Event Notification Report for January 15, 2016
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/14/2016 - 01/15/2016
Power Reactor
Event Number: 51659
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [1] [2] []
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: RICH MARTENS
HQ OPS Officer: DONALD NORWOOD
Region: 3 State: IL
Unit: [1] [2] []
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: RICH MARTENS
HQ OPS Officer: DONALD NORWOOD
Notification Date: 01/16/2016
Notification Time: 01:42 [ET]
Event Date: 01/15/2016
Event Time: 20:38 [CST]
Last Update Date: 01/16/2016
Notification Time: 01:42 [ET]
Event Date: 01/15/2016
Event Time: 20:38 [CST]
Last Update Date: 01/16/2016
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):
ERIC DUNCAN (R3DO)
ERIC DUNCAN (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 |
MOMENTARY LOSS OF SECONDARY CONTAINMENT
"On January 15, 2016 at 2038 CST, an alarm was received indicating Secondary Containment Differential Pressure rose unexpectedly above the Technical Specification Surveillance Requirement, SR 3.6.4.1.1, limit of 0.10 inch of vacuum water gauge. This loss of differential pressure occurred when Operations had entered the 2A Reactor Water Cleanup Pump room. The pump room door was closed and Secondary Containment Differential Pressure returned to Technical Specification limits in approximately 4 minutes. The Standby Gas Treatment System remained in standby and fully operable.
"This condition represents a failure to meet Surveillance Requirement 3.6.4.1.1. As a result, entry into Technical Specification 3.6.4.1, Condition A, was made momentarily due to secondary containment being inoperable.
"Given the temporary loss of secondary containment, this event is reportable under 50.72(b)(3)(v)(C) as an event or condition that could have prevented the fulfillment of a safety function.
"The NRC Senior Resident Inspector has been notified." The licensee also notified the State of Illinois Emergency Management Agency.
"On January 15, 2016 at 2038 CST, an alarm was received indicating Secondary Containment Differential Pressure rose unexpectedly above the Technical Specification Surveillance Requirement, SR 3.6.4.1.1, limit of 0.10 inch of vacuum water gauge. This loss of differential pressure occurred when Operations had entered the 2A Reactor Water Cleanup Pump room. The pump room door was closed and Secondary Containment Differential Pressure returned to Technical Specification limits in approximately 4 minutes. The Standby Gas Treatment System remained in standby and fully operable.
"This condition represents a failure to meet Surveillance Requirement 3.6.4.1.1. As a result, entry into Technical Specification 3.6.4.1, Condition A, was made momentarily due to secondary containment being inoperable.
"Given the temporary loss of secondary containment, this event is reportable under 50.72(b)(3)(v)(C) as an event or condition that could have prevented the fulfillment of a safety function.
"The NRC Senior Resident Inspector has been notified." The licensee also notified the State of Illinois Emergency Management Agency.
Agreement State
Event Number: 53482
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT
Licensee: VIA CHRISTI REGIONAL MEDICAL CENTER
Region: 4
City: WICHITA State: KS
County:
License #: 18-C753-01
Agreement: Y
Docket:
NRC Notified By: JAMES HARRIS
HQ OPS Officer: BETHANY CECERE
Licensee: VIA CHRISTI REGIONAL MEDICAL CENTER
Region: 4
City: WICHITA State: KS
County:
License #: 18-C753-01
Agreement: Y
Docket:
NRC Notified By: JAMES HARRIS
HQ OPS Officer: BETHANY CECERE
Notification Date: 07/02/2018
Notification Time: 11:27 [ET]
Event Date: 01/15/2016
Event Time: 00:00 [CDT]
Last Update Date: 07/02/2018
Notification Time: 11:27 [ET]
Event Date: 01/15/2016
Event Time: 00:00 [CDT]
Last Update Date: 07/02/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
GEOFFREY MILLER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - UNPLANNED CONTAMINATION
The following information was received from the State of Kansas via email:
"The licensee had an incident with an I-131 patient that resulted in the Iodine Patient room being badly contaminated along with the patient's bed and some other room furniture. The room is secured and removed from service. When the licensee has their Weekday management staff meeting on Monday, they develop a plan to complete the room decontamination and return it to service. The room is removed from clinical service at 2100 today (15 Jan 16).
"The contamination is contained within the room and there is no risk to Hospital staff or members of the public. No unintended dose to the patient, staff or other personnel. The patient was on a Foley catheter with the urine bag in a roll able pig. She got out of bed and walked around the room and "dragged" the pig. The hose connection inside the pig was damaged and urine spilled inside the pig and some was spilled on the floor. No one was contaminated - skin or clothing ... just the floor. The easily removable contamination / urine is cleaned up and will leave the room to decay for a half-life. That will make clean-up easier and also will reduce dose to those who are involved in the detailed cleanup.
"The licensee will notify the department when the room is returned to service.
"6/28/2018 - Patient administered 159.8 milliCuries Iodine-131 on 1/13/2016.
"The patient placed on a catheter because they were incontinent, had early Alzheimer's, and was not able to comply with instruction.
"The patient catheter with urine bag was placed in a 'rollable pig' which was dragged around the room when the patient walked around the room. The hose connection was damaged about the second day and urine spilled in the pig and onto the floor covering, bedding, linens, and absorbent chucks.
"The patient was released with an estimated 28 milliCuries Iodine-131 remaining on 1/15/2016.
"The initial room survey indicated high contamination levels. The decision was made to allow the contamination to decay over the weekend to allow for lower exposure to personnel performing the decontamination, and determine the contamination levels, location and a plan to decontaminate the room.
"The contamination was determined to be confined to the bed (mattress), linens, absorbent chucks and plastic sheeting. Minor contamination was found on the floor under the plastic sheeting.
"The contaminated items were removed from the room and held for 10 half-lives decay.
"The floor was surveyed and contaminated spots were decontaminated. The room was returned to clinical service Monday morning 1/18/2016. The time out of service was approximately 60 hours.
"6/29/2018 - Integrated Material Performance Evaluation Program (IMPEP) review identified the event had not been reported to the NRC as required."
Kansas Item Number: KS160001
The following information was received from the State of Kansas via email:
"The licensee had an incident with an I-131 patient that resulted in the Iodine Patient room being badly contaminated along with the patient's bed and some other room furniture. The room is secured and removed from service. When the licensee has their Weekday management staff meeting on Monday, they develop a plan to complete the room decontamination and return it to service. The room is removed from clinical service at 2100 today (15 Jan 16).
"The contamination is contained within the room and there is no risk to Hospital staff or members of the public. No unintended dose to the patient, staff or other personnel. The patient was on a Foley catheter with the urine bag in a roll able pig. She got out of bed and walked around the room and "dragged" the pig. The hose connection inside the pig was damaged and urine spilled inside the pig and some was spilled on the floor. No one was contaminated - skin or clothing ... just the floor. The easily removable contamination / urine is cleaned up and will leave the room to decay for a half-life. That will make clean-up easier and also will reduce dose to those who are involved in the detailed cleanup.
"The licensee will notify the department when the room is returned to service.
"6/28/2018 - Patient administered 159.8 milliCuries Iodine-131 on 1/13/2016.
"The patient placed on a catheter because they were incontinent, had early Alzheimer's, and was not able to comply with instruction.
"The patient catheter with urine bag was placed in a 'rollable pig' which was dragged around the room when the patient walked around the room. The hose connection was damaged about the second day and urine spilled in the pig and onto the floor covering, bedding, linens, and absorbent chucks.
"The patient was released with an estimated 28 milliCuries Iodine-131 remaining on 1/15/2016.
"The initial room survey indicated high contamination levels. The decision was made to allow the contamination to decay over the weekend to allow for lower exposure to personnel performing the decontamination, and determine the contamination levels, location and a plan to decontaminate the room.
"The contamination was determined to be confined to the bed (mattress), linens, absorbent chucks and plastic sheeting. Minor contamination was found on the floor under the plastic sheeting.
"The contaminated items were removed from the room and held for 10 half-lives decay.
"The floor was surveyed and contaminated spots were decontaminated. The room was returned to clinical service Monday morning 1/18/2016. The time out of service was approximately 60 hours.
"6/29/2018 - Integrated Material Performance Evaluation Program (IMPEP) review identified the event had not been reported to the NRC as required."
Kansas Item Number: KS160001