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Event Notification Report for August 31, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/30/2016 - 08/31/2016

** EVENT NUMBERS **


52193 52208 52209 52210

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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.

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Power Reactor Event Number: 52208
Facility: VOGTLE
Region: 2 State: GA
Unit: [3] [4] [ ]
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: DANIEL MICKINAC
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/30/2016
Notification Time: 16:05 [ET]
Event Date: 08/30/2016
Event Time: 11:04 [EDT]
Last Update Date: 08/30/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
JONATHAN BARTLEY (R2DO)
FFD GROUP (E-MA)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Under Construction 0 Under Construction
4 N N 0 Under Construction 0 Under Construction

Event Text

FITNESS-FOR-DUTY

A non-licensed employee supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.

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Power Reactor Event Number: 52209
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: JEONG LIM
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/30/2016
Notification Time: 18:07 [ET]
Event Date: 08/30/2016
Event Time: 09:35 [MST]
Last Update Date: 08/30/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
GREG WARNICK (R4DO)
FFD GROUP (E-MA)

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
3 N Y 100 Power Operation 100 Power Operation

Event Text

FITNESS-FOR-DUTY

A non-licensed employee supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been suspended.

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Power Reactor Event Number: 52210
Facility: WATTS BAR
Region: 2 State: TN
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: CHARLES BROESCHE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/30/2016
Notification Time: 21:49 [ET]
Event Date: 08/30/2016
Event Time: 21:20 [EDT]
Last Update Date: 08/31/2016
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
JONATHAN BARTLEY (R2DO)
CATHY HANEY (R2RA)
BRIAN McDERMOTT (NRR)
BERNARD STAPLETON (IRD)
CHRIS MILLER (NRR)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 98 Power Operation 0 Hot Standby

Event Text

NOTICE OF UNUSUAL EVENT - FIRE IN A MAIN BANK TRANSFORMER

A fault occurred on the unit 2 "B" main bank transformer resulting in an oil fire. The main turbine tripped resulting in a reactor trip. All control rods fully inserted and no safety or relief valves lifted. Decay heat is being removed via steam dumps to the main condenser and feeding steam generators with auxiliary feedwater. Electrical power is through the normal shutdown electrical lineup.

Offsite assistance was requested from the county and off duty fire brigade members.

At 2228, the fire was reported as out. Spray is continuing and a reflash watch is being set.

Unit 1 continued to operate at 100% power throughout the event.

Notified the DHS SWO, FEMA Ops Center, DHS NICC, FEMA National Watch Center (E-mail) and Nuclear SSA (E-mail).

* * * UPDATE AT 2352 EDT ON 08/30/2016 FROM MICHAEL BOTTORFF TO JEFF HERRERA * * *

"On August 30, 2016, at 2110 EDT, Watts Bar Nuclear Plant Unit 2 reactor tripped due to an electrical fault affecting the 2B Main Bank Transformer, resulting in a fire in the transformer.

"Concurrent with the reactor trip, the Auxiliary Feedwater system actuated as designed.

"All Control and Shutdown rods fully inserted. All safety systems responded as designed. The unit is currently stable in Mode 3, with decay heat removal via Auxiliary Feedwater and main steam dump systems. Unit 2 is in a normal shutdown electrical alignment.

"The fire was out at 2230 EDT. The cause of the fire is currently under investigation.

"The fire was reported at 2149 EDT. Local Fire Departments responded to the site as requested.

"The reactor trip and system actuation is being reported under 10CFR50.72(b)(3)(iv)(A) and 10CFR50.72 (b)(2)(iv)(B).

"There was no effect on WBN Unit 1.

"The NOUE was exited at 2342.

"The NRC Senior Resident Inspector has been notified."

The Licensee notified the State of Tennessee.

Notified the R2DO (Bartley), IRD MOC (Stapleton), NRR EO (Miller), DHS SWO, FEMA Ops Center, DHS NICC, FEMA National Watch Center (E-mail) and Nuclear SSA (E-mail).

Page Last Reviewed/Updated Wednesday, August 31, 2016
Wednesday, August 31, 2016