Source: https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2015/20151013en.html
Timestamp: 2020-08-08 18:27:40
Document Index: 393065279

Matched Legal Cases: ['art 21', 'ART 21', 'art 21', 'art 21', 'art 21', 'art 21', 'art 21', 'art 21']

NRC: Event Notification Report for October 13, 2015
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Event Notification Report for October 13, 2015
51303 51435 51437 51438 51441 51442 51462 51464
Part 21 Event Number: 51303
Rep Org: ATC-NUCLEAR
Licensee: MOORE INDUSTRIES
PART 21 INTERIM REPORT - POTENTIAL DEFECT ON P/N 535-601 MOORE INDUSTRIES MILLIAMP MODULES
The following information is a summary that was excerpted from a facsimile received from ATC-Nuclear:
"The basic component which is the subject of this notification is identified as Moore Industries Milliamp Module with part number (P/N) 535-601 (alternate P/N: 535-601-SSTRV) which has been provided individually and/or contained within a STS 535 Single Loop Process Controller.
"On December 22, 2014, ATC Nuclear received a 535 controller from Detroit Edison (DTE) with a failed Milliamp Module (P/N 535-601). The customer requested ATC Nuclear to perform a failure analysis to determine the cause of no output (0 Ma) on output 2 of the 535 controller. ATC Nuclear initiated a failure analysis in January 2015 that was broken down into several stages to determine the cause of the Milliamp Module failure. ATC Nuclear is continuing to evaluate the cause of the Milliamp Module failure and has preliminarily identified workmanship issues with a surface-mount fuse that is installed in the Milliamp Modules. ATC Nuclear has provided the results of the analysis to Moore Industries and Littelfuse to support or refute the workmanship concerns.
"Preliminary information provided by Littelfuse on June 11, 2015, was sufficient evidence to identify the existence of a deviation potentially associated with a substantial safety hazard (i.e., discovery as defined in 10 CFR Part 21). This information was documented as part of CAR 15T-24. Evaluation of reportability in accordance with 10 CFR Part 21 was not able to be completed within the 60 day evaluation period.
"The discovery date of the deviation requiring evaluation under 10 CFR Part 21 is June 11, 2015.
"ATC Nuclear has preliminarily identified a total of 285 Milliamp Modules with P/N 535-601 that have been supplied to customers by ATC Nuclear since 2010. However, there is not sufficient evidence to establish that all Milliamp Modules supplied to customers have defective Littelfuse surface-mount fuses (P/N 0448.100MR) installed. ATC Nuclear will continue to work with Moore Industries and Littelfuse to define the population of Milliamp
Modules that potentially have a defective surface-mount fuse installed. This information will become available once our 10 CFR Part 21 evaluation is completed.
"ATC Nuclear is reviewing customer purchase orders for Milliamp Modules to identify the population of Milliamp Modules that potentially have a defective surface-mount fuse installed. Additionally, ATC Nuclear is working with Moore Industries to purge its stock of potentially defective fuses. Additional time is needed to evaluate the condition of new surface-mount fuses and it is expected that this evaluation will be completed no later than October 9, 2015.
"Littelfuse identified a very low failure rate (< 0.001 %) in a preliminary report issued June 2015 spanning approximately an eighteen month period commencing January 2014. There were 356,250 fuses manufactured during this period. Littelfuse is conducting a more thorough review of this failure mechanism. There is no additional advice at this time."
For additional information, contact the following;
Vice President QA, ATC-Nuclear
777 Emory Valley Road, Oak Ridge, TN 37830
(865) 384-0124
* * * UPDATE FROM RAY CHALIFOUX TO DONALD NORWOOD AT 1602 EDT ON 10/9/2015 * * *
ATC Nuclear has concluded that the identified deviation could be considered a defect on the surface-mount fuses supplied by Littelfuse. However, ATC Nuclear determined that it does not have the capability to complete a 10 CFR Part 21 evaluation to determine if a substantial safety hazard exists.
A total of 285 Milliamp Modules with P/N 535-601 have been supplied to customers by ATC Nuclear since 2010. However, there is not sufficient evidence to establish that all Milliamp Modules supplied to customers have defective Littelfuse surface-mount fuses installed. ATC Nuclear identified Milliamp Modules supplied in the January 2013 - June 18, 2015 timeframe as potentially having defective Littelfuse surface-mount fuses. Nuclear plants that received Milliamp Modules which potentially have a defective surface-mount fuse were as follows: LaSalle, Fermi 2, Limerick, and Clinton.
ATC Nuclear has developed a Technical Bulletin to direct the purchasers and/or affected licensees for inspections to determined if the manufacturing defect could be present in their applications.
Notified R1DO (Bickett), R3DO (Stone), and via E-mail Part 21 Group.
Agreement State Event Number: 51441
License #: LA-2316-L01
Last Update Date: 10/02/2015
"An OHMART gauge was discovered with the shutters malfunctioning on a level gauge installed on processes. The shutters were stuck in the open position due to the buildup of grime and corrosive material from the operational environment. This device does not pose a radiation exposure hazard or a threat the work force or the general public. The device will remain in operation on the processes until the repair or replacement.
"The detected malfunction was discovered during the annual inventory/operational checks. These checks are required by condition # 7 of the radioactive material license, LA-2316-L01. The repairs will be made and documentation will be reviewed during the next inspection.
"The gauge detected was an OHMART Corp. gauge, Model Number SHF-2. The gauge/device S/N unknown is loaded with approximately 671 mCi of Cs-137 with source S/N 5895GK. BBP Sales was contacted to fix the problem by repairing the gauge or replacing the device."
Louisiana Event: LA-150016
Agreement State Event Number: 51442
Licensee: WAKE FOREST BAPTIST HEALTH
City: WINSTON-SALEM State: NC
License #: 034-0158-8
AGREEMENT STATE REPORT - GAMMA KNIFE TREATMENT TO INCORRECT LOCATION
"A Gamma Knife patient with trigeminal neuralgia was treated to the incorrect side. The intended side was the patient's right, however, the left side was treated. The prescription was 85 Gy @ 100%. The intended volume was approximately only 33.5 cubic mm which corresponds to the 80% isodose (68 Gy). The incorrect treatment location was determined as the patient completed treatment at approximately 1000 EDT. Once the situation was reviewed, discussed and confirmed by those involved with this treatment, the Radiation Safety Officer (RSO) was notified via phone call at approximately 1100 EDT. The RSO stated that he would contact the State to report the event. The patient has already been informed regarding what happened by the attending neurosurgeon, and after a short break, the patient was then treated to the correct side. The correct treatment was completed at approximately 1230 EDT. The attending radiation oncologist notified the referring physician practice at approximately 1400 EDT. Licensee will provide a required report within 15 days. They are still determining corrective actions to prevent reoccurrence. A state inspector will be on-site doing a follow up investigation Monday, 10/5/2015.
"The treatment isocenter was positioned incorrectly due to human error. More details to be gathered during site visit and investigation by Agency [North Carolina Division of Health and Human Services] scheduled for 1000 EDT, Monday, October 5, 2015. Corrective actions are being discussed by licensee.
"Note: Licensee radiation team and referring physician do not believe patient will suffer any acute deleterious effects at this time."
North Carolina NMED #NC150026
Power Reactor Event Number: 51462
FITNESS-FOR-DUTY REPORT INVOLVING A NON-SUPERVISORY LICENSED EMPLOYEE
A non-supervisory, licensed employee had a confirmed positive test for alcohol during a random fitness-for-duty test. The employee's access to the plant has been suspended.
Power Reactor Event Number: 51464
HQ OPS Officer: VINCE KLCO Notification Date: 10/09/2015
INADVERTENT SIREN ACTIVATION DURING TESTING
"At 1800 [CDT] on October 9, 2015 a polling test was initiated in Saint Johns Parish to test the circuitry of the installed sirens. During the polling test no sirens are expected to sound as it is only a circuitry test. Siren number SJ39 inadvertently sounded for 15 to 20 minutes, and no others. Saint Johns Parish notified the parish residents that the sounding of the siren was inadvertent via a Parish wide cable television channel and a press release. A contract vendor has disabled the siren and will troubleshoot and repair starting on October 12, 2015. All remaining sirens within Saint Johns Parish remain operational and capable of being activated when required. 0% of the population is affected by the loss of this siren due to siren overlap.
"Time to repair and restore siren SJ39 to service is still being investigated.
"This event is reportable pursuant to 10CFR 50.72 (b)(2)(xi), News Release or Notification of Other Government Agency.
Page Last Reviewed/Updated Tuesday, October 13, 2015