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Event Notification Report for March 30, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/29/2017 - 03/30/2017

** EVENT NUMBERS **


52628 52629 52646 52647 52648 52649

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 52628
Rep Org: MICHIGAN STATE UNIVERSITY
Licensee: MICHIGAN STATE UNIVERSITY
Region: 3
City: EAST LANSING State: MI
County: INGHAM
License #: 21-00021-29
Agreement: N
Docket: 030-0080
NRC Notified By: BRYAN HARRIS
HQ OPS Officer: DAN LIVERMORE
Notification Date: 03/22/2017
Notification Time: 08:10 [ET]
Event Date: 03/17/2017
Event Time: 10:00 [EDT]
Last Update Date: 03/22/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(2) - DOSE > SPECIFIED EFF LIMITS
Person (Organization):
ROBERT ORLIKOWSKI (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

WRONG MODE OF TREATMENT: PET SCAN ADMINSTERED WHEN CT SCAN WAS ORDERED

A PET scan was administered to a patient even though a CT scan was ordered by the prescribing physician. Initially the prescribing physician ordered a PET scan, but changed the order to a CT scan. An administrative error resulted in the order change not being implemented to reflect the change to a CT scan. The patient was provided all release forms for the PET scan and was aware that a PET scan was being administered. The patient received 1R of exposure. There was no harm to the patient.

* * * RETRACTION AT 1429 EDT ON 3/22/17 FROM BRYAN HARRIS TO DONG PARK * * *

The licensee has determined that this event did not meet reporting requirements.

The licensee notified Region 3 (Craffey). Notified R3DO (Orlikowski) and NMSS Events Resource via email.

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: 52629
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: ASPIRUS-WAUSAU HOSPITAL
Region: 3
City: WAUSAU State: WI
County:
License #: 073-1342-01
Agreement: Y
Docket:
NRC Notified By: DAVID REINDL
HQ OPS Officer: DONG HWA PARK
Notification Date: 03/22/2017
Notification Time: 17:18 [ET]
Event Date: 12/09/2016
Event Time: [CDT]
Last Update Date: 03/22/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ROBERT ORLIKOWSKI (R3DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - TOTAL DOSE LESS THAN 80 PERCENT OF PRESCRIBED DOSE

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

"On March 22, 2017, the [Wisconsin Department of Health Services] received a telephone call and email from the licensee's medical physicist that a medical event occurred on December 9, 2016, involving a permanent implant of I-125 seeds for a prostate manual brachytherapy procedure where the total dose delivered differs from the prescribed dose by 20% or more. This is a medical event as described in DHS 157.72(1)(a)1.a. The prescribed dose was 145 Gy; the dose delivered was 114 Gy. The licensee uses D90 (dose delivered to 90% of the clinical target volume) less than 80% for determining medical events. Using the licensee's dose based criteria; the dose received by the prostate was 78% of the intended dose. The underdose was identified during the post-implant computed tomography scan on January 9, 2017 and subsequent dosimetric analysis on January 27, 2017. The licensee's radiation oncologist informed the physicist that supplemental radiation will not be administered and that it is a reportable event on March 22, 2017. Corrective actions are being reviewed by the licensee's staff. DHS [Department of Health Services] inspectors will investigate this medical event."

Wisconsin Event ID No.: WI-170005

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: 52646
Facility: COMANCHE PEAK
Region: 4 State: TX
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RAUL MARTINEZ
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/29/2017
Notification Time: 03:28 [ET]
Event Date: 03/28/2017
Event Time: 19:57 [CDT]
Last Update Date: 03/29/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
THOMAS HIPSCHMAN (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

Event Text

UNANALYZED CONDITION FOR A POSTULATED MODERATE ENERGY LINE BREAK

"On March 28, 2017 at approximately 1957 CDT, a condition was discovered whereby a postulated moderate-energy line break (MELB) involving three fire protection (FP) pipe segments in the Safeguards Building did not contain MELB shielding. It was subsequently determined a postulated crack in one of the affected FP piping sections could adversely affect circuitry associated with the cooling support system for the train A RHR [Residual Heat Removal] pump room, potentially causing the ventilation system to be unavailable to support operation of the train A RHR pump. This condition is not consistent with the CPNPP licensing basis for the protection of essential safe shutdown RHR equipment.

"At approximately 1957 CDT train A RHR was declared inoperable but available and the unit entered a seventy-two hour LCO [Limiting Condition for Operation] Action Statement per Technical Specification 3.5.2 B pending completion of mitigative actions.

"Since Unit 1 train B RHR system components and related supporting equipment have been periodically declared inoperable at various times in the last three years for surveillance testing or maintenance, given the MELB condition, both trains of RHR and or support equipment could have been inoperable and this represents an unanalyzed condition per 10 CFR 50.72(b)(3)(ii)(B). At the time of discovery, train B RHR and support equipment were operable. Therefore, the identified condition is not reportable as a loss of safety function per 10 CFR 50.72(b)(3)(v).

"The Senior NRC Resident Inspector has been notified."

Compensatory actions will include installing a spray shield on the affected cable trays.

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Power Reactor Event Number: 52647
Facility: PALISADES
Region: 3 State: MI
Unit: [1] [ ] [ ]
RX Type: [1] CE
NRC Notified By: TERRY DAVIS
HQ OPS Officer: BETHANY CECERE
Notification Date: 03/29/2017
Notification Time: 18:10 [ET]
Event Date: 03/29/2017
Event Time: 15:08 [EDT]
Last Update Date: 03/29/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(B) - POT RHR INOP
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JAMNES CAMERON (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 70 Power Operation 70 Power Operation

Event Text

DISCOVERY OF NON-CONFORMING CONDITIONS DURING TORNADO HAZARDS ANALYSIS

"During an evaluation of protection for Technical Specification (TS) equipment from the damaging effects of tornados, Palisades Nuclear Plant personnel identified conditions in the plant design such that specific TS equipment is considered not adequately protected from tornado missiles.

"Specifically, vulnerabilities were identified in the following systems and components:
Service Water System - Service water pump discharge header and service water pump cable trays.
Fuel Oil Transfer System - Fuel oil transfer piping and transfer pump cable trays.
Emergency Diesel Generators - Vent lines on the fuel oil day tanks.
Control Room Heating, Ventilation, and Cooling System - Both the normal and emergency intake ducts.
Steam Driven Auxiliary Feedwater Pump - Feedwater pump relief valves.
Component Cooling Water System - Component cooling water surge tank.

"The identified vulnerabilities are being addressed in accordance with Enforcement Guidance Memorandum (EGM), 15-002, and Interim Staff Guidance, DSS-ISG-2016-01. Initial compensatory measures are in place."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 52648
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: MARK MOEBES
HQ OPS Officer: BETHANY CECERE
Notification Date: 03/29/2017
Notification Time: 23:36 [ET]
Event Date: 03/29/2017
Event Time: 18:44 [CDT]
Last Update Date: 03/29/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
EUGENE GUTHRIE (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 1 Startup 0 Hot Shutdown

Event Text

MANUAL SCRAM INITIATED DURING STARTUP

"At 1844 CDT on 3/29/2017, Unit 2 initiated a manual scram due to multiple rods inserting.

"At 1842 during Unit 2 start-up, Intermediate Range Monitor (IRM) 'G' drifted low. The operator adjusted the range down one position with no immediate reaction. At 1844, a spike on IRM 'G' caused a half scram on Reactor Protection System (RPS) 'A' trip system. The half scram was being reset after evaluating no trip condition was present. As the operator reset groups 2 and 3, a trip signal from IRM 'F' was received on the RPS 'B' trip system, resulting in rod insertion for groups 1 and 4. When the operator identified multiple rods inserting, the actions of procedure 2-AOI-100-1 were followed and a manual scram was inserted. Investigation is ongoing.

"All safety systems remained in standby readiness configuration. No Emergency Core Cooling System (ECCS) or Reactor Core Isolation Cooling (RCIC) reactor water level initiation set points were reached. Primary Containment Isolations Systems did not receive an actuation signal and performed as designed.

"This event is reportable within 4 hours per 10 CFR 50.72(b)(2)(iv)(B) 'any event or condition that results in actuation of the RPS when the reactor is critical except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation.' It is also reportable within 8 hours per 10 CFR 50.72(b)(3)(iv)(A) 'any event or condition that results in valid actuation of systems listed in paragraph (b)(3)(iv)(B) Reactor Protection System(RPS) including reactor scram and reactor trip'. This event requires an LER within 60 days per 10 CFR 50.73(a)(2)(iv)(A).

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 52649
Facility: COOK
Region: 3 State: MI
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: TIM SIEFER
HQ OPS Officer: DONG HWA PARK
Notification Date: 03/30/2017
Notification Time: 03:19 [ET]
Event Date: 03/30/2017
Event Time: 03:10 [EDT]
Last Update Date: 03/30/2017
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
JAMNES CAMERON (R3DO)
CHRIS MILLER (NRR)
JEFFERY GRANT (IRD)
BILL DEAN (NRR)
CYNTHIA PEDERSON (R3RA)

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 ALL CONTROL ROOM ANNUNCIATORS

"The Unit 1 DC Cook Nuclear Plant (CNP) Annunciator System failed on Thursday, March 30, 2017 at 0255 [EDT]. The failure resulted in a complete loss of all alarm function of the Annunciator System in the Unit 1 Control Room. Unit 2 was unaffected by this failure. At 0310 [EDT], an Unusual Event (UE) was declared due to System Malfunction S-6, Loss of Alarms or Indication, due to an unplanned loss of safety system annunciators and/or indications in the Control Room for greater than 15 minutes.

"The Unit 1 PPC [Plant Process Computer] and ERDS [Emergency Response Data System] remain functional and available.

"This notification is being made in accordance with 10 CFR 50.72(a)(1)(i) due to the declaration of an Emergency Classification specified in the licensee's approved Emergency Plan."

The licensee has notified the NRC Resident Inspector, the State and local agencies.

Notified DHS SWO, FEMA Ops Center, DHS NICC. Notified FEMA National Watch and Nuclear SSA via E-mail.

Page Last Reviewed/Updated Thursday, March 30, 2017
Thursday, March 30, 2017