Alert

Due to a lapse in appropriations, the NRC has ceased normal operations. However, excepted and exempted activities necessary to maintain critical health and safety functions—as well as essential progress on designated critical activities, including those specified in Executive Order 14300—will continue, consistent with the OMB-Approved NRC Lapse Plan.

Event Notification Report for February 8, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/07/2017 - 02/08/2017

** EVENT NUMBERS **

52441

52520

52521

!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor	Event Number: 52441
Facility: ARKANSAS NUCLEAR Region: 4 State: AR Unit: [1] [ ] [ ] RX Type: [1] B&W-L-LP,[2] CE NRC Notified By: STEVEN KIRSHBERGER HQ OPS Officer: BETHANY CECERE	Notification Date: 12/17/2016 Notification Time: 05:43 [ET] Event Date: 12/16/2016 Event Time: 14:00 [CST] Last Update Date: 02/07/2017
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL	Person (Organization): RAY KELLAR (R4DO)

Unit	SCRAM Code	RX CRIT	Initial PWR	Initial RX Mode	Current PWR	Current RX Mode
1	N	Y	33	Power Operation	33	Power Operation

Event Text

VENTILATION SYSTEM INOPERABLE

"At approximately 1400 CST on 12/16/16, during the performance of VEF-38A Lead Penetration Room Ventilation System (PRVS) Exhaust Fan Monthly Test, flow was found to be at 2000 SCFM with an operability limit of 1620 to 1980 SCFM. VEF-38A was declared inoperable. Unit 1 entered Technical Specification Limiting Condition for Operation (LCO) 3.7.11 Condition C for both trains of PRVS inoperable. With VEF-38A aligned as the lead fan and capable of auto-start, the operable standby fan (VEF-38B) would not have started.

"During the time that VEF-38A was inoperable and capable of auto-starting, the Unit 1 PRVS was in a condition that could have prevented the control of the release of radioactive material.

"At 1546 CST on 12/16/16, Unit 1 rendered VEF-38A incapable of auto starting by placing its hand switch in PULL-TO-LOCK. Unit 1 Entered LCO 3.7.11 condition A for one PRVS train inoperable and Exited LCO 3.7.11 Condition C.

"This is a notification per 10 CFR 50.72(b)(3)(v) for a condition that could have prevented the control of the release of radioactive material."

The licensee has notified the NRC Resident Inspector.

* * * UPDATE ON 2/7/17 AT 1528 EST FROM BUCHANON DICKSON TO DONG PARK * * *

"EN 52441 was initiated on December 16, 2016, when the VEF-38A fan flow was found to be in excess of the procedurally defined operability limit during the monthly lead penetration room ventilation system test.

"The revision of the procedure in use at the time had inadvertently included acceptance criterion for fan air flow in the monthly supplements. The monthly tests demonstrate the flow paths for the two trains are functional and open, but they are not performed in the designed Engineered Safeguards (ES) configuration. The monthly tests do not secure the normal supply and exhaust ventilation within the penetration room boundaries; therefore, flow may be outside limits required during the ES configuration. The 18 month surveillance, which measures the flowrate of the system while in the ES configuration, was completed in April 2016. The surveillance verified the system's operability. The systems have not been modified or altered since this surveillance; therefore the measured flowrate remains the same.

"The procedure has been revised subsequent to this event to remove the flowrate as an 'acceptance criterion' for the monthly test.

"Because the VEF-38A flow did not result in fan inoperability, both fan trains remained operable; therefore, ANO-1 did not lose a safety function to control a radioactive release. Based on that, conclusion EN 52441 is being retracted."

The licensee will notify the NRC Resident Inspector. Notified R4DO (Warnick).

Non-Agreement State	Event Number: 52520
Rep Org: WASHINGTON UNIVERSITY Licensee: WASHINGTON UNIVERSITY Region: 3 City: ST. LOUIS State: MO County: License #: 24-0016711 Agreement: N Docket: NRC Notified By: SUSAN M. LANHORST HQ OPS Officer: JEFF HERRERA	Notification Date: 01/31/2017 Notification Time: 10:15 [ET] Event Date: 04/08/2016 Event Time: [CST] Last Update Date: 01/31/2017
Emergency Class: 10 CFR Section: 35.3045(b) - PATIENT INTERVENTION DAMAGE	Person (Organization): ERIC DUNCAN (R3DO) NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

PATIENT DELIVERED RADIATION DOSE TO RIGHT LOBE OF LIVER VERSUS LEFT LOBE

The following was received via email:

"On 4/8/2016 a patient was being treated with Y-90 TheraSpheres. Written directive prescribed 4.15 GBq (117 mCi) Y-90 TheraSpheres to the left liver lobe. The catheter placement was confirmed by the Interventional Radiologist with an angiogram to administer the microspheres to the left liver lobe. The dose of 4.07 GBq of Y-90 TheraSpheres was administered. This patient was part of a study to image the location of the Y-90 TheraSpheres using a PET/MRI unit. The PET/MRI images were taken on 4/15/2016 and were read by a Radiation Oncology Authorized User on 4/16/2016. The PET/MRI images indicated that the majority of the microspheres were deposited in the right liver lobe. The Radiation Safety Officer (RSO) was immediately notified. Evaluation of the incident in accordance with the 'Yttrium-90 Microsphere Brachytherapy Sources and Devices TheraSphere and SIR-Spheres Licensing Guidance' (February 12, 2016, Revision 9) event reporting criteria was done by the RSO, Radiation Safety Committee (RSC) Chairman, Management and Radiation Oncology and the incident was judged not to be a medical event due to unintentional patient intervention. The patient and the physician were notified of the incident.

"The RSO has been discussing this incident with the University's NRC Region III Lead Inspector [Gattone] over the past few weeks. The Inspector let the RSO know that NRC Headquarters and Region III had determined that the incident is a medical event. The Inspector requested on 1/30/2017 that the RSO report the medical event to the NRC Operations Center."

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.

Agreement State	Event Number: 52521
Rep Org: OK DEQ RAD MANAGEMENT Licensee: NDE SOLUTIONS, LLC Region: 4 City: BRYAN State: TX County: License #: L05879 Agreement: Y Docket: NRC Notified By: KEVIN SAMPSON HQ OPS Officer: DONG HWA PARK	Notification Date: 01/31/2017 Notification Time: 15:05 [ET] Event Date: 01/30/2017 Event Time: [CST] Last Update Date: 01/31/2017
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): GEOFFREY MILLER (R4DO) NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA MALFUNCTION

The following report was received via e-mail:

"We [Oklahoma Department of Environmental Quality] have just been informed of an incident which occurred yesterday (1/30/2017) involving the failure of an industrial radiography source to retract. The licensee was NDE Solutions, LLC (TX license L05879) operating out of Bryan, TX. The incident occurred at a temporary job site near Checotah, OK. The licensee was working in Oklahoma under reciprocity. According to the report the drive cable failed, it isn't clear whether the source just wouldn't retract or became disconnected. The source was retrieved yesterday. The drive cable has been removed from service and is being returned to Texas."

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