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Event Notification Report for February 21, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/17/2017 - 02/21/2017

** EVENT NUMBERS **


52520 52545 52546 52563 52564 52566 52567 52568

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Non-Agreement State Event Number: 52520
Rep Org: WASHINGTON UNIVERSITY IN ST. LOUIS
Licensee: WASHINGTON UNIVERSITY IN ST. LOUIS
Region: 3
City: ST. LOUIS State: MO
County:
License #: 24-0016711
Agreement: N
Docket:
NRC Notified By: SUSAN M. LANGHORST
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: 02/20/2017
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.

* * * UPDATE FROM SUSAN LANGHORST (RSO) TO HOWIE CROUCH ON 2/20/17 AT 0923 EST * * *

The RSO provided some minor corrections to the organization name as well as correcting one date in the original report. The original report stated that PET/MRI images were taken on 4/15/16 when they were actually taken on 4/8/16.

Notified the R3DO (Pelke) and NMSS (via email).

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Agreement State Event Number: 52545
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: BEMIS CORPORATION
Region: 3
City: NEENAH State: WI
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: KYLE WALTON
HQ OPS Officer: JEFF HERRERA
Notification Date: 02/09/2017
Notification Time: 11:57 [ET]
Event Date: 02/08/2017
Event Time: 16:31 [CST]
Last Update Date: 02/09/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

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

Event Text

AGREEMENT STATE - RADIOACTIVE DEVICE FOUND IN SCRAP YARD

The following report was received from the Wisconsin Department of Health Services Radiation Protection Section via email:

"We [Wisconsin Department of Health] have an immediately reportable event under DHS 157.32(1)(a)1 regarding stolen, lost or missing material that is equal to or greater than 1,000 times the quantity specified in Appendix F. A phone message was left with the Wisconsin Department of Health Services at 1631 [CST] on February 8, 2017 [concerning] found radioactive material. The message was returned this morning, February 9, 2017 and the following information has been gathered. An NDC System 101 thickness gauge (SSD CA0471D102B), containing 150 mCi of Am-241 was recovered at a scrap yard in Wisconsin. The device was received in a load of scrap originating from Bemis Corporation in Neenah Wisconsin. The device, with serial number 11125, with 150 mCi of Am-241 assayed on 12/28/2009 is generally licensed to Bemis Corporation. The device was separated out of a load at Alter Trading in Green Bay Wisconsin. The State is currently in contact with both Alter Trading and Bemis Corporation to coordinate a response. An individual at Alter measured up to 3000 microR/h with their survey meter. The department will verify this measurement and determine if there is any contamination or personnel exposure. The department has dispatched staff to the site for response and to help facilitate transfer of the device to the owner."

Wisconsin Event ID No.: WI-170001

* * * UPDATE AT 1701 EST ON 02/09/07 FROM KYLE WALTON TO JEFF HERRERA * * *

The following update was received via email:

"Inspectors investigated on February 9 at Alter Trading in Green Bay, where the device was being stored. It was determined that the device had unintentionally been removed from a machine during maintenance work at Bemis Company, Inc. and that it was then grouped with scrap metal before being transported to Alter Trading. While the shutter was open, the time spent around the device by any employees or members of the public, or employees of either Bemis or Alter, is believed to be minimal. The shutter has been closed, and wipe tests confirm that there is no removable contamination. There are no known or suspected overexposures resulting from this incident. Bemis is working with a service provider to arrange for packaging and transportation of the gauge back to their facility. Inspectors will perform an inspection of Bemis on February 10 to gather more information."

Notified the R3DO (Kunowski) and NMSS Events (via email).

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

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Agreement State Event Number: 52546
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: MOTIVA ENTERPRISES LLC
Region: 4
City: PORT ARTHUR State: TX
County:
License #: 05211
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: DONALD NORWOOD
Notification Date: 02/09/2017
Notification Time: 13:12 [ET]
Event Date: 02/08/2017
Event Time: [CST]
Last Update Date: 02/09/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WARNICK (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - FIXED PROCESS GAUGE STUCK SHUTTER

The following information was received via E-mail:

"On February 9, 2017, the licensee notified the Agency [Texas Department of State Health Services] that on February 8, 2017, it was attempting to close the shutter on a Vega SHLG-1 fixed nuclear gauge to shut down the unit it was mounted on for maintenance and the shutter would not close. The gauge contains a 2,000 millicurie cesium-137 source, serial number 6380GG. The licensee reported there was no risk of exposure to employees or members of the public. A licensed service company is onsite and will secure a lead plate onto the device then remove the device and return it to the manufacturer for repairs.

"More information will be provided as it is obtained in accordance with SA-300."

Texas Incident No.: I-9463

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Power Reactor Event Number: 52563
Facility: HATCH
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: PAUL UNDERWOOD
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/17/2017
Notification Time: 17:46 [ET]
Event Date: 02/17/2017
Event Time: 14:14 [EST]
Last Update Date: 02/17/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
BRIAN BONSER (R2DO)

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 N 0 Refueling 0 Refueling

Event Text

SECONDARY CONTAINMENT INOPERABLE

"On 2/17/2017 at 1414 EST, secondary containment was declared inoperable due to the discovery of an 18-inch open pipe penetration in the secondary containment boundary. During walkdown activities, it was discovered that a blind flange installed to support removal of a Unit 2 secondary containment isolation valve had been installed on the wrong flange to provide isolation for secondary containment. At 1503 EST, the blind flange was moved to the correct side of the flange and secondary containment was declared operable.

"This event is reportable per 10 CFR 50.72(b)(3)(v)(C) as a condition that at the time of discovery could have prevented the fulfillment of the safety function of a system needed to control the release of radioactive material. In conjunction with operation of the Standby Gas Treatment (SGT) subsystems, secondary containment is designed to reduce the activity level of the fission products prior to release to the environment and to isolate and contain fission products that are released during certain operations. Therefore, the lack of a qualified isolation device to limit the release of radioactive material constitutes a loss of safety function due to a loss of secondary containment integrity.

"CR 10332592

"The NRC Resident has been notified."

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Power Reactor Event Number: 52564
Facility: LASALLE
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: WAYNE CLAYTON
HQ OPS Officer: DONG HWA PARK
Notification Date: 02/18/2017
Notification Time: 02:58 [ET]
Event Date: 02/17/2017
Event Time: 23:53 [CST]
Last Update Date: 02/18/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
PATRICIA PELKE (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 30 Power Operation 0 Hot Shutdown

Event Text

AUTOMATIC REACTOR SCRAM RESULTING FROM FEEDWATER REGULATING VALVE FAILURE

"This notification is being provided in accordance with 10CFR 50.72(b)(2)(iv)(B).

"On February 17, 2017 at 2353 CST, Unit 1 Reactor Automatic Scram signal was received due to Turbine Control Valves Fast Closure. The turbine trip was due to receipt of Level 8 Trip due to a failure of the Feedwater Regulating Valve to Full open. Plant is in a stable condition with reactor pressure being maintained by the Turbine Bypass valves. Reactor water level is being controlled with Feedwater thru the Low Flow Feedwater Regulating Valve. Further investigation into the cause of the event is in progress."

All control rods fully inserted, and decay heat is being removed via steam to the main condenser using bypass valves.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 52566
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: MICHAEL D. BRANSCUM
HQ OPS Officer: JEFF HERRERA
Notification Date: 02/19/2017
Notification Time: 00:21 [ET]
Event Date: 02/18/2017
Event Time: 15:37 [CST]
Last Update Date: 02/19/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(B) - POT RHR INOP
Person (Organization):
HEATHER GEPFORD (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

LOSS OF CONTROL BUILDING CHILLED WATER

"At 1537 CST on February 18th, 2017, while the plant was in MODE 5 for a scheduled refueling outage, the main control room experienced a loss of Control Building chilled water and the associated ventilation systems while attempting to alternate divisions for testing. An equipment malfunction in a breaker supplying a Main Control Room air handling unit caused a loss of both divisions of Control Room and Control Building chilled water systems and associated ventilation systems until 1737 CST. During the period between 1537 and 1737, neither division of Control Building chilled water was able to perform the support function for cooling Division 1 and 2 AC and DC power distribution systems or the support function for the Division 1 and 2 Control Room Fresh Air systems.

"Shutdown Cooling remained in service throughout this event. There were no apparent effects on any plant equipment from the loss of chill water and ventilation.

"The Division 1 Control Building chill water and ventilation system was returned to service at 1737 on February 18, 2017.

"Actions were initiated to terminate the OPDRV [operations with potential to drain the reactor vessel] that was in progress at the time of the event by installing the reactor recirculation pump seal. As a conservative measure, actions were initiated to set containment and containment was set at 2145.

"Troubleshooting and analysis is ongoing to confirm and correct the problem which caused the loss of the Control Building chill water and ventilation system.

"This condition is being reported in accordance with 10 CFR 50.72(b)(3)(v)(B).

"The NRC Senior Resident Inspector has been notified."

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Power Reactor Event Number: 52567
Facility: HATCH
Region: 2 State: GA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: RODGER LOWER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/20/2017
Notification Time: 01:14 [ET]
Event Date: 02/19/2017
Event Time: 23:23 [EST]
Last Update Date: 02/20/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
BRIAN BONSER (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling

Event Text

CONTAINMENT PENETRATION EXCEEDED ALLOWABLE LEAKAGE

"On 2/19/2017 at 2323 EST, during LLRT [local leak rate test] testing per 42SV-TET-001-2, 2T48F320 exceeded the maximum allowable leakage limit. The companion isolation valve in the same line (2T48F319) had previously failed LLRT. The failure of the 2T48F320 represents a failure of the 2T23X26 penetration to maintain primary containment integrity.

"This event is reportable per 10CFR50.72(b)(3)(ii)(A) since the failure of the 2T23X26 penetration caused primary containment leakage to exceed La [allowable leakage] and thus represents a degraded principle safety barrier.

"CR [condition report] 10333178.

"NRC Resident Inspector has been notified."

2T48F319 and 2T48F320 are 18 inch dampers.

This event places the licensee in a Technical Specification limit that requires the dampers to be repaired and pass LLRT prior to the plant entering Mode 3.

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Power Reactor Event Number: 52568
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: STEVEN CARTER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 02/20/2017
Notification Time: 17:24 [ET]
Event Date: 02/20/2017
Event Time: 12:40 [CST]
Last Update Date: 02/20/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
HEATHER GEPFORD (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

UNANALYZED CONDITION DUE TO POTENTIAL FAILURE OF CONTROL ROOM AND CONTROL BUILDING AIR HANDLING UNITS

"During the investigation associated with Event Notification 52566 that was reported on 2/18/17, it has been determined that an unanalyzed condition (new potential single failure concerns) exists. This condition exists only during periods of manually alternating divisions of Control Building Chilled Water systems; in that potential failures of Control Room Air Handling Units (HVC-ACU1A or B) or Control Building Air Handling Units (HVC-ACU2A or B) could fail in a manner that challenges the operability of the alternate division.

"As reported in Event Notification 52566, the impact of this event was a loss of safety function cooling to both Division 1 and 2 AC/DC power distribution systems and Divisions 1 and 2 Control Room Fresh Air systems.

"Contingency actions are in development to address the impact of the potential failure mode. The plant remains in a planned refueling outage, Mode 5 with water level greater than 23' above the vessel flange. Shutdown cooling remains in service and is not affected by this issue. Investigation is ongoing.

"The NRC Resident Inspector has been briefed on this issue."


* * * UPDATE FROM ROB MELTON TO DONALD NORWOOD AT 2129 EST ON 2/20/2017 * * *

The licensee updated information in the first paragraph of the original above with the following:

"During the investigation associated with Event Notification 52566 that was reported on 2/18/17, it has been determined that an unanalyzed condition (new potential single failure concerns) exists. During periods of alternating divisions of Control Building Chilled Water systems, the potential exists for failures of Control Room Air Handling Units (HVC-ACU1A or B) or Control Building Air Handling Units (HVC-ACU2A or B) that could challenge the operability of the alternate division."

The licensee notified the NRC Resident Inspector of this update.

Page Last Reviewed/Updated Tuesday, February 21, 2017
Tuesday, February 21, 2017