Event Notification Report for April 25, 2017
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/24/2017 - 04/25/2017
EVENT NUMBERS
52709527055270652707
Agreement State
Event Number: 52709
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: THOMAS JEFFERSON UNIVERSITY HOSPITAL
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0130
Agreement: Y
Docket:
NRC Notified By: JOE MELNIC
HQ OPS Officer: HOWIE CROUCH
Licensee: THOMAS JEFFERSON UNIVERSITY HOSPITAL
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0130
Agreement: Y
Docket:
NRC Notified By: JOE MELNIC
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/26/2017
Notification Time: 13:44 [ET]
Event Date: 04/25/2017
Event Time: 00:00 [EDT]
Last Update Date: 04/26/2017
Notification Time: 13:44 [ET]
Event Date: 04/25/2017
Event Time: 00:00 [EDT]
Last Update Date: 04/26/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RAY MCKINLEY (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
RAY MCKINLEY (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)
AGREEMENT STATE REPORT - MEDICAL EVENT DUE TO UNDERDOSE OF YITTRIUM-90 THERASPHERES
The following information was obtained from the Commonwealth of Pennsylvania via fax:
"Event Description: The event involved a patient who was scheduled to be treated with 11.87 mCi of Y-90 microspheres (TheraSphere), but only received an estimated 5.07 mCi, or 43% of the prescribed dose. The licensee reported the event to the Department [Pennsylvania Department of Environmental Protection] on April 25, 2017. Initial indication is that there was a faulty connection on the catheter line that allowed a leak to occur. The patient and referring physician were notified the day of the procedure. No Jefferson personnel skin contamination occurred. However, gloves, drapes and the patient's skin were contaminated. The patient was quickly decontaminated with alcohol wipes. All remaining areas were also decontaminated. A skin calculation is currently being completed by the licensee to determine the patient's exposure, if any. No overexposure is believed to have occurred.
"Cause of the Event: Unknown at this time. Suspected human error.
"Actions: The Department will perform a reactive inspection. The licensee will update their procedure to include additional checks of the Y-90 administration kit. More information will be provided upon receipt."
PA Event Report ID No.: PA170009
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 obtained from the Commonwealth of Pennsylvania via fax:
"Event Description: The event involved a patient who was scheduled to be treated with 11.87 mCi of Y-90 microspheres (TheraSphere), but only received an estimated 5.07 mCi, or 43% of the prescribed dose. The licensee reported the event to the Department [Pennsylvania Department of Environmental Protection] on April 25, 2017. Initial indication is that there was a faulty connection on the catheter line that allowed a leak to occur. The patient and referring physician were notified the day of the procedure. No Jefferson personnel skin contamination occurred. However, gloves, drapes and the patient's skin were contaminated. The patient was quickly decontaminated with alcohol wipes. All remaining areas were also decontaminated. A skin calculation is currently being completed by the licensee to determine the patient's exposure, if any. No overexposure is believed to have occurred.
"Cause of the Event: Unknown at this time. Suspected human error.
"Actions: The Department will perform a reactive inspection. The licensee will update their procedure to include additional checks of the Y-90 administration kit. More information will be provided upon receipt."
PA Event Report ID No.: PA170009
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: 52705
Facility: SUMMER
Region: 2 State: SC
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-AP1000,[3] W-AP1000
NRC Notified By: BRUCE BENNETT
HQ OPS Officer: MARK ABRAMOVITZ
Region: 2 State: SC
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-AP1000,[3] W-AP1000
NRC Notified By: BRUCE BENNETT
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/25/2017
Notification Time: 14:53 [ET]
Event Date: 04/25/2017
Event Time: 09:00 [EDT]
Last Update Date: 04/25/2017
Notification Time: 14:53 [ET]
Event Date: 04/25/2017
Event Time: 09:00 [EDT]
Last Update Date: 04/25/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ANTHONY MASTERS (R2DO)
ANTHONY MASTERS (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Defueled | 0 | Defueled |
FUEL HANDLING BRIDGE RADIATION MONITOR OUT OF SERVICE
"On April 25, 2017 at approximately 0900 [EDT], it was identified that power to RM-G8 Area Gamma Radiation Monitor for the Fuel Handling Building Bridge, had not been restored within 72 hours. RM-G8 was de-energized during the B train essential bus outage and was restored on April 25, 2017 at 1148. It was out of service for approximately 92 hours. Compensatory measures were in place per HPP-904 while RM-G8 was out of service.
"RM-G8 is identified in the emergency plan as an equipment important to emergency response. NUREG-1022, Rev. 3 Supplement 1 Event Report Guidelines 10 CFR 50.72(b)(3)(xiii), allows a 72 hour planned outage time to restore equipment important to emergency response.
"Since RM-G8 was not restored in 72 hours, it is reportable as an 8 hour ENS.
"This event should have been reported when it was known that the 72 hour outage time was not going to be met. This issue has been entered in the station's corrective action program."
Fuel inspections were occurring during this time with compensatory measures in place.
The licensee notified the NRC Resident Inspector.
"On April 25, 2017 at approximately 0900 [EDT], it was identified that power to RM-G8 Area Gamma Radiation Monitor for the Fuel Handling Building Bridge, had not been restored within 72 hours. RM-G8 was de-energized during the B train essential bus outage and was restored on April 25, 2017 at 1148. It was out of service for approximately 92 hours. Compensatory measures were in place per HPP-904 while RM-G8 was out of service.
"RM-G8 is identified in the emergency plan as an equipment important to emergency response. NUREG-1022, Rev. 3 Supplement 1 Event Report Guidelines 10 CFR 50.72(b)(3)(xiii), allows a 72 hour planned outage time to restore equipment important to emergency response.
"Since RM-G8 was not restored in 72 hours, it is reportable as an 8 hour ENS.
"This event should have been reported when it was known that the 72 hour outage time was not going to be met. This issue has been entered in the station's corrective action program."
Fuel inspections were occurring during this time with compensatory measures in place.
The licensee notified the NRC Resident Inspector.
Agreement State
Event Number: 52706
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: EQUISTAR CHEMICAL LP
Region: 4
City: PASADENA State: TX
County:
License #: 01854
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: EQUISTAR CHEMICAL LP
Region: 4
City: PASADENA State: TX
County:
License #: 01854
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/25/2017
Notification Time: 15:45 [ET]
Event Date: 04/25/2017
Event Time: 00:00 [CDT]
Last Update Date: 04/25/2017
Notification Time: 15:45 [ET]
Event Date: 04/25/2017
Event Time: 00:00 [CDT]
Last Update Date: 04/25/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - FIXED NUCLEAR GAUGE STUCK SHUTTER
The following report was submitted via e-mail:
"On April 25, 2017, the Agency [Texas Department of State Health Services] was contacted by a licensee to report that a gauge would not close during a preventive maintenance check and the shutter is stuck. The gauge is an Ohmart SH-F1A, serial number 6228GK, containing a 50 mCi Cs-137 source. The shutter is stuck in the normal [open] operating position. The licensee is in contact with the manufacturer for a repair plan and with licensing for an exemption to operate the gauge temporarily with a stuck shutter. No exposures to the public are expected."
Texas Incident: I-9480
The following report was submitted via e-mail:
"On April 25, 2017, the Agency [Texas Department of State Health Services] was contacted by a licensee to report that a gauge would not close during a preventive maintenance check and the shutter is stuck. The gauge is an Ohmart SH-F1A, serial number 6228GK, containing a 50 mCi Cs-137 source. The shutter is stuck in the normal [open] operating position. The licensee is in contact with the manufacturer for a repair plan and with licensing for an exemption to operate the gauge temporarily with a stuck shutter. No exposures to the public are expected."
Texas Incident: I-9480
Power Reactor
Event Number: 52707
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [2] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: MATTHEW SLOUKA
HQ OPS Officer: MARK ABRAMOVITZ
Region: 2 State: AL
Unit: [1] [2] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: MATTHEW SLOUKA
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/25/2017
Notification Time: 17:53 [ET]
Event Date: 04/25/2017
Event Time: 16:30 [CDT]
Last Update Date: 04/25/2017
Notification Time: 17:53 [ET]
Event Date: 04/25/2017
Event Time: 16:30 [CDT]
Last Update Date: 04/25/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
ANTHONY MASTERS (R2DO)
ANTHONY MASTERS (R2DO)
| 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 |
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
ENGINEERING RE-EVALUATION OF TORNADO IMPACTS
"Following engineering evaluation of tornado missile protection, the Emergency Diesel Generator (EDG) 7 day tank vent piping is subject to potential damage for EDGs D, 3A, 3B, 3C, and 3D. In the event that a tornado missile impact occurs on the aforementioned ventilation piping, there is a possibility that the vent lines could crimp. This could prevent the tanks from venting and would inhibit the transfer of fuel oil from the 7 day tank to the associated EDG. As a result, EDGs D, 3A, 3B, 3C, and 3D are inoperable for tornado missile protection and the Tech Spec actions cannot be met.
"These conditions are reportable IAW 10CFR50.72(b)(3)(ii)(B) for any event or condition that results in the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety.
"This issue is being addressed IAW EGM 15-002, Revision 1, Enforcement Discretion for Tornado-Generated Missile Protection Noncompliance.
"The NRC Resident Inspector has been notified."
"Following engineering evaluation of tornado missile protection, the Emergency Diesel Generator (EDG) 7 day tank vent piping is subject to potential damage for EDGs D, 3A, 3B, 3C, and 3D. In the event that a tornado missile impact occurs on the aforementioned ventilation piping, there is a possibility that the vent lines could crimp. This could prevent the tanks from venting and would inhibit the transfer of fuel oil from the 7 day tank to the associated EDG. As a result, EDGs D, 3A, 3B, 3C, and 3D are inoperable for tornado missile protection and the Tech Spec actions cannot be met.
"These conditions are reportable IAW 10CFR50.72(b)(3)(ii)(B) for any event or condition that results in the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety.
"This issue is being addressed IAW EGM 15-002, Revision 1, Enforcement Discretion for Tornado-Generated Missile Protection Noncompliance.
"The NRC Resident Inspector has been notified."