Event Notification Report for December 11, 2020

AGREEMENT STATE REPORT - PORTABLE DENSITY GUAGE RUN OVER

The following was received from the State of Washington via email:

"On Monday, November 30, 2020, at a construction site at 2800 MLK Jr South, Seattle, WA, a density gauge was run over by a mini dozer. The source was extended and in use at the time. When the device was run over, the handle that is used to extend and retract the source rod broke off from the gauge completely, leading to concern that the source rod had also broken off. Personnel on site were evacuated and the area secured.

"Because of the concern that the source rod had broken off, it was necessary to wait until a licensed entity that had the ability to handle the unshielded source arrived on site to continue recovery operations. Also, shortly after the incident, Northwest Technical Services (NTS), was hired for remedial action.

"When NTS personnel arrived, they were able to determine that the source rod had not detached as feared. A leak test to check the integrity of the source revealed no leakage and the source rod was able to be retracted back into the shielded gauge. Radiation readings and additional leak tests in the area were conducted to ensure there were no remaining safety concerns. There were none.

"The damaged source was taken to Northwest Technical Services in Snohomish, WA and has been secured while awaiting disposal."

Washington Incident Number: WA-20-026.

AGREEMENT STATE REPORT - RADIOGRAPHY SOURCE STUCK WITHIN SOURCE GUIDE TUBE

The following information was received via E-mail:

"Acuren Inspection, Inc. contacted the Louisiana Department of Environmental Quality / Emergency Response Services Division / Radiation Section on December 3, 2020, concerning an industrial radiography source that had been stuck within the source guide tube. The crew was using a QSA Global model - 880D, serial number - 14783, with an Ir-192 source, with source serial number - 11512M, with an activity of 41 Ci (1,517 GBq).

"On December 2, 2020, around 1640 CST, the source became stuck outside the camera in the source guide tube while performing radiography operations [when an equipment stand fell on the source guide tube leading it to become crimped]. There were no excessive radiation exposures. The industrial radiography crew's pocket dosimeters did not go off scale.

"A source retrieval team was sent out and had the source returned back into the camera by 2000 CST on December 2, 2020.

"The event occurred at Enbride Venice Facility in Venice, LA."

Louisiana Event Report ID No.: LA20200010

60-DAY OPTIONAL TELEPHONIC NOTIFICATION OF AN INVALID SPECIFIED SYSTEM ACTUATION

"This 60-day telephone notification is being submitted in accordance with paragraphs 10 CFR 50.73(a)(1) and 50.73(a)(2)(iv)(A) to report an invalid actuation of the 'B' train High Head Safety Injection Pump (3SIH*P1B), the 'B' train Low Pressure Safety Injection Pump (3RHS*P1B) and four Steam Generator Blowdown Containment isolation valves at Millstone Nuclear Power Station Unit 3.

"At 1908 EST on November 6, 2020, with Unit 3 in Mode 3, a partial invalid actuation of 'B' train Emergency Core Cooling System (ECCS) components occurred. The 'B' train SIH pump and the 'B' train RHS pump had started, and ran successfully on recirculation. Four Steam Generator Blowdown Containment isolation valves also closed. Due to this condition the 'B' Emergency Diesel Generator and the 'B' Emergency Generator Load Sequencer (EGLS) were declared inoperable and the required Technical Specification action statements were entered. Troubleshooting determined that this actuation was caused by a failure of one of the circuit boards in the 'B' train EGLS that caused a partial 'B' train 'SIS only' signal. Other 'B' Train components received the 'SIS only' signal but did not start because they were already running or were a backup to an already running component. Troubleshooting discovered a failed NAND gate on the 'B' Train EGLS XA93 circuit card. The card was replaced, retested, and the Technical Specification action statements were exited.

"The pumps and valves responded in accordance with plant design. No other equipment was affected during this event.

"There were no safety consequences or impacts on the health and safety of the public. The event was entered into the station's corrective action program.

"The actuation was not due to actual plant conditions or parameters meeting design criteria for an ECCS actuation. Therefore, this is considered an invalid actuation.

"The NRC Resident Inspector was notified."

PART 21 REPORT - CAMSHAFT KEY WITH INCORRECT STAMPING

The following is a summary of the report provided by the supplier:

ESI supplied stepped camshaft keys with an incorrect stamping. The keys are stamped "AFT" on one end to identify orientation during installation. Keys supplied by ESI have ''AFT" stamped on the opposite end of where they should be stamped. If installed incorrectly and the condition goes undetected during post-maintenance inspection activities, engine performance could suffer resulting in inability of the emergency diesel generator set to perform its safety-related function. This issue is therefore considered to be a reportable defect as defined by 10CFR-part 21.

The key is used in early Cooper-Bessemer model KSV diesel engines to locate the fuel pump cam on the engine's camshaft. This design has a stepped arrangement to provide 4-1/2 degree timing retard. The key is stamped "AFT" to designate the end facing the generator end of the engine. An additional "CAM" tamping designates the cam (up) surface. In the event the key is stamped incorrectly, it is feasible the key could be installed backward which would advance the timing by 9 degree from the desired position.

Date which the information of the defect or failure was obtained is October 20, 2020.

The extent of condition is limited to the part number supplied on the following two orders:

Part Number (KSV-16-6E#1)
Customer (Nebraska Public Power District (NPPD) - Cooper Nuclear Station)
Purchase Orders:
1. NPPD Purchase Order Number (4500106009), ESI Sales Order Number (3006001), Quantity - 5
2. NPPD Purchase Order Number (4500106222), ESI Sales Order Number (3006017), Quantity - 5

Corrective Actions

For affected users:
Camshaft keys installed on engines: No action is required provided post-maintenance injection timing was verified and subsequent engine performance was successful. An incorrectly installed key would be evident by a shift in fuel injection timing. If injection timing and/or engine performance has not been verified, then additional inspections should be performed to verify installed keys from the above referenced orders are oriented properly.

Camshaft keys in inventory (not-installed) on engines: Cooper Nuclear may elect to correct the mislabeled condition or return to ESI for rework. To correct the condition, surface grind to remove the existing "AFT" stamping. Stamp opposite end with "AFT" designation.

For affected ESI:
The dedication report will be revised to add clarification of the correct end for the "AFT" stamping. This will be completed by December 18, 2020.

Points of Contact: John Kriesel, Engineering Manager and Dan Roberts, Quality Manager at Engine Systems Inc. 175 Freight Rd. Rocky Mount, NC 27804. Office number: 252-977-2720

EN Revision Imported Date: 12/14/2020

EN Revision Text: AUTOMATIC REACTOR SCRAM DUE TO LOW STEAM GENERATOR WATER LEVEL

"On December 10, 2020 at 1608 CST, Arkansas Nuclear One, Unit 2 (ANO-2) experienced an automatic reactor scram from 100 percent power due to Low Steam Generator Water Level in 2E-24A Steam Generator. Emergency Feedwater actuated automatically due to low water level in the A Steam Generator. Due to inadequate control of the B Main Feedwater Control System, water level in the B Steam generator rose to a level requiring manual trip of the B Main Feedwater pump. Emergency Feedwater responded as designed to feed both steam generators automatically.

"All other systems responded as designed. All electrical power is being supplied from offsite power and maintaining unit electrical loads as designed.

"Unit 2 is currently stable in Mode 3 (Hot Standby) maintaining pressure and temperature via Emergency Feedwater and secondary system steaming.

"There are no indications of a radiological release on either unit as a result of this event.

"This report satisfies the reporting criteria of both 10 CFR 50.72(b)(2)(iv)(6) for the Reactor Protection System actuation and 10 CFR 50.72(b)(3)(iv)(A) for the actuation of the Emergency Feedwater System.

"The Arkansas Nuclear One NRC Senior Resident Inspector has been notified."


* * * UPDATE FROM JOHN LINDSEY TO DONALD NORWOOD AT 1605 EST ON 12/11/2020 * * *

"The purpose of this [report] is to provide an update to NRC Event Number 55028.

"The cause of the inadequate control of the B Main Feedwater Control System to control B Steam Generator Level was verified to be associated with the failure that led to the A Steam Generator low level condition.

"After taking action to trip the B Main Feedwater Pump, Emergency Feedwater was manually actuated for the B Steam Generator and the Emergency Feedwater System was verified to maintain proper automatic control of both Steam Generator levels.

"At the time of the initial event notification, plant temperature and pressure control had been transferred from Emergency Feedwater to Auxiliary Feedwater along with secondary system steaming."

The licensee notified the NRC Resident Inspector.

Notified R4DO (Kellar).

EN Revision Imported Date: 12/8/2020

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT REPORT - UNDERDOSAGE

The following was received from the Virginia Radioactive Materials Program via email:

"On December 3, 2020, at 1540 EST, the Virginia Radioactive Materials Program (VRMP) received a report from the licensee via telephone that a medical event occurred on December 3, 2020, as a result of a therapy procedure using SIR-Spheres Yttrium-90 resin microspheres. The prescribed dosage to the tumor was 27.9 milliCuries. The actual delivered dosage to the tumor was 20.03 milliCuries, which resulted a difference of 28.3 percent (under-dosage). The preliminary report indicated that this difference was determined based on the measurement of the remaining residual activity in the delivery system.

"Referring physician was notified and an Authorized User was requested to contact the patient concerning the event. The VRMP is working with the licensee to obtain additional information and this report will be updated once the licensee's investigation is complete and the information is received."

Event Report ID No.: VA20006

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.

* * * RETRACTION ON 12/08/20 AT 0922 EST FROM ASFAW FENTA TO SOLOMON SAHLE * * *

The following retraction was received from the Commonwealth of Virginia via email:

"On 12/7/2020, VRMP received a report from the licensee re-investigation the event by two independent teams on 12/4/2020 for verification. Both teams found an error on the first measurement of the remaining residual radioactivity in the delivery system. Based on the teams' new measurements, the dosage left over after the procedure was now calculated to be 1.4 milliCuries of Yttrium-90 versus the original value of 8 milliCuries. Those measurements were corrected for the radioactive decay to the time of the procedure. The new value is within the allowed dose deviation of a normal procedure (new estimate 5 percent deviation of prescription). Thus, VRMP requests the NRC Operation Center retract this event report."

Notified R1DO (Bower) and NMSS Event Notification via email.

AGREEMENT STATE REPORT - LOST HIGH DOSE RATE SOURCE WHILE IN TRANSIT

The following was received from the state of Louisiana via email:

"On December 04, 2020, Alpha-Omega Services RSO contacted the Louisiana Department of Environmental Quality / Emergency Response Services Division / Radiation Section to report that a High Dose Rate (HDR) Ir-192 source was lost in transit with the commercial carrier.

"The source was being shipped to Stanford University Medical Center, 820 Quarry Road, Palo Alto, CA 94304.

"The source serial number is 02-01-2922-001-111120-11438-41.

"The activity of the Ir-192 source was 11.44 Ci (423.22 GBq) on November 13, 2020 when it was shipped. The source was last tracked in the commercial carrier Memphis, TN Hub on November 14, 2020 at 06:07 am CST."

Louisiana Incident Number: LA20200011

THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL

Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)

AGREEMENT STATE REPORT - LOST IODINE-125 SEEDS

The following was received from the state of Arizona Department of Health Services (the Department) via email:

"The Department received notification from the licensee that seven approximately 0.4 milliCurie Iodine-125 seeds used for breast localization were discovered missing [during inventory on 12/1/2020]. The Department has requested additional information and continues to investigate the event."

Arizona Incident Number: 20-024.

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

AUTOMATIC REACTOR SCRAM DUE TO MAIN TURBINE / GENERATOR TRIP

"On December 11, 2020 at 1204 CST, Grand Gulf Nuclear Station (GGNS) experienced an Automatic Reactor Scram from 100 percent Reactor Power after a Main Turbine and Generator Trip.

"All Control Rods fully inserted and there were no complications. All systems responded as designed.

"Reactor pressure is being maintained with Main Turbine Bypass Valves. Reactor water level is being maintained in normal band with the condensate system.

"No radiological releases have occurred due to this event from the unit.

"The NRC Branch Chief has been notified."

DAMAGE NUCLEAR MOISTURE DENSITY GAUGE - RUNOVER

The following is a synopsis of a report received via telephone:

On December 11, 2020, the licensee reported that a CPN moisture density gauge (model MC-1DR-P) had been run-over and damaged. The gauge contained two sources (Americium-241 and Cesium-137). The activity of the Americium-241 is 1.85 GBq. The activity of Cesium-137 is 370 MBq. The shielding around sources is intact. Both sources are outside the gauge, but placed in lead containers. The manufacturer has been notified and the sources will be leak tested before returning to the manufacturer.

60-DAY OPTION TELEPHONIC NOTIFICATION OF AN INVALID SPECIFIED SYSTEM ACTUATION

"On October 13, 2020, at approximately 02:25 [MST], an automatic start of the Unit 1 'A' Train EDG and SP systems occurred following the restoration of power to the 'A' Train 4160 Volt Class Bus. The station was conducting a surveillance test during a Unit 1 refueling outage to verify the proper responses of the EDG and the Engineered Safety Features Actuation Systems to simulated design basis events. During the test, technicians installed a jumper across incorrect relay points that caused the running Unit 1 'A' Train EDG to trip, resulting in a loss of power to the 'A' Train 4160 Volt Class Bus.

"Following restoration of normal offsite power to the 'A' Train 4160 Volt Class Bus, the Loss of Power Actuation signal was reset, however, EDG start relay logic was not reset at the EDG Local Panel. This resulted in the Unit 1 'A' Train EDG and SP system actuations with the EDG running unloaded. The system actuations did not occur as a result of valid plant conditions or parameters and are therefore invalid.

"The Unit 1 'A' Train EDG and SP system actuations were complete and the systems started and functioned successfully.

"The event was attributed to a human performance error and entered into the corrective action program. There was no adverse impact to public health and safety nor to plant employees.

"The NRC Resident Inspectors have been informed."