Event Notification Report for April 20, 2017

TECHNICAL SPECIFICATION REQUIRED REPORT FOR AN ABNORMAL OCCURRENCE

"On 4/20/17 at 1449 CDT, the University of Missouri-Columbia Research Reactor (MURR) was shut down due to a failure of the regulating blade drive mechanism to move the regulating blade during reactor operation. This email is a required notification per MURR Technical Specification (TS) 6.6.c. (1) to report to the NRC Operations Center that an Abnormal Occurrence, as defined by MURR TS 1.1, had occurred. Specifically, MURR was not in compliance with all Limiting Conditions for Operations (LCOs). MURR was not in compliance with two (2) LCOs: 1. TS 3.2.a states, 'All control blades, including the regulating blade, shall be operable during reactor operation' and 2. TS 3.2.f states, 'The reactor shall not be operated unless the following rod run-in functions are operable.' Specifically, the rod run-in function that occurs when the regulating blade position is less than or equal to 10% withdrawn was not operable as TS 3.2.f.8 requires.

"The regulating blade drive mechanism was repaired, the required compliance procedure was conducted on the regulating blade, and permission from the Acting Facility Director was obtained prior to the reactor returning to operation later on 4/20/17. Currently, MURR is at 10 MW. A detailed event report will follow within 14 days as required by MURR TS 6.6.c.(3).

"The cause of this event is not related to the cause of the earlier regulating blade drive mechanism failure on 1/17/17."

AGREEMENT STATE REPORT - DELIVERED DOSE LESS THAN PRESCRIBED DOSE

The following information was provided by the State of South Carolina via email:

"On April 21, 2017, the licensee provided notification of a medical event that occurred on April 20, 2017. The licensee stated that a patient was administered a dose of Y-90 SIR-Spheres for treatment of a liver tumor. During the treatment process, the tubing used to administer the SIR-Spheres became clogged, and the full dose could not be administered. The prescribed dose for the patient was 120 Gy. The dose delivered to the patient was 90 Gy. The licensee indicated that the required written report detailing the event is being completed, and will be submitted to the Department [South Carolina Department of Health and Environmental Control] within the next few days. Updates to this event will be made through the NMED system."

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.

AGREEMENT STATE REPORT - UNSECURED RADIOGRAPHY CAMERA

The following report was received from the State of Louisiana via email:

"Event type: The source/exposure device, a QSA Global 880D s/n # D11837 loaded with 86.7 Ci Ir-192 source s/n #53959G, was left in an unlocked transport buggy and left unattended while the crew took a work break and moved to another work location at the site. Three crew members were in the area, but could not maintain surveillance of the unsecured source. The Bechtel Safety Officer walked up to the transport vehicle and observed the exposure device not secured or locked in the transport vehicle and the Mistras personnel did not have direct surveillance of the transport vehicle. The source incident was reported to the Mistras Group's RSO. Human error, operator distracted.

"Notifications: LDEQ [Louisiana Department of Environmental Control] was notified directly by [the Mistras Group's RSO] to an inspector during office hours approximately 1600 [CDT] on 04/20/2017.

"Event description: On 04/20/2017, approximately 1230 [CDT], the Bechtel Safety Office, BSO, made a site visit to where a Mistras Group crew was working on a liquid natural gas pipeline in Cameron Parish. The BSO observed an exposure device in an unlocked and unattended Mistras vehicle. The Mistras crew was working at this temporary jobsite and moved to help another crew member working at the site. The crew became distracted and left the vehicle unattended and unlocked. The BSO contacted the Mistras RSO about the incident. [The Mistras RSO] investigated and reported the incident to LDEQ. The incident was under control with no possible radiation exposures to the crew members or the general public.

"A LDEQ investigator was contacted to follow-up on the report."

Event Report ID No.: LA-17005.

AUTOMATIC REACTOR SCRAM DURING STARTUP

"On 04/20/2017 at 0302 EST during a reactor startup, a reactor scram resulted from upscale spike on two Intermediate Range Monitors (IRMs), 1C51K601A and 1C51K601B. IRM A, 1C51K601A is in Reactor Protection System Channel A and IRM B, 1C51K601B is in Reactor Protection System Channel B. All control rods fully inserted. No PCIS [Primary Containment Isolation System] actuations occurred and none were expected to occur based upon plant condition following the reactor scram.

"Investigation is in progress. Condition was not due to a true flux event.

"This event is reportable per 10 CFR 50.72(b)(2)(iv)(B) as an event or condition that resulted in actuation of the reactor protection system (RPS) when the reactor is critical except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation.

"CR 10356172

"The NRC Resident has been notified."

The reactor was at 0.5% (percent) power at the time of the event and will remain in Hot Shutdown pending the results of the root cause investigation.

SEISMIC MONITOR PANEL NON-FUNCTIONAL

"At 1306 [EDT] on April 20, 2017, Control Room Overhead Alarm C6-C4, Seismic Monitor Panel, was received. This alarm normally indicates an actuation of the Hope Creek OBE [Operational Basis Earthquake] Seismic Switch at 0.1g, however, this alarm was accompanied by no other indications of seismic activity. The indicator for a 0.01g earthquake was not actuated, no earthquake was felt on site, and the National Earthquake Information Center recorded no seismic activity in the area.

"The Seismic Monitor Panel was considered non-functional. With the Seismic Monitor Panel non-functional, the ability to classify EAL HA1.1, Operating Basis Earthquake Detected Onsite, was lost. Testing of the Seismic Monitor Panel is in progress to determine system functionality."

The licensee will notify the NRC Resident Inspector.

UNUSUAL EVENT DECLARED DUE TO HYDRAZINE IN CONTAINMENT

"At 2110 EDT, Salem control room received data that supported unacceptable levels of hydrazine concentration in the U2 Containment atmosphere based on Site Protection atmospheric sampling. The high hydrazine levels were caused due to Steam Generator [S/G] venting into the Containment atmosphere in support of maintenance for the current Salem Unit 2 Refueling Outage (2R22). The NIOSH habitability limit for hydrazine is 0.03 ppm (2 hour limit). Area samples indicated concentrations as high as 0.25 ppm. Salem Unit 2 Containment has been evacuated while a mitigation plan is being developed. There were no personnel injuries as a result of this occurrence. Salem Unit 2 defueling activities were in progress during this event. All fuel assemblies have been placed in a safe condition. All Salem Unit 2 Containment activities are currently on hold. There has been no impact to the equipment in the Unit 2 Containment, no adverse impact to any equipment located in the vicinity of the high hydrazine concentration, and no operational impact to the plant including Shutdown Cooling which is currently on RHR."

The Unusual Event was declared under EAL HU3.1, Toxic/Flammable Gas Release Affecting Plant Operations.

The licensee plans to issue a press release.

The licensee notified the NRC Resident Inspector, Lower Alloways Creek Township, State of New Jersey and State of Delaware.

Notified DHS SWO, FEMA Operations Center, DHS NICC, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).


* * * UPDATED FROM JOHN COOK TO DONALD NORWOOD AT 1305 EDT ON 4/21/2017 * * *

"Salem Unit 2 terminated the Unusual Event at 1258 EDT on 4/21/17. The basis for termination was no longer restricting access to the containment after getting two sets of satisfactory air sample results. With the access restored, normal plant operations can resume and EAL HU3.1 is no longer applicable.

"The details of the sample results are:
Fire Protection performed satisfactory results of no detectable Hydrazine (0.01 ppm with a NIOSH limit of 0.03 ppm) completed both at 1001 EDT and 1247 EDT at the following locations:
- (3) at 130 ft. elevation
- at 78 ft. in the bioshield
- at 78 ft. outside the bioshield.


"Additional mitigating actions taken following U2 Containment evacuation were as follows:
- FME screen installed on open manways for 21/23 S/G with additional plastic covering and tape to prevent further gas release into containment.
- Modified Containment Purge in service to maximize ventilation in Containment.
- 21/24 S/G draining to support filling and draining evolutions to reduce Hydrazine concentrations in the S/G's.
- Releasing tags on the AFWST to commence filling and further support filling and draining evolutions on the U2 S/G's."

The licensee notified the NRC Resident Inspector.

Notified R1DO (Arner), NRR EO (King), and IRD (Stapleton). Notified DHS SWO, FEMA Operations Center, DHS NICC, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

VALID REACTOR PROTECTION SYSTEM ACTUATION WHILE SHUTDOWN

"At 2345 [EDT] on 04/20/2017, the Unit 1 Reactor Mode Switch was taken to the Shutdown position to comply with Technical Specification 3.10.4 due to having no operable IRM's [Intermediate Range Monitors] in one quadrant of the reactor vessel as a result of maintenance activities. Placing the mode switch to Shutdown inserts a valid scram signal into the Reactor Protection System (RPS). All control rods had been previously inserted and no rod movement occurred when the mode switch was positioned to Shutdown.

"Due to this valid RPS scram, and not being a part of a preplanned evolution, this condition is reportable under criteria 50.72(b)(3)(iv)(A) as an event or condition that results in valid actuation of any of the systems listed in paragraph (b)(3)(iv)(B) of this section except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation."

The licensee notified the NRC Resident Inspector.

AGREEMENT STATE REPORT - MEDICAL EVENT DUE TO INCORRECT NUCLEAR MEDICAL SCAN PERFORMED

The following information was obtained from the state of Louisiana via email:

"[On] April 21, 2017, [the licensee's RSO] called [Louisiana Department of Environmental Quality (LDEQ)] to inquire if one of his facilities had a 'Recordable Event' or if the facility had a 'Reportable Medical Event'. The event occurred under the Ochsner Clinic Foundation Broad Scope Medical License (OCFBS), LA-0002-L01. The event involved 2 mCi of I-131 being administered as an error when the PA [Physician Assistant] was ordering a medical test/scan. The test should have been one for the parathyroid, but a thyroid scan was ordered in error in the EPIC System [health informatics software].

"[The] RSO for this licensee called in to see if the OMCBR [Ochsner Medical Center, Baton Rouge], Baton Rouge Medical Center error in administration had to be reported or just recorded for the OCFBS medical records. He was instructed it was a reportable event and he should investigate and make the appropriate corrective actions. The 2 mCi [of] I-131 was ordered and administered on [April] 18, 2017 and the error was discovered on April 20, 2017. The Nuclear Medicine Tech placed the patient on the table and the thyroid gland 'lit up' due to the I-131 uptake.

"According to [the RSO's] verbal report, the written orders were incomplete or did not exist; the parathyroid was the tissue to be scanned; and discovered on [April 20, 2017]. [The RSO] did a preliminary report on the phone April 21, 2017. His report gave an estimated target organ dose [of approximately] 600 rads to the thyroid. At that time, he stated there were additional aspects to be investigated, corrected, and reported.

"Corrective Action: The order capture procedure was changed recently and all of the Technologists, ordering Physicians, and Physician's Assistants will be re-trained in the current/new procedures. The wrong procedure was performed and the results will be sent to the referring physician. The patient was notified of the error.

"LDEQ considers this incident still open and subject to investigation and corrective action implementation."

LA Event Report ID No.: LA-170006

* * * UPDATE ON 6/8/17 AT 1515 EDT FROM JOSEPH NOBLE TO BETHANY CECERE * * *

The following information was obtained from the state of Louisiana via email:

"Investigated by LA:
Preliminary: Phone Investigation Event was discovered by the wrong organ uptake for the patient scan to be performed.
Facility findings wrong study ordered and wrong unit dose ordered and administered.
Facility request a site visit when fact can be delivered and management can be present.
Facility Investigation Visit, on 05/01/2017

"Findings:
PA ordered the unit dose without a written directive.
PA ordered the scan through the OMCBR electronic order/records system.
Patient was administered the I-131 and counselled when to return for the scan.
[Patient] returned after numerous attempts to contact [patient].
The desired scan was different from the wrong scan ordered.
At the scan time was when the ERROR was discovered.
The wrong activity was ordered and administered due to electronic ordering and records system without confirmations of orders.

"Facility Calculations: from 2.0 mCi NaI-131 unit absorbed dose. 10% to 30% uptake from 2 mCi NaI-131.
Absorbed Radiation Dose range to thyroid 1100 to 3200 rads with the thyroid gland dose approximately 1630 rads at 15.7 percent uptake from 1.65 NaI-131.
State Confirmation From FDA Prescribing Dosage for NaI-131, Table 1, Absorbed Radiation Doses.

"Corrective Actions:
'PROOF' of EPIC electronic patients records system and for ordering studies
Suspension of I-131 usage until system is corrected and staff training is complete
Training for Written Physician's orders and ordering scans
Confirming orders before administering drugs/isotopes"

NMED #170217

Notified R4DO (Rollins) and NMSS Events Notification by 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.