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Event Notification Report for January 12, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/11/2017 - 01/12/2017

** EVENT NUMBERS **


52473 52482 52484

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Agreement State Event Number: 52473
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NOT PROVIDED
Region: 1
City: NOT PROVIDED State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: NOT PROVIDED
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 01/04/2017
Notification Time: 16:03 [ET]
Event Date: 12/29/2016
Event Time: [EST]
Last Update Date: 01/04/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The following report was received via fax:

"We [New York State Department of Health] were informed on January 3, 2017 that on December 29, 2016, a 61 year old female patient was to receive SIR spheres Y90 infusion to 2 lesions in her liver at a hospital. The small lesion was to receive 10% and the large lesion was to receive 90% of 24.53 mCi Y90.

"Staff prepared 2 vials according to the Written Directive, and labeled each vial shield. When the first infusion, for the smaller lesion, was called for, a technologist took one vial to the IR room. She believed she had the correct 10% marked vial. She removed the top of the shielded container holding the vial, then she left the IR suite. The patient was injected. When the second infusion, for the large lesion, was called for, the same technologist took the second shielded vial from the hot lab and noticed that it was the one marked with the 10% label. It appears that the vials themselves were not labeled, only the lids of the containers holding the vials were labeled. Once they realized what had happened, they decided to infuse the second larger lesion with what was left over in the first vial as well as what was in the second vial. The licensee has not yet provided the values for the actual administered dose to each lesion. However, it appears clear that the discrepancy in the prescribed activity and administered activity for each lesion meets the reportable medical event criteria.

"[The licensee's] initial report stated there is no harm to the patient. A full report, including the actual activity delivered and a root cause analysis is required/pending."

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: 52482
Facility: VOGTLE
Region: 2 State: GA
Unit: [3] [4] [ ]
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: AMANDA PUGH
HQ OPS Officer: STEVE SANDIN
Notification Date: 01/11/2017
Notification Time: 13:52 [ET]
Event Date: 01/11/2017
Event Time: 10:58 [EST]
Last Update Date: 01/11/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
SCOTT SHAEFFER (R2DO)
FFD GROUP (EMAI)
SHANE SANDAL (R2)

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 TEST POSITIVE FOR NON-LICENSED SUPERVISOR

A non-licensed supervisor tested positive for alcohol during a for-cause test. The individual's access to the site has been terminated pending the results of an investigation.

The licensee notified RII (Patterson) and the NRC Resident Inspector.

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Power Reactor Event Number: 52484
Facility: COMANCHE PEAK
Region: 4 State: TX
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: HUNTER SCHILL
HQ OPS Officer: DONALD NORWOOD
Notification Date: 01/11/2017
Notification Time: 16:56 [ET]
Event Date: 01/11/2017
Event Time: 15:00 [CST]
Last Update Date: 01/11/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
NICK TAYLOR (R4DO)

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

TEFLON FOUND IN CONTAINMENT SPRAY PUMP COMPONENTS

"On September 16, 2016, Comanche Peak reported an unanalyzed condition and potential loss of safety function per 10 CFR 50.72(b)(3)(ii)(B) and 10 CFR 50.72(b)(3)(v) related to Teflon (PTFE) installed in the pressure gauge diaphragm seal assemblies for all four of the Centrifugal Charging Pumps and both of the Positive Displacement Charging Pumps on Units 1 and 2 (EN#52244). On November 14, 2016, this event was subsequently retracted.

"On December 12, 2016, during the ongoing extent of condition review, Teflon was also found to be installed in the suction and discharge pressure gauge diaphragm seal assemblies for the Unit 1 and 2 Containment Spray Pumps. On January 11, 2017 at approximately 1500 CDT, the reportability evaluation determined that reasonable assurance did not exist that the Containment Spray system would have been able to fulfill its design function of removing heat from the containment environment without impacting the applicable dose limits.

"Teflon (PTFE) is a restricted material normally prohibited from use in contact with reactor coolant or in radiation environments. Teflon (PTFE) is not radiation tolerant and degrades in a radiation environment. The Teflon (PTFE) used in these diaphragm seal assemblies could fail during a postulated Loss of Coolant Accident (LOCA) which could cause the Containment Spray Pumps on Units 1 and 2 to be inoperable, and exceed system leakage limits. This could challenge dose limits and in plant post-accident accessibility. This represents an unanalyzed condition. The pressure gauges and diaphragm seals for all of the Unit 1 and 2 Containment Spray Pumps have been isolated and the Unit 1 and 2 Containment Spray Pumps are operable. The Teflon (PTFE) has likely existed in these diaphragm seals since initial plant licensing. Luminant Power is continuing to investigate the extent of this condition and potential repair techniques.

"The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Thursday, January 12, 2017
Thursday, January 12, 2017