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Event Notification Report for May 6, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/05/2016 - 05/06/2016

** EVENT NUMBERS **


51888 51890 51908 51910

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Non-Agreement State Event Number: 51888
Rep Org: SPECTRUM HEALTH
Licensee: SPECTRUM HEALTH
Region: 3
City: GRAND RAPIDS State: MI
County:
License #: 21-00243-06
Agreement: N
Docket:
NRC Notified By: EVAN BOOTE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/27/2016
Notification Time: 17:09 [ET]
Event Date: 04/27/2016
Event Time: 14:05 [EDT]
Last Update Date: 04/27/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(2) - DOSE > SPECIFIED EFF LIMITS
Person (Organization):
ANN MARIE STONE (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

MEDICAL EVENT - DOSE GIVEN TO INCORRECT SEGMENT OF THE LIVER

During a Y-90 TheraSphere treatment (hepatocellular carcinoma) to the right lobe of the liver segments 5, 6, 7, and 8 (estimated volume of 1290 ml), the catheter moved and the dose was actually given to medial segment 4 (estimated volume of 330 ml). The prescribed dose was 120 Gy (3.3 GBq) and the delivered dose was approximately 118.5 Gy as determined by bremmstrahlung imaging. Segment 4 was previously treated and there was some residual cancer at this location. This dose is not expected to have detrimental effects on the patient.

It is anticipated that segments 5,6,7,8 will be treated at some future time.

The patient has been notified and the prescribing physician will be 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.

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Agreement State Event Number: 51890
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: ASARCO, THE MISSION UNIT
Region: 4
City: SAHARITA State: AZ
County:
License #: AZ 10-017
Agreement: Y
Docket:
NRC Notified By: BRIAN GORETZKI
HQ OPS Officer: BETHANY CECERE
Notification Date: 04/28/2016
Notification Time: 12:49 [ET]
Event Date: 04/23/2016
Event Time: [MST]
Last Update Date: 04/28/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEREMY GROOM (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)
ANGELA MCINTOSH (NMSS)

Event Text

AGREEMENT STATE REPORT - EMPLOYEES POTENTIALLY EXPOSED TO RADIATION

The following was received via email from Arizona:

"On April 26th, the Agency [Arizona Radiation Regulatory Agency] was contacted by the licensee who indicated that seventeen employees had been exposed to ionizing radiation by a nuclear gauge while working on Crusher Number Three. The nuclear gauge was mounted on the shoot above the crusher. The workers involved worked in the area of concern from Saturday April 23rd until Tuesday April 26th, when the Radiation Safety Officer was notified of the incident.

"The gauge involved is used for level detection in the shoot and contains 150 millicuries of Cesium-137. Radiation levels in the work area have yet to be determined.

"The investigation into this event is ongoing.

"The U.S. NRC and Arizona Governor's office are being notified of this event."

Arizona Incident number 16-006.

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Power Reactor Event Number: 51908
Facility: POINT BEACH
Region: 3 State: WI
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: RYAN RODE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/05/2016
Notification Time: 11:36 [ET]
Event Date: 05/04/2016
Event Time: 14:00 [CDT]
Last Update Date: 05/05/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
NICK VALOS (R3DO)
FITNESS FOR DUTY GRO (EMAI)

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

FITNESS FOR DUTY POLICY VIOLATION

"An individual failed to comply with the NextEra Energy fitness-for-duty policy during a follow-up fitness-for-duty test. The individual's access to the plant has been terminated. This is reportable under 10 CFR 26.719(b)(2)(ii).

"The licensee has notified the NRC Resident Inspector."

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Power Reactor Event Number: 51910
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [ ] [ ]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: DAVID HECKMAN
HQ OPS Officer: BETHANY CECERE
Notification Date: 05/05/2016
Notification Time: 15:39 [ET]
Event Date: 05/05/2016
Event Time: 05:00 [MST]
Last Update Date: 05/05/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
JOHN KRAMER (R4DO)

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

Event Text

HIGH PRESSURE SAFETY INJECTION VALVE BONNET LEAKAGE IDENTIFIED DURING REFUELING OUTAGE

"The following event description is based on information currently available. If through subsequent reviews of this event additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS or under the reporting requirements of 10 CFR 50.73.

"At 0500 MST on May 5, 2016, engineering personnel determined that leakage from the bonnet seal weld of the Train B High Pressure Safety Injection (HPSI) system loop 2A injection valve, SIBUV0616, constituted reactor coolant system pressure boundary leakage. This is being reported as a degradation of a principal safety barrier pursuant to 10 CFR 50.72(b)(3)(ii)(A).

"The leak was identified during a planned activity in which Operations was filling the refueling pool using HPSI pump B. Leakage was stopped when a plant operator closed SIBUV0616.

"PVNGS Unit 1 was shut down for its 19th refueling outage (1R19) on April 9, 2016, at 0000 MST and is in Mode 6.

"The NRC Resident Inspectors have been informed of this condition."

Page Last Reviewed/Updated Friday, May 06, 2016
Friday, May 06, 2016