Event Notification Report for December 06, 2016
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/05/2016 - 12/06/2016
Power Reactor
Event Number: 52476
Facility: BELLEFONTE
Region: 2 State: AL
Unit: [] [2] []
RX Type: [1] B&W-R-LP (205),[2] B&W-R-LP (205)
NRC Notified By: GORDON ARENT
HQ OPS Officer: STEVEN VITTO
Region: 2 State: AL
Unit: [] [2] []
RX Type: [1] B&W-R-LP (205),[2] B&W-R-LP (205)
NRC Notified By: GORDON ARENT
HQ OPS Officer: STEVEN VITTO
Notification Date: 01/06/2017
Notification Time: 12:20 [ET]
Event Date: 12/06/2016
Event Time: 00:00 [CST]
Last Update Date: 01/06/2017
Notification Time: 12:20 [ET]
Event Date: 12/06/2016
Event Time: 00:00 [CST]
Last Update Date: 01/06/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.55(e) - CONSTRUCT DEFICIENCY
10 CFR Section:
50.55(e) - CONSTRUCT DEFICIENCY
Person (Organization):
STEVE ROSE (R2DO)
PART 21/50.55 REACT (EMAI)
STEVE ROSE (R2DO)
PART 21/50.55 REACT (EMAI)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | N | 0 | 0 |
CONTAINMENT VERTICAL TENDON FAILED
"During a routine inspection on December 6, 2016, Tennessee Valley Authority (TVA) found the Unit 2 Reactor Building Containment Vertical Tendon V281 rock anchor/tendon anchor coupling had failed. The anchor coupling appears to have sheared in the threaded portion allowing the anchor head for the vertical tendon and the anchor head for the rock anchor tendon to separate. TVA had inspected the failed tendon coupling on October 19, 2016, and identified no signs of component specific damage or improper installation creating the potential for an unknown common mode failure.
"Cause of Deficiency: At this time, the cause for the failure of the V281 rock anchor/tendon anchor coupling is unknown.
"Safety Significance: As noted previously, the cause for the failure of the V281 rock anchor/tendon anchor coupling is unknown. As a result, the extent of condition can not be determined at this time. If multiple containment tendons are found to be losing the capability to carry tendon design force, and this condition was left uncorrected, it could reduce the capability of the containment structure to perform its design function. TVA had previously completed an analysis of containment structure integrity considering a single tendon coupler failure as a result of a similar failure of a Unit 1 Reactor Building Containment Vertical Tendon V9 in 2009 and determined that the containment structure is maintaining its design capability.
"Interim Action: Upon discovery on December 6, 2016, the following actions were taken by BLN [Bellefonte] personnel:
Access to the Unit 2 tendon gallery was restricted. The area of the V281 tendon failure was subsequently cleaned. Grease samples were obtained and sent to TVA Central Labs for analysis. The couplings from both the rock anchor and tendon anchor locations were removed and sent to TVA Central Labs for metallurgical analysis. Grease samples were also collected from adjacent tendons (V272 through V290) to evaluate if conditions are similar to tendon V281 samples. The failure was entered into the BLN Corrective Action Program (Condition Report 1239343).
"Update Schedule: TVA plans to provide an update to this report by May 25, 2017 following the completion of the metallurgical and grease analysis."
The Licensee has notified the NRC Construction Inspector (Baptist).
"During a routine inspection on December 6, 2016, Tennessee Valley Authority (TVA) found the Unit 2 Reactor Building Containment Vertical Tendon V281 rock anchor/tendon anchor coupling had failed. The anchor coupling appears to have sheared in the threaded portion allowing the anchor head for the vertical tendon and the anchor head for the rock anchor tendon to separate. TVA had inspected the failed tendon coupling on October 19, 2016, and identified no signs of component specific damage or improper installation creating the potential for an unknown common mode failure.
"Cause of Deficiency: At this time, the cause for the failure of the V281 rock anchor/tendon anchor coupling is unknown.
"Safety Significance: As noted previously, the cause for the failure of the V281 rock anchor/tendon anchor coupling is unknown. As a result, the extent of condition can not be determined at this time. If multiple containment tendons are found to be losing the capability to carry tendon design force, and this condition was left uncorrected, it could reduce the capability of the containment structure to perform its design function. TVA had previously completed an analysis of containment structure integrity considering a single tendon coupler failure as a result of a similar failure of a Unit 1 Reactor Building Containment Vertical Tendon V9 in 2009 and determined that the containment structure is maintaining its design capability.
"Interim Action: Upon discovery on December 6, 2016, the following actions were taken by BLN [Bellefonte] personnel:
Access to the Unit 2 tendon gallery was restricted. The area of the V281 tendon failure was subsequently cleaned. Grease samples were obtained and sent to TVA Central Labs for analysis. The couplings from both the rock anchor and tendon anchor locations were removed and sent to TVA Central Labs for metallurgical analysis. Grease samples were also collected from adjacent tendons (V272 through V290) to evaluate if conditions are similar to tendon V281 samples. The failure was entered into the BLN Corrective Action Program (Condition Report 1239343).
"Update Schedule: TVA plans to provide an update to this report by May 25, 2017 following the completion of the metallurgical and grease analysis."
The Licensee has notified the NRC Construction Inspector (Baptist).
Agreement State
Event Number: 54041
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: ST NICHOLAS HOSPITAL
Region: 3
City: SHEBOYGAN State: WI
County:
License #: 117-1302-01
Agreement: Y
Docket:
NRC Notified By: JOSEPH ROSS
HQ OPS Officer: JEFFREY WHITED
Licensee: ST NICHOLAS HOSPITAL
Region: 3
City: SHEBOYGAN State: WI
County:
License #: 117-1302-01
Agreement: Y
Docket:
NRC Notified By: JOSEPH ROSS
HQ OPS Officer: JEFFREY WHITED
Notification Date: 05/02/2019
Notification Time: 14:47 [ET]
Event Date: 12/06/2016
Event Time: 00:00 [CDT]
Last Update Date: 05/10/2019
Notification Time: 14:47 [ET]
Event Date: 12/06/2016
Event Time: 00:00 [CDT]
Last Update Date: 05/10/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DARIUSZ SZWARC (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
DARIUSZ SZWARC (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - I-125 APPLICATOR LEAK TEST FAILURE
The following was received via e-mail:
During a Wisconsin Department of Health Services inspection a previously unreported event was discovered. The date of the event is still being determined.
"While performing a manual brachytherapy procedure, the Mick applicator became jammed and the licensee switched to a different applicator to finish the procedure. Following the procedure, the [Radiation Safety Officer] RSO wiped the jammed device and found contamination so several I-125 seeds were isolated and held for decay in storage."
This indicates that the device failed a leak test, which is a reportable event.
* * * UPDATE ON 05/10/2019 AT 1108 EDT FROM JOSEPH ROSS TO JEFFERY HERRERA * * *
"On December 6, 2016, while performing a manual brachytherapy procedure, a Mick applicator became jammed when the oncologist was attempting to insert a seed. The radiation oncologist removed the Mick applicator and switched to an extra Mick applicator with a different cartridge of seeds. A surgeon continued implanting seeds with the physicist to finish the procedure. Meanwhile, the radiation oncologist forcefully extracted the cartridge from the jammed Mick applicator. This was when the physicist/RSO believed that a seed was ruptured. Following the procedure, the RSO took the Mick applicator to the nuclear medicine hot lab and wiped the device and cartridge. The RSO found contamination on the seeds/cartridge so thirteen I-125 seeds (.333mCi each) were isolated and held for decay in storage in the hot lab.
"There is no indication of contamination in the operating room surveys or any expected uptake by the patient."
Notified R3DO (Stoedter) and NMSS Events (via email).
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 was received via e-mail:
During a Wisconsin Department of Health Services inspection a previously unreported event was discovered. The date of the event is still being determined.
"While performing a manual brachytherapy procedure, the Mick applicator became jammed and the licensee switched to a different applicator to finish the procedure. Following the procedure, the [Radiation Safety Officer] RSO wiped the jammed device and found contamination so several I-125 seeds were isolated and held for decay in storage."
This indicates that the device failed a leak test, which is a reportable event.
* * * UPDATE ON 05/10/2019 AT 1108 EDT FROM JOSEPH ROSS TO JEFFERY HERRERA * * *
"On December 6, 2016, while performing a manual brachytherapy procedure, a Mick applicator became jammed when the oncologist was attempting to insert a seed. The radiation oncologist removed the Mick applicator and switched to an extra Mick applicator with a different cartridge of seeds. A surgeon continued implanting seeds with the physicist to finish the procedure. Meanwhile, the radiation oncologist forcefully extracted the cartridge from the jammed Mick applicator. This was when the physicist/RSO believed that a seed was ruptured. Following the procedure, the RSO took the Mick applicator to the nuclear medicine hot lab and wiped the device and cartridge. The RSO found contamination on the seeds/cartridge so thirteen I-125 seeds (.333mCi each) were isolated and held for decay in storage in the hot lab.
"There is no indication of contamination in the operating room surveys or any expected uptake by the patient."
Notified R3DO (Stoedter) and NMSS Events (via email).
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.