Event Notification Report for October 17, 2016
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/16/2016 - 10/17/2016
Agreement State
Event Number: 52304
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NOT PROVIDED
Region: 1
City: State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JANAKI KRISHNAMOORTHY
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: NOT PROVIDED
Region: 1
City: State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JANAKI KRISHNAMOORTHY
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 10/19/2016
Notification Time: 10:34 [ET]
Event Date: 10/17/2016
Event Time: 00:00 [EDT]
Last Update Date: 10/19/2016
Notification Time: 10:34 [ET]
Event Date: 10/17/2016
Event Time: 00:00 [EDT]
Last Update Date: 10/19/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - MEDICAL UNDERDOSE
The following report was received via fax:
"Radiation Safety Staff from a hospital in New York called on 10/18/2016 to report that for a patient who was treated with SIR Spheres [containing Y-90] on 10/17/16, it was estimated that about 22.5% less than intended had been delivered. 4.05 mCi was ordered. Assayed at 4.2 mCi. Post treatment survey of the device and residuals showed 1.06 mCi left over. Which means 3.14 mCi was administered, instead of the intended 4.05 mCi. They will mail a report within a week."
New York state Event #NYDOH-NY-16-07
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 via fax:
"Radiation Safety Staff from a hospital in New York called on 10/18/2016 to report that for a patient who was treated with SIR Spheres [containing Y-90] on 10/17/16, it was estimated that about 22.5% less than intended had been delivered. 4.05 mCi was ordered. Assayed at 4.2 mCi. Post treatment survey of the device and residuals showed 1.06 mCi left over. Which means 3.14 mCi was administered, instead of the intended 4.05 mCi. They will mail a report within a week."
New York state Event #NYDOH-NY-16-07
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: 52413
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [] []
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: ROBERT CHU
HQ OPS Officer: JEFF ROTTON
Region: 4 State: AZ
Unit: [1] [] []
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: ROBERT CHU
HQ OPS Officer: JEFF ROTTON
Notification Date: 12/07/2016
Notification Time: 16:59 [ET]
Event Date: 10/17/2016
Event Time: 15:19 [MST]
Last Update Date: 12/07/2016
Notification Time: 16:59 [ET]
Event Date: 10/17/2016
Event Time: 15:19 [MST]
Last Update Date: 12/07/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
VINCENT GADDY (R4DO)
VINCENT GADDY (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
INVALID ENGINEERED SAFETY FEATURES ACTUATION SYSTEM (ESFAS) SIGNAL
"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 10CFR50.73.
"This telephone notification is being made pursuant to the reporting requirements of 10 CFR 50.73(a)(2)(iv)(A) and 50.73(a)(1) to describe an invalid actuation of the Palo Verde Nuclear Generating Station (PVNGS) Unit 1 train A emergency diesel generator (EDG), train A high pressure safety injection (HPSI) pump, and train A essential spray pond (SP) pump. These components are portions of the emergency ac electrical power system, the emergency core cooling system, and the emergency service water system, respectively, as described in 10 CFR 50.73(a)(2)(iv)(B).
"On October 17, 2016 at approximately 1519, Mountain Standard Time, a portion of the Unit 1 train A engineered safety features equipment was automatically started by the balance-of-plant (BOP) engineered safety features actuation system (ESFAS) while the plant was at steady state conditions. Initiation of the train A ESFAS actuation signal was momentary, and the ESFAS actuation signal cleared 0.2 seconds after being initiated. The invalid ESFAS signal initiated a test-mode start signal for the train A EDG and started the train A HPSI pump. The train A essential SP pump started in support of the train A EDG.
"All actuated components started and functioned successfully. No systems started in response to actual plant conditions, and no actuation was required to mitigate the consequences of an event. The invalid HPSI actuation neither resulted in an emergency core cooling system discharge, nor should it have. The invalid actuation was the consequence of a spurious momentary signal into the BOP-ESFAS control panel due to an intermittent high resistance electrical connection. The event was entered into the PVNGS corrective action program. There were no adverse impacts to public health and safety nor to plant employees.
"The NRC Resident Inspectors have been informed."
"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 10CFR50.73.
"This telephone notification is being made pursuant to the reporting requirements of 10 CFR 50.73(a)(2)(iv)(A) and 50.73(a)(1) to describe an invalid actuation of the Palo Verde Nuclear Generating Station (PVNGS) Unit 1 train A emergency diesel generator (EDG), train A high pressure safety injection (HPSI) pump, and train A essential spray pond (SP) pump. These components are portions of the emergency ac electrical power system, the emergency core cooling system, and the emergency service water system, respectively, as described in 10 CFR 50.73(a)(2)(iv)(B).
"On October 17, 2016 at approximately 1519, Mountain Standard Time, a portion of the Unit 1 train A engineered safety features equipment was automatically started by the balance-of-plant (BOP) engineered safety features actuation system (ESFAS) while the plant was at steady state conditions. Initiation of the train A ESFAS actuation signal was momentary, and the ESFAS actuation signal cleared 0.2 seconds after being initiated. The invalid ESFAS signal initiated a test-mode start signal for the train A EDG and started the train A HPSI pump. The train A essential SP pump started in support of the train A EDG.
"All actuated components started and functioned successfully. No systems started in response to actual plant conditions, and no actuation was required to mitigate the consequences of an event. The invalid HPSI actuation neither resulted in an emergency core cooling system discharge, nor should it have. The invalid actuation was the consequence of a spurious momentary signal into the BOP-ESFAS control panel due to an intermittent high resistance electrical connection. The event was entered into the PVNGS corrective action program. There were no adverse impacts to public health and safety nor to plant employees.
"The NRC Resident Inspectors have been informed."