Event Notification Report for July 30, 2019
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/29/2019 - 07/30/2019
Power Reactor
Event Number: 54190
Facility: SOUTH TEXAS
Region: 4 State: TX
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: KEITH MINK
HQ OPS Officer: DONALD NORWOOD
Region: 4 State: TX
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: KEITH MINK
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/31/2019
Notification Time: 15:55 [ET]
Event Date: 07/30/2019
Event Time: 15:21 [CDT]
Last Update Date: 08/21/2019
Notification Time: 15:55 [ET]
Event Date: 07/30/2019
Event Time: 15:21 [CDT]
Last Update Date: 08/21/2019
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):
JEREMY GROOM (R4DO)
JEREMY GROOM (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 |
DISCOVERY OF CONDITION THAT COULD HAVE PREVENTED FULFILLMENT OF A SAFETY FUNCTION
"South Texas Project (STP) Unit 1 reactor head vent valve B1RCHCV0601 was declared inoperable on December 29, 2018, STP Unit 1 reactor head vent valve B1RCHCV0602 was declared inoperable on July 30, 2019. Technical Specification 3.3.3.5 requires one of two reactor head vent valves to be operable. This issue placed the plant in a 30-day Technical Specification Action.
"At 0741 CDT on July 31, 2019, South Texas Project Electric Generating Station (STPEGS) made a determination based on firm evidence that reactor head vent valve B1RCHCV0602 had been inoperable since June 24, 2019. This results in a condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.
"This report is being made pursuant to 10 CFR 50.72(b)(3)(v)(D), 'any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.
"The inoperable equipment is required for accident conditions and presents no danger to the health and safety of the public or the safe operation of the units.
"The NRC Resident Inspector has been notified."
* * * UPDATE FROM PAUL BURTON TO KERBY SCALES AT 1108 EDT ON 8/21/19 * * *
"The Event Date and Time provided in EN# 54190 should have been reported as 7/30/2019 at 1521 CDT, since this was the time of discovery of a condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident."
"The NRC Resident Inspector has been notified.
"Notified R4DO (Young)."
"South Texas Project (STP) Unit 1 reactor head vent valve B1RCHCV0601 was declared inoperable on December 29, 2018, STP Unit 1 reactor head vent valve B1RCHCV0602 was declared inoperable on July 30, 2019. Technical Specification 3.3.3.5 requires one of two reactor head vent valves to be operable. This issue placed the plant in a 30-day Technical Specification Action.
"At 0741 CDT on July 31, 2019, South Texas Project Electric Generating Station (STPEGS) made a determination based on firm evidence that reactor head vent valve B1RCHCV0602 had been inoperable since June 24, 2019. This results in a condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.
"This report is being made pursuant to 10 CFR 50.72(b)(3)(v)(D), 'any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.
"The inoperable equipment is required for accident conditions and presents no danger to the health and safety of the public or the safe operation of the units.
"The NRC Resident Inspector has been notified."
* * * UPDATE FROM PAUL BURTON TO KERBY SCALES AT 1108 EDT ON 8/21/19 * * *
"The Event Date and Time provided in EN# 54190 should have been reported as 7/30/2019 at 1521 CDT, since this was the time of discovery of a condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident."
"The NRC Resident Inspector has been notified.
"Notified R4DO (Young)."
Agreement State
Event Number: 54231
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: TEXAS ONCOLOGY PA
Region: 4
City: DALLAS State: TX
County:
License #: L04878
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: BETHANY CECERE
Licensee: TEXAS ONCOLOGY PA
Region: 4
City: DALLAS State: TX
County:
License #: L04878
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: BETHANY CECERE
Notification Date: 08/20/2019
Notification Time: 11:19 [ET]
Event Date: 07/30/2019
Event Time: 00:00 [CDT]
Last Update Date: 08/20/2019
Notification Time: 11:19 [ET]
Event Date: 07/30/2019
Event Time: 00:00 [CDT]
Last Update Date: 08/20/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CALE YOUNG (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
CALE YOUNG (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - INCORRECT DOSAGE ADMINISTERED
The following was received via email:
"On August 19, 2019, the Agency [Texas Department of State Health Services] was notified by the licensee's radiation safety officer (RSO) that a medical event had occurred. The event occurred on a patient who was prescribed to receive four treatments of lutetium-177 at 200 milliCuries each. After the third treatment, the physician was supposed to change the dose of the fourth and final dose to 100 milliCuries. The radiopharmaceutical was ordered, and the dose was administered. The RSO stated that during the review of the patient's treatment, they found the pharmacy had sent a unit dose of 200 milliCuries instead of the requested 100 milliCuries. The RSO stated both the prescribing physician and the patient were notified of the error. No adverse effects are expected on the patient.
"The Agency has requested additional information on this event. Additional information will be provided as it is received in accordance with SA-300."
* * * UPDATE ON 8/20/19 AT 1133 EDT FROM ART TUCKER TO BETHANY CECERE * * *
"On August 20, 2019, the licensee contacted the Agency and stated the treatment site was the mid-gut. The treatment was conducted on July 30, 2019. The error was discovered the day of the event. Additional information will be provided as it is received in accordance with SA-300."
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 email:
"On August 19, 2019, the Agency [Texas Department of State Health Services] was notified by the licensee's radiation safety officer (RSO) that a medical event had occurred. The event occurred on a patient who was prescribed to receive four treatments of lutetium-177 at 200 milliCuries each. After the third treatment, the physician was supposed to change the dose of the fourth and final dose to 100 milliCuries. The radiopharmaceutical was ordered, and the dose was administered. The RSO stated that during the review of the patient's treatment, they found the pharmacy had sent a unit dose of 200 milliCuries instead of the requested 100 milliCuries. The RSO stated both the prescribing physician and the patient were notified of the error. No adverse effects are expected on the patient.
"The Agency has requested additional information on this event. Additional information will be provided as it is received in accordance with SA-300."
* * * UPDATE ON 8/20/19 AT 1133 EDT FROM ART TUCKER TO BETHANY CECERE * * *
"On August 20, 2019, the licensee contacted the Agency and stated the treatment site was the mid-gut. The treatment was conducted on July 30, 2019. The error was discovered the day of the event. Additional information will be provided as it is received in accordance with SA-300."
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: 54188
Facility: FERMI
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: ETHAN HAUSER
HQ OPS Officer: ANDREW WAUGH
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: ETHAN HAUSER
HQ OPS Officer: ANDREW WAUGH
Notification Date: 07/30/2019
Notification Time: 15:42 [ET]
Event Date: 07/30/2019
Event Time: 10:14 [EDT]
Last Update Date: 07/30/2019
Notification Time: 15:42 [ET]
Event Date: 07/30/2019
Event Time: 10:14 [EDT]
Last Update Date: 07/30/2019
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):
RHEX EDWARDS (R3DO)
RHEX EDWARDS (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
UNPLANNED HIGH PRESSUE COOLANT INJECTION INOPERABILITY
"On July 30, 2019, at 1014 EDT, the Division 2 Mechanical Draft Cooling Tower (MDCT) Fan D was declared inoperable due to a trip of the fan while placing in it high speed. The MDCT Fans are required to support operability of the Ultimate Heat Sink (UHS). The UHS is required to support operability of the Division 2 Emergency Equipment Cooling Water (EECW) system. The EECW system cools various safety related components, including the High Pressure Coolant Injection (HPCI) system room cooler. An unplanned HPCI inoperability occurred based on a loss of the HPCI Room Cooler. Investigation revealed that a high speed breaker control power fuse had blown. The control power fuse was replaced, the MDCT Fan D was tested satisfactorily, and HPCI was declared operable at 1431 EDT. This report is being made pursuant to 10 CFR 50.72(b)(3)(v)(D) based on an unplanned HPCI inoperability."
The licensee has notified the NRC Senior Resident Inspector
"On July 30, 2019, at 1014 EDT, the Division 2 Mechanical Draft Cooling Tower (MDCT) Fan D was declared inoperable due to a trip of the fan while placing in it high speed. The MDCT Fans are required to support operability of the Ultimate Heat Sink (UHS). The UHS is required to support operability of the Division 2 Emergency Equipment Cooling Water (EECW) system. The EECW system cools various safety related components, including the High Pressure Coolant Injection (HPCI) system room cooler. An unplanned HPCI inoperability occurred based on a loss of the HPCI Room Cooler. Investigation revealed that a high speed breaker control power fuse had blown. The control power fuse was replaced, the MDCT Fan D was tested satisfactorily, and HPCI was declared operable at 1431 EDT. This report is being made pursuant to 10 CFR 50.72(b)(3)(v)(D) based on an unplanned HPCI inoperability."
The licensee has notified the NRC Senior Resident Inspector