Alert

Due to a lapse in appropriations, the NRC has ceased normal operations. However, excepted and exempted activities necessary to maintain critical health and safety functions—as well as essential progress on designated critical activities, including those specified in Executive Order 14300—will continue, consistent with the OMB-Approved NRC Lapse Plan.

Event Notification Report for February 12, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/11/2016 - 02/12/2016

** EVENT NUMBERS **

Agreement State	Event Number: 51709
Rep Org: WA OFFICE OF RADIATION PROTECTION Licensee: ISORAY Region: 4 City: RICHLAND State: WA County: License #: WN-L0213-1 Agreement: Y Docket: NRC Notified By: ANINE GRUMBLES HQ OPS Officer: JEFF HERRERA	Notification Date: 02/04/2016 Notification Time: 16:47 [ET] Event Date: 02/04/2016 Event Time: [PST] Last Update Date: 02/08/2016
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): GREG PICK (R4DO) NMSS_EVENTS_NOTIFIC (EMAI) CNSC (CANADA) (FAX)

This material event contains a "Less than Cat 3 " level of radioactive material.

Event Text

AGREEMENT STATE - LOST SHIPMENT OF CS-131 BRACHYTHERAPY SEEDS

The following report was received from the Washington Department of Health, Office of Radiation Protection via email:

"[On] 2/4/16, [a common carrier] has lost track of a RAM [radioactive material] Cs-131 brachytherapy seed shipment sent to a patient near Atlanta, GA. The seeds did not reach their destination in time for the implant in a patient at a clinic approximately 1 to 1.5 hrs from Atlanta, so the customer alerted IsoRay. According to IsoRay's Radiation Safety Officer, [the common carrier] is looking for the package. [The common carrier] thinks there is a possibility that the shipment may have been mistakenly transferred from the [common carriers] plane to the US Postal Service at the air field in Atlanta. IsoRay's Radiation Safety Officer called Washington State at [approximately] 9:40 AM [EST] to report the loss. Additional information is forthcoming."

Washington Incident Number: WA-16-004

* * * UPDATE FROM ANINE GRUMBLES TO DANIEL MILLS AT 1750 EST ON 2/08/2016 * * *

The following was received from Washington via email:

"Quantity of seeds in order: 48
"Air kerma strength in micrograys per sq. meter/hr (U) - 2.02 - 2.08 = total 98 U
"Total apparent activity= 154 mCI (range from 3.17 - 3.26 mCi/seed)
"T1/2 = 9.69 days [half-life]"

Notified R4DO (O'Keefe), NMSS_EVENTS_NOTIFICATION (email), and CNSC Canada (email).

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

Agreement State	Event Number: 51710
Rep Org: KY DEPT FOR PUBLIC HEALTH & SAFETY Licensee: KINGS DAUGHTER MEDICAL CENTER Region: 1 City: ASHLAND State: KY County: License #: 202-066-26 Agreement: Y Docket: NRC Notified By: JEANNIE MERWIN HQ OPS Officer: DANIEL MILLS	Notification Date: 02/04/2016 Notification Time: 16:13 [ET] Event Date: 02/04/2016 Event Time: 15:00 [CST] Last Update Date: 02/04/2016
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JOHN ROGGE (R1DO) NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following was received from Kentucky via fax:

"KY RHB [Kentucky Radiation Health Branch] was notified via telephone by the radiation oncologist at the facility [Licensee] of a possible medical event. The medical event involved a patient treated for prostate cancer with I-125 [Iodine 125] seeds. The 30 day post-implant dosimetry determined the dose delivered to the target organ based on D90 was less than 80 percent [of prescribed dose]. The state [Kentucky] will continue to keep NRC informed of the status of the investigation."

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: 51725
Facility: LASALLE Region: 3 State: IL Unit: [1] [2] [ ] RX Type: [1] GE-5,[2] GE-5 NRC Notified By: MARK ZICKEFOOSE HQ OPS Officer: HOWIE CROUCH	Notification Date: 02/11/2016 Notification Time: 01:20 [ET] Event Date: 02/10/2016 Event Time: 22:07 [CST] Last Update Date: 02/11/2016
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION	Person (Organization): DAVID HILLS (R3DO)

Unit	SCRAM Code	RX CRIT	Initial PWR	Initial RX Mode	Current PWR	Current RX Mode
1	N	Y	91	Power Operation	91	Power Operation
2	N	Y	100	Power Operation	100	Power Operation

Event Text

SECONDARY CONTAINMENT INOPERABLE

"This report is being made pursuant to 10CFR50.72(b)(3)(v)(C), event or condition that could have prevented fulfillment of a safety function needed to control the release of radioactive material and 10CFR50.72(b)(3)(v)(D), event or condition that could have prevented fulfillment of a safety function needed to mitigate the consequences of an accident. LaSalle Station's Unit 1 and Unit 2 were in Mode 1. At 2207 [CST] [on 2/10/16], Secondary Containment Differential Pressure dropped below the Technical Specification (TS) 3.6.4.1 minimum of 0.25 inches water vacuum. The initial indications are a failure of one Unit 1 Reactor Building Exhaust Isolation Damper, which resulted in a trip of the Unit 1 Reactor Building Exhaust Fans. At 2245, Secondary Containment Differential Pressure was restored to within the TS 3.6.4.1 limits by securing and isolating the Unit 1 Reactor Building Ventilation System. Troubleshooting plans are being developed to determine cause of the damper failure and to correct the deficient condition."

The licensee has notified the NRC Resident Inspector.

Power Reactor	Event Number: 51729
Facility: PERRY Region: 3 State: OH Unit: [1] [ ] [ ] RX Type: [1] GE-6 NRC Notified By: TONY KLEDZIK HQ OPS Officer: DONALD NORWOOD	Notification Date: 02/11/2016 Notification Time: 19:38 [ET] Event Date: 02/11/2016 Event Time: 15:04 [EST] Last Update Date: 02/11/2016
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION	Person (Organization): DAVID HILLS (R3DO)

Unit	SCRAM Code	RX CRIT	Initial PWR	Initial RX Mode	Current PWR	Current RX Mode
1	N	N	0	Cold Shutdown	0	Cold Shutdown

Event Text

AUTOMATIC START OF EMERGENCY DIESEL GENERATOR AND LOSS OF SHUTDOWN COOLING

"At 1504 EST on February 11, 2016, with the plant shutdown in a forced outage, the Division 1, 4.16 Kv Safety Bus (EH11) lost power. Division 1 Shutdown Cooling was in service at the time and the Division 1 Shutdown Cooling pump A tripped. The Division 1 Emergency Diesel Generator (EDG) started and loaded EH11 as designed. However, the Emergency Service Water (ESW) A pump, which supplies cooling water to the EDG did not start. Due to the absence of cooling water to the EDG, operators took manual action to secure the Division 1 EDG. Division 2 Shutdown Cooling was operable during this transient and was subsequently started. The Division 1 Shutdown Cooling common suction isolation valve (1E12F0008) had previously been de-energized in the open position to support planned maintenance. The Division 2 Shutdown Cooling isolation valve was not affected by the loss of bus EH11. Shutdown Cooling was re-established at 1544 EST using the Division 2 Shutdown Cooling pump. Reactor coolant temperature rose from approximately 89 degrees Fahrenheit to 115 degrees Fahrenheit during the event. The cause of the loss of EH11 and subsequent failure of ESW A pump to start are currently under investigation.

"This event is being reported under 10 CFR 50.72(b)(3)(iv)(A) as a specific system actuation due to the auto start of the Division 1 EDG on a valid signal.

"The plant remains shutdown with Division 2 Shutdown Cooling in operation. The plant is in a normal electrical line up with the exception of bus EH11 being de-energized."

The licensee notified the NRC Resident Inspector.

Power Reactor	Event Number: 51730
Facility: GINNA Region: 1 State: NY Unit: [1] [ ] [ ] RX Type: [1] W-2-LP NRC Notified By: KENNETH CORL HQ OPS Officer: HOWIE CROUCH	Notification Date: 02/12/2016 Notification Time: 03:51 [ET] Event Date: 02/11/2016 Event Time: 23:05 [EST] Last Update Date: 02/12/2016
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION	Person (Organization): RAY POWELL (R1DO)

Unit	SCRAM Code	RX CRIT	Initial PWR	Initial RX Mode	Current PWR	Current RX Mode
1	N	Y	100	Power Operation	100	Power Operation

Event Text

EMERGENCY DIESEL GENERATOR AUTO-STARTED DUE TO THE LOSS OF A STATION SERVICE TRANSFORMER

"On 02/11/2016, at 2305 [EST], Ginna Station experienced a loss of Station Service Transformer 12A causing Emergency Diesel Generator 1A to automatically start due to under-voltage signals to safeguards buses 14 and 18. All plant systems responded as designed. Control room operators stabilized the plant per abnormal operating procedures. The plant is currently in a 100/0 electrical lineup [supplied by the 12B Service Station Transformer] on the off site circuit 767 with the 1A Emergency Diesel Generator secured. The loss of the station service transformer is currently under investigation.

"This is reportable as a valid system actuation that was not part of a pre-planned sequence during testing.

"The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Thursday, March 25, 2021