Event Notification Report for October 01, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
9/28/2018 - 10/1/2018

** EVENT NUMBERS **


53546 53614 53616 53630

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!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 53546
Facility: PRAIRIE ISLAND
Region: 3     State: MN
Unit: [1] [2] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: JEFFREY HUMAN
HQ OPS Officer: OSSY FONT
Notification Date: 08/10/2018
Notification Time: 23:13 [ET]
Event Date: 08/10/2018
Event Time: 00:00 [CDT]
Last Update Date: 09/29/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(B) - POT RHR INOP
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
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

Event Text

EMERGENCY DIESEL GENERATOR COOLING WATER PUMPS DECLARED INOPERABLE

"On 8/10/2018 at 1445 [CDT] both trains of Cooling Water [Cooling Water Pumps for Emergency Diesel Generators] were declared INOPERABLE and both units entered [Technical Specification] (TS) 3.0.3 due to corroded jacket cooling water plugs for [the] 12 and 22 cooling water pump motors; therefore this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v). At 1543 [CDT], 08/10/2018 the 121 Cooling Water pump was aligned to the "A" Cooling Water train and the TS 3.0.3 condition was exited for both units. [After restoring train A cooling water the site entered a seven day limiting condition for operations, TS 3.7.8 for one inoperable cooling water pump.]

"There was no impact on the health and safety of the public or plant personnel."

The NRC Resident Inspector has been notified.

* * * RETRACTION ON 09/29/2018 AT 2128 EDT FROM BRIAN JOHNSON TO OSSY FONT * * *

"Testing and forensic analysis performed subsequent to the notification has determined the as-found condition would not have impacted either diesel-driven pumps' ability to start, run, and meet flow/pressure requirements to perform their required safety function. Therefore, EN# 53546 is being retracted.

"The NRC Resident Inspector has been notified of the Event Notification retraction."

Notified R3DO (Kozak).

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Agreement State Event Number: 53614
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: EARTH SYSTEMS PACIFIC
Region: 4
City: VENTURA   State: CA
County:
License #: 8166-56
Agreement: Y
Docket:
NRC Notified By: DONALD OESTERLE
HQ OPS Officer: PHIL NATIVIDAD
Notification Date: 09/20/2018
Notification Time: 15:24 [ET]
Event Date: 09/19/2018
Event Time: 00:00 [PDT]
Last Update Date: 09/20/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL O'KEEFE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DAMAGED GAUGE AT CONSTRUCTION SITE

The following information was received from the State of California via email:

"On September 19, 2018, the [Radiation Safety Officer] RSO notified the [California Radiological Health Branch] that a CPN soils gauge, model MC-1DR # MD00605736 containing 10 mCi of Cs-137 and 50 mCi of Am-241/Be had been run over by construction equipment at a temporary job site in Camarillo, CA. The gauge operator had placed the gauge near his test area, but was 15 feet away when the accident occurred. After the accident, he immediately stopped all work in the area and cordoned off an area 30 feet around the damaged gauge before calling his RSO.

"A radiation survey meter was available from a local radiography company who met the RSO and the gauge operator at accident site. The shaft housing the rod above the cesium source was snapped off from the gauge. The source was in the 'safe mode' during the accident and remained in the shielded area of the gauge. The gauge was able to be loaded into the shipping container for return to the permanent storage location. Radiation surveys were performed with a Bicron GM detector and no contamination was found in the area. The root cause is operator error by the gauge operator. The gauge will be disposed thru the manufacturer (CPN)."

California Report No.: 5010-091918

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 53616
Rep Org: MISSOURI BAPTIST MEDICAL CENTER
Licensee: MISSOURI BAPTIST MEDICAL CENTER
Region: 3
City: RSO   State: MO
County:
License #: 24-11128-02
Agreement: N
Docket:
NRC Notified By: AMY ETTLING
HQ OPS Officer: JEFF HERRERA
Notification Date: 09/21/2018
Notification Time: 17:40 [ET]
Event Date: 09/21/2018
Event Time: 00:00 [CDT]
Last Update Date: 10/03/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
ROBERT ORLIKOWSKI (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

POSSIBLE EXTRAVASATION OF RA-223

"The patient's first dose of 110.3 microCuries, 4.3 mL, of Ra-223 (Xofigo) was administered today, 9/21/18 at 1040 CDT. An IV was placed by RN [Registered Nurse] in the patient's left wrist. The IV was flushed with saline and blood return was checked and present prior to administration of Ra-223 by [the] MD [medical doctor]. The Ra-223 was delivered by MD. After delivery, the MD began [a] saline flush and after approximately 5cc of saline, noted resistance and a cold bulge near the infusion site. He was not able to get blood return. The RN was called in to check the IV and was not able to get blood return. It was noted an infiltration/extravasation had occurred. The IV was removed with catheter noted to be intact. Prior to the infusion the patient was told that the infusion should not be painful and he did not acknowledge any pain or discomfort during or after infusion. At this time it is not known if there was an extravasation of Ra-223 because the infiltration/extravasation was not noted until during the second saline flush. The patient and patient's family were notified at the time of the incident."

* * * RETRACTION ON 10/03/18 AT 1525 EDT FROM TOM MOENSTER TO RICHARD SMITH * * *

The licensee does not believe there was more than 10 percent of therapy dose that was not infiltrated. Based on the fact that the swelling went down in less than 45 minutes post imaging of the wrist, compared to the body, leads the Radiation Safety Officer (RSO) to believe most of the therapy dose went throughout the body.

Notified R3DO (Orth) and NMSS vis 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.

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Power Reactor Event Number: 53630
Facility: PEACH BOTTOM
Region: 1     State: PA
Unit: [] [3] []
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: PAUL BOKUS
HQ OPS Officer: OSSY FONT
Notification Date: 09/30/2018
Notification Time: 15:29 [ET]
Event Date: 09/30/2018
Event Time: 00:00 [EDT]
Last Update Date: 09/30/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(A) - ECCS INJECTION
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
FRANK ARNER (R1DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
3 A/R Y 100 Power Operation 0 Hot Shutdown

Event Text

AUTOMATIC SCRAM DUE TO A LOSS OF TWO CONDENSATE PUMPS

"On Sunday, September 30, 2018, at 1130 EDT, an automatic scram was received on U3 following a loss of two condensate pumps. Following the reactor scram, water level lowered from normal level of 23" to below 1" which resulted in automatic Group II and Group III isolations. Reactor water level lowered to -48" which resulted in initiation of the High Pressure Coolant Injection and Reactor Core Isolation Cooling systems. Reactor water level and reactor pressure have been restored to their normal bands. All systems responded properly to the event. Unit 3 remains in Mode 3 with reactor pressure being controlled on the turbine bypass valves. The cause and details of the event are under investigation.

"This report is being made in accordance with 10 CFR 50.72(b)(2)(iv)(A), 10 CFR 50.72(b)(2)(iv)(B), and 10 CFR 50.72(b)(3)(iv)(A).

"All control rods inserted. Decay heat is being removed via the main condenser.

"The NRC Resident Inspector has been notified."

A notification to the media and a press release were made.

Unit 2 was unaffected and continues coastdown to refueling.

Page Last Reviewed/Updated Thursday, March 25, 2021