| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
11/09/2015 - 11/10/2015 ** EVENT NUMBERS ** |
 | Agreement State | Event Number: 51511 | Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: ST. LUKE'S UNIVERSITY HEALTH NETWORK
Region: 1
City: BETHLEHEM State: PA
County:
License #: PA-0073
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: DANIEL MILLS | Notification Date: 11/02/2015
Notification Time: 10:34 [ET]
Event Date: 10/30/2015
Event Time: [EST]
Last Update Date: 11/02/2015 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
JOHN ROGGE (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
| Event Text UNDERDOSE DUE TO MALFUNCTION OF THE DOSE DELIVERY SYSTEM
The following was received via email:
"During the administration of an yttrium-90 SIR Spheresr procedure, a portion of the dose began to leak out of the top of the vial containing the activity. To prevent contamination of the interventional radiographic suite, the medical physicist and authorized user aborted the administration. It is estimated that only 10 - 20% of the dose noted on the written directive was actually delivered to the patient. The patient and radiation safety officer were notified immediately following the cancellation of the administration and the patient has agreed to be treated again in the near future. Knowing the exact administered activity is nearly impossible given the characteristics of the procedure and radiopharmaceutical. No harm is expected to the patient.
"The event seems to be due to a malfunction of the dose delivery system. It appeared to the interventional radiologist that the leak was located at the top of the dose vial and likely at the original puncture site of the radiopharmacy upon preparation of the dose for administration."
Event Report # PA150028
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: 51522 | Facility: PALO VERDE
Region: 4 State: AZ
Unit: [ ] [2] [ ]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: C. R. OROZCO
HQ OPS Officer: DONALD NORWOOD | Notification Date: 11/09/2015
Notification Time: 08:40 [ET]
Event Date: 11/09/2015
Event Time: 05:47 [MST]
Last Update Date: 11/09/2015 | Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
| Person (Organization):
DAVID PROULX (R4DO)
MARC DAPAS (R4RA)
WILLIAM DEAN (DNRR)
JEFFERY GRANT (IRD)
SCOTT MORRIS (NRR)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 2 | N | N | 0 | Cold Shutdown | 0 | Cold Shutdown | Event Text UNUSUAL EVENT DECLARED DUE TO CONTAINMENT FIRE ALARM
"The following event description is based on information currently available. If through subsequent reviews of this event additional information is identified that is pertinent to this event or alters the information being provided at this time a follow-up notification will be made via the ENS or under the reporting requirements of 10 CFR 50.73.
"During Palo Verde Nuclear Generating Station Unit 2 containment pressurization for integrated leak rate testing in Mode 5, a containment fire alarm in Fire Zone 63B (Steam Generator 2 all elevations of containment) was received. Containment temperature and pressure at time of event were 72 degrees F and 13 PSIG.
"Due to the inability to access containment to validate the fire alarm, an Unusual Event (HU2.1) was declared at 0547 [MST] for a Fire in containment which was unable to be validated within 15 minutes of receipt. No safety functions have been impacted due to the fire alarm. No automatic or manual RPS or ESF actuations occurred and none were required.
"Actions are being taken to depressurize containment to enter and validate the fire alarm.
"The NRC Resident Inspector has been notified."
There has been no effect on U-1 or U-3 due to this fire alarm.
Notified DHS SWO, FEMA Ops Center, NICC Watch Officer and via E-mail only FEMA NWC and Nuclear SSA.
* * * UPDATE FROM ROB WARNER TO DONALD NORWOOD AT 1125 EST ON 11/9/2015 * * *
"Containment was entered following depressurization. Operations and Fire Protection personnel inspection of containment and Fire Zone 63B identified no indication of fire or smoke and the fire alarm was determined to be invalid. No other impacts to plant equipment were identified. The Unusual Event was terminated on 11/9/2015 at 0901 MST.
"The NRC Resident Inspector has been notified."
Notified R4DO (Proulx), NRR EO (Morris), and IRD (Grant).
Notified DHS SWO, FEMA Ops Center, NICC Watch Officer and via E-mail only FEMA NWC and Nuclear SSA. |
| Power Reactor | Event Number: 51523 | Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: KENNETH GRACIA
HQ OPS Officer: VINCE KLCO | Notification Date: 11/09/2015
Notification Time: 09:10 [ET]
Event Date: 11/09/2015
Event Time: 08:00 [EST]
Last Update Date: 11/09/2015 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
| Person (Organization):
FRANK ARNER (R1DO)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | N | Y | 100 | Power Operation | 100 | Power Operation | Event Text TECHNICAL SUPPORT CENTER UNAVAILABLE DUE TO PLANNED MAINTENANCE
"On Monday, November 9, 2015 at 0800 [EST], planned routine maintenance was initiated on the Technical Support Center/Operations Support Center (TSC/OSC) ventilation system. The planned maintenance is to replace the charcoal filters and test the HVAC trains. All other TSC/OSC functions remain available.
"Under certain accident conditions the TSC/OSC may become unavailable as a result of the ventilation system not being available. Existing Emergency Procedures direct the responsible Emergency Plant Manager to relocate the TSC/OSC staff to the designated alternate location. The affected Emergency Response Organization facility leads have been informed.
"The licensee has notified the NRC Senior Resident Inspector.
"The Commonwealth of Massachusetts will be notified.
"This notification to the USNRC Operations Center is being made in accordance with 10 CFR 50.72(b)(3)(xiii) due to the potential loss of an Emergency Response Facility (ERF)."
* * * UPDATE ON 11/9/15 AT 1750 EST FROM KENNETH GRACIA TO DONG PARK * * *
"At 1730 EST on Monday, November 9, 2015, the TSC/OSC ventilation system was restored to service."
The licensee will notify the NRC Resident Inspector.
Notified R1DO (Arner). |
| Power Reactor | Event Number: 51526 | Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: BRYAN HEAVILIN
HQ OPS Officer: DONALD NORWOOD | Notification Date: 11/10/2015
Notification Time: 04:15 [ET]
Event Date: 11/09/2015
Event Time: 20:40 [PST]
Last Update Date: 11/10/2015 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
| Person (Organization):
DAVID PROULX (R4DO)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 2 | N | Y | 100 | Power Operation | 100 | Power Operation | Event Text REACTOR BUILDING VACUUM LESS THAN TECHNICAL SPECIFICATIONS REQUIREMENT
"At 2040 PST on 11/9/2015, Reactor Building (Secondary Containment) pressure increased to above the Technical Specification Surveillance requirement of 0.25 inches vacuum water gauge for approximately seven minutes. Operators took action to manually start Standby Gas Treatment System to restore Reactor Building pressure. This event is reportable as an event that could have prevented fulfillment of a safety function needed to control the release of radiation and mitigate the consequences of an accident. The cause of the event is under investigation.
"There were no radiological releases associated with the event.
"No safety system actuations or isolations occurred.
"The licensee notified the NRC Resident Inspector." | |