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Event Notification Report for August 16, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/15/2017 - 08/16/2017

** EVENT NUMBERS **


52890 52903 52904 52905 52908

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Agreement State Event Number: 52890
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: LOMA LINDA MEDICAL CENTER
Region: 4
City: SAN BERNARDINO State: CA
County:
License #: 0060-36
Agreement: Y
Docket:
NRC Notified By: KATHLEEN HARKNESS
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/08/2017
Notification Time: 17:12 [ET]
Event Date: 08/04/2017
Event Time: [PDT]
Last Update Date: 08/08/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HEATHER GEPFORD (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - Y-90 TREATMENT UNDERDOSE

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

"The RSO [Radiation Safety Officer] of Loma Linda Medical Center notified the RHB [Radiologic Health Branch] Brea ICE [Inspection, Compliance and Enforcement] office on August 7, 2017, that a medical event occurred on Friday, August 4, 2017. A patient was admitted to the hospital for treatment of liver carcinoma. The treatment plan involved use of Nordion model TheraSpheres (Y-90 glass microspheres manual brachytherapy) for radio-embolism to the right lobe of the liver. The patient's written directive called for aggregate treatment of 121Gy (5.241 GBq) of Y-90 to the right lobe target area, but only 9.7 Gy (0.420 GBq) was delivered. The overall percent delivery to target tissue was 8.1%.

"The patient's lung dose from shunting was 1.01 Gy at 4.8% lung shunting factor. The patient and referring physician were informed of the event on 8/4/2017. The medical event is still being investigated, but is thought that a slow injection flowrate may have caused sedimentation of the microspheres in the delivery system. After a few days for decay, a more intensive review of the delivery system will be conducted."

CA 5010 Number: 080417

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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Power Reactor Event Number: 52903
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: STEPHEN J. KAPOSTASY
HQ OPS Officer: DONG HWA PARK
Notification Date: 08/15/2017
Notification Time: 04:58 [ET]
Event Date: 08/14/2017
Event Time: 22:57 [EDT]
Last Update Date: 08/15/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
AARON McCRAW (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

SECONDARY CONTAINMENT MOMENTARY LOW VACUUM

"On August 14th, 2017 at 2257 [EDT], while shutting down the Annulus Exhaust Gas Treatment System (AEGTS) Train B, secondary containment pressure momentarily lowered. This resulted in the Technical Specification (TS) for Secondary Containment to not be met for 15 seconds. The minimum Secondary Containment vacuum observed during that time was 0.52 inch of vacuum water gauge.

"Secondary Containment pressure was returned to within the TS operability limit of 0.66 inch of vacuum water gauge (TS SR 3.6.4.1.1) by the AEGTS Train A that remained in operation. There were no radiological releases associated with this event.

"Declaring Secondary Containment inoperable is reportable under [10 CFR] 50.72(b)(3)(v)(C) & (D) for an event or condition that could have prevented the fulfillment of a safety function of a system that is needed to:(C) Control the release of radioactive material; or (D) Mitigate the consequences of an accident.

"The licensee has notified the NRC Resident Inspector."

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Power Reactor Event Number: 52904
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: TODD STRINGFELLOW
HQ OPS Officer: DONALD NORWOOD
Notification Date: 08/15/2017
Notification Time: 08:07 [ET]
Event Date: 08/15/2017
Event Time: 07:48 [EDT]
Last Update Date: 08/15/2017
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
HAROLD GRAY (R1DO)
BRIAN HOLIAN (NRR)
DAVID LEW (R1 D)
WILLIAM GOTT (IRD)
CHRIS MILLER (NRR)

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

UNUSUAL EVENT DUE TO FIRE ALARM IN CONTAINMENT

On August 15, 2017 at 0748 EDT, an Unusual Event was declared at Millstone Unit 2 due to a fire alarm indication in containment that was unable to be verified extinguished within 15 minutes. Current containment parameters do not indicate an actual fire. A containment entry is planned to verify that there is no fire. Unit 2 continues at 100% power. Unit 3 was unaffected. The NRC remains in Normal mode.

The licensee notified the NRC Resident Inspector and State and local government agencies.

Notified DHS SWO, FEMA Ops Center, DHS NICC. Notified FEMA National Watch and Nuclear SSA via E-mail.


* * * UPDATE FROM TODD STRINGFELLOW TO DONALD NORWOOD AT 0953 EDT ON 8/15/2017 * * *

At 0951 EDT, the Unusual Event was terminated. No signs of an actual fire were present upon containment entry. All alarms are cleared and they are investigating the cause of the alarm.

The licensee notified the NRC Resident Inspector and State and local government agencies.

Notified R1DO (Gray), NRR EO (Miller), and IRD (Gott). Notified DHS SWO, FEMA Ops Center, DHS NICC. Notified FEMA National Watch and Nuclear SSA via E-mail.

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Power Reactor Event Number: 52905
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: MAUREEN KARIUKI
HQ OPS Officer: VINCE KLCO
Notification Date: 08/15/2017
Notification Time: 14:07 [ET]
Event Date: 08/15/2017
Event Time: 11:46 [CDT]
Last Update Date: 08/15/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
THOMAS FARNHOLTZ (R4DO)

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

DISCOVERY OF NON-CONFORMING CONDITIONS DURING TORNADO HAZARDS ANALYSIS

"On August 15, 2017, during evaluation of protection for Technical Specification (TS) equipment from the damaging effects of tornados, Callaway Plant identified a non-conforming condition in the plant design such that specific Technical Specification equipment is considered not to be adequately protected from tornado missiles.

"The recirculation lines for all three independent trains of Auxiliary Feedwater (AFW) connect to the Condensate Storage Tank (CST) inside the CST Valve House, which is not a tornado missile-resistant structure. The direct impact by a design basis missile could result in crimping of the recirculation lines, thereby creating the potential to cause damage to the Train A and B Motor-Driven Auxiliary Feedwater Pumps (MDAFPs) and the Turbine-Driven Auxiliary Feedwater Pump (TDAFP) by restricting recirculation flow to less than the design requirements.

"This condition is reportable per 10 CFR 50.72(b)(3)(ii)(B) for any event or condition that results in the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety, and per 10 CFR 50.72(b)(3)(v) for any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to (A) shut down the reactor and maintain it in a safe shutdown condition, (B) remove residual heat, or (D) mitigate the consequences of an accident.

"These conditions are being addressed in accordance with NRC's Enforcement Guidance Memorandum EGM 15-002 and Interim Staff Guidance DSS-ISG-2016-01 [enforcement discretion and interim guidance documents].

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 52908
Facility: RIVER BEND
Region: 4 State: LA
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: JACK MCCOY
HQ OPS Officer: JEFF HERRERA
Notification Date: 08/15/2017
Notification Time: 20:21 [ET]
Event Date: 08/15/2017
Event Time: 15:13 [CDT]
Last Update Date: 08/15/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
FFD GROUP (EMAI)

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

FITNESS FOR DUTY - BLIND SAMPLE RETURNED WITH INACCURATE RESULTS

"A blind sample provided from an independent laboratory to fleet testing facility was returned with inaccurate results. This is in violation of 10 CFR 26.719(c)(3) and requires a 24-hour report."

The licensee has notified the NRC Resident Inspector.

Page Last Reviewed/Updated Wednesday, August 16, 2017
Wednesday, August 16, 2017