Event Notification Report for May 14, 2015
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/13/2015 - 05/14/2015
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 51070
Facility: HATCH
Region: 2 State: GA
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: GUY GRIFFIS
HQ OPS Officer: JEFF ROTTON
Region: 2 State: GA
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: GUY GRIFFIS
HQ OPS Officer: JEFF ROTTON
Notification Date: 05/14/2015
Notification Time: 23:02 [ET]
Event Date: 05/14/2015
Event Time: 16:00 [EDT]
Last Update Date: 07/08/2015
Notification Time: 23:02 [ET]
Event Date: 05/14/2015
Event Time: 16:00 [EDT]
Last Update Date: 07/08/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
BRIAN BONSER (R2DO)
BRIAN BONSER (R2DO)
| 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 |
UNANALYZED CONDITION DUE TO EXCESSIVE TOXIC CHEMICALS ONSITE
"On May 14, 2015, it was determined that the number of 55 gallon drums of 2-Butoxyethanol analyzed to be transported and stored within the owner-controlled area (OCA) at any one time had been exceeded. It was discovered that contrary to the toxic gas analysis performed, fourteen 55-gallon drums of 2-Butoxyethanol were transported and stored in the OCA to support the construction of a dome being built to provide storage for FLEX equipment. The number of drums exceeded the limitation specified in the toxic gas analysis performed as part of the design project for transportation and storage could potentially impact Control Room habitability, emergency diesel generator air intake and have an adverse impact on security personnel.
"Upon determination that an unanalyzed condition existed, Operations placed the control room ventilation system in the 'isolation mode' until the number of drums on-site was reduced within the analyzed number. A substantial covering had been placed over the drums which also decreased the likelihood that any of the drums would fail and would also limit the potential dispersion of chemicals should a breach occur.
"The excess number of drums of 2-Butoxyethanol being transported and stored on-site is considered an unanalyzed condition that significantly degraded plant safety and is reportable in accordance with 10CFR50.72(b)(3)(ii)(B)."
The allowed number of 55 gallon drums of 2-butoxyethanol allowed per the current toxic gas analysis is 4 drums. The number of drums has been reduced to 2 as of 2024 EDT.
The licensee has notified the NRC Resident Inspector.
* * * UPDATE FROM PAUL UNDERWOOD TO VINCE KLCO ON 7/8/2015 AT 1657 EDT * * *
"Further investigation into the chemicals transported on-site (F183M, of which 2-Butoxyethanol is a component) revealed that an on-site spill of all fourteen 55-gallon drums will not adversely affect Main Control Room Habitability, Security Personnel, or the Emergency Diesel Generators (EDGs).
"The Control Room Habitability Determination flowchart in Attachment 3 of NMP-CH-002-002 establishes a 10 mmHg vapor pressure threshold for determining if chemicals need to be evaluated for impact on the Main Control Room. Chemicals with a vapor pressure less than 10 mmHg do not need to be evaluated for control room habitability. The basis for the threshold is found in Reg Guide 1.78 Revision 0 section C.5.a, 'For chemicals that are not gases at 100F and normal atmospheric pressure but are liquids with vapor pressures in excess of 10 torr (10 mmHg), consideration should be given to the rate of flashing and boil off to determine the rate of release to the atmosphere and the appropriate time duration of the release.' The individual chemical component (including 2-Butoxyethanol) vapor pressures are less than 10 mmHg.
"As their vaporization rate is too low to adversely affect Control Room Habitability, it is also too low to create a hazard for Security personnel or to adversely affect the Emergency Diesel Generators.
"Based on this information, the transportation and storage of these chemical barrels did NOT represent a condition that significantly degraded plant safety. As such, this condition has been determined to no longer meet reporting requirement 10CFR50.72(b)(3)(ii)(B) and is therefore NOT reportable. Based on this information the previous notification for Event 51070 is being retracted."
The licensee notified the NRC Resident Inspector
Notified the R2DO (McCoy).
"On May 14, 2015, it was determined that the number of 55 gallon drums of 2-Butoxyethanol analyzed to be transported and stored within the owner-controlled area (OCA) at any one time had been exceeded. It was discovered that contrary to the toxic gas analysis performed, fourteen 55-gallon drums of 2-Butoxyethanol were transported and stored in the OCA to support the construction of a dome being built to provide storage for FLEX equipment. The number of drums exceeded the limitation specified in the toxic gas analysis performed as part of the design project for transportation and storage could potentially impact Control Room habitability, emergency diesel generator air intake and have an adverse impact on security personnel.
"Upon determination that an unanalyzed condition existed, Operations placed the control room ventilation system in the 'isolation mode' until the number of drums on-site was reduced within the analyzed number. A substantial covering had been placed over the drums which also decreased the likelihood that any of the drums would fail and would also limit the potential dispersion of chemicals should a breach occur.
"The excess number of drums of 2-Butoxyethanol being transported and stored on-site is considered an unanalyzed condition that significantly degraded plant safety and is reportable in accordance with 10CFR50.72(b)(3)(ii)(B)."
The allowed number of 55 gallon drums of 2-butoxyethanol allowed per the current toxic gas analysis is 4 drums. The number of drums has been reduced to 2 as of 2024 EDT.
The licensee has notified the NRC Resident Inspector.
* * * UPDATE FROM PAUL UNDERWOOD TO VINCE KLCO ON 7/8/2015 AT 1657 EDT * * *
"Further investigation into the chemicals transported on-site (F183M, of which 2-Butoxyethanol is a component) revealed that an on-site spill of all fourteen 55-gallon drums will not adversely affect Main Control Room Habitability, Security Personnel, or the Emergency Diesel Generators (EDGs).
"The Control Room Habitability Determination flowchart in Attachment 3 of NMP-CH-002-002 establishes a 10 mmHg vapor pressure threshold for determining if chemicals need to be evaluated for impact on the Main Control Room. Chemicals with a vapor pressure less than 10 mmHg do not need to be evaluated for control room habitability. The basis for the threshold is found in Reg Guide 1.78 Revision 0 section C.5.a, 'For chemicals that are not gases at 100F and normal atmospheric pressure but are liquids with vapor pressures in excess of 10 torr (10 mmHg), consideration should be given to the rate of flashing and boil off to determine the rate of release to the atmosphere and the appropriate time duration of the release.' The individual chemical component (including 2-Butoxyethanol) vapor pressures are less than 10 mmHg.
"As their vaporization rate is too low to adversely affect Control Room Habitability, it is also too low to create a hazard for Security personnel or to adversely affect the Emergency Diesel Generators.
"Based on this information, the transportation and storage of these chemical barrels did NOT represent a condition that significantly degraded plant safety. As such, this condition has been determined to no longer meet reporting requirement 10CFR50.72(b)(3)(ii)(B) and is therefore NOT reportable. Based on this information the previous notification for Event 51070 is being retracted."
The licensee notified the NRC Resident Inspector
Notified the R2DO (McCoy).
Agreement State
Event Number: 53531
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: ALEXIAN BROTHERS MEDICAL CENTER
Region: 3
City: ELK GROVE VILLAGE State: IL
County:
License #: IL-01418-01
Agreement: Y
Docket:
NRC Notified By: GARY FORSEE
HQ OPS Officer: BETHANY CECERE
Licensee: ALEXIAN BROTHERS MEDICAL CENTER
Region: 3
City: ELK GROVE VILLAGE State: IL
County:
License #: IL-01418-01
Agreement: Y
Docket:
NRC Notified By: GARY FORSEE
HQ OPS Officer: BETHANY CECERE
Notification Date: 07/30/2018
Notification Time: 17:10 [ET]
Event Date: 05/14/2015
Event Time: 00:00 [CDT]
Last Update Date: 07/30/2018
Notification Time: 17:10 [ET]
Event Date: 05/14/2015
Event Time: 00:00 [CDT]
Last Update Date: 07/30/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
STEVE ORTH (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
STEVE ORTH (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - BRACHYTHERAPY SOURCE DID NOT FULLY RETRACT
The following report was received by e-mail from the state of Illinois:
"During a routine inspection [Illinois Emergency Management] Agency inspectors discovered an unreported event that occurred on May 14, 2015. On that date an intravascular brachytherapy procedure was attempted using two BRX-0346 extra-long delivery catheters with a Novoste transfer device and a 40mm Best Vascular, Inc. Sr-90 source train. On the initial treatment attempt, the source would not extend to the treatment location and was promptly returned to the transfer device. A kinked catheter was suspected and a second BRX-0346 XL catheter was put in place. The same train was sent into the second catheter and the same inability to reach the treatment location encountered. At this point, the hydraulic return mechanism failed to return the source train to the transfer device. The licensee's emergency procedure was employed and the entire system was manually removed from the patient. The transfer device, delivery catheter and source train were placed in a temporary storage container and locked in the hot lab. The patient was surveyed and no radioactivity was found to be above background. The treatment was aborted.
"The licensee was able to determine that a deformation in the delivery catheter impeded movement of the source train to the treatment location. The source was found to be lodged in the catheter, approximately 11.3 cm from the attachment point to the transfer device. As a result, exposure occurred in the aortic root. Estimates on the exposure to the surrounding tissue is pending from the licensee. Best Vascular representatives were reportedly notified and arrived at the licensee's site the following day for evaluation and return shipping to the manufacturer.
"A deformation in the catheter was confirmed as the root cause. The event was not reported to the State. Supporting documentation was reviewed on 7/30/18 and determined to be, at a minimum an equipment-related event. Pending exposure estimates, this is also being entered as a possible medical event and will remain open while the investigation continues.
"Radionuclide: Sr-90
Activity: 58.65 mCi (2.17005 GBq)
Dose: 18.4 rad (184 mGy)"
Illinois Item Number: IL180031
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 report was received by e-mail from the state of Illinois:
"During a routine inspection [Illinois Emergency Management] Agency inspectors discovered an unreported event that occurred on May 14, 2015. On that date an intravascular brachytherapy procedure was attempted using two BRX-0346 extra-long delivery catheters with a Novoste transfer device and a 40mm Best Vascular, Inc. Sr-90 source train. On the initial treatment attempt, the source would not extend to the treatment location and was promptly returned to the transfer device. A kinked catheter was suspected and a second BRX-0346 XL catheter was put in place. The same train was sent into the second catheter and the same inability to reach the treatment location encountered. At this point, the hydraulic return mechanism failed to return the source train to the transfer device. The licensee's emergency procedure was employed and the entire system was manually removed from the patient. The transfer device, delivery catheter and source train were placed in a temporary storage container and locked in the hot lab. The patient was surveyed and no radioactivity was found to be above background. The treatment was aborted.
"The licensee was able to determine that a deformation in the delivery catheter impeded movement of the source train to the treatment location. The source was found to be lodged in the catheter, approximately 11.3 cm from the attachment point to the transfer device. As a result, exposure occurred in the aortic root. Estimates on the exposure to the surrounding tissue is pending from the licensee. Best Vascular representatives were reportedly notified and arrived at the licensee's site the following day for evaluation and return shipping to the manufacturer.
"A deformation in the catheter was confirmed as the root cause. The event was not reported to the State. Supporting documentation was reviewed on 7/30/18 and determined to be, at a minimum an equipment-related event. Pending exposure estimates, this is also being entered as a possible medical event and will remain open while the investigation continues.
"Radionuclide: Sr-90
Activity: 58.65 mCi (2.17005 GBq)
Dose: 18.4 rad (184 mGy)"
Illinois Item Number: IL180031
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.