Event Notification Report for July 25, 2017
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/24/2017 - 07/25/2017
Agreement State
Event Number: 52880
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: FORT SANDERS REGIONAL MEDICAL CENTER
Region: 1
City: KNOXVILLE State: TN
County:
License #: R-47003
Agreement: Y
Docket:
NRC Notified By: ANDREW HOLCOMB
HQ OPS Officer: JEFF HERRERA
Licensee: FORT SANDERS REGIONAL MEDICAL CENTER
Region: 1
City: KNOXVILLE State: TN
County:
License #: R-47003
Agreement: Y
Docket:
NRC Notified By: ANDREW HOLCOMB
HQ OPS Officer: JEFF HERRERA
Notification Date: 08/01/2017
Notification Time: 10:28 [ET]
Event Date: 07/25/2017
Event Time: 00:00 [EDT]
Last Update Date: 08/01/2017
Notification Time: 10:28 [ET]
Event Date: 07/25/2017
Event Time: 00:00 [EDT]
Last Update Date: 08/01/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
DAN SCHROEDER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
DAN SCHROEDER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - MISADMINISTRATION DUE TO PROBLEM WITH A DELIVERY CATHETER
The following report was received from the Tennessee Department of Environmental Conservation Division of Radiological Health via email:
"[A] Yttrium-90 TheraSpheres patient procedure misadministration [occurred] due to [a] 'kinked' delivery catheter. [Approximately] 60 Gray [was] administered of [the] prescribed 120 Gray. [Two] manufacturer representatives were in attendance throughout procedure, 'proctoring' the physician. According to both proctors, the case was performed per manufacturer instructions, but unfortunately, the kinked catheter prohibited the complete dose from being administered."
Tennessee Radiological Event No. TN-17-147
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 report was received from the Tennessee Department of Environmental Conservation Division of Radiological Health via email:
"[A] Yttrium-90 TheraSpheres patient procedure misadministration [occurred] due to [a] 'kinked' delivery catheter. [Approximately] 60 Gray [was] administered of [the] prescribed 120 Gray. [Two] manufacturer representatives were in attendance throughout procedure, 'proctoring' the physician. According to both proctors, the case was performed per manufacturer instructions, but unfortunately, the kinked catheter prohibited the complete dose from being administered."
Tennessee Radiological Event No. TN-17-147
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.
Power Reactor
Event Number: 52872
Facility: WATTS BAR
Region: 2 State: TN
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BRIAN MCLINAY
HQ OPS Officer: VINCE KLCO
Region: 2 State: TN
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BRIAN MCLINAY
HQ OPS Officer: VINCE KLCO
Notification Date: 07/25/2017
Notification Time: 11:07 [ET]
Event Date: 07/25/2017
Event Time: 04:28 [EDT]
Last Update Date: 07/25/2017
Notification Time: 11:07 [ET]
Event Date: 07/25/2017
Event Time: 04:28 [EDT]
Last Update Date: 07/25/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
ALAN BLAMEY (R2DO)
ALAN BLAMEY (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | M/R | N | 0 | Hot Standby | 0 | Hot Standby |
MANUAL REACTOR TRIP DUE TO ROD POSITION INDICATION SYSTEM BEING INOPERABLE
"On July 25, 2017, at 0428 Eastern Daylight Time (EDT) Watts Bar Nuclear Plant (WBN) Unit 2 was in Mode 3, beginning a Reactor Startup. While in the initial phase of withdrawing the first of four Control Rod banks, the two associated group demand position indicators deviated greater than 2 steps from each other. In accordance with Technical Requirement 3.1.7, Position Indication System, Shutdown, with one or more group demand position indicators inoperable, the reactor trip breakers are to be opened immediately. Operations personnel opened the reactor trip breakers immediately by initiating a manual trip of the Reactor Protection System (RPS). The Auxiliary Feedwater system was in service and controlling Steam Generator water levels at the time of the event and did not receive any valid actuation signals. No other system actuations occurred as a result of this reactor trip and all systems operated as designed.
"The cause of the position indication system inoperability is currently under investigation.
"NRC Resident Inspector has been notified."
"On July 25, 2017, at 0428 Eastern Daylight Time (EDT) Watts Bar Nuclear Plant (WBN) Unit 2 was in Mode 3, beginning a Reactor Startup. While in the initial phase of withdrawing the first of four Control Rod banks, the two associated group demand position indicators deviated greater than 2 steps from each other. In accordance with Technical Requirement 3.1.7, Position Indication System, Shutdown, with one or more group demand position indicators inoperable, the reactor trip breakers are to be opened immediately. Operations personnel opened the reactor trip breakers immediately by initiating a manual trip of the Reactor Protection System (RPS). The Auxiliary Feedwater system was in service and controlling Steam Generator water levels at the time of the event and did not receive any valid actuation signals. No other system actuations occurred as a result of this reactor trip and all systems operated as designed.
"The cause of the position indication system inoperability is currently under investigation.
"NRC Resident Inspector has been notified."