United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2017 > March 31

Event Notification Report for March 31, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/30/2017 - 03/31/2017

** EVENT NUMBERS **


52628 52629 52634 52635 52640 52645 52649 52650 52651 52652

To top of page
!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!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.

To top of page
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.

To top of page
Agreement State Event Number: 52634
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: BRASKEM AMERICA INC
Region: 4
City: FREEPORT State: TX
County:
License #: 06443
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: JEFF HERRERA
Notification Date: 03/23/2017
Notification Time: 17:30 [ET]
Event Date: 03/22/2017
Event Time: [CDT]
Last Update Date: 03/23/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - FOUR STUCK SHUTTERS IDENTIFIED DURING A SIX MONTH INSPECTION

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

"On March 23, 2017, [at 1545 CDT] a consulting company called the Agency [Texas Department of State Health Services] to report that on March 22, 2017, during [a] six month inspection of devices, four devices were found with stuck shutters. Two Ohmart Vega devices contained cesium-137, models SHLG with source serial numbers SM-6918 (120 milliCuries) and 5811GK (5000 milliCuries). The other two were [the] same manufacturer, same isotope, but model SHF2 with source serial numbers M-0076 and M-0077 at 200 milliCuries each. The consulting service is in contact with the licensee's radiation safety officer who is submitting a request to amend the license maintaining the devices in the open position until repaired. No exposures are anticipated and the repairs should be performed within the next 90 days. Updates will be provided as received."

Texas Incident #: I 9473

To top of page
Agreement State Event Number: 52635
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: UNIVERSITY OF TEXAS MD ANDERSON CANCER CENTER
Region: 4
City: HOUSTON State: TX
County:
License #: 52635
Agreement: Y
Docket:
NRC Notified By: IRENE CASARES
HQ OPS Officer: JEFF HERRERA
Notification Date: 03/23/2017
Notification Time: 18:13 [ET]
Event Date: 03/23/2017
Event Time: [CDT]
Last Update Date: 03/24/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - PACKAGE RECEIVED WITH REMOVABLE CONTAMINATION

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

"On March 23, 2017 the radiation safety officer [RSO] from a hospital called stating a package was received from BTX Global Logistics (31x2130417) containing a Germania-Gallium generator. The device was intact and not leaking although the outside of the package had removable contamination at 21,866 dpm over a 300 cm squared area. The RSO stated she contacted the delivery service. She [the RSO] explained that the device she received wasn't leaking and the contamination may be inside their vehicle. She [the RSO] stated that the package was received at 1221 [CDT] at the hospital. Her staff confirmed the device was not leaking and the contamination was on the outside of the package. Investigation ongoing. Updates to be provided as received."

* * * UPDATE AT 1211 EDT ON 3/24/17 FROM CHRIS MOORE TO JEFF HERRERA * * *

The following update was received from the Texas Department of Health Services via email:

"On March 23, 2017 the Radiation Safety Officer (RSO) from The University of Texas MD Anderson Cancer Center called stating a package was received from BTX Global Logistics (31x2130417) at 1221 containing a Germania-Gallium generator. The device was intact in a package although the bottom of the package was contaminated. The highest level of contamination was 466 dpm per square cm based on 777,425 dpm over a 16 inch by 16 inch area of the box. The inside of the box was not contaminated and the generator was not leaking. The only spread of contamination from the box was onto a cart used to transport the generator from the loading dock to the lab. The cart was decontaminated. The contamination appears to be a low energy beta emitter with a short life in the 2-3 hour range. The contamination cannot be detected by a GM or scintillator probe only by the use of liquid scintillation counter. The hospital is attempting to identify the radionuclide. The Agency [Texas Department of Health Services] surveyed the transport vehicle, contents and driver for the delivery vehicle with a pancake probe for contamination on March 23, 2017. This was completed prior to understanding that it would not be detectable with available probes so today the vehicle will be surveyed with wipes. The package was picked up from Houston Intercontinental Airport on the evening of March 22, 2017 after clearing customs from a [common carrier] Aircraft flying from Germany. BTX Global Logistics picked up the package on March 22, 2017, placed it in their warehouse until it was delivered on March 23, 2017. Both times while the package was being transported in the vehicle, there were no other packages in the vehicle. There were no other deliveries of radioactive material in this vehicle over the last 2 days. The investigation is ongoing."

Texas Incident #: I 9474.

Notified the R4DO (Drake) and NMSS Events (Email).

To top of page
!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 52640
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [ ] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: ANDREW MCNEIL
HQ OPS Officer: KARL DIEDERICH
Notification Date: 03/25/2017
Notification Time: 09:28 [ET]
Event Date: 03/25/2017
Event Time: 01:42 [EDT]
Last Update Date: 03/30/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
BRICE BICKETT (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation

Event Text

REFUELING WATER TANK LEVEL INADVERTENTLY LOWERED BELOW TS

"While performing a purification subsystem alignment on the Unit-2 Refueling Water Tank, an inadvertent transfer of Refueling Water Tank level to the common Spent Fuel Pool occurred. This transfer resulted in lowering Unit-2 Refueling Water Tank level below the Technical Specification [TS] required limit for the current mode of operation at 0142 [EDT] on 3/25/17. Upon recognition of the inadvertent transfer, Operations secured the lineup and restored Unit-2 Refueling Water Tank level to its normal operating band at 0225 on 3/25/17.

"This event is reportable under 10 CFR 50.72(b)(3)(v)(D) '...any event or condition that at the time of discovery could have prevented the fulfillment of the safety function structures or systems that are needed to mitigate the consequences of an accident.' With less than the required Technical Specification volume in the Refueling Water Tank, insufficient volume existed in the Refueling Water Tank to maintain 30 minutes of full flow Safety Injection, and subsequent continued pump operation after transition to recirculation mode of operation."

This level is required by Technical Specification 3.5.4.B and has a one hour action statement to restore level.

The NRC Resident Inspector has been notified.


* * * RETRACTION FROM KENT MILLS TO DONALD NORWOOD AT 1637 EDT ON 3/30/2017 * * *

"The purpose of this notification is to retract ENS notification 52640 made on March 25, 2017 for Calvert Cliffs. After further evaluation, it has been determined that the volume of water in the Unit 2 Refueling Water Tank was never below the TS required volume of 400,000 gallons. The evaluation considered the as-found condition of the level transmitter and the existing environmental conditions of the tank in determining the actual RWT water volume on the day of the event. Therefore, this event does not meet the criteria of 10 CFR 50.72(b)(3)(v)(D) and the ENS report is being retracted."

The licensee will notify the NRC Resident Inspector.

Notified R1DO (Cook).

To top of page
Power Reactor Event Number: 52645
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: DUSTIN SCURLOCK
HQ OPS Officer: BETHANY CECERE
Notification Date: 03/28/2017
Notification Time: 14:47 [ET]
Event Date: 01/31/2017
Event Time: 14:25 [EST]
Last Update Date: 03/30/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
BILL COOK (R1DO)

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

Event Text

60-DAY REPORT DUE TO INVALID ECCS ACTUATION SIGNAL

"The following report is made pursuant to 10 CFR 50.73(a)(2)(iv)(A) due to an unintended initiation signal that occurred on January 31, 2017 with James A. FitzPatrick Nuclear Power Plant (JAF) in Mode 5 at zero (0) percent power.

"On January 31, 2017 at 1425 [EST] the control room received multiple annunciations associated with the following Systems / Trains:
Primary Containment Isolation System (PCIS) / Trains A and B
Residual Heat Removal System (RHR) / Trains A and B
Core Spray (CS) / Trains A and B
Reactor Core Isolation Cooling (RCIC)

"All four (4) Emergency Diesel Generators (EDG) auto-started with their associated Emergency Service Water pumps operating. RHR and CS both received initiation signals but were defeated per procedure. The HPCI [High Pressure Coolant Injection] auxiliary oil pump was taken to Pull-to-Lock per procedure, and the RCIC steam isolation valve cycled until the breaker was opened to close the valve.

"An evaluation concluded that the [Emergency Core Cooling System - ECCS] initiation signals were caused by the opening of a portable job box that was stored near sensitive equipment. Upon opening the job box, the lid bumped a reference leg resulting in the initiation signals. All initiation signals were reset and systems restored to normal shutdown lineups."

The licensee notified the NRC Resident Inspector.

* * * UPDATE ON 3/30/17 AT 0840 EDT FROM DUSTIN SCURLOCK TO DONG PARK * * *

To the original report, the licensee added, "This condition recurred at 1624 [EDT on 1/31/17]."

The licensee notified the NRC Resident Inspector. Notified R1DO (Cook).

To top of page
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.

* * * UPDATE FROM MAX MILLER TO DONG PARK AT 0821 EDT ON 3/30/2017 * * *

"Unit 1 DC Cook Nuclear Plant Annunciator System has been returned to functional. Unusual Event Classification was terminated at 0817 EDT on 3/30/17."

The NRC Resident Inspector will be notified.

Notified R3DO (Cameron), NRR EO (Miller), and IRD (Grant). Notified DHS SWO, FEMA Ops Center, DHS NICC. Notified FEMA National Watch and Nuclear SSA via E-mail.

To top of page
Power Reactor Event Number: 52650
Facility: HATCH
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: GUY GRIFFIS
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/30/2017
Notification Time: 12:58 [ET]
Event Date: 03/30/2017
Event Time: 09:22 [EDT]
Last Update Date: 03/30/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
EUGENE GUTHRIE (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 97 Power Operation 97 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

UNANALYZED CONDITION DUE TO POTENTIAL TORNADO GENERATED MISSILES

"During the evaluation of tornado missile vulnerabilities and the potential impacts to safety-related plant equipment, it was concluded that the following structures are vulnerable to tornado generated missiles:

"All five of the Unit 1 and Unit 2 Emergency Diesel Generator (EDG) fuel oil storage tanks have ventilation pipe extending approximately 5 feet above grade. In the event that a tornado missile impact occurs on the aforementioned ventilation piping, there is a possibility that the vent lines could crimp. This could prevent the tanks from venting and inhibit the transfer of fuel oil from the main fuel oil storage tanks to the day tank. Ultimately, this causes the emergency diesels to be inoperable.

"These conditions are reportable per 10 CFR 50.72(b)(3)(ii)(B) and 10 CFR 50.72(b)(3)(v)(D) for any event or condition that results in the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety and also an event or condition that could have prevented fulfillment of a safety function needed to mitigate the consequence of an accident. This issue is being addressed in accordance with EGM-15-002, Revision 1, Enforcement Discretion for Tornado-Generated Missile Protection Noncompliance.

"The NRC Resident Inspector has also been notified."

To top of page
Power Reactor Event Number: 52651
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: JEFF YEAGER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/30/2017
Notification Time: 20:05 [ET]
Event Date: 03/30/2017
Event Time: 17:10 [EDT]
Last Update Date: 03/30/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
MICHAEL KUNOWSKI (R3DO)

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

Event Text

SECONDARY CONTAINMENT TECHNICAL SPECIFICATION NOT MET

"On March 30, 2017 at 1710 EDT, with Reactor Building HVAC in service maintaining normal building pressure, Reactor Building pressure began to rise for an unknown reason. The Technical Specification (TS) for secondary containment pressure boundary was not met for approximately 50 seconds. Division 1 Standby Gas Treatment System was started and returned Secondary Containment pressure to the TS operability limit of 0.125 inches of vacuum water gauge (TS SR 3.6.4.1.1). The highest pressure observed on the Main Control Room indications was 0.105 inches of vacuum water gauge. During the event, Operations with the Potential to Drain the Reactor Vessel (OPDRV) were in progress. Actions to immediately suspend OPDRVs were taken.

"Investigation of the cause of the event is in progress. There were no radiological releases associated with this event.

"Declaring secondary containment inoperable is reportable under 10 CFR 50.72(b)(3)(v)(C) as an event or condition that could have prevented the fulfillment of a safety function needed to control the release of radioactive material.

"The licensee has notified the NRC Resident Inspector."

To top of page
Power Reactor Event Number: 52652
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JEREMY COBBS
HQ OPS Officer: VINCE KLCO
Notification Date: 03/30/2017
Notification Time: 21:58 [ET]
Event Date: 03/30/2017
Event Time: 16:30 [PDT]
Last Update Date: 03/30/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
THOMAS HIPSCHMAN (R4DO)
CHRIS MILLER (NRR)
JEFFERY GRANT (IRD)

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

OFFSITE NOTIFICATION DUE TO ONSITE FATALITY

"At 1630 PDT on March 30, 2017, a non-work related fatality occurred on the Diablo Canyon Power Plant property. The individual's work location was outside of the Protected Area. The fatality was not related to the health and safety of the public. Specifically, a contractor for Pacific Gas and Electric (PG&E) was found in the Security Training Building unresponsive. The individual was promptly attended to by Diablo Canyon personnel. The individual was subsequently pronounced dead by the San Luis Obispo County Paramedics.

"PG&E has not observed any heightened public, media, or government concerns as a result of the fatality. Because the fatality is unrelated to Diablo Canyon Power Plant industrial or radiological health and safety, no news release is planned.

"Because the fatality was not work related, nor the result of an accident, no notification to other government agencies was made at the time. However, PG&E will make a notification to the California Occupational Safety and Health Administration. Thus this ENS notification is in response to a notification to another government agency in accordance with 10 CFR 50.72(b)(2)(xi).

"The NRC Senior Resident Inspector and Resident Inspector have been notified."

Page Last Reviewed/Updated Friday, March 31, 2017
Friday, March 31, 2017