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Event Notification Report for January 3, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/30/2016 - 01/03/2017

** EVENT NUMBERS **


52457 52459 52460 52465 52468 52469 52471 52472

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Agreement State Event Number: 52457
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSITY OF PENNSYLVANIA
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 12/22/2016
Notification Time: 12:46 [ET]
Event Date: 12/20/2016
Event Time: [EST]
Last Update Date: 12/22/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES NOGGLE (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following report was received via fax:

"On December 20, 2016, a leak occurred during an administration of Yttrium-90 (Y-90) TheraSpheres to a patient, resulting in less than 80% of the prescribed dosage being administered. A total of about 8.99 millicurie of Y-90 activity was administered; or 34.6% of the prescribed 25.95 mCi activity. The prescribed dose was 17,470 rad (174.7 gray), with the leak resulting in a dose to the patient's liver of about 6,040 rad (60.4 Gy). The leak also caused contamination of the administration area, which was immediately and successfully decontaminated. As an under-dose, no immediate harmful effect to the patient resulted from the event. The referring physician and patient were made aware of the event during the procedure."

Pennsylvania event: PA-160040

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: 52459
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: WESTROCK TEXAS LP
Region: 4
City: SILSBEE State: TX
County:
License #: 01095
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 12/23/2016
Notification Time: 15:00 [ET]
Event Date: 12/23/2016
Event Time: [CST]
Last Update Date: 12/23/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

This material event contains a "Less than Cat 3 " level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LEAKING KRYPTON-85 SOURCE

The following report was received via e-mail:

"On November 17, 2016 the Agency [Texas Department of State Health Services] received notice from a service company that it had a gauge which appeared to have leaked the radioactive material. The gauge potentially leaked Krypton-85 gas because the device failed to operate normally. The device activity did not produce acceptable measurements and was removed from service/operation. The device was removed from service by the service company and set into a storage area and labeled to prevent movement. The licensee made arrangements for the manufacturer to service the gauge stating to the Agency [Texas Department of State Health Services] that it would take the manufacturer three weeks before it could schedule a visit to the plant site. The manufacturer must confirm that Kr-85 indeed did leak from the gauge.

"Device information provided included by the licensee:
Manufacturer - Valmet/Metso,
Gauge model - BMW2,
Gauge S/N - 50048138,
Isotope - Kr-85,
Activity - 400mCi,
Source S/N - QA00168.

"On December 23, 2016, the licensee verbally confirmed the device had leaked the Kr-85 gas. The manufacturer will be providing a service description and details of how the device was checked and or repaired. Awaiting the service report from the manufacture."

The seam on the source capsule had ruptured.

Texas incident: I-9442

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

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Agreement State Event Number: 52460
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: REGENTS OF THE UNIVERSITY OF CALIFORNIA, LOS ANGELES
Region: 4
City: LOS ANGELES State: CA
County:
License #: 1335-19
Agreement: Y
Docket:
NRC Notified By: K. HARKNESS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 12/23/2016
Notification Time: 16:30 [ET]
Event Date: 12/22/2016
Event Time: [PST]
Last Update Date: 12/23/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL UNDERSOSE

The following report was received via e-mail:

"On December 22, 2016, UCLA's alternate RSO for UCLA sent an e-mail to an RHB ICE inspector for the Radiologic Health Branch [RHB] to report a medical event, per 10 CFR 35.3045.

"A patient with metastatic sarcoma of the liver was treated by an authorized user at the medical center with Sirtex SIR-spheres containing yttrium-90 (Y-90) on December 22, 2016. A post treatment dose assessment was completed by radiation safety personnel. The authorized user prescribed 0.2 GBq (5.49 mCi) of Y-90 SIR-spheres to the left lobe of the patient's liver, but only 4.07 mCi or 74.1% was delivered. This underdose of 25.9 % caused a medical event to be reported. The patient was also treated with Y-90 SIR-spheres to the right lobe of the liver in compliance with the physician's written directive. The patient was notified by the physician and UCLA's radiation safety office is investigating the cause of the event."

California event: 122216

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: 52465
Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-2
NRC Notified By: SADOT RIOS
HQ OPS Officer: JEFF ROTTON
Notification Date: 12/29/2016
Notification Time: 09:25 [ET]
Event Date: 12/29/2016
Event Time: 02:50 [EST]
Last Update Date: 12/30/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JON LILLIENDAHL (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

LOSS OF TECHNICAL SUPPPORT CENTER VENTILATION SYSTEM

"Oyster Creek Generating Station has experienced a loss of the TSC [Technical Support Center] ventilation system.

"If an emergency is declared requiring TSC activation during the time TSC ventilation is non-functional, the TSC will be staffed and activated using existing emergency planning procedure unless the TSC becomes uninhabitable due to ambient temperature, radiological, or other conditions. If relocation of the TSC becomes necessary, the Emergency Director will relocate the TSC staff to an alternate location in accordance with applicable site procedures.

"This notification is being made in accordance with 10 CFR 50.72(b)(3)(xiii) due to a potential loss of the TSC. An update will be provided once the TSC ventilation has been restored to normal operation.

"The NRC Resident Inspector has been notified."


* * * UPDATED FROM JOSH MCGUIRE TO DONALD NORWOOD AT 1521 EST ON 12/30/16 * * *

"At 1410 EST on 12/30/16, maintenance is complete and the TSC ventilation system has been restored to normal operation."

The licensee notified the NRC Resident Inspector. Notified R1DO (Lilliendahl).

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Power Reactor Event Number: 52468
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: DAVID DUESING
HQ OPS Officer: DONALD NORWOOD
Notification Date: 12/30/2016
Notification Time: 14:40 [ET]
Event Date: 12/28/2016
Event Time: 22:29 [EST]
Last Update Date: 12/30/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MARK JEFFERS (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 98 Power Operation 98 Power Operation

Event Text

LOSS OF SAFETY FUNCTION DUE TO TWO INOPERABLE STANDBY LIQUID CONTROL SUBSYSTEMS

"On December 28, 2016 at 2119 EST, the Standby Liquid Control system (SLC) subsystem A was declared inoperable in accordance with the surveillance instruction for performance of a routine surveillance test. At 2229 EST, control room operators received an out-of-service alarm for the explosive-actuated injection valve for SLC subsystem B and declared subsystem B inoperable, thereby rendering both subsystems inoperable. With both subsystems inoperable, the SLC system was unable to fulfill its safety function. At 2335, the surveillance was completed and subsystem A was restored to operable status, which restored the ability for the system to fulfill its safety function.

"Troubleshooting determined that the cause for subsystem B inoperability was an intermittent electrical connection for the explosive-actuated injection valve. Repairs were conducted and the subsystem was restored to operable status on December 29, 2016 at 1708 EST.

"This issue was entered into the Corrective Action Program and during post reportability review, it was determined that this was a reportable event under 10 CFR 50.72(b)(3)(v)(A) for an event or condition that could have prevented the fulfillment of a safety function of a system that is needed to shut down the reactor and maintain it in a safe shutdown condition and under 10 CFR 50.72(b)(3)(v)(D) for a system that was unavailable for accident mitigation.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 52469
Facility: SEQUOYAH
Region: 2 State: TN
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: THEODORE DOUKAS
HQ OPS Officer: DONALD NORWOOD
Notification Date: 12/30/2016
Notification Time: 16:37 [ET]
Event Date: 12/30/2016
Event Time: 13:05 [EST]
Last Update Date: 12/30/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
STEVE ROSE (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R N 0 Hot Standby 0 Hot Standby

Event Text

MANUAL REACTOR TRIP DUE TO CONTROL ROD NOT WITHDRAWING AS EXPECTED

"On 12/30/16 at 1302 EST, Unit 1 began withdrawing control bank rods for an approach to criticality following a refueling outage. At 1305 EST, operators observed that control rod H-6 did not withdraw. Operators entered the applicable Abnormal Operating Procedure. Operators tripped the reactor as required by plant procedures and entered applicable Emergency Operating Procedures. The act of manually tripping the reactor generated a valid trip signal in the plant Reactor Protection System.

"Following the reactor trip, all safety related equipment operated as designed. Auxiliary feedwater was already supplying the Steam Generators; a Feedwater Isolation occurred due to plant conditions.

"Unit 1 is currently being maintained in Mode 3 at NOT/NOP, approximately 548 degrees F and 2235 psig, with auxiliary feedwater supplying the steam generators, and decay heat removal via the steam dumps.

"Method of decay heat removal is Steam Generators via the steam dumps. Current reactor coolant system conditions: Temperature at 548 degrees F and stable, pressure 2235 psig and stable. All control and shutdown banks are inserted. Electrical alignment is normal, supplied by offsite power. No impact to Unit 2, Unit 2 is in Mode 1 at 100 percent power."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 52471
Facility: SALEM
Region: 1 State: NJ
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: PETER HARSH
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 01/02/2017
Notification Time: 15:21 [ET]
Event Date: 01/01/2017
Event Time: 19:55 [EST]
Last Update Date: 01/02/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
JON LILLIENDAHL (R1DO)
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

Event Text

FITNESS-FOR-DUTY

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

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 52472
Facility: LASALLE
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: MARK SMITH
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 01/02/2017
Notification Time: 17:49 [ET]
Event Date: 01/02/2017
Event Time: 12:52 [CST]
Last Update Date: 01/02/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
MARK JEFFERS (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION OF A MALFUNCTION OF TWO LASALLE COUNTY WARNING SIRENS

"At approximately 1403 (CST) on January 2, 2017, LaSalle County Station was informed by the LaSalle County Sheriff that two warning sirens had malfunctioned at approximately 1252 earlier this afternoon. The warning sirens had inadvertently operated for nearly 3 minutes during maintenance at the LaSalle County 911 Communications Center. The warning sirens have been restored to standby and are fully functional. No other emergency notification systems or sirens were affected.

"The licensee has notified the NRC Resident Inspector of the issue."

Page Last Reviewed/Updated Tuesday, January 03, 2017
Tuesday, January 03, 2017