Event Notification Report for November 17, 2016
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/16/2016 - 11/17/2016
Agreement State
Event Number: 52389
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: INTEGRIS HEALTH
Region: 4
City: OKLAHOMA CITY State: OK
County:
License #: OK-11022-01
Agreement: Y
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: INTEGRIS HEALTH
Region: 4
City: OKLAHOMA CITY State: OK
County:
License #: OK-11022-01
Agreement: Y
Docket:
NRC Notified By: KEVIN SAMPSON
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/22/2016
Notification Time: 12:17 [ET]
Event Date: 11/17/2016
Event Time: 00:00 [CST]
Last Update Date: 11/22/2016
Notification Time: 12:17 [ET]
Event Date: 11/17/2016
Event Time: 00:00 [CST]
Last Update Date: 11/22/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - I-125 SEED LEFT INSIDE A PATIENT
"Yesterday (November 21, 2016) we [Oklahoma Department of Environmental Quality] were notified by Integris Health (OK-11022-01) that a brachytherapy seed containing 0.1 mCi of I-125 had been lost. The seed was implanted in a patient on November 14 for localization of a non-palpable breast lesion. The tissue was removed on November 17 and sent to pathology. The patient had also had a sentinel node procedure on the same day and received a dose of Tc-99. The licensee believed that the seed had been removed with the specimen. The specimen was sent to the pathology lab on November 18 and showed no radiation when surveyed there. The licensee initiated a search of their facilities at that time. The patient returned to the hospital yesterday for their post-operative evaluation, was again surveyed, and the seed was detected.
"Yesterday evening, the licensee emailed us that the seed had actually been left in the patient. We are making this notification as a possible medical event. The licensee is performing a dose calculation on the patient. Our investigation is ongoing and we will provide more information as it becomes available."
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.
"Yesterday (November 21, 2016) we [Oklahoma Department of Environmental Quality] were notified by Integris Health (OK-11022-01) that a brachytherapy seed containing 0.1 mCi of I-125 had been lost. The seed was implanted in a patient on November 14 for localization of a non-palpable breast lesion. The tissue was removed on November 17 and sent to pathology. The patient had also had a sentinel node procedure on the same day and received a dose of Tc-99. The licensee believed that the seed had been removed with the specimen. The specimen was sent to the pathology lab on November 18 and showed no radiation when surveyed there. The licensee initiated a search of their facilities at that time. The patient returned to the hospital yesterday for their post-operative evaluation, was again surveyed, and the seed was detected.
"Yesterday evening, the licensee emailed us that the seed had actually been left in the patient. We are making this notification as a possible medical event. The licensee is performing a dose calculation on the patient. Our investigation is ongoing and we will provide more information as it becomes available."
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.
Power Reactor
Event Number: 52374
Facility: FARLEY
Region: 2 State: AL
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: CHUCK BAREFIELD
HQ OPS Officer: DONALD NORWOOD
Region: 2 State: AL
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: CHUCK BAREFIELD
HQ OPS Officer: DONALD NORWOOD
Notification Date: 11/17/2016
Notification Time: 20:51 [ET]
Event Date: 11/17/2016
Event Time: 18:59 [CST]
Last Update Date: 11/17/2016
Notification Time: 20:51 [ET]
Event Date: 11/17/2016
Event Time: 18:59 [CST]
Last Update Date: 11/17/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
OMAR LOPEZ (R2DO)
OMAR LOPEZ (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 99 | Power Operation | 93 | Power Operation |
TECHNICAL SPECIFICATION REQUIRED SHUTDOWN INITIATED
"At 1859 CST on November 17, 2016, Farley Nuclear Plant Unit 1 initiated a shutdown from approximately 99 percent reactor power. The shutdown was initiated per Technical Specification LCO 3.0.3. This LCO entry was based on having no operable steam flow channels on the C loop for Farley Nuclear Plant Unit 1.
"Unit 2 as not affected.
"The NRC Resident Inspector has been notified."
"At 1859 CST on November 17, 2016, Farley Nuclear Plant Unit 1 initiated a shutdown from approximately 99 percent reactor power. The shutdown was initiated per Technical Specification LCO 3.0.3. This LCO entry was based on having no operable steam flow channels on the C loop for Farley Nuclear Plant Unit 1.
"Unit 2 as not affected.
"The NRC Resident Inspector has been notified."
Power Reactor
Event Number: 52377
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: JACOB SERENO
HQ OPS Officer: BETHANY CECERE
Region: 3 State: IL
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: JACOB SERENO
HQ OPS Officer: BETHANY CECERE
Notification Date: 11/18/2016
Notification Time: 13:40 [ET]
Event Date: 11/17/2016
Event Time: 17:00 [CST]
Last Update Date: 11/18/2016
Notification Time: 13:40 [ET]
Event Date: 11/17/2016
Event Time: 17:00 [CST]
Last Update Date: 11/18/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
HIRONORI PETERSON (R3DO)
HIRONORI PETERSON (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 |
INCORRECT METHOD USED FOR CALCULATION OF CONTROL ROOM HABITABILITY
"During the NRC CDBI [Component Design Basis Inspection], it was identified that the calculation used to demonstrate Control Room Habitability following a Design Basis Accident (DBA) utilized an inappropriate methodology. Specifically, the calculation used dual air inlets for the emergency zones as the type of system used for Main Control [Room] Ventilation (VC) system. In order to use the dual inlet type system in the analysis, each of the VC subsystems is required to be single failure proof. The VC system is single failure proof, but the individual subsystems at the inlet, as designed, are not.
"The dual inlet type system allows for certain calculated dose concentrations to be reduced by a factor of 4. Elimination of this reduction factor results in higher calculated control room dose following a DBA which exceeds the 5 Rem limit.
"This event is reportable under 10 CFR 50.72(b)(3)(ii)(B), 'Any event or condition that results in the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety.'"
A standing order has been issued for compensatory actions in the event of an emergency.
The licensee notified the NRC Resident Inspector.
"During the NRC CDBI [Component Design Basis Inspection], it was identified that the calculation used to demonstrate Control Room Habitability following a Design Basis Accident (DBA) utilized an inappropriate methodology. Specifically, the calculation used dual air inlets for the emergency zones as the type of system used for Main Control [Room] Ventilation (VC) system. In order to use the dual inlet type system in the analysis, each of the VC subsystems is required to be single failure proof. The VC system is single failure proof, but the individual subsystems at the inlet, as designed, are not.
"The dual inlet type system allows for certain calculated dose concentrations to be reduced by a factor of 4. Elimination of this reduction factor results in higher calculated control room dose following a DBA which exceeds the 5 Rem limit.
"This event is reportable under 10 CFR 50.72(b)(3)(ii)(B), 'Any event or condition that results in the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety.'"
A standing order has been issued for compensatory actions in the event of an emergency.
The licensee notified the NRC Resident Inspector.
Agreement State
Event Number: 52392
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: BIONOMICS, INC.
Region: 1
City: OAK RIDGE State: TN
County:
License #: R-73021
Agreement: Y
Docket:
NRC Notified By: MARK ANDREWS
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: BIONOMICS, INC.
Region: 1
City: OAK RIDGE State: TN
County:
License #: R-73021
Agreement: Y
Docket:
NRC Notified By: MARK ANDREWS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 11/23/2016
Notification Time: 12:11 [ET]
Event Date: 11/17/2016
Event Time: 00:00 [EST]
Last Update Date: 11/23/2016
Notification Time: 12:11 [ET]
Event Date: 11/17/2016
Event Time: 00:00 [EST]
Last Update Date: 11/23/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JAMES DWYER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
JAMES DWYER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - MISPLACED AM-241 SOURCE
The following report was received via e-mail:
"The Tennessee Division of Radiological Health was notified on November 22, 2016, of the discovery by Bionomics staff of an Americium-241 source in a shipment to Bionomics of depleted uranium counterweights. The 2 mCi source is reported to be part of an aircraft fuel gauge."
Tennessee Event: TN-16-166
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
The following report was received via e-mail:
"The Tennessee Division of Radiological Health was notified on November 22, 2016, of the discovery by Bionomics staff of an Americium-241 source in a shipment to Bionomics of depleted uranium counterweights. The 2 mCi source is reported to be part of an aircraft fuel gauge."
Tennessee Event: TN-16-166
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