Home NRC Library Document Collections Events, Reports Associated with Event Notification Reports 2019

Event Notification Report for October 22, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/21/2019 - 10/22/2019

** EVENT NUMBERS **

Agreement State	Event Number: 54326
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES Licensee: EXXONMOBIL CORPORATION Region: 4 City: BAYTOWN State: TX County: License #: RAM - L01134 Agreement: Y Docket: NRC Notified By: ARTHUR TUCKER HQ OPS Officer: DONALD NORWOOD	Notification Date: 10/11/2019 Notification Time: 16:35 [ET] Event Date: 10/11/2019 Event Time: 00:00 [CDT] Last Update Date: 10/11/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): RAY KELLAR (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

PROCESS GAUGE STUCK SHUTTER

The following information was receive from the Texas Department of State Health Services (the Agency) vial e-mail:

"On October 11, 2019, the Agency was notified by the licensee's radiation safety officer (RSO) that the shutter on a Vega Americas SHLG-2 source holder containing a 5,000 milliCurie cesium-137 source was stuck in the open position. The stuck shutter was found during a routine check of the gauge. Open is the normal operating position. The RSO stated the gauge does not pose an exposure risk to any individual. The RSO stated a service company has been contacted to look at the gauge. The RSO stated they have not determined if they will repair or replace the gauge. Additional information will be provided as it is received in accordance with SA 300."

Texas Incident No.: I-9720

Agreement State	Event Number: 54327
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES Licensee: MEMORIAL HERMANN HEALTH SYSTEM Region: 4 City: HOUSTON State: TX County: License #: RAM - L00650 Agreement: Y Docket: NRC Notified By: ARTHUR TUCKER HQ OPS Officer: DONALD NORWOOD	Notification Date: 10/11/2019 Notification Time: 18:29 [ET] Event Date: 10/11/2019 Event Time: 00:00 [CDT] Last Update Date: 10/11/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): RAY KELLAR (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MISADMINISTRATION OF Y-90 MICROSPHERES

The following information was received from the Texas Department of State Health Services (the Agency) via E-mail:

"On October 11, 2019, the Agency was contacted by the licensee's radiation safety officer (RSO) who reported a medical event had occurred at their facility. The RSO stated that the event involved a patient who was to receive a treatment with yttrium-90 microspheres. The administering physician had difficulties setting up the injection apparatus and installed an additional piece of tubing in-line with the injection tubing. Because of the additional length of tubing, the patient received only five percent of the prescribed activity. The RSO stated there would be no adverse effects on the patient. The RSO stated both the patient and the prescribing physician have been notified of the error. The RSO stated that the bulk of the microspheres (activity) remained in the tubing and no contamination was found in the area where the treatment occurred. The RSO stated the physician decided they would perform the procedure again and use the activity needed to bring total activity administered to the activity initially prescribed. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident No.: I-9721

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: 54340
Facility: PEACH BOTTOM Region: 1 State: PA Unit: [] [3] [] RX Type: [2] GE-4,[3] GE-4 NRC Notified By: KEVIN GROMANN HQ OPS Officer: KERBY SCALES	Notification Date: 10/21/2019 Notification Time: 01:23 [ET] Event Date: 10/21/2019 Event Time: 00:50 [EDT] Last Update Date: 10/21/2019
Emergency Class: UNUSUAL EVENT 10 CFR Section: 50.72(a) (1) (i) - EMERGENCY DECLARED	Person (Organization): DON JACKSON (R1DO) DAVID LEW (R1RA) HO NEIH (NRR) CHRIS MILLER (NRR EO) WILLIAM GOTT (IRD)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

Power Operation

Startup

Event Text

UNUSUAL EVENT DECLARED DUE TO NO CONTROL ROD MOVEMENT WITH MANUAL SCRAM ACTUATION

"While Unit 3 was shutting down for 3R22 refueling outage, the mode switch was taken to shutdown position which is a manual scram signal. The manual scram signal was not received from the mode switch. A subsequent manual scram was inserted with the use of the manual scram push buttons. The Unit 3 reactor is shutdown with all rods inserted."

Unit 2 was unaffected by the event and remains in Mode 1 at 100 percent power.

The licensee notified the NRC Resident Inspector, Pennsylvania and Maryland State Agencies, local government. A media press release is planned.

Notified DHS SWO, FEMA Operations Center, DHS NICC, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email), FEMA Region 3 Watch Office (email).

* * * UPDATE AT 0316 EDT ON 10/21/19 FROM KEVIN GROMANN TO BETHANY CECERE * * *

"Conditions no longer meet an Emergency Actuation Level and will not deteriorate. Unit 3 reactor is shutdown with all control rods fully inserted. The NOUE was terminated at 0230 EDT."

The licensee notified the NRC Resident Inspector, Pennsylvania and Maryland State Agencies, local government.

Notified the R1DO (Jackson), NRR EO (Miller), IRDMOC (Gott), R1RA (Lew via email), NRR (Nieh via email), DHS SWO, FEMA Operations Center, DHS NICC, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email), FEMA Region 3 Watch Office (email).

Power Reactor	Event Number: 54341
Facility: BROWNS FERRY Region: 2 State: AL Unit: [] [] [3] RX Type: [1] GE-4,[2] GE-4,[3] GE-4 NRC Notified By: MATTHEW SLOUKA HQ OPS Officer: OSSY FONT	Notification Date: 10/21/2019 Notification Time: 15:52 [ET] Event Date: 12/29/2018 Event Time: 02:20 [CDT] Last Update Date: 10/21/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION	Person (Organization): BRADLEY DAVIS (R2DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

100

Power Operation

Event Text

INVALID ACTUATION OF A SIGNAL AFFECTING MORE THAN ONE SYSTEM

"This 60-day telephone notification is being made per the reporting requirements specified by 10 CFR 50.73(a)(2)(iv)(A) and 10 CFR 50.73(a)(1) to describe an invalid actuation of a general containment isolation signal affecting more than one system. On December 29, 2018, at approximately 0220 Central Standard Time (CST), Browns Ferry Nuclear Plant (BFN), Unit 3 experienced an unexpected loss of power to the 3A Reactor Protection System (RPS) Bus due to the trip of the 3A RPS motor generator (MG) set. This resulted in Primary Containment Isolation System (PCIS) groups 2, 3, 6, and 8 isolations, and initiation of Standby Gas Treatment Trains A, B, and C and Control Room Emergency Ventilation System Train A. All affected safety systems responded as expected.

"This event is being reported as a late 60 day non-emergency notification. This missed notification was identified on August 23, 2019.

"Plant conditions which initiate PCIS Group 2 actuations are Reactor Vessel Low Water Level (Level 3) or High Drywell Pressure. The PCIS Group 3 actuations are initiated by Reactor Vessel Low Water Level (Level 3) or Reactor Water Cleanup Area High Temperature. The PCIS Group 6 actuations are initiated by Reactor Vessel Low Water Level (Level 3), High Drywell Pressure, or Reactor Building Ventilation Exhaust High Radiation (Reactor Zone or Refuel Zone). The PCIS Group 8 actuations are initiated by Low Reactor Vessel Water Level (Level 3) or High Drywell Pressure. At the time of the event, these conditions did not exist; therefore, the actuation of the PCIS was invalid.

"The cause of the trip of the RPS MG Set was a failure of the motor winding insulation of all three phases.

"There were no safety consequences or impact to the health and safety of the public as a result of this event.

"This event was entered into the Corrective Action Program as Condition Reports 1478564 and 1543534.

"The NRC Resident Inspector has been notified of this event."

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