. The Division is waiting for additional information pertaining to the incident and will provide an update once the information is received."
Utah Event Report ID number: UT 230007
The following additional information was obtained from the Utah Division of Waste Management and Radiation Control in accordance with Headquarters Operations Officers Report Guidance:
The location is listed as 'Unknown' since the location where the portable gauge was in use when it was damaged is currently unknown but will be provided once that information is received.
* * * RETRACTION ON OCTOBER 4, 2023 AT 1809 EDT FROM SPENCER WICKHAM TO KAREN COTTON * * *
The following information is a summary of an email provided by the Utah Division of Waste Management and Radiation Control (the Division):
After review of additional information provided to the Division by the licensee, it was determined that the gauge only received minor damage to the gauge casing. All equipment of the gauge necessary for safety worked as intended. Therefore the event was not reportable and requested by the Division to be withdrawn.
Notified R4DO (Kellar), NMSS Events (email).
Non-Agreement State
Event Number: 56763
Rep Org: Marathon Pipe Line LLC
Licensee: Marathon Pipe Line LLC
Region: 3
City: Indianapolis State: IN
County:
License #: GL-714799-28
Agreement: N
Docket:
NRC Notified By: Matthew Grimes
HQ OPS Officer: Sam Colvard
Licensee: Marathon Pipe Line LLC
Region: 3
City: Indianapolis State: IN
County:
License #: GL-714799-28
Agreement: N
Docket:
NRC Notified By: Matthew Grimes
HQ OPS Officer: Sam Colvard
Notification Date: 09/28/2023
Notification Time: 13:35 [ET]
Event Date: 09/28/2023
Event Time: 00:00 [EDT]
Last Update Date: 09/28/2023
Notification Time: 13:35 [ET]
Event Date: 09/28/2023
Event Time: 00:00 [EDT]
Last Update Date: 09/28/2023
Emergency Class: Non Emergency
10 CFR Section:
30.50(b)(2) - Safety Equipment Failure
10 CFR Section:
30.50(b)(2) - Safety Equipment Failure
Person (Organization):
Orlikowski, Robert (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Orlikowski, Robert (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
NON-AGREEMENT STATE REPORT - STUCK OPEN SHUTTER
The following information was provided by the licensee via phone:
On September 27, 2023, at 1500 EDT, Marathon Pipe Line, LLC evaluated that a fixed density gauge device shutter (Ohmart/VEGA, SR-2, SN 3767GG, Cs-137 250 mCi) was stuck in the open position. The device is located in a locked location with controlled access. There was no personnel exposure. The vendor has been contacted for repairs.
The following information was provided by the licensee via phone:
On September 27, 2023, at 1500 EDT, Marathon Pipe Line, LLC evaluated that a fixed density gauge device shutter (Ohmart/VEGA, SR-2, SN 3767GG, Cs-137 250 mCi) was stuck in the open position. The device is located in a locked location with controlled access. There was no personnel exposure. The vendor has been contacted for repairs.
Power Reactor
Event Number: 56774
Facility: North Anna
Region: 2 State: VA
Unit: [2] [] []
RX Type: [1] W-3-LP,[2] W-3-LP,[3] M-4-LP
NRC Notified By: Bob Page
HQ OPS Officer: Karen Cotton-Gross
Region: 2 State: VA
Unit: [2] [] []
RX Type: [1] W-3-LP,[2] W-3-LP,[3] M-4-LP
NRC Notified By: Bob Page
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 10/03/2023
Notification Time: 12:55 [ET]
Event Date: 10/03/2023
Event Time: 11:54 [EDT]
Last Update Date: 10/04/2023
Notification Time: 12:55 [ET]
Event Date: 10/03/2023
Event Time: 11:54 [EDT]
Last Update Date: 10/04/2023
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(ii)(A) - Degraded Condition
10 CFR Section:
50.72(b)(3)(ii)(A) - Degraded 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 | N | 0 | Refueling | 0 | Refueling |
DEGRADED CONDITION
The following information was provided by the licensee via email:
"At 1154 EDT on 10/03/23, investigation into a boric acid indication was determined to be through a leak on a weld-o-let upstream of a pressurizer level transmitter isolation valve. Unit 2 is currently in MODE 6 with reactor coolant system (RCS) operational leakage limits not applicable. The leak is not quantifiable as it only consists of a small amount of dry boric acid at the location. The failure constitutes welding or material defects in the primary coolant system that are unacceptable under ASME Section XI.
"Therefore, this is a degraded condition reportable under 10 CFR 50.72(b)(3)(ii)(A). This condition does not affect the health and safety of the public or station employees."
The Resident Inspector was notified.
The following information was provided by the licensee via email:
"At 1154 EDT on 10/03/23, investigation into a boric acid indication was determined to be through a leak on a weld-o-let upstream of a pressurizer level transmitter isolation valve. Unit 2 is currently in MODE 6 with reactor coolant system (RCS) operational leakage limits not applicable. The leak is not quantifiable as it only consists of a small amount of dry boric acid at the location. The failure constitutes welding or material defects in the primary coolant system that are unacceptable under ASME Section XI.
"Therefore, this is a degraded condition reportable under 10 CFR 50.72(b)(3)(ii)(A). This condition does not affect the health and safety of the public or station employees."
The Resident Inspector was notified.
Part 21
Event Number: 56683
Rep Org: Curtiss Wright Flow Control Co.
Licensee: Curtiss Wright Flow Control Co.
Region: 3
City: Cincinnati State: OH
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Tim Franchuk
HQ OPS Officer: Karen Cotton-Gross
Licensee: Curtiss Wright Flow Control Co.
Region: 3
City: Cincinnati State: OH
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Tim Franchuk
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 08/17/2023
Notification Time: 13:17 [ET]
Event Date: 06/22/2023
Event Time: 00:00 [EDT]
Last Update Date: 10/05/2023
Notification Time: 13:17 [ET]
Event Date: 06/22/2023
Event Time: 00:00 [EDT]
Last Update Date: 10/05/2023
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):
Miller, Mark (R2DO)
Part 21/50.55 Reactors, - (EMAIL)
Miller, Mark (R2DO)
Part 21/50.55 Reactors, - (EMAIL)
EN Revision Imported Date: 10/6/2023
EN Revision Text: PART 21 INTERIM REPORT - FAILURE OF CURTISS WRIGHT SUPPLIED SAFETY RELATED RELAY
The following is a summary of the Part 21 report provided by Curtiss Wright:
On June 20, 2023, Duke Energy sent a letter to Curtiss Wright (CW) to formally notify them that a Tyco (Agastat) relay had failed. Duke Energy had identified certain contacts that were found sticking in the open position.
The relay was returned to CW for evaluation; however, CW could not duplicate the failure. As the relay is questionable for reliable service, CW is having the relay returned to Tyco for their evaluation. Once the evaluation is complete, the current report will be updated. CW anticipates an update to the notification with final results by October 15th.
Affected plant: Catawba
* * * UPDATE ON OCTOBER 5, 2023 AT 1146 EDT FROM JENNIFER HARRISON TO KAREN COTTON * * *
The following information was provided by Curtiss Wright via email:
"The relay was subsequently returned to TYCO for their evaluation. TYCO tested the relay with and without the LL auxiliary switch option and could not duplicate the failure. In all tested conditions, the relay performed within manufacturer specifications, and with no contact binding.
"As the noted failure could not be reproduced by Curtiss-Wright or TYCO, there is no evidence of part malfunction and thus no further evaluation or notification applies."
Notified RDO2 (Miller) and Part 21/50.55 Reactors
EN Revision Text: PART 21 INTERIM REPORT - FAILURE OF CURTISS WRIGHT SUPPLIED SAFETY RELATED RELAY
The following is a summary of the Part 21 report provided by Curtiss Wright:
On June 20, 2023, Duke Energy sent a letter to Curtiss Wright (CW) to formally notify them that a Tyco (Agastat) relay had failed. Duke Energy had identified certain contacts that were found sticking in the open position.
The relay was returned to CW for evaluation; however, CW could not duplicate the failure. As the relay is questionable for reliable service, CW is having the relay returned to Tyco for their evaluation. Once the evaluation is complete, the current report will be updated. CW anticipates an update to the notification with final results by October 15th.
Affected plant: Catawba
* * * UPDATE ON OCTOBER 5, 2023 AT 1146 EDT FROM JENNIFER HARRISON TO KAREN COTTON * * *
The following information was provided by Curtiss Wright via email:
"The relay was subsequently returned to TYCO for their evaluation. TYCO tested the relay with and without the LL auxiliary switch option and could not duplicate the failure. In all tested conditions, the relay performed within manufacturer specifications, and with no contact binding.
"As the noted failure could not be reproduced by Curtiss-Wright or TYCO, there is no evidence of part malfunction and thus no further evaluation or notification applies."
Notified RDO2 (Miller) and Part 21/50.55 Reactors
Part 21
Event Number: 56720
Rep Org: Paragon Energy Solutions, LLC
Licensee: Paragon Energy Solutions, LLC
Region: 1
City: York State: SC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Richard Knott
HQ OPS Officer: Ernest West
Licensee: Paragon Energy Solutions, LLC
Region: 1
City: York State: SC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Richard Knott
HQ OPS Officer: Ernest West
Notification Date: 09/06/2023
Notification Time: 17:50 [ET]
Event Date: 09/05/2023
Event Time: 00:00 [EDT]
Last Update Date: 10/05/2023
Notification Time: 17:50 [ET]
Event Date: 09/05/2023
Event Time: 00:00 [EDT]
Last Update Date: 10/05/2023
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):
Young, Matt (R1DO)
Miller, Mark (R2DO)
Part 21/50.55 Reactors, - (EMAIL)
Young, Matt (R1DO)
Miller, Mark (R2DO)
Part 21/50.55 Reactors, - (EMAIL)
EN Revision Imported Date: 10/6/2023
EN Revision Text: PART 21 - CIRCUIT BREAKER POTENTIAL DEFECTS
The following is a synopsis of information from Paragon Energy Solutions, LLC received via email.
On 9/5/2023, Paragon was informed of two recent failures of Eaton JD/HJD series circuit breakers. In both cases, troubleshooting identified an OEM terminal lug (part number TA250KB) installed on the breaker line side connection point was loose creating a high resistance connection leading to breaker damage and interruption of power to the connected load. Paragon has taken action to identify and quarantine in-process work on these breakers until appropriate inspections can be performed and entered this issue into their non-conformance/corrective action process. Paragon is working with the breaker manufacturer to help in determination of cause and formal corrective action to prevent recurrence. Paragon is also developing tests to determine if the TA250KB terminal lug can be inadvertently loosened during normal breaker installation/replacement into its associated motor control center cubicle. Paragon Engineering and Quality Assurance departments are collaborating, and final corrective action should be completed by 10/5/2023.
Point of Contact:
Richard Knott
Vice President Quality Assurance
Paragon Energy Solutions LLC
817-284-0077
Affected plants:
Beaver Valley
Limerick
North Anna
Sequoyah
Susquehanna
* * * UPDATE ON OCTOBER 5, 2023 AT 1737 EDT FROM RICHARD KNOTT TO KAREN COTTON * * *
The results of Paragon Engineering and Quality Assurance departments' final corrective action plan regarding the Eaton JD/HJD series circuit breakers OEM terminal lug (part number TA250KB) collaboration are as follows:
Paragon has taken action to identify and quarantine in-process work on these breakers until appropriate inspections can are performed and is also working with the breaker manufacturer (Eaton) to help in determination of cause and formal corrective action to prevent any recurrence.
Paragon will also conduct torque checks of all breaker lugs installed on J Frame molded case circuit breakers (MCCBs) currently in inventory.
Paragon completed testing to determine if the TA250KB terminal lug can be inadvertently loosened during normal breaker installation/replacement into its associated motor control center cubicle. Results indicated that the lug remains tight to the required torque value during removal and installation.
To mitigate potential for recurrence regardless of what Eaton determines as the cause, Paragon Electrical Engineering group will conduct training on this issue and will revise commercial grade dedication plans (CGDs) for J Frame MCCBs containing these lugs to include a torque check.
These reported failures are the first reported to Paragon. For breakers installed prior to 2017, it is likely that routine surveillance or preventive maintenance activities on the motor control centers containing this series of MCCBs would have identified overheating conditions or nuisance tripping. Paragon recommends purchasers and licensees perform inspections of affected motor control center cubicles containing the JD/HJD series MCCBs and any spares contained in plant inventory. Additionally, the hold down screws for the terminal lugs should be checked for tightness during breaker replacement activities.
Notified: R1DO(Young), R2DO(Miller) and Part 21/50.55 Reactors
EN Revision Text: PART 21 - CIRCUIT BREAKER POTENTIAL DEFECTS
The following is a synopsis of information from Paragon Energy Solutions, LLC received via email.
On 9/5/2023, Paragon was informed of two recent failures of Eaton JD/HJD series circuit breakers. In both cases, troubleshooting identified an OEM terminal lug (part number TA250KB) installed on the breaker line side connection point was loose creating a high resistance connection leading to breaker damage and interruption of power to the connected load. Paragon has taken action to identify and quarantine in-process work on these breakers until appropriate inspections can be performed and entered this issue into their non-conformance/corrective action process. Paragon is working with the breaker manufacturer to help in determination of cause and formal corrective action to prevent recurrence. Paragon is also developing tests to determine if the TA250KB terminal lug can be inadvertently loosened during normal breaker installation/replacement into its associated motor control center cubicle. Paragon Engineering and Quality Assurance departments are collaborating, and final corrective action should be completed by 10/5/2023.
Point of Contact:
Richard Knott
Vice President Quality Assurance
Paragon Energy Solutions LLC
817-284-0077
Affected plants:
Beaver Valley
Limerick
North Anna
Sequoyah
Susquehanna
* * * UPDATE ON OCTOBER 5, 2023 AT 1737 EDT FROM RICHARD KNOTT TO KAREN COTTON * * *
The results of Paragon Engineering and Quality Assurance departments' final corrective action plan regarding the Eaton JD/HJD series circuit breakers OEM terminal lug (part number TA250KB) collaboration are as follows:
Paragon has taken action to identify and quarantine in-process work on these breakers until appropriate inspections can are performed and is also working with the breaker manufacturer (Eaton) to help in determination of cause and formal corrective action to prevent any recurrence.
Paragon will also conduct torque checks of all breaker lugs installed on J Frame molded case circuit breakers (MCCBs) currently in inventory.
Paragon completed testing to determine if the TA250KB terminal lug can be inadvertently loosened during normal breaker installation/replacement into its associated motor control center cubicle. Results indicated that the lug remains tight to the required torque value during removal and installation.
To mitigate potential for recurrence regardless of what Eaton determines as the cause, Paragon Electrical Engineering group will conduct training on this issue and will revise commercial grade dedication plans (CGDs) for J Frame MCCBs containing these lugs to include a torque check.
These reported failures are the first reported to Paragon. For breakers installed prior to 2017, it is likely that routine surveillance or preventive maintenance activities on the motor control centers containing this series of MCCBs would have identified overheating conditions or nuisance tripping. Paragon recommends purchasers and licensees perform inspections of affected motor control center cubicles containing the JD/HJD series MCCBs and any spares contained in plant inventory. Additionally, the hold down screws for the terminal lugs should be checked for tightness during breaker replacement activities.
Notified: R1DO(Young), R2DO(Miller) and Part 21/50.55 Reactors
Agreement State
Event Number: 56765
Rep Org: Kentucky Dept of Radiation Control
Licensee: University of Kentucky
Region: 1
City: Lexington State: KY
County:
License #: 202-049-22
Agreement: Y
Docket:
NRC Notified By: Russell Hestand
HQ OPS Officer: Lawrence Criscione
Licensee: University of Kentucky
Region: 1
City: Lexington State: KY
County:
License #: 202-049-22
Agreement: Y
Docket:
NRC Notified By: Russell Hestand
HQ OPS Officer: Lawrence Criscione
Notification Date: 09/29/2023
Notification Time: 10:55 [ET]
Event Date: 09/28/2023
Event Time: 09:30 [CDT]
Last Update Date: 10/02/2023
Notification Time: 10:55 [ET]
Event Date: 09/28/2023
Event Time: 09:30 [CDT]
Last Update Date: 10/02/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Lally, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Lally, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - POSSIBLE MISADMINISTRATION
The following information was provided by the Kentucky Department for Public Health and Safety, Radiation Health Branch (KY RHB) via email:
"KY RHB was notified on 9/29/2023, by a representative from the University of Kentucky that two patients were scheduled for treatment with Lu-177, one with commercially available Lu-177 dotatate (Lutathera) and one under a research protocol also using Lu-177 dotatate but distributed under an investigational new drug label. Both vials contained the same drug and differed only in their label for distribution / intended use. The nuclear medicine technologist prepared and administered Lu-177 dotatate from the vial labeled for research to the standard of care patient instead of the correct (commercial) vial. The patient received the correct amount of drug (prescribed activity), the correct chemical form (identical Lu-177 dotatate) by the correct route of administration as intended for their treatment. However, since the drug was dispensed from the vial distributed under the investigational new drug application intended for the research study patient, KY RHB considers this to meet the reporting requirements in Part 35 for a medical event.
"The physician was informed, the patient was informed, and no harm is anticipated as a result of this incident. Additional notifications have also been made as required considering the involvement of investigational drug product and the Institutional Review Board.
"The incident remains under evaluation and investigation for corrective actions."
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 Kentucky Department for Public Health and Safety, Radiation Health Branch (KY RHB) via email:
"KY RHB was notified on 9/29/2023, by a representative from the University of Kentucky that two patients were scheduled for treatment with Lu-177, one with commercially available Lu-177 dotatate (Lutathera) and one under a research protocol also using Lu-177 dotatate but distributed under an investigational new drug label. Both vials contained the same drug and differed only in their label for distribution / intended use. The nuclear medicine technologist prepared and administered Lu-177 dotatate from the vial labeled for research to the standard of care patient instead of the correct (commercial) vial. The patient received the correct amount of drug (prescribed activity), the correct chemical form (identical Lu-177 dotatate) by the correct route of administration as intended for their treatment. However, since the drug was dispensed from the vial distributed under the investigational new drug application intended for the research study patient, KY RHB considers this to meet the reporting requirements in Part 35 for a medical event.
"The physician was informed, the patient was informed, and no harm is anticipated as a result of this incident. Additional notifications have also been made as required considering the involvement of investigational drug product and the Institutional Review Board.
"The incident remains under evaluation and investigation for corrective actions."
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: 56766
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Rush University Medical Center
Region: 3
City: Chicago State: IL
County:
License #: IL-01766-01
Agreement: Y
Docket:
NRC Notified By: Whitney Cox
HQ OPS Officer: Thomas Herrity
Licensee: Rush University Medical Center
Region: 3
City: Chicago State: IL
County:
License #: IL-01766-01
Agreement: Y
Docket:
NRC Notified By: Whitney Cox
HQ OPS Officer: Thomas Herrity
Notification Date: 09/29/2023
Notification Time: 14:55 [ET]
Event Date: 09/28/2023
Event Time: 00:00 [CDT]
Last Update Date: 09/29/2023
Notification Time: 14:55 [ET]
Event Date: 09/28/2023
Event Time: 00:00 [CDT]
Last Update Date: 09/29/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Orlikowski, Robert (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Orlikowski, Robert (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT
The following was received from the Illinois Emergency Management Agency (the Agency) via email:
"On September 29, 2023, the Agency was contacted by Rush University Medical Center of a potential medical event. The administration was determined to be clinically effective with no adverse patient impact reported.
"The medical event took place on September 28, 2023. The patient and the referring physician were notified within 24 hours. The Y-90 Therasphere dose was 23.5 percent less than the prescribed dose. Agency inspectors are scheduled to perform a reactionary inspection on October 3, 2023. Additional information is forthcoming from the licensee and updates will be sent as they are available."
Illinois Item Number: IL230027
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 Illinois Emergency Management Agency (the Agency) via email:
"On September 29, 2023, the Agency was contacted by Rush University Medical Center of a potential medical event. The administration was determined to be clinically effective with no adverse patient impact reported.
"The medical event took place on September 28, 2023. The patient and the referring physician were notified within 24 hours. The Y-90 Therasphere dose was 23.5 percent less than the prescribed dose. Agency inspectors are scheduled to perform a reactionary inspection on October 3, 2023. Additional information is forthcoming from the licensee and updates will be sent as they are available."
Illinois Item Number: IL230027
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: 56767
Rep Org: Virginia Rad Materials Program
Licensee: ECS Mid-Atlantic, LLC
Region: 1
City: Salem State: VA
County:
License #: 770-314-5
Agreement: Y
Docket:
NRC Notified By: Sheila Nelson
HQ OPS Officer: Sam Colvard
Licensee: ECS Mid-Atlantic, LLC
Region: 1
City: Salem State: VA
County:
License #: 770-314-5
Agreement: Y
Docket:
NRC Notified By: Sheila Nelson
HQ OPS Officer: Sam Colvard
Notification Date: 09/29/2023
Notification Time: 18:43 [ET]
Event Date: 09/29/2023
Event Time: 09:30 [EDT]
Last Update Date: 10/02/2023
Notification Time: 18:43 [ET]
Event Date: 09/29/2023
Event Time: 09:30 [EDT]
Last Update Date: 10/02/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Lally, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Lally, Christopher (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE
The following report summary was received by email from Virginia Radioactive Materials Program (VRMP):
"On September 29, 2023, at approximately 0930 EDT, a Troxler moisture density gauge (model number: 3430, serial number: 32732, 8 mCi Cs-137, 40 mCi Am-241:Be) was struck by a bulldozer while the rod was extended out into the soil for measurements. The area was secured. The gauge was left in place so that the source would remain shielded by the soil and the radiation safety officer (RSO) was notified. The impact cracked the plastic housing and significantly bent the source rod handle above the gauge. The RSO verified that the source rod below the gauge was still intact. They were unable to get the source to retract. With the source inserted back into the soil, survey readings were obtained by the licensee as follows: 1 mR/hr on top of the gauge on contact; @ 5 ft away to the side 0.1 mR/hr.
"According to the RSO, no public exposure occurred. The licensee has fitted a lead pig [lead shielded container] around the source for transport to a licensed nuclear gauge service company."
Virginia Event Report ID Number: VA230002
The following report summary was received by email from Virginia Radioactive Materials Program (VRMP):
"On September 29, 2023, at approximately 0930 EDT, a Troxler moisture density gauge (model number: 3430, serial number: 32732, 8 mCi Cs-137, 40 mCi Am-241:Be) was struck by a bulldozer while the rod was extended out into the soil for measurements. The area was secured. The gauge was left in place so that the source would remain shielded by the soil and the radiation safety officer (RSO) was notified. The impact cracked the plastic housing and significantly bent the source rod handle above the gauge. The RSO verified that the source rod below the gauge was still intact. They were unable to get the source to retract. With the source inserted back into the soil, survey readings were obtained by the licensee as follows: 1 mR/hr on top of the gauge on contact; @ 5 ft away to the side 0.1 mR/hr.
"According to the RSO, no public exposure occurred. The licensee has fitted a lead pig [lead shielded container] around the source for transport to a licensed nuclear gauge service company."
Virginia Event Report ID Number: VA230002
Power Reactor
Event Number: 56779
Facility: Vogtle 3/4
Region: 2 State: GA
Unit: [4] [] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: William Garrett
HQ OPS Officer: Karen Cotton-Gross
Region: 2 State: GA
Unit: [4] [] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: William Garrett
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 10/05/2023
Notification Time: 12:29 [ET]
Event Date: 08/07/2023
Event Time: 14:39 [EDT]
Last Update Date: 10/06/2023
Notification Time: 12:29 [ET]
Event Date: 08/07/2023
Event Time: 14:39 [EDT]
Last Update Date: 10/06/2023
Emergency Class: Non Emergency
10 CFR Section:
50.73(a)(1) - Invalid Specif System Actuation
10 CFR Section:
50.73(a)(1) - Invalid Specif System Actuation
Person (Organization):
Miller, Mark (R2DO)
Miller, Mark (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 4 | N | N | 0 | Defueled | 0 | Cold Shutdown |
EN Revision Imported Date: 10/6/2023
EN Revision Text: 60-DAY OPTIONAL TELEPHONIC NOTIFICATION FOR AN INVALID SPECIFIED SYSTEM ACTUATION
The following information was provided by the licensee via phone and email:
"At 1439 EDT on August 7, 2023, a spurious level spike on the unit 4 reactor coolant system (RCS) level instrument (4-RCS-LT160A, 'Hot Leg 1 Level') caused actuation of containment isolation, reactor trip, automatic depressurization system (ADS) stage 4, and in containment refueling water storage tank (IRWST) isolation signals. The spurious level changes caused an invalid signal based on the incidental response of the 4-RCS-LT160A instrumentation due to water spray that was being used for reactor vessel cleaning (being performed prior to initial fuel loading). The level fluctuations resulted in engineered safety features actuation signals (containment isolation, ADS stage 4, and IRWST isolation signals) and a reactor trip signal, with the reactor trip signal already present. Three containment isolation valves closed due to the containment isolation signal that was generated. These valves were: 4-CAS-V014, 'instrument air supply containment isolation, air-operated valve,' 4-SFS-V034, 'spent fuel pool cooling system suction header containment isolation, motor-operated valve,' and 4-SFS-V035, 'spent fuel pool cooling system suction header containment isolation, motor-operated valve.' The other automatic containment isolation valves were either already closed at the time of the event or properly removed from service. All affected equipment functioned properly. The other actuation signals that were observed during this event (ADS stage 4, IRWST isolation, and reactor trip) did not result in any equipment changing position or automatically operating (i.e., the actuation signals occurred while the systems were properly removed from service).
"Units 1, 2, and 3 were not affected. This event did not result in any adverse impact to the health and safety of the public."
The NRC Resident Inspector was notified.
EN Revision Text: 60-DAY OPTIONAL TELEPHONIC NOTIFICATION FOR AN INVALID SPECIFIED SYSTEM ACTUATION
The following information was provided by the licensee via phone and email:
"At 1439 EDT on August 7, 2023, a spurious level spike on the unit 4 reactor coolant system (RCS) level instrument (4-RCS-LT160A, 'Hot Leg 1 Level') caused actuation of containment isolation, reactor trip, automatic depressurization system (ADS) stage 4, and in containment refueling water storage tank (IRWST) isolation signals. The spurious level changes caused an invalid signal based on the incidental response of the 4-RCS-LT160A instrumentation due to water spray that was being used for reactor vessel cleaning (being performed prior to initial fuel loading). The level fluctuations resulted in engineered safety features actuation signals (containment isolation, ADS stage 4, and IRWST isolation signals) and a reactor trip signal, with the reactor trip signal already present. Three containment isolation valves closed due to the containment isolation signal that was generated. These valves were: 4-CAS-V014, 'instrument air supply containment isolation, air-operated valve,' 4-SFS-V034, 'spent fuel pool cooling system suction header containment isolation, motor-operated valve,' and 4-SFS-V035, 'spent fuel pool cooling system suction header containment isolation, motor-operated valve.' The other automatic containment isolation valves were either already closed at the time of the event or properly removed from service. All affected equipment functioned properly. The other actuation signals that were observed during this event (ADS stage 4, IRWST isolation, and reactor trip) did not result in any equipment changing position or automatically operating (i.e., the actuation signals occurred while the systems were properly removed from service).
"Units 1, 2, and 3 were not affected. This event did not result in any adverse impact to the health and safety of the public."
The NRC Resident Inspector was notified.