Event Notification Report for November 17, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/16/2023 - 11/17/2023
Agreement State
Event Number: 56828
Rep Org: WA Office of Radiation Protection
Licensee: Multi-Care Health System Auburn Event
Region: 4
City: Auburn State: WA
County:
License #: WN-M017
Agreement: Y
Docket:
NRC Notified By: Boris Tsenov
HQ OPS Officer: Thomas Herrity
Licensee: Multi-Care Health System Auburn Event
Region: 4
City: Auburn State: WA
County:
License #: WN-M017
Agreement: Y
Docket:
NRC Notified By: Boris Tsenov
HQ OPS Officer: Thomas Herrity
Notification Date: 11/02/2023
Notification Time: 11:03 [ET]
Event Date: 10/31/2023
Event Time: 09:00 [PDT]
Last Update Date: 11/16/2023
Notification Time: 11:03 [ET]
Event Date: 10/31/2023
Event Time: 09:00 [PDT]
Last Update Date: 11/16/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Roldan-Otero, Lizette (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Roldan-Otero, Lizette (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 11/16/2023
EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSEOF Y-90 MICROSPHERES
The following information was received from the Washington State Department of Health via email:
"At approximately 0900 (PDT) on10/31/2023 at the Auburn Medical Center, a patient was treated with Y-90 Theraspheres utilizing three separate vials. The first vial was administered without issue, however, the second and third vials experienced some resistance as noted by the authorized physician. All three vials were administered by approximately 9:45 AM.
"The licensee estimated that the patient received 54.5 percent of the targeted 118 Gray total dose to the liver. The patient was not held and was in post-procedure recovery for a few hours before being discharged."
Washington Incident Number: WA-23-029
* * * UPDATE ON 11/15/23 AT 1855 EST FROM BORIS TSENOV TO ERIC SIMPSON * * *
The following information was received from the Washington State Department of Health via email:
"Attached is the final report for the reported medical event # WA-23-029.
"We are also reviewing the event closely and are available to provide further information if needed."
Notified R4DO (Vossmar) and NMSS Events via email.
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.
EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSEOF Y-90 MICROSPHERES
The following information was received from the Washington State Department of Health via email:
"At approximately 0900 (PDT) on10/31/2023 at the Auburn Medical Center, a patient was treated with Y-90 Theraspheres utilizing three separate vials. The first vial was administered without issue, however, the second and third vials experienced some resistance as noted by the authorized physician. All three vials were administered by approximately 9:45 AM.
"The licensee estimated that the patient received 54.5 percent of the targeted 118 Gray total dose to the liver. The patient was not held and was in post-procedure recovery for a few hours before being discharged."
Washington Incident Number: WA-23-029
* * * UPDATE ON 11/15/23 AT 1855 EST FROM BORIS TSENOV TO ERIC SIMPSON * * *
The following information was received from the Washington State Department of Health via email:
"Attached is the final report for the reported medical event # WA-23-029.
"We are also reviewing the event closely and are available to provide further information if needed."
Notified R4DO (Vossmar) and NMSS Events via email.
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: 56843
Rep Org: Texas Dept of State Health Services
Licensee: Core Laboratories LP
Region: 4
City: Abilene State: TX
County:
License #: L 03835
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Eric Simpson
Licensee: Core Laboratories LP
Region: 4
City: Abilene State: TX
County:
License #: L 03835
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Eric Simpson
Notification Date: 11/09/2023
Notification Time: 13:45 [ET]
Event Date: 11/08/2023
Event Time: 00:00 [CST]
Last Update Date: 11/09/2023
Notification Time: 13:45 [ET]
Event Date: 11/08/2023
Event Time: 00:00 [CST]
Last Update Date: 11/09/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Warnick, Greg (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
CNSNS (Mexico), - (EMAIL)
Warnick, Greg (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
CNSNS (Mexico), - (EMAIL)
AGREEMENT STATE REPORT - LOST RADIOACTIVE MATERIAL
The following information was provided by the Texas Department of State Health Services (the Department) via phone and email:
"On November 9, 2023, the Department was notified by the licensee that a shipment of 960 millicuries of iridium - 192 Zero Wash had not arrived at its Alice, Texas, location. The licensee stated the shipment was scheduled to arrive in Alice, Texas on October 31, 2023. The licensee stated that the carrier used often misses the arrival date by as much as a week, so they did not start looking for the shipment until November 7, 2023. The licensee contacted the shipping company and the last know location of the shipment is Abilene, Texas. The shipper is searching that location for the material. The licensee stated the material was shipped inside a 55 gallon drum. It is currently believed that it is not likely that any individual would exceed any exposure limits. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Number 10065
Texas NMED Number: TX230051
* * * UPDATE ON 11/9/23 AT 1529 EST FROM ART TUCKER TO KERBY SCALES * * *
The following update was provided by the Texas Department of State Health Services via email:
"On November 9, 2023, the licensee reported they had located the missing shipment of 960 millicuries of iridium - 192 Zero Wash. The licensee had placed two orders for the materials for two separate locations and the shipping company had inadvertently delivered both shipments to the same location."
Notified R4DO (Warnick), and NMSS Event Notifications, ILTAB, and CSNS Mexico via email.
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
The following information was provided by the Texas Department of State Health Services (the Department) via phone and email:
"On November 9, 2023, the Department was notified by the licensee that a shipment of 960 millicuries of iridium - 192 Zero Wash had not arrived at its Alice, Texas, location. The licensee stated the shipment was scheduled to arrive in Alice, Texas on October 31, 2023. The licensee stated that the carrier used often misses the arrival date by as much as a week, so they did not start looking for the shipment until November 7, 2023. The licensee contacted the shipping company and the last know location of the shipment is Abilene, Texas. The shipper is searching that location for the material. The licensee stated the material was shipped inside a 55 gallon drum. It is currently believed that it is not likely that any individual would exceed any exposure limits. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Number 10065
Texas NMED Number: TX230051
* * * UPDATE ON 11/9/23 AT 1529 EST FROM ART TUCKER TO KERBY SCALES * * *
The following update was provided by the Texas Department of State Health Services via email:
"On November 9, 2023, the licensee reported they had located the missing shipment of 960 millicuries of iridium - 192 Zero Wash. The licensee had placed two orders for the materials for two separate locations and the shipping company had inadvertently delivered both shipments to the same location."
Notified R4DO (Warnick), and NMSS Event Notifications, ILTAB, and CSNS Mexico via email.
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
Agreement State
Event Number: 56847
Rep Org: SC Dept of Health & Env Control
Licensee: Medical University Hospital
Region: 1
City: Charleston State: SC
County:
License #: 081
Agreement: Y
Docket:
NRC Notified By: Korina Koci
HQ OPS Officer: Eric Simpson
Licensee: Medical University Hospital
Region: 1
City: Charleston State: SC
County:
License #: 081
Agreement: Y
Docket:
NRC Notified By: Korina Koci
HQ OPS Officer: Eric Simpson
Notification Date: 11/10/2023
Notification Time: 10:02 [ET]
Event Date: 11/09/2023
Event Time: 17:00 [EST]
Last Update Date: 11/10/2023
Notification Time: 10:02 [ET]
Event Date: 11/09/2023
Event Time: 17:00 [EST]
Last Update Date: 11/10/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Eve, Elise (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Eve, Elise (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - PATIENT RECEIVED 45 PERCENT UNDERDOSE
The following was received from the South Carolina Department of Health and Environmental Control (Department) via phone and email:
"The South Carolina Department of Health and Environmental Control was notified via telephone at approximately 0930 EST on 11/10/23 that a medical event had been discovered by the licensee on 11/09/23 at approximately 1700 EST. The Medical University of South Carolina (MUSC) reported an underdose to a patient's liver during a Y-90 microsphere procedure by 45 percent of the prescribed 500 Gray (Gy) dose. MUSC estimates that the patient received 276 Gy of the intended 500 Gy dose. The licensee reported that the total dose or activity delivered differs from the prescribed dose or activity, as documented in the written directive, by 20 percent or more.
"The licensee reports no immediate or ongoing concerns to public health and safety. Department inspectors will be dispatched to the facility to investigate this event. This event is still under investigation by the South Carolina Department of Health and Environmental Control."
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 South Carolina Department of Health and Environmental Control (Department) via phone and email:
"The South Carolina Department of Health and Environmental Control was notified via telephone at approximately 0930 EST on 11/10/23 that a medical event had been discovered by the licensee on 11/09/23 at approximately 1700 EST. The Medical University of South Carolina (MUSC) reported an underdose to a patient's liver during a Y-90 microsphere procedure by 45 percent of the prescribed 500 Gray (Gy) dose. MUSC estimates that the patient received 276 Gy of the intended 500 Gy dose. The licensee reported that the total dose or activity delivered differs from the prescribed dose or activity, as documented in the written directive, by 20 percent or more.
"The licensee reports no immediate or ongoing concerns to public health and safety. Department inspectors will be dispatched to the facility to investigate this event. This event is still under investigation by the South Carolina Department of Health and Environmental Control."
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
Power Reactor
Event Number: 56856
Facility: Calvert Cliffs
Region: 1 State: MD
Unit: [2] [] []
RX Type: [1] CE,[2] CE
NRC Notified By: Corey Donahoo
HQ OPS Officer: Adam Koziol
Region: 1 State: MD
Unit: [2] [] []
RX Type: [1] CE,[2] CE
NRC Notified By: Corey Donahoo
HQ OPS Officer: Adam Koziol
Notification Date: 11/16/2023
Notification Time: 05:15 [ET]
Event Date: 11/16/2023
Event Time: 02:27 [EST]
Last Update Date: 11/16/2023
Notification Time: 05:15 [ET]
Event Date: 11/16/2023
Event Time: 02:27 [EST]
Last Update Date: 11/16/2023
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical 50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical 50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
Defrancisco, Anne (R1DO)
Defrancisco, Anne (R1DO)
| 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 |
AUTOMATIC REACTOR TRIP
The following information was provided by the licensee via email:
"At 0227 EST on 11/16/23, Calvert Cliffs Unit 2 experienced an automatic trip from the reactor protection system (RPS) based on reactor trip bus undervoltage (UV). At that time, a loss of U-4000-22 (13 kV to 4 kV transformer) caused a loss of 22, 23, and 24 4 kV busses. This resulted in a loss of both motor generator (MG) sets causing the reactor trip bus UV. The loss of 22 and 23 4 kV non-safety related busses resulted in a loss of main feedwater. Auxiliary feedwater (AFW) was manually initiated and is feeding both steam generators. The 2B diesel generator (DG) started and restored the 24 4 kV safety related bus. Heat removal is via the normal turbine bypass valves to the main condenser.
"RPS actuation is reportable under 10 CFR 50.72(b)(2)(iv)(B) - 4 hour report
"ESFAS (engineering safety features actuation system) actuation (2B DG start on UV) is reportable under 10 CFR 50.72(b)(3)(iv)(A) - 8 hour report
"AFW operation is reportable under 10 CFR 50.73(a)(2)(iv)(A) - 60 day report
"The NRC Senior Resident Inspector has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
All rods fully inserted. There was no impact on Unit 1 operations. Unit 2 is stable in mode 3.
* * * UPDATE ON AT 0940 EST FROM KERRY HUMMER TO ADAM KOZIOL * * *
"ESFAS actuation (AFW manual initiation) is reportable under 10CFR50.72(b)(3)(iv)(A) - 8 hour report"
Notified R1DO (Defrancisco).
The following information was provided by the licensee via email:
"At 0227 EST on 11/16/23, Calvert Cliffs Unit 2 experienced an automatic trip from the reactor protection system (RPS) based on reactor trip bus undervoltage (UV). At that time, a loss of U-4000-22 (13 kV to 4 kV transformer) caused a loss of 22, 23, and 24 4 kV busses. This resulted in a loss of both motor generator (MG) sets causing the reactor trip bus UV. The loss of 22 and 23 4 kV non-safety related busses resulted in a loss of main feedwater. Auxiliary feedwater (AFW) was manually initiated and is feeding both steam generators. The 2B diesel generator (DG) started and restored the 24 4 kV safety related bus. Heat removal is via the normal turbine bypass valves to the main condenser.
"RPS actuation is reportable under 10 CFR 50.72(b)(2)(iv)(B) - 4 hour report
"ESFAS (engineering safety features actuation system) actuation (2B DG start on UV) is reportable under 10 CFR 50.72(b)(3)(iv)(A) - 8 hour report
"AFW operation is reportable under 10 CFR 50.73(a)(2)(iv)(A) - 60 day report
"The NRC Senior Resident Inspector has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
All rods fully inserted. There was no impact on Unit 1 operations. Unit 2 is stable in mode 3.
* * * UPDATE ON AT 0940 EST FROM KERRY HUMMER TO ADAM KOZIOL * * *
"ESFAS actuation (AFW manual initiation) is reportable under 10CFR50.72(b)(3)(iv)(A) - 8 hour report"
Notified R1DO (Defrancisco).
Power Reactor
Event Number: 56858
Facility: Brunswick
Region: 2 State: NC
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Jason Williamson
HQ OPS Officer: Ian Howard
Region: 2 State: NC
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Jason Williamson
HQ OPS Officer: Ian Howard
Notification Date: 11/16/2023
Notification Time: 12:12 [ET]
Event Date: 11/16/2023
Event Time: 09:06 [EST]
Last Update Date: 11/16/2023
Notification Time: 12:12 [ET]
Event Date: 11/16/2023
Event Time: 09:06 [EST]
Last Update Date: 11/16/2023
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Miller, Mark (R2DO)
Miller, Mark (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
FAILED FITNESS FOR DUTY TEST
The following information was provided by the licensee via phone and email:
"At 0906 Eastern Standard Time (EST) on November 16, 2023, it was determined that a non-licensed employee supervisor failed a test specified by the Fitness for Duty (FFD) testing program. The individual's authorization for site access has been removed.
"The NRC Resident Inspector has been notified."
The following information was provided by the licensee via phone and email:
"At 0906 Eastern Standard Time (EST) on November 16, 2023, it was determined that a non-licensed employee supervisor failed a test specified by the Fitness for Duty (FFD) testing program. The individual's authorization for site access has been removed.
"The NRC Resident Inspector has been notified."
Power Reactor
Event Number: 56861
Facility: South Texas
Region: 4 State: TX
Unit: [2] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Neil Rocha
HQ OPS Officer: Ian Howard
Region: 4 State: TX
Unit: [2] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Neil Rocha
HQ OPS Officer: Ian Howard
Notification Date: 11/16/2023
Notification Time: 21:30 [ET]
Event Date: 11/16/2023
Event Time: 15:41 [CST]
Last Update Date: 11/16/2023
Notification Time: 21:30 [ET]
Event Date: 11/16/2023
Event Time: 15:41 [CST]
Last Update Date: 11/16/2023
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
Vossmar, Patricia (R4DO)
Vossmar, Patricia (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
ESSENTIAL CHILLER TRAINS INOPERABLE
The following information was provided by the licensee via phone and email:
"11/05/23, 2200 CST: Essential Chiller 'B' train and associated cascading equipment were declared INOPERABLE for planned maintenance. Unit 2 entered the Configuration Risk Management Program as required by Technical Specifications on 11/12/23 at 2200.
"11/16/23, 1541: Essential Chiller 'C' train and associated cascading equipment were declared INOPERABLE due to an unexpected material condition causing the Essential Chiller to trip. The most limiting [Limiting Condition of Operability] LCO is 3.7.7, Action c.
"This condition resulted in the INOPERABILITY of two of the three safety trains required for the accident mitigating function including: High Head Safety Injection, Low Head Safety Injection, Containment Spray, Electrical Auxiliary Building HVAC, Control Room Envelope HVAC, Essential Chilled Water.
"This is an 8 hour reportable condition per 10CFR50.72(b)(3)(v)(D) because it could affect the ability to mitigate the consequences of an accident.
"A risk analysis was performed for the equipment INOPERABILITY and mitigating actions have been taken per site procedures. All 'A' train equipment remains operable."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The 'B' train Emergency Diesel Generator was also inoperable due to planned maintenance and continues to be inoperable. It was considered in the Configuration Risk Management Program and it was determined this condition could be maintained. LCO 3.7.7, Action c requires reactor shutdown within 72 hours.
The following information was provided by the licensee via phone and email:
"11/05/23, 2200 CST: Essential Chiller 'B' train and associated cascading equipment were declared INOPERABLE for planned maintenance. Unit 2 entered the Configuration Risk Management Program as required by Technical Specifications on 11/12/23 at 2200.
"11/16/23, 1541: Essential Chiller 'C' train and associated cascading equipment were declared INOPERABLE due to an unexpected material condition causing the Essential Chiller to trip. The most limiting [Limiting Condition of Operability] LCO is 3.7.7, Action c.
"This condition resulted in the INOPERABILITY of two of the three safety trains required for the accident mitigating function including: High Head Safety Injection, Low Head Safety Injection, Containment Spray, Electrical Auxiliary Building HVAC, Control Room Envelope HVAC, Essential Chilled Water.
"This is an 8 hour reportable condition per 10CFR50.72(b)(3)(v)(D) because it could affect the ability to mitigate the consequences of an accident.
"A risk analysis was performed for the equipment INOPERABILITY and mitigating actions have been taken per site procedures. All 'A' train equipment remains operable."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The 'B' train Emergency Diesel Generator was also inoperable due to planned maintenance and continues to be inoperable. It was considered in the Configuration Risk Management Program and it was determined this condition could be maintained. LCO 3.7.7, Action c requires reactor shutdown within 72 hours.
Part 21
Event Number: 56764
Rep Org: Flowserve
Licensee: Flowserve
Region: 1
City: Lynchburg State: VA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Christopher Shaffer
HQ OPS Officer: Lawrence Criscione
Licensee: Flowserve
Region: 1
City: Lynchburg State: VA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Christopher Shaffer
HQ OPS Officer: Lawrence Criscione
Notification Date: 09/29/2023
Notification Time: 08:36 [ET]
Event Date: 09/29/2023
Event Time: 00:00 [EDT]
Last Update Date: 11/17/2023
Notification Time: 08:36 [ET]
Event Date: 09/29/2023
Event Time: 00:00 [EDT]
Last Update Date: 11/17/2023
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):
Lally, Christopher (R1DO)
Miller, Mark (R2DO)
Orlikowski, Robert (R3DO)
Young, Cale (R4DO)
Part 21/50.55 Reactors, - (EMAIL)
Lally, Christopher (R1DO)
Miller, Mark (R2DO)
Orlikowski, Robert (R3DO)
Young, Cale (R4DO)
Part 21/50.55 Reactors, - (EMAIL)
EN Revision Imported Date: 11/20/2023
EN Revision Text: PART 21 INTERIM REPORT - DEVIATION ASSOCIATED WITH AN SMB-1 GEARED LIMIT SWITCH ASSEMBLY
The following information was provided by Flowserve via phone and email:
"The purpose of this letter is to provide written notification of an evaluation of a deviation in a basic component in accordance with 10 CFR21.21(a)(2). This interim report pertains to actuator geared limit switch assemblies contained in SMB-1 actuators supplied to Bopp & Reuther Valves for use in safety related applications at Bruce Nuclear Generating Station.
"Flowserve - Limitorque was contacted by Bruce Power who reported a malfunction of an actuator geared limit switch (GLS) assembly which occurred while attempting to set the valve travel position limits prior to placing the actuator into service. Site inspections of the GLS assembly revealed damage to the GLS drive pinion which engages with the actuator drive train. Site photos and dimensional measurements of the drive pinion requested by Flowserve indicate that the GLS was assembled with an incorrect drive pinion resulting in the malfunction. Use of an incorrect subcomponent in the assembly constitutes the deviation to the design being evaluated. The actuator GLS assembly is a safety related component. A malfunction of the GLS in service has the potential to affect the safety function of the actuator.
"The assembly containing the deviation is a 4-train geared limit switch (GLS) assembly part number 10168 supplied in SMB-1 actuators manufactured on Flowserve order 175377.001 Three actuators (serial numbers L1226986, L1226987, & L1226988) were shipped to Bopp & Reuther Valves on 2/4/2020.
"Flowserve's evaluation of this issue is ongoing and will not be completed within 60 days. The evaluation is expected to be completed by 11/17/2023 pending return of the affected components to Flowserve for inspection. Questions concerning this notification can be directed to Chris Shaffer, Quality Manager."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
This issue was identified at a Canadian reactor plant owned by Bruce Power. The Quality Manager at Flowserve is not currently aware of any affected US reactor plants.
* * * UPDATE ON 11/17/2023 AT 0914 EST FROM CHRISTOPHER SHAFFER TO ERIC SIMPSON * * *
Flowserve Quality Assurance Manager submitted the Final Part 21 Report pertaining to a deviation in a basic component in accordance with 10 CFR 21.21(a)(2). The report concluded that the evaluated deviation constitutes a reportable defect affecting three actuators listed in the final report.
Notified R1DO (Defrancisco), R2DO (Miller), R3DO (Feliz-Adorno), R4DO (Vossmar), and Part 21 Reactors (email).
EN Revision Text: PART 21 INTERIM REPORT - DEVIATION ASSOCIATED WITH AN SMB-1 GEARED LIMIT SWITCH ASSEMBLY
The following information was provided by Flowserve via phone and email:
"The purpose of this letter is to provide written notification of an evaluation of a deviation in a basic component in accordance with 10 CFR21.21(a)(2). This interim report pertains to actuator geared limit switch assemblies contained in SMB-1 actuators supplied to Bopp & Reuther Valves for use in safety related applications at Bruce Nuclear Generating Station.
"Flowserve - Limitorque was contacted by Bruce Power who reported a malfunction of an actuator geared limit switch (GLS) assembly which occurred while attempting to set the valve travel position limits prior to placing the actuator into service. Site inspections of the GLS assembly revealed damage to the GLS drive pinion which engages with the actuator drive train. Site photos and dimensional measurements of the drive pinion requested by Flowserve indicate that the GLS was assembled with an incorrect drive pinion resulting in the malfunction. Use of an incorrect subcomponent in the assembly constitutes the deviation to the design being evaluated. The actuator GLS assembly is a safety related component. A malfunction of the GLS in service has the potential to affect the safety function of the actuator.
"The assembly containing the deviation is a 4-train geared limit switch (GLS) assembly part number 10168 supplied in SMB-1 actuators manufactured on Flowserve order 175377.001 Three actuators (serial numbers L1226986, L1226987, & L1226988) were shipped to Bopp & Reuther Valves on 2/4/2020.
"Flowserve's evaluation of this issue is ongoing and will not be completed within 60 days. The evaluation is expected to be completed by 11/17/2023 pending return of the affected components to Flowserve for inspection. Questions concerning this notification can be directed to Chris Shaffer, Quality Manager."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
This issue was identified at a Canadian reactor plant owned by Bruce Power. The Quality Manager at Flowserve is not currently aware of any affected US reactor plants.
* * * UPDATE ON 11/17/2023 AT 0914 EST FROM CHRISTOPHER SHAFFER TO ERIC SIMPSON * * *
Flowserve Quality Assurance Manager submitted the Final Part 21 Report pertaining to a deviation in a basic component in accordance with 10 CFR 21.21(a)(2). The report concluded that the evaluated deviation constitutes a reportable defect affecting three actuators listed in the final report.
Notified R1DO (Defrancisco), R2DO (Miller), R3DO (Feliz-Adorno), R4DO (Vossmar), and Part 21 Reactors (email).
Fuel Cycle Facility
Event Number: 56851
Facility: Framatome ANP Richland
Region: 2 State: WA
Unit: [] [] []
RX Type: Uranium Fuel Fabrication
Comments: Leu Conversion
Fabrication & Scrap Recovery
Commercial Lwr Fuel
NRC Notified By: Calvin Manning
HQ OPS Officer: Ernest West
Region: 2 State: WA
Unit: [] [] []
RX Type: Uranium Fuel Fabrication
Comments: Leu Conversion
Fabrication & Scrap Recovery
Commercial Lwr Fuel
NRC Notified By: Calvin Manning
HQ OPS Officer: Ernest West
Notification Date: 11/13/2023
Notification Time: 15:13 [ET]
Event Date: 11/02/2023
Event Time: 10:45 [PST]
Last Update Date: 11/13/2023
Notification Time: 15:13 [ET]
Event Date: 11/02/2023
Event Time: 10:45 [PST]
Last Update Date: 11/13/2023
Emergency Class: Non Emergency
10 CFR Section:
PART 70 APP A (c) - Offsite Notification/News Rel
10 CFR Section:
PART 70 APP A (c) - Offsite Notification/News Rel
Person (Organization):
Miller, Mark (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Miller, Mark (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
CONCURRENT REPORT FOR DEGRADED CONNECTOR
The following information was provided by the licensee via phone and email:
"Pursuant to 10 CFR 70 Appendix A (c), Framatome is making this concurrent report:
"On November 2, 2023, Framatome made a courtesy telephone call to the Washington Department of Health (WDOH) about a degraded flexible connector on an exhaust duct downstream of the final HEPA filter.
"On November 3, 2023, WDOH requested that Framatome submit a report within ten days regarding this notification. Framatome will be submitting the requested report today, [November 13, 2023]."
The following information was provided by the licensee via phone and email:
"Pursuant to 10 CFR 70 Appendix A (c), Framatome is making this concurrent report:
"On November 2, 2023, Framatome made a courtesy telephone call to the Washington Department of Health (WDOH) about a degraded flexible connector on an exhaust duct downstream of the final HEPA filter.
"On November 3, 2023, WDOH requested that Framatome submit a report within ten days regarding this notification. Framatome will be submitting the requested report today, [November 13, 2023]."
Power Reactor
Event Number: 56863
Facility: River Bend
Region: 4 State: LA
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: Jason Shidaker
HQ OPS Officer: Sam Colvard
Region: 4 State: LA
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: Jason Shidaker
HQ OPS Officer: Sam Colvard
Notification Date: 11/18/2023
Notification Time: 02:51 [ET]
Event Date: 11/17/2023
Event Time: 23:55 [CST]
Last Update Date: 11/18/2023
Notification Time: 02:51 [ET]
Event Date: 11/17/2023
Event Time: 23:55 [CST]
Last Update Date: 11/18/2023
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical 50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical 50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
Vossmar, Patricia (R4DO)
Vossmar, Patricia (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | M/R | Y | 24 | Power Operation | 0 | Hot Shutdown |
MANUAL REACTOR SCRAM
The following information was provided by the licensee via phone and email:
"On November 17, 2023, at 2215 CST, River Bend Station (RBS) was operating at 30 percent reactor power performing plant startup activities when an isolation of low-pressure feedwater string `A' occurred. The team entered applicable alternate operating procedures and inserted control rods to exit the restricted region of the power to flow map. Feedwater temperature continued to lower until it challenged the prohibited region of the AOP-0007 graph requiring a reactor scram. The team inserted a manual reactor scram at 2355 from 24 percent reactor power. All control rods fully inserted and there were no complications. All systems responded as designed. Currently RBS Unit 1 is stable with reactor level being maintained 10 to 51 inches with feed and condensate, and pressure being maintained 500 to 1090 psig using steam drains.
"This event is being reported under 10 CFR 50.72(b)(2)(iv)(B), as any event or condition that results in actuation of the Reactor Protection System (RPS) when the reactor is critical and 10 CFR 50.72(b)(3)(iv)(A) Specified System Actuation as result of Group 3 isolations.
"The NRC Senior Resident inspector has been notified.
"No radiological releases have occurred due to this event from the unit."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The electric plant is in a normal lineup for current plant conditions with all emergency diesel generators available. The cause of the initial isolation of low-pressure feedwater string "A" is still under investigation.
The following information was provided by the licensee via phone and email:
"On November 17, 2023, at 2215 CST, River Bend Station (RBS) was operating at 30 percent reactor power performing plant startup activities when an isolation of low-pressure feedwater string `A' occurred. The team entered applicable alternate operating procedures and inserted control rods to exit the restricted region of the power to flow map. Feedwater temperature continued to lower until it challenged the prohibited region of the AOP-0007 graph requiring a reactor scram. The team inserted a manual reactor scram at 2355 from 24 percent reactor power. All control rods fully inserted and there were no complications. All systems responded as designed. Currently RBS Unit 1 is stable with reactor level being maintained 10 to 51 inches with feed and condensate, and pressure being maintained 500 to 1090 psig using steam drains.
"This event is being reported under 10 CFR 50.72(b)(2)(iv)(B), as any event or condition that results in actuation of the Reactor Protection System (RPS) when the reactor is critical and 10 CFR 50.72(b)(3)(iv)(A) Specified System Actuation as result of Group 3 isolations.
"The NRC Senior Resident inspector has been notified.
"No radiological releases have occurred due to this event from the unit."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The electric plant is in a normal lineup for current plant conditions with all emergency diesel generators available. The cause of the initial isolation of low-pressure feedwater string "A" is still under investigation.
Power Reactor
Event Number: 56864
Facility: Harris
Region: 2 State: NC
Unit: [1] [] []
RX Type: [1] W-3-LP
NRC Notified By: Scott Faulkner
HQ OPS Officer: Sam Colvard
Region: 2 State: NC
Unit: [1] [] []
RX Type: [1] W-3-LP
NRC Notified By: Scott Faulkner
HQ OPS Officer: Sam Colvard
Notification Date: 11/19/2023
Notification Time: 00:53 [ET]
Event Date: 11/18/2023
Event Time: 21:38 [EST]
Last Update Date: 11/19/2023
Notification Time: 00:53 [ET]
Event Date: 11/18/2023
Event Time: 21:38 [EST]
Last Update Date: 11/19/2023
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
Person (Organization):
Miller, Mark (R2DO)
Miller, Mark (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
OFFSITE NOTIFICATION - REPORT TO ANOTHER GOVERNMENT AGENCY
The following information was provided by the licensee via phone and email:
"At 2138 EST on November 18, 2023, Harris Nuclear Plant notified the National Response Center of a biodegradable oil leak that entered the Harris Lake. The North Carolina Department of Environmental Quality will also be notified of this condition on November 19, 2023. The oil leak was less than one gallon and came from a temporary pump. The leak has stopped, and spill cleanup is underway. This condition did not violate any NRC regulations or reporting criteria. This notification is being made solely as a four-hour, non-emergency notification for a notification to another government agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi).
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
The following information was provided by the licensee via phone and email:
"At 2138 EST on November 18, 2023, Harris Nuclear Plant notified the National Response Center of a biodegradable oil leak that entered the Harris Lake. The North Carolina Department of Environmental Quality will also be notified of this condition on November 19, 2023. The oil leak was less than one gallon and came from a temporary pump. The leak has stopped, and spill cleanup is underway. This condition did not violate any NRC regulations or reporting criteria. This notification is being made solely as a four-hour, non-emergency notification for a notification to another government agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi).
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
Power Reactor
Event Number: 56865
Facility: Quad Cities
Region: 3 State: IL
Unit: [1] [2] []
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: Harrison Grimm
HQ OPS Officer: John Russell
Region: 3 State: IL
Unit: [1] [2] []
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: Harrison Grimm
HQ OPS Officer: John Russell
Notification Date: 11/19/2023
Notification Time: 14:44 [ET]
Event Date: 11/18/2023
Event Time: 20:20 [CST]
Last Update Date: 11/19/2023
Notification Time: 14:44 [ET]
Event Date: 11/18/2023
Event Time: 20:20 [CST]
Last Update Date: 11/19/2023
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Feliz-Adorno, Nestor (R3DO)
FFD Group, (EMAIL)
Feliz-Adorno, Nestor (R3DO)
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 | Y | 100 | Power Operation | 100 | Power Operation |
FITNESS FOR DUTY REPORT
The following information was provided by the licensee via phone and fax:
"On November 18, 2023, the presence of alcohol was discovered inside the protected area. In accordance with the Constellation Fitness For Duty (FFD) Program, the individual has been escorted offsite and access to the plant denied pending the results of an investigation.
"This event is being reported under 10 CFR 26.719(b)(1) as it represents a significant FFD violation.
"The NRC Resident Inspector has been notified."
The following information was provided by the licensee via phone and fax:
"On November 18, 2023, the presence of alcohol was discovered inside the protected area. In accordance with the Constellation Fitness For Duty (FFD) Program, the individual has been escorted offsite and access to the plant denied pending the results of an investigation.
"This event is being reported under 10 CFR 26.719(b)(1) as it represents a significant FFD violation.
"The NRC Resident Inspector has been notified."