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Event Notification Report for August 30, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/29/2016 - 08/30/2016

** EVENT NUMBERS **


52056 52148 52193

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 52056
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: PAUL GALLANT
HQ OPS Officer: JEFF HERRERA
Notification Date: 06/30/2016
Notification Time: 18:19 [ET]
Event Date: 06/30/2016
Event Time: 14:30 [EDT]
Last Update Date: 08/29/2016
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):
HAROLD GRAY (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

BOTH PRIMARY CONTAINMENT ISOLATION VALVES FOR A PENETRATION POTENTIALLY INOPERABLE

"On June 30, 2016 at 1430 [EDT], with the reactor at 100 [percent] and the mode switch in RUN, Pilgrim Station determined both Primary Containment Isolation Valves (PCIVs) CV-5065-91 and CV-5065-92 for Drywell Penetration X-32A were inoperable due to the potential failure of relays relied on to perform the primary containment isolation function.

"The valves have been closed and deactivated in the isolated condition in accordance with Technical Specification Limiting Condition For Operation Action Statement 3.7.A.2.b.

"Preparations are in progress to replace the relays to restore the valves to operable status.

"This 8-hour notification is being made in accordance with 10 CFR 50.72 (b)(3)(v)(C) and 10 CFR 50.72 (b)(3)(v)(D).

"The licensee has notified the NRC Senior Resident Inspector.

"The licensee will notify the Commonwealth of Massachusetts."


* * * RETRACTION FROM KEN GRACIA TO DONALD NORWOOD AT 1720 EDT ON 8/29/2016 * * *

"This notification is being made to retract event notification EN 52056 made by Pilgrim Nuclear Power Station on June 30, 2016, that reported the potential failure of relays that could have prevented the fulfillment of the safety function of primary containment isolation valves (PCIVs) needed to control the release of radioactive material and mitigate the consequences of an accident.

"Post replacement testing of the removed relays associated with PCIV CV-5065-91 and CV-5065-92 demonstrated the ability of these relays to perform the required safety function. Based on the test results, no loss of PCIS safety function occurred while the relays were physically installed and operating. Therefore, Event Number 52056, made on June 30, 2016, is being retracted.

"The NRC Senior Resident Inspector has been notified."

Notified R1DO (Powell).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 52148
Facility: BYRON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: PAT COMERFORD
HQ OPS Officer: DANIEL MILLS
Notification Date: 08/02/2016
Notification Time: 17:55 [ET]
Event Date: 08/02/2016
Event Time: 09:34 [CDT]
Last Update Date: 08/29/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
RICHARD SKOKOWSKI (R3DO)

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

WATERTIGHT DOOR DISCOVERED OPEN AND UNATTENDED

"On August 2, 2016 at 0934 CDT, Byron Operators entered and exited 1BOL 8.1 Conditions B and F for the 1A and 1B Diesel Generators due to 0DSSD192 (1B DOST Watertight Door) being discovered open and unattended. 0DSSD192 was closed within 5 minutes of discovery.

"0DSSD192 protects the DOST [diesel oil storage tank] transfer pumps from the effects of a postulated failure of a Circulating Water expansion joint at the condenser waterboxes in the Turbine Building. An open watertight door associated with one DOST has the potential of making both Diesel Generators inoperable.

"This event is reportable per 10 CFR 50.72(b)(3)(v)(D) for any event or condition that could have prevented fulfillment of a safety function of structures or systems that are needed to mitigate the consequences of an accident.

"The licensee has notified the NRC Resident Inspector."


* * * RETRACTION FROM SHANE HARVEY TO DONALD NORWOOD AT 1627 EDT ON 8/29/2016 * * *

"The purpose of this report is to retract a previous report made on August 2, 2016 at 1755 EDT (EN 52148). Notification of the event to the NRC was initially made for a condition where the station determined that an open watertight door associated with one DOST [Diesel Oil Storage Tank] had the potential to make both Diesel Generators inoperable, and the condition was reported under 10 CFR 50.72(b)(3)(v)(D) for any event or condition that could have prevented fulfillment of a safety function of structures or systems that are needed to mitigate the consequences of an accident.

"Upon further investigation, Byron Station has concluded that the 1A Diesel Generator was never inoperable, and therefore, no loss of safety function occurred. Based on this, the prior ENS notification is being retracted.

"The NRC Senior Resident Inspector has been notified."

Notified R3DO (Dickson).

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Agreement State Event Number: 52193
Rep Org: COLORADO DEPT OF HEALTH
Licensee: ST. MARY'S HOSPITAL AND MEDICAL CENTER
Region: 4
City: GRAND JUNCTION State: CO
County:
License #: CO 014-03
Agreement: Y
Docket:
NRC Notified By: DEREK BAILEY
HQ OPS Officer: JEFF HERRERA
Notification Date: 08/22/2016
Notification Time: 16:59 [ET]
Event Date: 07/13/2016
Event Time: [MDT]
Last Update Date: 08/22/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY KELLAR (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MISADMINISTRATION DURING A THYROID ABLATION PROCEDURE

The following was reported by the Colorado Department of Health Radioactive Materials Unit via email:

"CDPHE [Colorado Department of Public Health and Environment] became aware of the misadministration on the morning of Monday August 22, 2016. The event was reported to CDPHE on Friday August 19, 2016 at approximately 1630 [CDT] via a message that was left on an office voicemail inbox.

"The misadministration occurred during a thyroid ablation procedure on July 13, 2016. The prescribed dose was 75 milliCuries of I-131, and 78 milliCuries was delivered to the patient. The patient became aware that she was pregnant at the time of the procedure and notified St. Mary's Hospital and Medical Center on Tuesday, August 16, 2016. The gestation at time of procedure was estimated to be 9 days post conception. The Hospital's RSO reported an estimated dose to fetus of approximately 20 centiGray.

"The patient was given a pregnancy test prior to the procedure and the test results were negative. The licensee is claiming the misadministration was a result of patient non-compliance because the patient was instructed not to have sexual contact prior to the procedure. A written report from the licensee is pending; and will be followed-up by a formal investigation."

Colorado Event Identification Number: CO16-I16-17

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.

Page Last Reviewed/Updated Tuesday, August 30, 2016
Tuesday, August 30, 2016