Event Notification Report for September 22, 2015
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/21/2015 - 09/22/2015
Agreement State
Event Number: 51417
Rep Org: COLORADO DEPT OF HEALTH
Licensee: ST. THOMAS MORE HOSPITAL AND PROGRESSIVE CARE
Region: 4
City: CANON CITY State: CO
County:
License #: CO 397-01
Agreement: Y
Docket:
NRC Notified By: PHILLIP PETERSON
HQ OPS Officer: JOHN SHOEMAKER
Licensee: ST. THOMAS MORE HOSPITAL AND PROGRESSIVE CARE
Region: 4
City: CANON CITY State: CO
County:
License #: CO 397-01
Agreement: Y
Docket:
NRC Notified By: PHILLIP PETERSON
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/22/2015
Notification Time: 17:22 [ET]
Event Date: 09/22/2015
Event Time: 00:00 [MDT]
Last Update Date: 09/22/2015
Notification Time: 17:22 [ET]
Event Date: 09/22/2015
Event Time: 00:00 [MDT]
Last Update Date: 09/22/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - UNPLANNED CONTAMINATION EVENT
The following report was received from the State of Colorado via email:
"On September 22, 2015, during a routine inspection at Colorado licensee St. Thomas More Hospital and Progressive Care (license CO 397-01), [Colorado State] inspectors noted multiple areas with contamination. Upon further investigation, the inspectors learned a patient earlier in the day was undergoing a diagnostic test involving nebulized Tc-99m DTPA for a lung scan. The patient began coughing and pulled off the mask during administration and coughed, spreading the contamination in the diagnostic area. The patient began to require elevated levels of medical care and nursing staff and nuclear medicine staff may have been contaminated while caring for the patient. Arrangements were made to transfer the patient to a different medical facility via helicopter. The second facility was notified and nuclear medicine technologists surveyed the helicopter and patient upon arrival with no contamination found.
"Reporting requirement: 10 CFR 30.50(b)(3); Colorado Part 4, Section 4.52.2.4
"Cause and corrective action: patient intervention. St. Thomas More has closed the affected areas to allow for decay. Surveys will be performed in affected areas prior to re-opening for additional patients.
"A full report of investigation and evaluations will follow within the next 30 days.
"Incident identification: CO15-I15-27"
The following report was received from the State of Colorado via email:
"On September 22, 2015, during a routine inspection at Colorado licensee St. Thomas More Hospital and Progressive Care (license CO 397-01), [Colorado State] inspectors noted multiple areas with contamination. Upon further investigation, the inspectors learned a patient earlier in the day was undergoing a diagnostic test involving nebulized Tc-99m DTPA for a lung scan. The patient began coughing and pulled off the mask during administration and coughed, spreading the contamination in the diagnostic area. The patient began to require elevated levels of medical care and nursing staff and nuclear medicine staff may have been contaminated while caring for the patient. Arrangements were made to transfer the patient to a different medical facility via helicopter. The second facility was notified and nuclear medicine technologists surveyed the helicopter and patient upon arrival with no contamination found.
"Reporting requirement: 10 CFR 30.50(b)(3); Colorado Part 4, Section 4.52.2.4
"Cause and corrective action: patient intervention. St. Thomas More has closed the affected areas to allow for decay. Surveys will be performed in affected areas prior to re-opening for additional patients.
"A full report of investigation and evaluations will follow within the next 30 days.
"Incident identification: CO15-I15-27"
Power Reactor
Event Number: 51512
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: DUSTIN SCURLOCK
HQ OPS Officer: DONG HWA PARK
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: DUSTIN SCURLOCK
HQ OPS Officer: DONG HWA PARK
Notification Date: 11/03/2015
Notification Time: 16:19 [ET]
Event Date: 09/22/2015
Event Time: 16:09 [EDT]
Last Update Date: 11/03/2015
Notification Time: 16:19 [ET]
Event Date: 09/22/2015
Event Time: 16:09 [EDT]
Last Update Date: 11/03/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
JOHN ROGGE (R1DO)
JOHN ROGGE (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 |
SECONDARY CONTAINMENT DIFFERENTIAL PRESSURE EXCEEDED TECHNICAL SPECIFICATION ALLOWED VALUE
"On September 22, 2015, with James A. Fitzpatrick Nuclear Power Plant operating at 100 percent power, the Emergency and Plant Information Computer (EPIC) indicated a spike in Secondary Containment differential pressure during performance of a surveillance test associated with automatic initiation of the Standby Gas Treatment System. Plant data systems recorded Secondary Containment differential pressure exceeding the Technical Specification allowed value. The Secondary Containment differential pressure was at or above zero inches of water for approximately ten (10) seconds, and then immediately trended negative following auto-start of one of the trains of Standby Gas Treatment. An operator was subsequently dispatched to the ventilation control panel, and verified that Secondary Containment differential pressure was more negative than the Technical Specification allowed value.
"This condition was entered into the Corrective Action Program, and subsequently, it was determined that the approximate ten second duration that Secondary Containment differential pressure was greater than the Technical Specification allowed value was reportable pursuant to 10 CFR 50.72(b)(3)(v)(C), as an event or condition that could have prevented fulfillment of a safety function. Secondary Containment was Operable following reestablishment of greater than or equal to 0.25 inches of water vacuum, and remains Operable."
The licensee has notified the NRC Resident Inspector.
"On September 22, 2015, with James A. Fitzpatrick Nuclear Power Plant operating at 100 percent power, the Emergency and Plant Information Computer (EPIC) indicated a spike in Secondary Containment differential pressure during performance of a surveillance test associated with automatic initiation of the Standby Gas Treatment System. Plant data systems recorded Secondary Containment differential pressure exceeding the Technical Specification allowed value. The Secondary Containment differential pressure was at or above zero inches of water for approximately ten (10) seconds, and then immediately trended negative following auto-start of one of the trains of Standby Gas Treatment. An operator was subsequently dispatched to the ventilation control panel, and verified that Secondary Containment differential pressure was more negative than the Technical Specification allowed value.
"This condition was entered into the Corrective Action Program, and subsequently, it was determined that the approximate ten second duration that Secondary Containment differential pressure was greater than the Technical Specification allowed value was reportable pursuant to 10 CFR 50.72(b)(3)(v)(C), as an event or condition that could have prevented fulfillment of a safety function. Secondary Containment was Operable following reestablishment of greater than or equal to 0.25 inches of water vacuum, and remains Operable."
The licensee has notified the NRC Resident Inspector.