Event Notification Report for October 14, 2015
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/13/2015 - 10/14/2015
Power Reactor
Event Number: 51473
Facility: GRAND GULF
Region: 4 State: MS
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: SEAN DUNFEE
HQ OPS Officer: JEFF ROTTON
Region: 4 State: MS
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: SEAN DUNFEE
HQ OPS Officer: JEFF ROTTON
Notification Date: 10/15/2015
Notification Time: 22:02 [ET]
Event Date: 10/14/2015
Event Time: 12:20 [CDT]
Last Update Date: 10/15/2015
Notification Time: 22:02 [ET]
Event Date: 10/14/2015
Event Time: 12:20 [CDT]
Last Update Date: 10/15/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
GEOFFREY MILLER (R4DO)
GEOFFREY MILLER (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 |
TWO CONTAINMENT ISOLATION VALVES NOT PROPERLY TESTED PER TECHNICAL SPECIFICATIONS
"At 1220 CDT on October 14, 2015, GGNS identified that in June 2013, testing of two containment isolation valves in a penetration were not tested in accordance with Technical Specification Surveillance Requirement 3.6.1.3.9. Specifically, the pressure used to demonstrate operability of the penetration did not meet the post-Extended Power Uprate expected highest Containment pressure during an accident.
"The valves were declared inoperable and isolated in accordance with Technical Specification 3.6.1.3, Primary Containment Isolation Valves (PCIVs) . Even though a reasonable assurance that the safety function could be met existed based on previous analysis and testing, the containment penetration was declared inoperable until appropriate testing could be completed to demonstrate operability. Testing of the penetration was completed at 1101 CDT on October 15, 2015 and demonstrated that both penetration valves were operable at the higher test pressure for the entire time period between June 2013 and October 15, 2015.
"In accordance with NUREG-1022, Event Reporting Guidelines 10 CFR 50.72 and 50.73, Section 3.2.7, Event or Condition that Could Have Prevented Fulfillment of a Safety Function, requires that when a signal train system is declared inoperable the condition must be reported under 10CFR 50.72(b)(3)(v)(C)."
The licensee notified the NRC Resident Inspector.
"At 1220 CDT on October 14, 2015, GGNS identified that in June 2013, testing of two containment isolation valves in a penetration were not tested in accordance with Technical Specification Surveillance Requirement 3.6.1.3.9. Specifically, the pressure used to demonstrate operability of the penetration did not meet the post-Extended Power Uprate expected highest Containment pressure during an accident.
"The valves were declared inoperable and isolated in accordance with Technical Specification 3.6.1.3, Primary Containment Isolation Valves (PCIVs) . Even though a reasonable assurance that the safety function could be met existed based on previous analysis and testing, the containment penetration was declared inoperable until appropriate testing could be completed to demonstrate operability. Testing of the penetration was completed at 1101 CDT on October 15, 2015 and demonstrated that both penetration valves were operable at the higher test pressure for the entire time period between June 2013 and October 15, 2015.
"In accordance with NUREG-1022, Event Reporting Guidelines 10 CFR 50.72 and 50.73, Section 3.2.7, Event or Condition that Could Have Prevented Fulfillment of a Safety Function, requires that when a signal train system is declared inoperable the condition must be reported under 10CFR 50.72(b)(3)(v)(C)."
The licensee notified the NRC Resident Inspector.
Agreement State
Event Number: 51470
Rep Org: COLORADO DEPT OF HEALTH
Licensee: UNIVERSITY OF COLORADO HOSPITAL
Region: 4
City: AURORA State: CO
County:
License #: CO828-01
Agreement: Y
Docket:
NRC Notified By: CARRIE ROMANCHEK
HQ OPS Officer: JEFF ROTTON
Licensee: UNIVERSITY OF COLORADO HOSPITAL
Region: 4
City: AURORA State: CO
County:
License #: CO828-01
Agreement: Y
Docket:
NRC Notified By: CARRIE ROMANCHEK
HQ OPS Officer: JEFF ROTTON
Notification Date: 10/15/2015
Notification Time: 13:55 [ET]
Event Date: 10/14/2015
Event Time: 14:30 [MDT]
Last Update Date: 10/15/2015
Notification Time: 13:55 [ET]
Event Date: 10/14/2015
Event Time: 14:30 [MDT]
Last Update Date: 10/15/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
GEOFFREY MILLER (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
GEOFFREY MILLER (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
COLORADO AGREEMENT STATE REPORT - PATIENT RECEIVED 40 PERCENT LESS THAN PRESCRIBED DOSE
The following information was provided by the State of Colorado via email:
"The [licensee] RSO reported that a patient received 40 percent less than the prescribed dose during a TheraSphere (Y-90) treatment on 10/14/2015. The exact cause is still under investigation.
"Initial written direction was for 120 Gy. However, due to unavailability of this dose the written directive was amended to 140 Gy and the dose was ordered.
"The AU [Authorized User] reported that stasis was not reached and it was believed the patient received the entire dose. The associated survey meter was reading 0 and the AU flushed the system 3 times - the meter continued to read 0. The procedure ended around 1430 MDT.
"After the procedure the AMP [Authorized Medical Physicist] reviewed the paperwork, took waste measurements and performed calculations. At this point 40 Gy was found in the waste. The RSO was notified at 1545 MDT."
At this time, it is not known if the patient has been notified.
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 provided by the State of Colorado via email:
"The [licensee] RSO reported that a patient received 40 percent less than the prescribed dose during a TheraSphere (Y-90) treatment on 10/14/2015. The exact cause is still under investigation.
"Initial written direction was for 120 Gy. However, due to unavailability of this dose the written directive was amended to 140 Gy and the dose was ordered.
"The AU [Authorized User] reported that stasis was not reached and it was believed the patient received the entire dose. The associated survey meter was reading 0 and the AU flushed the system 3 times - the meter continued to read 0. The procedure ended around 1430 MDT.
"After the procedure the AMP [Authorized Medical Physicist] reviewed the paperwork, took waste measurements and performed calculations. At this point 40 Gy was found in the waste. The RSO was notified at 1545 MDT."
At this time, it is not known if the patient has been notified.
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.