United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2016 > February 23

Event Notification Report for February 23, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/22/2016 - 02/23/2016

** EVENT NUMBERS **


51674 51731 51735 51749 51750

To top of page
Part 21 Event Number: 51674
Rep Org: CURTISS WRIGHT NUCLEAR DIVISION
Licensee: CURTISS WRIGHT NUCLEAR DIVISION
Region: 1
City: HUNTSVILLE State: AL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: SAMUEL BLEDSOE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 01/22/2016
Notification Time: 14:09 [ET]
Event Date: 01/21/2016
Event Time: [CST]
Last Update Date: 02/22/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
HAROLD GRAY (R1DO)
PART 21/50.55 REACT (EMAI)

Event Text

PART 21 NOTIFICATION - POTENTIAL DEFECT IN OKONITE TAPE SPLICES

The following information was obtained from Curtiss-Wright Nuclear Division via fax and email:

"This letter is issued to provide initial notification of a potential defect in Okonite Tape Splices. The potential defect is inadequate radiation testing performed by Steris/lsomedix.

"In response to NRC Information Notice 2015-12: 'Unaccounted for Error Terms Associated with the Irradiation Testing and Environmental Qualification of Important-to-Safety Components,' an investigation was performed to determine if products had radiation testing performed by Steris/lsomedix, and any impact. This investigation commenced on November 25, 2015.

"It was determined on January 21, 2016 that the qualification of Okonite Tape Splices is affected by the unaccounted for error terms discussed in Information Notice 2015-12. This product has only been provided to James A. FitzPatrick Nuclear Power Plant. This customer will be notified today.

"As a corrective action, Qualification Report PEI-TR-842900-1 will be revised to decrease the Total Integrated Dose (TID) reported by 9.6% based upon the guidance of Information Notice 2015-012. This revision will be provided to James A. FitzPatrick Nuclear Power Plant within 30 days of this notification. Notification will be provided when this corrective action is complete.

"If additional information is required, please contact me by the methods provided below or Quality Assurance Manager Tony Gill: 256-426-4558, tgill@curtisswright.com."

* * * UPDATE FROM SAMUEL BLEDSOE TO VINCE KLCO VIA FACSIMILE ON 2/22/2016 AT 1434 EDT * * *

"February 22, 2016

"To whom it may concern:

"On January 22, 2016, Curtiss-Wright Nuclear issued an initial notification letter to the Nuclear Regulatory Commission and customer James A. FitzPatrick Nuclear Power Plant concerning a potential defect in Okonite Tape Splices. The potential defect was inadequate radiation testing performed by Steris/lsomedix. As a corrective action, Qualification Report PEI-TR-842900-1 has been revised to decrease the Total Integrated Dose (TID) reported by 9.6% based upon the guidance of NRC Information Notice 2015-012: 'Unaccounted for Error Terms Associated with the Irradiation Testing and Environmental Qualification of Important-to-Safety Components.' As of this date, Qualification Report PEl-TR-842900-1, Revision C has been provided to James A. FitzPatrick Nuclear Power Plant. This letter provides the final status and closeout of the above referenced 10CFR21 notification. If you require additional details or would like to discuss further, please contact me by the methods provided below or Quality Assurance Manager Tony Gill: 256-426-4558, tgill@curtisswright.com.

"Sincerely,
Samuel Bledsoe
Engineering Manager

"Nuclear Division
Curtiss-Wright
125 West Park Loop, Huntsville, AL 35806
T: 256.924.74481 M: 256.690.78521 F: 256.722.8533"

Notified R1DO (Ferdas) and Part 21 Group via email.

To top of page
Agreement State Event Number: 51731
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: COVESTRO LLC
Region: 4
City: BAYTOWN State: TX
County:
License #: 01577
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/12/2016
Notification Time: 13:07 [ET]
Event Date: 02/11/2016
Event Time: [CST]
Last Update Date: 02/12/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL OKEEFE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - FIXED GAUGE SHUTTER FOUND IN STUCK OPEN POSITION

The following information was provided by the State of Texas via email:

"On February 12, 2016, the Agency [Texas Department of State Health Services] was notified by the licensee's radiation safety officer (RSO) that on February 11, 2016, while performing a routine inspection of a Berthold model LB 300 l nuclear gauge, they found the source shutter was stuck in the open position. Open is the normal position for the gauge shutter. The gauge contains a one millicurie (original activity, current activity 0.07 mCi.) Cobalt-60 source. The RSO stated the dose rates at and around the gauge are normal. He [the RSO] stated no individuals, including members of the general public, will be exposed to any additional radiation due to the failure. The RSO stated the manufacturer has been contacted and will be at the licensee's facility the week of February 15, 2016 to fix or replace the gauge. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I-9378

To top of page
Agreement State Event Number: 51735
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: ST JOSEPH'S HOSPITAL
Region: 1
City: ATLANTA State: GA
County:
License #: GA 296-6
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 02/15/2016
Notification Time: 08:47 [ET]
Event Date: 02/15/2016
Event Time: [EST]
Last Update Date: 02/15/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY POWELL (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

The following report was received from the State of Georgia via email:

"The following was reported to the State of Georgia on February 15, 2016.

"The patient was prepped for the delivery of doses of 18 and 21 Gy to 14 subcentimeter brain metastases with Gamma Knife stereotactic radiosurgery. The frame adapter was placed on the patient's stereotactic head frame by a Gamma Knife trained registered nurse, supervised by Authorized Medical Physicist [AMP], and Authorized User [AU]. After five of the planned 14 lesions were treated, the patient was given a break in order to use the restroom and for additional medication. During this treatment break, the AU and AMP entered the room to release the patient from the restraining device and assist [the patient] to the rest room. It was at that point that it was discovered that the restraining device was locked, but not in the correct position. The displaced distance was measured and determined to be a maximum discrepancy of 2 cm in one plane. The AMP and AU applied the displacement to the treatment plan to determine which areas were treated and which were not. It was determined that a potential misadministration had occurred.

"The RSO [Radiation Safety Officer] was notified to discuss the course of action. Following discussions with the AMP, AU, the medical director, the prescribing physician and radiation safety officer, it was decided that there was a potential medical event or misadministration as defined in 391-3-17-.05(115)(a)3 or 391-3-17-.05(115)(b).

"The cause of the event is uncertain at this time. The head restraining device should not have been able to be secured unless it was in the proper position. An investigation is ongoing and additional information is being sought.

"The patient received an unintended radiation dose to normal brain tissue, however, it was determined by the authorized user in consult with the medical physicist that little clinical effect will be demonstrated due to this inadvertent exposure. The patient, the patient's family and the patient's referring physician were informed of the event. After extensive discussions, it was agreed by all parties that the treatment would be completed to ensure that the correct dose is delivered to the remaining target areas.

"This is all the data available at the moment. A reactive inspection is currently underway and updates are soon to follow."

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
Power Reactor Event Number: 51749
Facility: LIMERICK
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: KRIS STRAUSSER
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/22/2016
Notification Time: 16:19 [ET]
Event Date: 02/22/2016
Event Time: 13:11 [EST]
Last Update Date: 02/22/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
MARC FERDAS (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

SPURIOUS ACTUATION OF ONE EMERGENCY SIREN DURING PLANNED MAINTENANCE

Limerick Generating Station Main Control Room was informed that a Limerick Emergency Preparedness Zone (EPZ) siren located in Skippack Township, Montgomery County, Pennsylvania was sounding by an off-site vendor. This notification is being made in accordance with SAF 1.9 due to a spurious actuation of Limerick Emergency Preparedness Zone (EPZ) siren.

"The alarm actuated for approximately 90 seconds following preventative maintenance.

"No actual plant emergency exists.

"All Limerick EPZ sirens remain functional; no other reportability threshold(s) have been met or exceeded."

The licensee informed State and local authorities and the NRC Resident Inspector.

To top of page
Power Reactor Event Number: 51750
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DARVIN DUTTRY
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/22/2016
Notification Time: 18:47 [ET]
Event Date: 02/22/2016
Event Time: 13:45 [EST]
Last Update Date: 02/22/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
MARC FERDAS (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 92 Power Operation 92 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

UNIT 1 SECONDARY CONTAINMENT INOPERABLE WHEN PERSONNEL OPENED BOTH ACCESS DOORS SIMULTANEOUSLY

"On February 22, 2016 at 1345 [EST]. Secondary Containment became inoperable due to failure to meet a Surveillance Requirement (SR 3.6.4.1.3) on Unit 1.

"The inoperability was caused when Unit 1 Reactor Building Airlock doors were inadvertently opened simultaneously.

"Secondary Containment was restored February 22, 2016 at 1346 when the doors were closed.

"This event is being reported under 10 CFR 50.72(b)(3)(v)(C) and per the guidance of NUREG 1022, Rev. 3 section 3.2.7 as a loss of a Safety Function. There is no redundant Susquehanna Secondary Containment system."

The licensee informed the NRC Resident Inspector.

Page Last Reviewed/Updated Tuesday, February 23, 2016
Tuesday, February 23, 2016