Event Notification Report for March 24, 2016
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/23/2016 - 03/24/2016
Agreement State
Event Number: 51822
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: SHAW INDUSTRIES GROUP, INC
Region: 1
City: CHICKAMAUGA State: GA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MONICA JOHNSON
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: SHAW INDUSTRIES GROUP, INC
Region: 1
City: CHICKAMAUGA State: GA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: MONICA JOHNSON
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/24/2016
Notification Time: 16:13 [ET]
Event Date: 03/24/2016
Event Time: 00:00 [EDT]
Last Update Date: 03/24/2016
Notification Time: 16:13 [ET]
Event Date: 03/24/2016
Event Time: 00:00 [EDT]
Last Update Date: 03/24/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RAY MCKINLEY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
RAY MCKINLEY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - FIXED INDUSTRIAL GAUGE SHUTTER BROKEN
The following information was received via e-mail:
"On Thursday, March 24, 2016, it was reported to the Department [Georgia Department of Radioactive Materials] by Shaw Industries Group, Inc., Plant SI in Chickamauga, GA that the shutter on a fixed industrial gauge is broken. The gauge was shielded, removed from its fixed location, and transferred to a secure storage location. The manufacturer has been contacted and will repair the gauge. A complaint has been opened in CTS [ Complaint Tracking System] and our office [Georgia Department of Radioactive Materials] has an ongoing investigation."
The following information was received via e-mail:
"On Thursday, March 24, 2016, it was reported to the Department [Georgia Department of Radioactive Materials] by Shaw Industries Group, Inc., Plant SI in Chickamauga, GA that the shutter on a fixed industrial gauge is broken. The gauge was shielded, removed from its fixed location, and transferred to a secure storage location. The manufacturer has been contacted and will repair the gauge. A complaint has been opened in CTS [ Complaint Tracking System] and our office [Georgia Department of Radioactive Materials] has an ongoing investigation."
Power Reactor
Event Number: 51820
Facility: PALISADES
Region: 3 State: MI
Unit: [1] [] []
RX Type: [1] CE
NRC Notified By: PAUL RHODES
HQ OPS Officer: KARL DIEDERICH
Region: 3 State: MI
Unit: [1] [] []
RX Type: [1] CE
NRC Notified By: PAUL RHODES
HQ OPS Officer: KARL DIEDERICH
Notification Date: 03/24/2016
Notification Time: 08:58 [ET]
Event Date: 03/24/2016
Event Time: 02:11 [EDT]
Last Update Date: 03/24/2016
Notification Time: 08:58 [ET]
Event Date: 03/24/2016
Event Time: 02:11 [EDT]
Last Update Date: 03/24/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
ROBERT DALEY (R3DO)
ROBERT DALEY (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 |
CONTROL ROOM VENTILATION DECLARED INOPERABLE
"At approximately 0211 [EDT], on March 24, 2016, both control room ventilation filtration trains were declared inoperable in accordance with Technical Specification 3.7.10, Condition B, due to a control room boundary door not being fully closed. Following routine security rounds, the door was unable to be fully closed due to the door's locking bolts not retracting back into the door body, causing interference between the door and door frame.
"Mitigating actions have been implemented that ensure control room envelope (CRE) occupant radiological exposures will not exceed limits, and CRE occupants are protected from chemical and smoke hazards. Repairs to the door are currently in progress.
"Technical Specification 3.7.10 allows control room boundary doors to be opened intermittently, under administrative control for preplanned activities, provided the doors can be rapidly restored to the design condition. Previous evaluations of the door not being fully closed for a limited time concluded no loss of safety function had existed.
"This condition had no impact on the health and safety of the public.
"The NRC Resident Inspector has been notified."
"At approximately 0211 [EDT], on March 24, 2016, both control room ventilation filtration trains were declared inoperable in accordance with Technical Specification 3.7.10, Condition B, due to a control room boundary door not being fully closed. Following routine security rounds, the door was unable to be fully closed due to the door's locking bolts not retracting back into the door body, causing interference between the door and door frame.
"Mitigating actions have been implemented that ensure control room envelope (CRE) occupant radiological exposures will not exceed limits, and CRE occupants are protected from chemical and smoke hazards. Repairs to the door are currently in progress.
"Technical Specification 3.7.10 allows control room boundary doors to be opened intermittently, under administrative control for preplanned activities, provided the doors can be rapidly restored to the design condition. Previous evaluations of the door not being fully closed for a limited time concluded no loss of safety function had existed.
"This condition had no impact on the health and safety of the public.
"The NRC Resident Inspector has been notified."
Agreement State
Event Number: 51841
Rep Org: COLORADO DEPT OF HEALTH
Licensee: PRESBYTERIAN ST. LUKE'S MEDICAL CENTER
Region: 4
City: DENVER State: CO
County: DENVER
License #: CO 632-06
Agreement: Y
Docket:
NRC Notified By: DEREK BAILEY
HQ OPS Officer: VINCE KLCO
Licensee: PRESBYTERIAN ST. LUKE'S MEDICAL CENTER
Region: 4
City: DENVER State: CO
County: DENVER
License #: CO 632-06
Agreement: Y
Docket:
NRC Notified By: DEREK BAILEY
HQ OPS Officer: VINCE KLCO
Notification Date: 03/31/2016
Notification Time: 17:58 [ET]
Event Date: 03/24/2016
Event Time: 00:00 [MDT]
Last Update Date: 03/31/2016
Notification Time: 17:58 [ET]
Event Date: 03/24/2016
Event Time: 00:00 [MDT]
Last Update Date: 03/31/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
MEDICAL EVENT - DOSE MISADMINISTRATION
The following information was received from the State of Colorado via email:
"The Colorado Department of Public Health and Environment - Radioactive Materials Unit was notified on March 25, at [1041 MDT] of a misadministration that occurred on the evening of March 24, 2016. The licensee is Presbyterian St. Luke's Medical Center. A patient was given approximately 70% of the prescribed SIR-Spheres dose due to a clogged catheter.
"The investigation is ongoing and a corrective action has not yet been determined."
Colorado Report: CO16-M16-02
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 information was received from the State of Colorado via email:
"The Colorado Department of Public Health and Environment - Radioactive Materials Unit was notified on March 25, at [1041 MDT] of a misadministration that occurred on the evening of March 24, 2016. The licensee is Presbyterian St. Luke's Medical Center. A patient was given approximately 70% of the prescribed SIR-Spheres dose due to a clogged catheter.
"The investigation is ongoing and a corrective action has not yet been determined."
Colorado Report: CO16-M16-02
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.