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Event Notification Report for August 9, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/08/2017 - 08/09/2017

** EVENT NUMBERS **


52880 52886 52891 52892

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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
Notification Date: 08/01/2017
Notification Time: 10:28 [ET]
Event Date: 07/25/2017
Event Time: [EDT]
Last Update Date: 08/01/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAN SCHROEDER (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

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.

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Fuel Cycle Facility Event Number: 52886
Facility: LOUISIANA ENERGY SERVICES
RX Type:
Comments: URANIUM ENRICHMENT FACILITY
                   GAS CENTRIFUGE FACILITY
Region: 2
City: EUNICE State: NM
County: LEA
License #: SNM-2010
Agreement: Y
Docket: 70-3103
NRC Notified By: NORMA WELLS
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/04/2017
Notification Time: 10:56 [ET]
Event Date: 08/03/2017
Event Time: 15:00 [MDT]
Last Update Date: 08/04/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (a)(4) - ALL SAFETY ITEMS UNAVAILABLE
Person (Organization):
BINOY DESAI (R2DO)
BERNARD STAPLETON (IRD)
GRETCHEN RIVERA-CAPE (NMSS)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

ADMINISTRATIVE CRITICALITY CONTROLS NOT USED

The following was received from the licensee via email:

"(1) Radiological or chemical hazards involved, including isotopes, quantities, and chemical and physical form of any material released.

"There was no material released.

"(2) Actual or potential health and safety consequences to the workers, the public, and the environment, including relevant chemical and radiation data for actual personnel exposures to radiation or radioactive materials or hazardous chemicals produced from licensed materials (e.g., level of radiation exposure, concentration of chemicals, and duration of exposure);

"No personnel were exposed to radiation, radioactive materials or hazardous chemicals. IROFS54a [Items Relied On For Safety] and IROFS54b are administrative criticality controls for the SCDT [Small Component Decontamination Train] and limit the amount of U-235 to less than 730g. The material was put into the SCDT without using bookkeeping procedures which could have potentially led to a criticality in the SCDT.

"(3) The sequence of occurrences leading to the event, including degradation or failure of structures, systems, equipment, components, and activities of personnel relied on to prevent potential accidents or mitigate their consequences; and

"Last week material from the pH adjustment tanks on the LECTS [Liquid Effluent Collection and Transfer System] slab tanks was moved into the SCDT without the use of administrative criticality control IROFS54a and 54b. During a work package review yesterday (8/3/2017) the transfer into the SCDT was questioned by the lSA engineering group. Material was approximately 250ml of waste water and 12L of NaOH solution in a 5 gallon bottle. Conservative estimate of the total amount of U-235 in the Slab Tanks at the time the 250ml of waste water was removed was less than 600 g U-235.

"(4) Whether the remaining structures, systems, equipment, components, and activities of personnel relied on to prevent potential accidents or mitigate their consequences are available and reliable to perform their function;

"The amount of material transferred into the SCDT was below subcritical mass limits therefore UUSA [URENCO USA] could not enter into a condition in which 10 CFR 70.61 performance requirements would not have been met

"(5) External conditions affecting the event;

"None.

"(6) Additional actions taken by the licensee in response to the event;

"When the event was discovered an anomalous condition was declared and Recycling and Engineering made a conservative estimate of how much material could potentially be in the SCDT. It was determined that if they had transferred all of the waste water from the slab tank into the SCDT it would still have been below the acceptance criteria for IROFS54a and IROFS54b. Furthermore the 250mL of waste water and the 12L of NaOH solution were transferred in a 5 gallon container which is a single parameter safe value for 6 w/o% enrichment. Based on this discovery at no time would the SCDT have exceeded 10 CFR 70.61 performance requirements.

"(7) Status of the event (e.g., whether the event is on-going or was terminated);

"No event took place, the material transferred to the SCDT never exceeded subcritical mass limits.

"(8) Current and planned site status, including any declared emergency class;

"No emergency class declared. Stop work issued for the LECTS and Decontamination room recycling activities. Anomalous condition is in the process of being lifted

"(9) Notifications, related to the event, that were made or are planned to any local, State, or other Federal agencies;

"One hour (late) report to the NRC; this is a conservative response based on a prior NOV. No other notifications were made.

"(10) Status of any press releases, related to the event that were made or are planned.

"None."

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Power Reactor Event Number: 52891
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: DAVID O'DONNELL
HQ OPS Officer: VINCE KLCO
Notification Date: 08/08/2017
Notification Time: 20:22 [ET]
Event Date: 08/08/2017
Event Time: 15:54 [EDT]
Last Update Date: 08/08/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MARK JEFFERS (R3DO)

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

HIGH PRESSURE CORE SPRAY SYSTEM SUPPRESSION POOL LEVEL INSTRUMENTATION INOPERABLE

"On August 8, 2017, at 1554 hours [EDT], during restoration from testing of the High Pressure Core Spray (HPCS) Suppression Pool Level High Instrumentation, unexpected as-left indications were found that impacted both of the required channels of instrumentation. Subsequent venting of the instrumentation lines was completed and both channels of instrumentation are reading consistent with previously taken as-found data. The instrumentation was declared OPERABLE at 1635. The initial cause of the unexpected as-left indications appears to be the introduction of air into the instrumentation lines during the calibration activities.

"This is considered a loss of safety function based on both of the HPCS Suppression Pool Level High Instrumentation channels being declared INOPERABLE and the loss of the automatic HPCS suction swap to the Suppression Pool on a high level. This event is being reported in accordance with 10 CFR 50.72(b)(3)(v)(D). The [NRC Resident Inspector] has been notified."

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Power Reactor Event Number: 52892
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: RONALD FRY
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/08/2017
Notification Time: 22:33 [ET]
Event Date: 08/08/2017
Event Time: 20:44 [EDT]
Last Update Date: 08/08/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
BRICE BICKETT (R1DO)

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

LOSS OF SECONDARY CONTAINMENT DIFFERENTIAL PRESSURE

"On August 8th, 2017 at 2044 hrs. [EDT] a loss of secondary containment differential pressure (D/P) occurred due to an apparent equipment failure. This caused a reduction in Reactor Building Zone II (Unit 2) D/P to less than the required 0.25 inch WC [water column] per SR [Surveillance Requirement] 3.6.4.1.1.

"Reactor Building Zone II Exhaust Fans were manually swapped and Reactor Building Zone II D/P was restored to greater than 0.25 inch WC by 2112 hrs.

"Reactor Building Zone 1 (Unit 1) and Zone 3 (Units 1&2) ventilation remained in service and stable.

"This event is being reported under 10 CFR 50.72(b)(3)(v)(c) and per the guidance of NUREG 1022 Rev 3 section 3.2.7 as a loss of a Safety Function. There is no redundant Susquehanna Secondary Containment system."

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Wednesday, August 09, 2017
Wednesday, August 09, 2017