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Event Notification Report for March 23, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/22/2017 - 03/23/2017

** EVENT NUMBERS **


52611 52612 52630

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Agreement State Event Number: 52611
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: HARDIN MEMORIAL HOSPITAL
Region: 1
City: ELIZABETHTOWN State: KY
County:
License #: 202-029-22
Agreement: Y
Docket:
NRC Notified By: MARISSA VEGA VELEZ
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/14/2017
Notification Time: 17:35 [ET]
Event Date: 02/16/2017
Event Time: [CDT]
Last Update Date: 03/14/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HAROLD GRAY (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - ADMINISTERED DOSE LOWER THAN PRESCRIBED DOSE

The following information was received from the Commonwealth of Kentucky via email:

"Hardin Memorial Hospital (HMH) reported that a patient only received 106 mCi of I-131, instead of the prescribed 150 mCi post-thyroidectomy on 2/16/17. Two capsules of I-131 were received from the radiopharmacy in a single vial. When the technologist gave the patient the vial, the patient shook the contents of the vial into her mouth only swallowing one capsule. The tech did not see one capsule remained in the vial. Surveys on the package (containing the vial) that was to be sent back to the radiopharmacy were higher than background so [it] was held for decay. Another survey on 2/28/17 was taken and was still higher than background so the tech opened the package and discovered the remaining pill."

Kentucky Event Report ID No.: KY170002

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: 52612
Rep Org: COLORADO DEPT OF HEALTH
Licensee: FRONT RANGE INSPECTIONS
Region: 4
City: LITTLETON State: CO
County:
License #: G/L
Agreement: Y
Docket:
NRC Notified By: LINDA BARTISH
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/15/2017
Notification Time: 16:22 [ET]
Event Date: 03/15/2017
Event Time: 09:00 [MDT]
Last Update Date: 03/15/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NEIL OKEEFE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

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

Event Text

COLORADO AGREEMENT STATE REPORT - MISSING CO-57 ANALYZER SOURCE

The following information was obtained from the state of Colorado via email:

"The general license section of the Radioactive Materials Program [at the Colorado Department of Public Health and Environment (CDPHE)] sent out annual notifications requesting response regarding a Cobalt 57, 0.165 mCi, FA4C Analyzer Source serial #C9285 distributed under Edax Portable Products Division back in July 22, 1996. After 10 years of sending a report requesting information to the [business] address with no response, our [CDPHE] general license section is closing out this record."

Colorado Event Report ID No.: CO17-0007

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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Power Reactor Event Number: 52630
Facility: WATTS BAR
Region: 2 State: TN
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DAMON FEGLEY
HQ OPS Officer: KARL DIEDERICH
Notification Date: 03/23/2017
Notification Time: 02:48 [ET]
Event Date: 03/23/2017
Event Time: 00:14 [EDT]
Last Update Date: 03/23/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
MIKE ERNSTES (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 16 Power Operation 3 Startup

Event Text

AUTOMATIC START OF AUXILIARY FEED WATER

"On March 23, 2017, at 0014 EDT, Watts Bar Nuclear Plant Unit 2 (WBN2) experienced an unplanned trip of both Turbine Driven Main Feed Pumps (TDMFP) following a loss of Main Condenser Vacuum. The trip of both TDMFPs caused an automatic start of both Motor Driven Auxiliary Feed Water Pumps and the Turbine Driven Auxiliary Feed Water Pump. [The] cause of the loss of Main Condenser Vacuum is currently under investigation."

The plant was performing a normal startup, and had just synced the main generator to the grid. Subsequent to the event, the plant was transitioned to Mode 3 by inserting all rods with a manual trip. Decay heat is being removed via the atmospheric relief valves.

Unit 1 remains in Mode 5 for a refueling outage.

The licensee has notified the NRC Resident Inspector.

Page Last Reviewed/Updated Thursday, March 23, 2017
Thursday, March 23, 2017