Event Notification Report for November 12, 2024
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/11/2024 - 11/12/2024
Part 21
Event Number: 57484
Rep Org: Flowserve US Inc.
Licensee:
Region: 1
City: Lynchburg State: VA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Chris Shaffer
HQ OPS Officer: Sam Colvard
Licensee:
Region: 1
City: Lynchburg State: VA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Chris Shaffer
HQ OPS Officer: Sam Colvard
Notification Date: 01/02/2025
Notification Time: 13:08 [ET]
Event Date: 11/12/2024
Event Time: 00:00 [EST]
Last Update Date: 02/20/2025
Notification Time: 13:08 [ET]
Event Date: 11/12/2024
Event Time: 00:00 [EST]
Last Update Date: 02/20/2025
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):
Lilliendahl, Jon (R1DO)
Part 21/50.55 Reactors, - (EMAIL)
Lilliendahl, Jon (R1DO)
Part 21/50.55 Reactors, - (EMAIL)
EN Revision Imported Date: 2/20/2025
EN Revision Text: PART 21 INTERIM REPORT - TORQUE SWITCH FAILURES
The following is a summary of information provided by the licensee via phone and email:
During installation of a replacement torque switch into a SMB-00 actuator at Beaver Valley Nuclear Power Station, technicians reported that the roller subassembly which connects the torque switch to the actuator drive train was loose and easily removed from the torque switch. The condition was identified on a quantity of two torque switches. Investigations by Flowserve indicate that the torque switch assemblies contain a manufacturing error resulting in the torque switch roller pin to be improperly secured in the tripper arm. This condition can potentially result in the roller subassembly becoming detached from the torque switch rendering the torque switch assembly non-functional. However, none of the components were installed in plant equipment.
The extent of condition investigation of the issue is ongoing, and the expected date of completion is on or before 2/28/25.
Known plant affected: Beaver Valley Nuclear Power Station
Contact information:
Chris Shaffer, Global Quality Manager - ACV for
Arie van Eyk, Director, Plant Manager
Flowserve US Inc.
5114 Woodall Road
Lynchburg VA 24502
(434) 258-5074
cshaffer@flowserve.com
* * * UPDATE ON 2/14/2025 AT 1501 EST FROM KYLE SAWYER TO ERNEST WEST * * *
The following is a synopsis of information received via phone and email:
Flowserve completed their final report pertaining to SMB-00 torque switch assemblies. Flowserve identified replacements parts under Limitorque part number 11501-010 are affected as well as original equipment switches contained in new SMB/SB-00 actuators.
Flowserve also provided an updated list of affected power plants. All affected plants have been notified by Flowserve.
Updated known affected U.S. nuclear power plant sites:
Beaver Valley
Watts Bar
Sequoyah
McGuire
Catawba
Point Beach
River Bend
Calvert Cliffs
Limerick
Notified R1DO (Henrion), R2DO (Penmetsa), R3DO (Orlikowski), R4DO (Dixon), and Part 21/50.55 Reactors (email)
EN Revision Text: PART 21 INTERIM REPORT - TORQUE SWITCH FAILURES
The following is a summary of information provided by the licensee via phone and email:
During installation of a replacement torque switch into a SMB-00 actuator at Beaver Valley Nuclear Power Station, technicians reported that the roller subassembly which connects the torque switch to the actuator drive train was loose and easily removed from the torque switch. The condition was identified on a quantity of two torque switches. Investigations by Flowserve indicate that the torque switch assemblies contain a manufacturing error resulting in the torque switch roller pin to be improperly secured in the tripper arm. This condition can potentially result in the roller subassembly becoming detached from the torque switch rendering the torque switch assembly non-functional. However, none of the components were installed in plant equipment.
The extent of condition investigation of the issue is ongoing, and the expected date of completion is on or before 2/28/25.
Known plant affected: Beaver Valley Nuclear Power Station
Contact information:
Chris Shaffer, Global Quality Manager - ACV for
Arie van Eyk, Director, Plant Manager
Flowserve US Inc.
5114 Woodall Road
Lynchburg VA 24502
(434) 258-5074
cshaffer@flowserve.com
* * * UPDATE ON 2/14/2025 AT 1501 EST FROM KYLE SAWYER TO ERNEST WEST * * *
The following is a synopsis of information received via phone and email:
Flowserve completed their final report pertaining to SMB-00 torque switch assemblies. Flowserve identified replacements parts under Limitorque part number 11501-010 are affected as well as original equipment switches contained in new SMB/SB-00 actuators.
Flowserve also provided an updated list of affected power plants. All affected plants have been notified by Flowserve.
Updated known affected U.S. nuclear power plant sites:
Beaver Valley
Watts Bar
Sequoyah
McGuire
Catawba
Point Beach
River Bend
Calvert Cliffs
Limerick
Notified R1DO (Henrion), R2DO (Penmetsa), R3DO (Orlikowski), R4DO (Dixon), and Part 21/50.55 Reactors (email)
Agreement State
Event Number: 57421
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: G.E. Healthcare DBA/Medi+Physics
Region: 3
City: Arlington Heights State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Tenisha Meadows
Licensee: G.E. Healthcare DBA/Medi+Physics
Region: 3
City: Arlington Heights State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Tenisha Meadows
Notification Date: 11/13/2024
Notification Time: 13:18 [ET]
Event Date: 11/12/2024
Event Time: 00:00 [CST]
Last Update Date: 11/13/2024
Notification Time: 13:18 [ET]
Event Date: 11/12/2024
Event Time: 00:00 [CST]
Last Update Date: 11/13/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Edwards, Rhex (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
CNSNS (Mexico), - (FAX)
Edwards, Rhex (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
CNSNS (Mexico), - (FAX)
AGREEMENT STATE REPORT - LOST PACKAGE
The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:
"On November 10, 2024, GE Healthcare reportedly shipped two vials containing 20.0 mCi of I-123 each from their Arlington Heights, IL facility to RLS USA in Sunnyvale, CA. The UN2915 Yellow-II package was loaded at the United Cargo facility in Chicago, IL onto United Flight UA 1878. Although tracking details indicate the package was received by United upon arrival at the San Francisco terminal, the package could not be located for pickup. At this time, a search at the Chicago facility has confirmed it is not on site and the San Francisco United facility claims they do not have the package. As a result, GE Healthcare declared the package as missing on 11/12/2024 and reported the matter to the Agency. The California program staff were notified as well. The vials are shipped within shielded containers and have currently decayed to approximately 1.0 mCi each. There is no indication of damage, intentional theft, or diversion. The quantity of radioactive material present would not be useful for illicit intent."
Illinois Item Number: IL240027
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 Illinois Emergency Management Agency (the Agency) via email:
"On November 10, 2024, GE Healthcare reportedly shipped two vials containing 20.0 mCi of I-123 each from their Arlington Heights, IL facility to RLS USA in Sunnyvale, CA. The UN2915 Yellow-II package was loaded at the United Cargo facility in Chicago, IL onto United Flight UA 1878. Although tracking details indicate the package was received by United upon arrival at the San Francisco terminal, the package could not be located for pickup. At this time, a search at the Chicago facility has confirmed it is not on site and the San Francisco United facility claims they do not have the package. As a result, GE Healthcare declared the package as missing on 11/12/2024 and reported the matter to the Agency. The California program staff were notified as well. The vials are shipped within shielded containers and have currently decayed to approximately 1.0 mCi each. There is no indication of damage, intentional theft, or diversion. The quantity of radioactive material present would not be useful for illicit intent."
Illinois Item Number: IL240027
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: 57423
Rep Org: WA Office of Radiation Protection
Licensee: Acuren
Region: 4
City: Anacortes State: WA
County:
License #: IR067
Agreement: Y
Docket:
NRC Notified By: John Martell
HQ OPS Officer: Tenisha Meadows
Licensee: Acuren
Region: 4
City: Anacortes State: WA
County:
License #: IR067
Agreement: Y
Docket:
NRC Notified By: John Martell
HQ OPS Officer: Tenisha Meadows
Notification Date: 11/13/2024
Notification Time: 21:09 [ET]
Event Date: 11/12/2024
Event Time: 13:00 [PST]
Last Update Date: 04/14/2025
Notification Time: 21:09 [ET]
Event Date: 11/12/2024
Event Time: 13:00 [PST]
Last Update Date: 04/14/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Young, Cale (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Silberfeld, Dafna (NMSS)
Young, Cale (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Silberfeld, Dafna (NMSS)
EN Revision Imported Date: 4/15/2025
EN Revision Text: AGREEMENT STATE REPORT - OVEREXPOSURE FROM RADIOGRAPHY SOURCE
The following information was provided by the Washington State Office of Radiation Protection (the Department) via email:
"Radiography was being performed in a tank at the refinery. [A radiation protection boundary was set up around a tank], and the source was secured in the exposure device. One radiographer was outside the boundary and the other radiographer was inside the boundary with another individual (contractor) outside of the tank. The contractor was in a lift moving upwards next to the tank. Unfortunately, due to a miscommunication between the radiographers and the contractor, the two individuals outside the tank and within the radiation boundaries were exposed to the source for 2 minutes.
"The licensee radiation safety officer (RSO) estimates 1.8 R radiation exposure for the 2 minutes duration right outside the tank as a worst-case scenario. The RSO is currently performing a dose investigation of the affected contract personnel and radiographer. The RSO recommended the contactor to receive medical monitoring (blood draw) as a precaution. The Department set expectations for the licensee to send a full detailed report on findings for this incident. More information to follow for this incident report."
Device information:
Isotope: 87 Ci of Ir-192
Manufacturer: QSA Global
Device Model: 880D
Incident number: WA-24-022
* * * UPDATE ON 11/14/2024 AT 1958 EDT FROM JOHN MARTELL TO TENISHA MEADOWS * * *
The following information was provided by the Washington State Office of Radiation Protection (the Department) via email:
"On 11/14/2024, inspectors from the Department will be conducting a reactive onsite visit of the overexposure event which occurred on 11/12/2024. The inspectors will be meeting at the refinery site where the overexposure occurred with the licensee representatives including the RSO to gather information on the event related to what and how the event occurred and to review related records.
"The Department staff will continue to gather information on the event to determine the extent of the exposures, the potential root cause of this incident, any correlation to previous incidents with this licensee, and appropriate corrective actions. This may include potential enforcement actions in addition to the corrective actions. Updates will be provided as additional information is received."
Notified R4DO (Young), NMSS MSST Deputy Division Director (Silberfeld), and NMSS (email)
* * * UPDATE ON 04/14/2025 AT 1827 EDT FROM MARK HERNANDEZ TO IAN HOWARD * * *
The following is a summary of information provided by the Department via email:
The total dose received is 1.7 mrem for two individuals on the lift and 4 mrem for the other individual inside the tank. After the reactive inspection and interviews were performed, a violation letter was sent to the licensee for individuals not wearing proper dosimetry in a radiation area and not contacting the emergency response number after discovery of the unmonitored exposure. All corrective actions have been completed by the licensee and the investigation is closed.
Notified R4DO (Drake) and NMSS Events Notification (email)
EN Revision Text: AGREEMENT STATE REPORT - OVEREXPOSURE FROM RADIOGRAPHY SOURCE
The following information was provided by the Washington State Office of Radiation Protection (the Department) via email:
"Radiography was being performed in a tank at the refinery. [A radiation protection boundary was set up around a tank], and the source was secured in the exposure device. One radiographer was outside the boundary and the other radiographer was inside the boundary with another individual (contractor) outside of the tank. The contractor was in a lift moving upwards next to the tank. Unfortunately, due to a miscommunication between the radiographers and the contractor, the two individuals outside the tank and within the radiation boundaries were exposed to the source for 2 minutes.
"The licensee radiation safety officer (RSO) estimates 1.8 R radiation exposure for the 2 minutes duration right outside the tank as a worst-case scenario. The RSO is currently performing a dose investigation of the affected contract personnel and radiographer. The RSO recommended the contactor to receive medical monitoring (blood draw) as a precaution. The Department set expectations for the licensee to send a full detailed report on findings for this incident. More information to follow for this incident report."
Device information:
Isotope: 87 Ci of Ir-192
Manufacturer: QSA Global
Device Model: 880D
Incident number: WA-24-022
* * * UPDATE ON 11/14/2024 AT 1958 EDT FROM JOHN MARTELL TO TENISHA MEADOWS * * *
The following information was provided by the Washington State Office of Radiation Protection (the Department) via email:
"On 11/14/2024, inspectors from the Department will be conducting a reactive onsite visit of the overexposure event which occurred on 11/12/2024. The inspectors will be meeting at the refinery site where the overexposure occurred with the licensee representatives including the RSO to gather information on the event related to what and how the event occurred and to review related records.
"The Department staff will continue to gather information on the event to determine the extent of the exposures, the potential root cause of this incident, any correlation to previous incidents with this licensee, and appropriate corrective actions. This may include potential enforcement actions in addition to the corrective actions. Updates will be provided as additional information is received."
Notified R4DO (Young), NMSS MSST Deputy Division Director (Silberfeld), and NMSS (email)
* * * UPDATE ON 04/14/2025 AT 1827 EDT FROM MARK HERNANDEZ TO IAN HOWARD * * *
The following is a summary of information provided by the Department via email:
The total dose received is 1.7 mrem for two individuals on the lift and 4 mrem for the other individual inside the tank. After the reactive inspection and interviews were performed, a violation letter was sent to the licensee for individuals not wearing proper dosimetry in a radiation area and not contacting the emergency response number after discovery of the unmonitored exposure. All corrective actions have been completed by the licensee and the investigation is closed.
Notified R4DO (Drake) and NMSS Events Notification (email)