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Event Notification Report for May 1, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/28/2017 - 05/01/2017

** EVENT NUMBERS **


52697 52703 52704 52715 52716 52718

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Agreement State Event Number: 52697
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NOT PROVIDED
Region: 1
City: NOT PROVIDED State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JANAKI KRISHNAMOORTHY
HQ OPS Officer: DONG HWA PARK
Notification Date: 04/20/2017
Notification Time: 15:38 [ET]
Event Date: 04/12/2017
Event Time: [EDT]
Last Update Date: 04/20/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - LESS THAN INTENDED DOSE ADMINISTERED TO THE PATIENT

The following information was provided by the State of New York via facsimile:

"On 04/12/2017, a patient with widespread neoplasm of liver, intrahepatic bile duct, received treatment with Y90 SIRTEX microspheres to 2 separate segments in the right lobe. The intended activities were 0.946 GBq (25.6 mCi) to a small segment and 2.38 GBq (64.3 mCi) to the large segment.

"On 4/18/17, during a review of the patient's medical record, the AU [authorized user] physician discovered that the activity ordered for the large lesion was 0.38 GBq, not 2.38 GBq, as the written directive had stated. NYS DOH [New York State Department of Health] was informed on 4/19/17. Both the patient and the referring physician have been informed. AU physician stated that there is no harm to the patient, because they plan to administer the deficit dose to this segment in the right lobe during the procedure scheduled to treat the left lobe next month.

"The licensee stated that documentation/communication appears to be the primary cause. Facility is investigating. Will update when more information becomes available."

NY Event Report ID No. NYDOH-NY-17-07

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: 52703
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: MEDICAL UNIVERSITY OF SOUTH CAROLINA
Region: 1
City: CHARLESTON State: SC
County:
License #: 081
Agreement: Y
Docket:
NRC Notified By: JIM PETERSON
HQ OPS Officer: DONG HWA PARK
Notification Date: 04/21/2017
Notification Time: 14:37 [ET]
Event Date: 04/20/2017
Event Time: [EDT]
Last Update Date: 04/21/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - DELIVERED DOSE LESS THAN PRESCRIBED DOSE

The following information was provided by the State of South Carolina via email:

"On April 21, 2017, the licensee provided notification of a medical event that occurred on April 20, 2017. The licensee stated that a patient was administered a dose of Y-90 SIR-Spheres for treatment of a liver tumor. During the treatment process, the tubing used to administer the SIR-Spheres became clogged, and the full dose could not be administered. The prescribed dose for the patient was 120 Gy. The dose delivered to the patient was 90 Gy. The licensee indicated that the required written report detailing the event is being completed, and will be submitted to the Department [South Carolina Department of Health and Environmental Control] within the next few days. Updates to this event will be made through the NMED system."

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: 52704
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: MISTRAS GROUP, INC.
Region: 4
City:  State: LA
County:
License #: LA-10986-L01
Agreement: Y
Docket:
NRC Notified By: JOSEPH NOBLE
HQ OPS Officer: DONG HWA PARK
Notification Date: 04/21/2017
Notification Time: 17:05 [ET]
Event Date: 04/20/2017
Event Time: 12:30 [CDT]
Last Update Date: 04/21/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - UNSECURED RADIOGRAPHY CAMERA

The following report was received from the State of Louisiana via email:

"Event type: The source/exposure device, a QSA Global 880D s/n # D11837 loaded with 86.7 Ci Ir-192 source s/n #53959G, was left in an unlocked transport buggy and left unattended while the crew took a work break and moved to another work location at the site. Three crew members were in the area, but could not maintain surveillance of the unsecured source. The Bechtel Safety Officer walked up to the transport vehicle and observed the exposure device not secured or locked in the transport vehicle and the Mistras personnel did not have direct surveillance of the transport vehicle. The source incident was reported to the Mistras Group's RSO. Human error, operator distracted.

"Notifications: LDEQ [Louisiana Department of Environmental Control] was notified directly by [the Mistras Group's RSO] to an inspector during office hours approximately 1600 [CDT] on 04/20/2017.

"Event description: On 04/20/2017, approximately 1230 [CDT], the Bechtel Safety Office, BSO, made a site visit to where a Mistras Group crew was working on a liquid natural gas pipeline in Cameron Parish. The BSO observed an exposure device in an unlocked and unattended Mistras vehicle. The Mistras crew was working at this temporary jobsite and moved to help another crew member working at the site. The crew became distracted and left the vehicle unattended and unlocked. The BSO contacted the Mistras RSO about the incident. [The Mistras RSO] investigated and reported the incident to LDEQ. The incident was under control with no possible radiation exposures to the crew members or the general public.

"A LDEQ investigator was contacted to follow-up on the report."

Event Report ID No.: LA-17005.

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Power Reactor Event Number: 52715
Facility: MONTICELLO
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: JASON BREVIG
HQ OPS Officer: BETHANY CECERE
Notification Date: 04/28/2017
Notification Time: 21:21 [ET]
Event Date: 04/28/2017
Event Time: 16:43 [CDT]
Last Update Date: 04/28/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
KARLA STOEDTER (R3DO)

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

Event Text

OFFSITE NOTIFICATION FOR RELEASE OF WASTEWATER

"This report is being made pursuant to 10 CFR 50.72(b)(2)(xi), as an event where notification to other government agencies has been made. On April 28, 2017, notification to the Minnesota State Duty Office was made due to a non-compliance with release of wastewater requirements in the Monticello Nuclear Generating Plant's National Pollutant Discharge Elimination System permit. There were no consequences to the health and safety of the public."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 52716
Facility: SOUTH TEXAS
Region: 4 State: TX
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BRAD HARDT
HQ OPS Officer: JEFF ROTTON
Notification Date: 04/29/2017
Notification Time: 17:59 [ET]
Event Date: 04/29/2017
Event Time: 16:23 [CDT]
Last Update Date: 04/29/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
MICHAEL HAY (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 15 Power Operation 15 Power Operation
2 N Y 90 Power Operation 90 Power Operation

Event Text

OFFSITE NOTIFICATION DUE TO SMALL GRASS FIRE IN OWNER CONTROLLED AREA

"A grass fire was reported to the Unit 1 control room at 1102 CDT. The grass fire was reported to be in the owner controlled area 1/2 mile west of the protected area and switchyard. The local fire department was dispatched to fight the grass fire. The fire was reported to be out at 1155 CDT. No plant equipment was damaged and the operation of the plant was not affected. Region 12 (Houston) of the Texas Commission of Environmental Quality (TCEQ) was notified of the event at 1623 CDT for visible emissions resulting from the grass fire. No further actions are required by the TCEQ at this time and no press release is planned."

An insulator on a 345 kV line failed and the attached line separated and hit the ground. A spark was created when the 345 kV line hit the ground and started a fire that eventually grew to a 20 feet x 20 feet area.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 52718
Facility: SEABROOK
Region: 1 State: NH
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: PAUL DUNDIN
HQ OPS Officer: BETHANY CECERE
Notification Date: 04/29/2017
Notification Time: 21:19 [ET]
Event Date: 04/29/2017
Event Time: 18:44 [EDT]
Last Update Date: 04/29/2017
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):
RAY MCKINLEY (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 12 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP DUE TO STEAM GENERATOR HI-HI LEVEL SIGNAL AND FEEDWATER ISOLATION

"At 1844 [EDT] on 04/29/2017, while the unit was in a low power condition exiting from a refueling outage, the reactor was manually tripped following a P-14 signal (Steam Generator Hi-Hi Level) and a resulting feedwater isolation signal. All control rods were verified to be fully inserted. The cause of the ['B'] steam generator high level is currently being investigated.

"Emergency feedwater actuated at 1845 due to a low-low water level in steam generator 'D'. Plant equipment response is being evaluated and the plant is stabilized in Mode 3 with decay heat removal through the steam dump system to the condensers. There was no release and the emergency feedwater system has been restored to standby.

"The event description is based on information currently available. If through subsequent reviews of this event, additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow up notification will be made via the ENS or under the reporting requirements of 10 CFR 50.73."

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Monday, May 01, 2017
Monday, May 01, 2017