United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2016 > February 16

Event Notification Report for February 16, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/12/2016 - 02/16/2016

** EVENT NUMBERS **


51709 51710 51713 51714 51730 51732 51733 51734

To top of page
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

To top of page
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.

To top of page
Agreement State Event Number: 51713
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: LARKIN COMMUNITY HOSPITAL, MIAMI NEUROSCIENCE CENTER
Region: 1
City: MIAMI State: FL
County:
License #: 2825-2
Agreement: Y
Docket:
NRC Notified By: TIM DUNN
HQ OPS Officer: DANIEL MILLS
Notification Date: 02/05/2016
Notification Time: 13:39 [ET]
Event Date: 02/04/2016
Event Time: [EST]
Last Update Date: 02/05/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN ROGGE (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - POTENTIAL MEDICAL MISADMINISTRATION

The following was received from Florida via email:

"Licensee reported a possible medical event on Feb. 4th, while performing a Gamma Knife treatment. The treatment was planned for 11 sites to receive 18 Gy, and 5 sites to receive 11 Gy. After the completion of 15 sites, the treatment was stopped to re-sedate the patient, (at this time the stereotactic frame was still in position). Two minutes after starting the final site with 11 Gy, the patient awoke and started moving significantly. The patient was instructed to stay still for the remainder of the treatment. When the patient was brought out of the device the frame was not in the original position. It is not known if the frame became dislodged during the treatment, or if it occurred when exiting the device. If movement of the frame occurred during treatment: site 16 would have received a 74.5 percent underdose of 2.8 Gy and an approximated cerebellar volume of 0.7cc was treated with 9.3 Gy. Any further investigation will be referred to Licensing and Materials."

Florida Incident # FL16-024

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
Agreement State Event Number: 51714
Rep Org: UTAH DEPT OF ENVIRONMENTAL QUALITY
Licensee: UNIVERSITY OF UTAH
Region: 4
City: SALT LAKE CITY State: UT
County:
License #:
Agreement: Y
Docket:
NRC Notified By: PHILIP GRIFFIN
HQ OPS Officer: DANIEL MILLS
Notification Date: 02/05/2016
Notification Time: 17:55 [ET]
Event Date: 02/02/2016
Event Time: [MST]
Last Update Date: 02/05/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

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

Event Text

LOST TRITIUM EXIT SIGN

The following was received from Utah via email:

"On February 2, 2016, the licensee [University of Utah] was performing a 6-month inventory of the H-3 exit signs, when the individual performing the inventory noticed that one of the licensee's signs was missing. The licensee left a message with the University's facilities management office to see if the sign was removed by them. On February 5, 2016, the licensee was informed by the management group that they had not removed the sign. The licensee then determined that the sign was missing and presumed stolen. The licensee then notified the DWMRC [Utah Department of Environmental Quality, Division of Waste Management and Radiation Control] of the missing sign. The licensee will continue to investigate the incident, and will submit a written report to the DWMRC. The DWMRC will possibly perform an investigation on February 8, 2016.

"Manufacturer: unknown (possibly Safety Lite Corporation)
"Model: unknown
"Serial #: T3478
"Possibly acquired by the licensee in 2003.
"Activity: unknown (presumed >20 Ci of H-3)"

Utah Event # UT160001

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

To top of page
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."

To top of page
Power Reactor Event Number: 51732
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: RANDALL MOORE
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 02/13/2016
Notification Time: 09:09 [ET]
Event Date: 02/13/2016
Event Time: 02:06 [CST]
Last Update Date: 02/13/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
ROBERT ORLIKOWSKI (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 99 Power Operation 99 Power Operation

Event Text

SECONDARY CONTAINMENT INOPERABLE

"On 02/13/2016 at 0206 CST, an unexpected trip of a Fuel Building ventilation exhaust fan occurred and secondary containment differential pressure became positive. Secondary containment was declared INOPERABLE when Technical Specification-required differential pressure was not being maintained and entered LCO 3.6.4.1 Action A.1

"At 0256 (CST), the standby gas treatment system was started and secondary containment differential pressure was restored to Technical Specification requirements at 0257 CST.

"This loss of secondary containment is reportable under 10 CFR 50.72(b)(3)(v)(C) as an event or condition that could have prevented fulfillment of a safety function needed to control the release of radioactive material.

"The cause of the fuel building exhaust fan trip is unknown at this time. The NRC Resident Inspector has been notified."

To top of page
Power Reactor Event Number: 51733
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: BILL HART
HQ OPS Officer: DONALD NORWOOD
Notification Date: 02/13/2016
Notification Time: 14:45 [ET]
Event Date: 02/13/2016
Event Time: 10:00 [PST]
Last Update Date: 02/13/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
NEIL OKEEFE (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 75 Power Operation 75 Power Operation

Event Text

RADWASTE BUILDING NOBLE GAS MONITOR OUT-OF-SERVICE

"On 2/10/2016 at 1000 PST, Columbia entered a planned evolution to perform channel functional tests on the RadWaste Building noble gas monitor (WEA-RIS-14). Compensatory measures were implemented per station procedures. The station is experiencing equipment issues and the monitor has not been restored within 72 hours (2/13/2016 at 1000 PST) from the start of the outage. The extended outage of this radiological monitoring instrument is, therefore, being reported as a major loss of radiological assessment capability in accordance with regulation 10 CFR 50.72(b)(3)(xiii).

"Compensatory measures will remain in place until the WEA instrument is restored.

"The NRC Resident Inspector has been notified.

"Note: Reactor Power is 75 percent due to a planned plant downpower for unrelated scheduled work with a planned return to 100 percent at 1900 PST on 2/14/16."

To top of page
Power Reactor Event Number: 51734
Facility: SALEM
Region: 1 State: NJ
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JASON MORGAN
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/14/2016
Notification Time: 23:13 [ET]
Event Date: 02/14/2016
Event Time: 20:58 [EST]
Last Update Date: 02/14/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
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
2 A/R Y 100 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP ON MAIN GENERATOR PROTECTION TRIP

"This 4-hour and 8-hour notification is being made to report that Salem Unit 2 had an unplanned automatic reactor trip. The trip occurred because the Unit 2 main generator tripped on generator protection with reactor power greater than P-9 (49%). The cause of the generator protection trip that resulted in the reactor trip is unknown at this time. A troubleshooting team is being assembled to determine the exact cause for the generator protection actuation.

"All control rods inserted on the reactor trip. All ECCS and ESF systems functioned as expected. The motor driven and steam driven auxiliary feed pumps started as expected on steam generator low level.

"Salem Unit 2 is currently in mode 3. Reactor Coolant System pressure is at 2235 psig and temperature is 547 degrees Fahrenheit with decay heat removal via the main steam dumps and auxiliary feedwater systems. Unit 2 has no active technical specification action statement in effect requiring a lower mode of operation.

"No safety related equipment or major secondary plant equipment was tagged for maintenance prior to the event. There were no personnel injuries as a result of this event."

There was no impact on Salem Unit 1.

The licensee informed the NRC Resident Inspector and will inform the Lower Alloways Creek Township (LAC).

Page Last Reviewed/Updated Tuesday, February 16, 2016
Tuesday, February 16, 2016