Event Notification Report for April 01, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/31/2021 - 04/01/2021
Agreement State
Event Number: 55151
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: TW LaQuay Marine LLC
Region: 4
City: Brownsville State: TX
County:
License #: L 07072
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Thomas Herrity
Licensee: TW LaQuay Marine LLC
Region: 4
City: Brownsville State: TX
County:
License #: L 07072
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Thomas Herrity
Notification Date: 03/23/2021
Notification Time: 14:18 [ET]
Event Date: 03/23/2021
Event Time: 00:00 [CDT]
Last Update Date: 03/23/2021
Notification Time: 14:18 [ET]
Event Date: 03/23/2021
Event Time: 00:00 [CDT]
Last Update Date: 03/23/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
GREG WERNER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
GREG WERNER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - STUCK SHUTTER
The following was received from the state of Texas (The Agency) via email:
"On March 23, 2021, the Agency was notified by the licensee's radiation safety officer (RSO) that while conducting routine inspections the shutter on a Berthold LB 7440 nuclear gauge could not be closed. Open is the normal operating position. The gauge contains a 500 millicurie (original activity) cesium-137 source. The RSO stated the gauge is not an exposure risk to any individuals. The RSO stated the gauge manufacturer has been contacted and they are making arrangements to repair the gauge. The gauge is located on a barge currently working in the Intercoastal Waterway near Brownsville, Texas. Additional information will be provided as it is received in accordance with SA-300."
Texas Event Number: 9833
The following was received from the state of Texas (The Agency) via email:
"On March 23, 2021, the Agency was notified by the licensee's radiation safety officer (RSO) that while conducting routine inspections the shutter on a Berthold LB 7440 nuclear gauge could not be closed. Open is the normal operating position. The gauge contains a 500 millicurie (original activity) cesium-137 source. The RSO stated the gauge is not an exposure risk to any individuals. The RSO stated the gauge manufacturer has been contacted and they are making arrangements to repair the gauge. The gauge is located on a barge currently working in the Intercoastal Waterway near Brownsville, Texas. Additional information will be provided as it is received in accordance with SA-300."
Texas Event Number: 9833
Agreement State
Event Number: 55152
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: University Hospitals of Cleveland
Region: 3
City: Cleveland State: OH
County:
License #: 02110180077
Agreement: Y
Docket:
NRC Notified By: Michael J Rubadue
HQ OPS Officer: Thomas Herrity
Licensee: University Hospitals of Cleveland
Region: 3
City: Cleveland State: OH
County:
License #: 02110180077
Agreement: Y
Docket:
NRC Notified By: Michael J Rubadue
HQ OPS Officer: Thomas Herrity
Notification Date: 03/24/2021
Notification Time: 16:19 [ET]
Event Date: 06/12/2019
Event Time: 00:00 [EDT]
Last Update Date: 03/24/2021
Notification Time: 16:19 [ET]
Event Date: 06/12/2019
Event Time: 00:00 [EDT]
Last Update Date: 03/24/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
ROBERT ORLIKOWSKI (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ROBERT ORLIKOWSKI (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - FAILURE TO REPORT UNDERDOSE TO PATIENT
The following was received from the state of Ohio via email:
"During a routine inspection an unreported medical event [that occurred in 2019] involving Yttrium-90 'SirSpheres' was discovered. During patient treatment the licensee encountered increasing resistance to the delivery of the microspheres, leading the licensee to believe the patient had reached stasis. After further investigation the licensee determined the cause of the resistance was clogging of the microcatheter. The dose delivered to the patient was 79.2 percent of the prescribed dose. A subsequent treatment was given to the patient to make up for the underdose. At the time the licensee's procedures did not consider this as a reportable event. The reportable event procedures have been updated."
Ohio Item Number: OH210001
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 state of Ohio via email:
"During a routine inspection an unreported medical event [that occurred in 2019] involving Yttrium-90 'SirSpheres' was discovered. During patient treatment the licensee encountered increasing resistance to the delivery of the microspheres, leading the licensee to believe the patient had reached stasis. After further investigation the licensee determined the cause of the resistance was clogging of the microcatheter. The dose delivered to the patient was 79.2 percent of the prescribed dose. A subsequent treatment was given to the patient to make up for the underdose. At the time the licensee's procedures did not consider this as a reportable event. The reportable event procedures have been updated."
Ohio Item Number: OH210001
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: 55160
Facility: Fermi
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: John Rodeman
HQ OPS Officer: Thomas Herrity
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: John Rodeman
HQ OPS Officer: Thomas Herrity
Notification Date: 03/30/2021
Notification Time: 14:00 [ET]
Event Date: 03/30/2021
Event Time: 10:58 [EDT]
Last Update Date: 03/30/2021
Notification Time: 14:00 [ET]
Event Date: 03/30/2021
Event Time: 10:58 [EDT]
Last Update Date: 03/30/2021
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):
ORTH, STEVE (R3)
ORTH, STEVE (R3)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
OFFSITE NOTIFICATION DUE TO SEWAGE SPILL
"At 1058 EDT on 3/30/2021, during routine pump down activities from the sites Equalization Basin, open to the environment (consisting of groundwater and runnoff), to a sanitary system manhole, there was a backflow from the sanitary system to the environment (nearby grassy area). The total amount of overflow is estimated to be 150 gallons. Fermi 2 Environment is currently investigating and clean-up is in progress and the backflow has stopped. The cause of the backflow is under investigation.
"As a result of the backflow reaching the environment, reports are being made to the Michigan Department of Environment, Great Lakes, and Energy (EGLE), the Monroe County Health Department, and the local news media. Since these reports are in the process of being made, this is considered a News Release or Notification to Other Government Agencies, therefore this event is reportable under 10 CFR 50.72(b)(2)(xi).
"The licensee has notified the NRC Resident Inspector."
"At 1058 EDT on 3/30/2021, during routine pump down activities from the sites Equalization Basin, open to the environment (consisting of groundwater and runnoff), to a sanitary system manhole, there was a backflow from the sanitary system to the environment (nearby grassy area). The total amount of overflow is estimated to be 150 gallons. Fermi 2 Environment is currently investigating and clean-up is in progress and the backflow has stopped. The cause of the backflow is under investigation.
"As a result of the backflow reaching the environment, reports are being made to the Michigan Department of Environment, Great Lakes, and Energy (EGLE), the Monroe County Health Department, and the local news media. Since these reports are in the process of being made, this is considered a News Release or Notification to Other Government Agencies, therefore this event is reportable under 10 CFR 50.72(b)(2)(xi).
"The licensee has notified the NRC Resident Inspector."
Part 21
Event Number: 55162
Rep Org: Paragon Energy Solutions
Licensee: Paragon Energy Solutions
Region: 4
City: Fort Worth State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Tracy Bolt
HQ OPS Officer: Joanna Bridge
Licensee: Paragon Energy Solutions
Region: 4
City: Fort Worth State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Tracy Bolt
HQ OPS Officer: Joanna Bridge
Notification Date: 03/30/2021
Notification Time: 16:50 [ET]
Event Date: 03/30/2021
Event Time: 16:50 [CDT]
Last Update Date: 03/30/2021
Notification Time: 16:50 [ET]
Event Date: 03/30/2021
Event Time: 16:50 [CDT]
Last Update Date: 03/30/2021
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):
JANDA, DONNA (R1DO)
MILLER, MARK (R2DO)
ORTH, STEVE (R3DO)
ALEXANDER, RYAN (R4DO)
PART 21/50.55 REACTORS, - (EMAIL)
JANDA, DONNA (R1DO)
MILLER, MARK (R2DO)
ORTH, STEVE (R3DO)
ALEXANDER, RYAN (R4DO)
PART 21/50.55 REACTORS, - (EMAIL)
PART 21 - FAILURE OF SIZE 1 AND 2 FREEDOM SERIES FVR STARTERS
The following is a summary of information received from Paragon Energy Solutions:
North Anna Station has identified instances where Size 1 and 2 starters have failed to function as expected in assemblies that were originally supplied by NLI. The Mechanical Interlock exhibited binding that prevented the contactor to close when energized.
The identified starters are utilized in an application of operating Motor Operated Valves.
Date of Discovery: 3/29/2021
Formal notification will be submitted on or before 4/29/2021.
Affected plants:
North Anna
Should you have any questions regarding this matter, please contact:
Tracy Bolt
Chief Nuclear Officer
Paragon Energy Solutions
817-284-0077
tbolt@paragones.com
The following is a summary of information received from Paragon Energy Solutions:
North Anna Station has identified instances where Size 1 and 2 starters have failed to function as expected in assemblies that were originally supplied by NLI. The Mechanical Interlock exhibited binding that prevented the contactor to close when energized.
The identified starters are utilized in an application of operating Motor Operated Valves.
Date of Discovery: 3/29/2021
Formal notification will be submitted on or before 4/29/2021.
Affected plants:
North Anna
Should you have any questions regarding this matter, please contact:
Tracy Bolt
Chief Nuclear Officer
Paragon Energy Solutions
817-284-0077
tbolt@paragones.com
Part 21
Event Number: 55167
Rep Org: AMETEK SOLIDSTATE CONTROLS
Licensee: AMETEK SOLIDSTATE CONTROLS
Region: 3
City: COLUMBUS State: OH
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Ethan Salsbury
HQ OPS Officer: Lloyd Desotell
Licensee: AMETEK SOLIDSTATE CONTROLS
Region: 3
City: COLUMBUS State: OH
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Ethan Salsbury
HQ OPS Officer: Lloyd Desotell
Notification Date: 04/01/2021
Notification Time: 17:20 [ET]
Event Date: 04/01/2021
Event Time: 00:00 [EDT]
Last Update Date: 04/01/2021
Notification Time: 17:20 [ET]
Event Date: 04/01/2021
Event Time: 00:00 [EDT]
Last Update Date: 04/01/2021
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)
PART 21 REPORT - FAILURE OF AMETEK 300V, 250A CLAMP DIODES
The following is a synopsis of a Part 21 interim report received by email:
"COMPONENT DESCRIPTION - 300V, 250 A clamp diodes with Vishay/International Rectifier part numbers IN3737 and IN3737R and Ametek part numbers 07-600250-00 and 07-600251-00, respectively.
Diode failures occurred in 20kVA Inverters, Ametek part number 85-VC0200-41 with serial numbers C84733-0211 and C84733-0511. Two failed diodes returned for evaluation were manufactured in India in 2004.
"PROBLEM EXPERIENCED - TVA has experienced 5 diode failures since November of 2017. The diode failures experienced at TVA resulted in alarms for abnormal conditions and equipment alarms for fan failure, inverter fuse blown, and inverter failure. The equipment will transfer to bypass when a diode fails.
"POTENTIAL CAUSE - Diodes installed in the TVA equipment were shorted in most cases and degraded in one instance. Only two of the shorted diodes were sent to AMETEK SCI for evaluation.
"While the precise cause of this failure is unknown, diode failures are generally attributed to transient voltage spikes and overheating. TVA did indicate there have not been any transient events on the DC bus that could have caused this failure.
"The inverters at TVA are loaded below 50%. This could contribute to increased heat and stress on the diodes due to increased current draw. However, test data from the original testing of the equipment at no load did not show elevated temperatures on the diodes.
"EFFECT ON SYSTEM PERFORMANCE - Failures described above could result in loss of output voltage and transfer of the static switch to the bypass source which could result in potential loss of load.
"EVALUATION OF THE POTENTIAL DEFECT - AMETEK is sending the parts to the original manufacturer for further evaluation with the intent to obtain more insight on the interior condition of the diodes. The targeted completion date for this evaluation of the two diodes returned is June 1, 2021."
The following is a synopsis of a Part 21 interim report received by email:
"COMPONENT DESCRIPTION - 300V, 250 A clamp diodes with Vishay/International Rectifier part numbers IN3737 and IN3737R and Ametek part numbers 07-600250-00 and 07-600251-00, respectively.
Diode failures occurred in 20kVA Inverters, Ametek part number 85-VC0200-41 with serial numbers C84733-0211 and C84733-0511. Two failed diodes returned for evaluation were manufactured in India in 2004.
"PROBLEM EXPERIENCED - TVA has experienced 5 diode failures since November of 2017. The diode failures experienced at TVA resulted in alarms for abnormal conditions and equipment alarms for fan failure, inverter fuse blown, and inverter failure. The equipment will transfer to bypass when a diode fails.
"POTENTIAL CAUSE - Diodes installed in the TVA equipment were shorted in most cases and degraded in one instance. Only two of the shorted diodes were sent to AMETEK SCI for evaluation.
"While the precise cause of this failure is unknown, diode failures are generally attributed to transient voltage spikes and overheating. TVA did indicate there have not been any transient events on the DC bus that could have caused this failure.
"The inverters at TVA are loaded below 50%. This could contribute to increased heat and stress on the diodes due to increased current draw. However, test data from the original testing of the equipment at no load did not show elevated temperatures on the diodes.
"EFFECT ON SYSTEM PERFORMANCE - Failures described above could result in loss of output voltage and transfer of the static switch to the bypass source which could result in potential loss of load.
"EVALUATION OF THE POTENTIAL DEFECT - AMETEK is sending the parts to the original manufacturer for further evaluation with the intent to obtain more insight on the interior condition of the diodes. The targeted completion date for this evaluation of the two diodes returned is June 1, 2021."