United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2015 > November 2

Event Notification Report for November 2, 2015

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/30/2015 - 11/02/2015

** EVENT NUMBERS **


51394 51493 51508 51509

To top of page
Part 21 Event Number: 51394
Rep Org: EMERSON PROCESS MANAGEMENT
Licensee: EMERSON PROCESS MANAGEMENT
Region: 3
City: MARSHALLTOWN State: IA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: GEORGE BAILINGER
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/15/2015
Notification Time: 07:12 [ET]
Event Date: 07/16/2015
Event Time: [CDT]
Last Update Date: 10/30/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
SILAS KENNEDY (R1DO)
BINOY DESAI (R2DO)
KENNETH RIEMER (R3DO)
THOMAS FARNHOLTZ (R4DO)
PART 21/50.55 REACT (EMAI)

Event Text

INTERIM PART 21 REPORT - ACTUATOR FAIL MODE DEVIATION AND POTENTIAL NON-CONSERVATIVE ACTUATOR SIZING

The following information was received via fax:

"Pursuant to 10 CFR 21.21(a)(2), Fisher Controls International LLC ('Fisher') is providing required written interim notification of a deviation or failure to comply in product shipped to the Krsko Nuclear Station ('Krsko') located in Slovenia.

"On July 16, 2015, Fisher became aware of an issue with an actuator fail mode for an 8 [inch] 2052- Control Disc valve, Serial Number 19443837. The affected valve was supplied in a 'Fail Closed' configuration rather than the desired 'Fail Open' configuration. Fisher has corrected the configuration and retested the affected valve at the Krsko site. Krsko has since accepted the valve for installation.

"During the investigation, it was also noted there was an increase in one of the sizing factors for the valve that may have led to a non-conservative actuator sizing for this and other valves provided to this Krsko site. Fisher is currently performing an extent-of-condition review of safety-related rotary orders in order to confirm that correct orientations and actuator sizing were provided. Any identified deficiencies will be reported per the requirements of 10 CFR21.21(b). This review is expected to be completed by October 23, 2015. Additionally, all current safety related rotary orders in-house are being reviewed prior to shipment. This notice affects only rotary valves with Fisher factory mounted actuators.

"Corrective Action CAR 1756 has been opened to document corrective actions taken to prevent reoccurrence.

"Should there be any further questions concerning this matter, please contact Benjamin Ahrens, Manager, Quality by email at Benjamin.Ahrens@Emerson.com or via phone at 641-754-2249."

* * * UPDATE FROM GEORGE BAILINGER (VIA FAX) AT 1634 EDT ON 10/30/15 * * *

As excerpted from the fax:

"Extent of condition investigations into both issues have determined that no additional valve configurations have shipped with these deficiencies."

Fisher issued Fisher Information Notice 2015-02 pertaining to the particulars of this event.

Notified R1DO (Cahill), R2DO (Bonser), R3DO (Duncan) and R4DO (Okeefe). NRR/NRO Part 21 group was notified via email.

To top of page
Agreement State Event Number: 51493
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: VILLE PLATTE MEDICAL CENTER, LLC
Region: 4
City: VILLE PLATTE State: LA
County:
License #: LA-2956-L01,
Agreement: Y
Docket:
NRC Notified By: JOE NOBLE
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/23/2015
Notification Time: 13:06 [ET]
Event Date: 10/16/2015
Event Time: 12:00 [CDT]
Last Update Date: 10/23/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - PATIENT DOSED WITH WRONG ORGAN UPTAKE TAG

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

"On October 19, 2015, the Radiology/Nuclear Medicine Manager, reported that on October 16, 2015 at 1200 hours, a PRN Licensed Nuclear Medicine Tech inadvertently dosed a patient with 25 mCi of Tc-99-MDP. The error was detected shortly after administration. The patient had physician's orders to have a cardiac scan utilizing 25 mCi of Tc-99-Tetrofosmin. The isotope activity was correct. However, the organ uptake tag was incorrect.

"The error resulted from the Nuclear Medicine Tech not using the patient two identifiers before administering the unit dose. The activity was correct for the unit dose, but the organ uptake tag was different.

"The facility employees were off and a PRN Tech was filling-in on that Friday. This Tech is used at the facility frequently when an essential employee is absent. He is no stranger to the work environment of the Facility/Licensee.

"The source was a 25 mCi Tc-99 unit dose. He performed the receipt procedures, unit dose assay, and utilized procedures to administer the isotope, but did not cross-reference the name on the unit dose with the individual who received the injection.

"This site is a Medical Institution. The unit doses are kept in a locked 'HOT' lab in the Nuclear Medicine Department. KLS Physics Consultants was called in the help with the reporting requirements.

"The Tech was counselled and retrained in the facility's procedures for patient identification and administration of radioactive materials for human in vivo imaging.

"The patient will receive the correct unit dose and scan, 25 mCi Tc-99-Tetrofosmin, for a cardiac scan at a later date."

Event Report ID No.: LA-150018, T166800

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.

To top of page
Research Reactor Event Number: 51508
Facility: TEXAS A&M UNIVERSITY
RX Type: 1000 KW TRIGA (CONVERSION)
Comments:
Region: 0
City: COLLEGE STATION State: TX
County: BRAZOS
License #: R-83
Agreement: Y
Docket: 05000128
NRC Notified By: SEAN MCDEAVITT
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/30/2015
Notification Time: 13:53 [ET]
Event Date: 10/30/2015
Event Time: 12:42 [CDT]
Last Update Date: 10/30/2015
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
ALLEN HOWE (NRR)
JENNIFER UHLE (NRR)
WILLIAM GOTT (IRD)
AL ADAMS (NRR)
DUANE HARDESTY (NRR)

Event Text

NOTIFICATION OF UNUSUAL EVENT DUE TO A TORNADO WARNING ON TEXAS A&M CAMPUS

At 1250 CDT, a Notification of Unusual Event was declared at the Texas A&M Nuclear Science Center due to a tornado warning on the Texas A&M Campus. The reactor was secured and Science Center staff were evacuated to their designated tornado shelter in the facility. There is no risk to public health and safety.

The tornado warning is in effect until 1345 CDT.

* * * UPDATE FROM JERRY NEWHOUSE TO HOWIE CROUCH AT 1735 EDT ON 10/30/15 * * *

At 1342 CDT, the tornado warning was terminated. The licensee conducted a facility walkdown and did not observe any damage to the facility. At 1400 CDT, the Notification of Unusual Event was terminated. The licensee notified their NRC Project Manager (Hardesty).

Notified NRR (Reed), NRR EO (Howe), IRD (Gott), DHS SWO, FEMA Ops, DHS NICC, Nuclear SSA (email) and FEMA Watch Center (email).

To top of page
Power Reactor Event Number: 51509
Facility: DRESDEN
Region: 3 State: IL
Unit: [ ] [2] [3]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: MICHAEL CIKO
HQ OPS Officer: HOWIE CROUCH
Notification Date: 10/30/2015
Notification Time: 17:38 [ET]
Event Date: 10/30/2015
Event Time: 14:29 [CDT]
Last Update Date: 10/30/2015
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
ERIC DUNCAN (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 89 Power Operation 89 Power Operation
3 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION DUE TO LOST OF LIFT STATION POWER

"At 1429 CDT, Dresden Nuclear Power Station (DNPS) notified the Illinois Environmental Protection Agency (IEPA) of an upset condition involving the loss of power to the DNPS lift station. The lift station power was lost at approximately 1350 CDT, and in response, DNPS entered abnormal operating procedures to limit hot canal levels. Power was restored to the lift station at approximately 1500 CDT. There was no impact to the health and safety of the public or to the environment.

"The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Monday, November 02, 2015
Monday, November 02, 2015