Event Notification Report for July 12, 2017
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/11/2017 - 07/12/2017
Power Reactor
Event Number: 52850
Facility: WATTS BAR
Region: 2 State: TN
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DAVID ALLEN
HQ OPS Officer: DONG HWA PARK
Region: 2 State: TN
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DAVID ALLEN
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/12/2017
Notification Time: 16:05 [ET]
Event Date: 07/12/2017
Event Time: 12:38 [EDT]
Last Update Date: 07/12/2017
Notification Time: 16:05 [ET]
Event Date: 07/12/2017
Event Time: 12:38 [EDT]
Last Update Date: 07/12/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
BRIAN BONSER (R2DO)
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 | Cold Shutdown | 0 | Cold Shutdown |
UNANALYZED CONDITION RELATED TO GDC-5 [GENERAL DESIGN CRITERION-5] FOR DUAL UNIT OPERATION
"On July 12, 2017, at 1238 Eastern Daylight Time (EDT), Watts Bar Nuclear Plant (WBN) determined that a preliminary analysis shows adequate Essential Raw Cooling Water (ERCW) flow may not be in place during dual unit limiting design basis conditions of one unit in Hot Shutdown on Residual Heat Removal (RHR) cooling when the other unit experiences a Loss of Coolant Accident (LOCA). Based on preliminary analysis, during a Unit 1 LOCA, Unit 1 receives adequate flow when following existing procedural guidance; however, Unit 2 may not receive adequate flow to meet cool-down requirements with design basis maximum temperatures. During a Unit 2 LOCA, however, current procedural guidance is not adequate to ensure the proper system alignment to establish correct ERCW Component Cooling Water (CCS) Heat Exchanger A and B flow rates for either unit's cool down requirements.
"Unit 2 has been shutdown for an extended period of time such that the flow delivered by ERCW is adequate to serve both Unit 1 in a LOCA and Unit 2 in less than Mode 3.
"The NRC Resident Inspector has been notified."
"On July 12, 2017, at 1238 Eastern Daylight Time (EDT), Watts Bar Nuclear Plant (WBN) determined that a preliminary analysis shows adequate Essential Raw Cooling Water (ERCW) flow may not be in place during dual unit limiting design basis conditions of one unit in Hot Shutdown on Residual Heat Removal (RHR) cooling when the other unit experiences a Loss of Coolant Accident (LOCA). Based on preliminary analysis, during a Unit 1 LOCA, Unit 1 receives adequate flow when following existing procedural guidance; however, Unit 2 may not receive adequate flow to meet cool-down requirements with design basis maximum temperatures. During a Unit 2 LOCA, however, current procedural guidance is not adequate to ensure the proper system alignment to establish correct ERCW Component Cooling Water (CCS) Heat Exchanger A and B flow rates for either unit's cool down requirements.
"Unit 2 has been shutdown for an extended period of time such that the flow delivered by ERCW is adequate to serve both Unit 1 in a LOCA and Unit 2 in less than Mode 3.
"The NRC Resident Inspector has been notified."
Agreement State
Event Number: 52851
Rep Org: COLORADO DEPT OF HEALTH
Licensee: UNIVERSITY OF COLORADO HOSPITAL
Region: 4
City: AURORA State: CO
County:
License #: CO 828-01
Agreement: Y
Docket:
NRC Notified By: SHIYA WANG
HQ OPS Officer: VINCE KLCO
Licensee: UNIVERSITY OF COLORADO HOSPITAL
Region: 4
City: AURORA State: CO
County:
License #: CO 828-01
Agreement: Y
Docket:
NRC Notified By: SHIYA WANG
HQ OPS Officer: VINCE KLCO
Notification Date: 07/13/2017
Notification Time: 10:33 [ET]
Event Date: 07/12/2017
Event Time: 11:00 [MDT]
Last Update Date: 07/13/2017
Notification Time: 10:33 [ET]
Event Date: 07/12/2017
Event Time: 11:00 [MDT]
Last Update Date: 07/13/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - MISADMINISTRATION OF TREATMENT
The following information was received from the State of Colorado via email:
"This is an initial report regarding a misadministration event in Colorado.
"University of Colorado Hospital (License Number: CO 828-01) had a misadministration of Y-90 microspheres (SIRTex SIRSpheres) on Wednesday, July 12, 2017. At approximately 11 [MDT], the post administration measurements of the waste from the SIRSpheres Administration indicated that the activity administered to segment 2/3 of the patient's liver was only 68.7 percent of the prescribed activity. The written directive called for an activity of 0.24 GBq and residual waste activity measurements indicated that 0.165 GBq was delivered. The physician indicated that stasis was not reached during the administration to this segment. There was a separate administration to segment [four] of the liver in which stasis was reached.
"Follow-up information will be provided after they are available."
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.
The following information was received from the State of Colorado via email:
"This is an initial report regarding a misadministration event in Colorado.
"University of Colorado Hospital (License Number: CO 828-01) had a misadministration of Y-90 microspheres (SIRTex SIRSpheres) on Wednesday, July 12, 2017. At approximately 11 [MDT], the post administration measurements of the waste from the SIRSpheres Administration indicated that the activity administered to segment 2/3 of the patient's liver was only 68.7 percent of the prescribed activity. The written directive called for an activity of 0.24 GBq and residual waste activity measurements indicated that 0.165 GBq was delivered. The physician indicated that stasis was not reached during the administration to this segment. There was a separate administration to segment [four] of the liver in which stasis was reached.
"Follow-up information will be provided after they are available."
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.