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Event Notification Report for December 12, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/11/2017 - 12/12/2017

** EVENT NUMBERS **


53102 53103 53110 53111 53112

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Agreement State Event Number: 53102
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: MCNDT LEASING
Region: 3
City: CHANNAHON State: IL
County:
License #: IL-01875-01
Agreement: Y
Docket:
NRC Notified By: C. GIBB VINSON
HQ OPS Officer: DONG HWA PARK
Notification Date: 12/04/2017
Notification Time: 16:07 [ET]
Event Date: 12/01/2016
Event Time: [CST]
Last Update Date: 12/04/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANN MARIE STONE (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - FAILURE OF SOURCE CONNECTION

The following report was received from the Illinois Emergency Management Agency via email:

"Illinois Emergency Management Agency discovered a radiography incident involving McNDT Leasing, which had not been properly reported. The incident involved an exposure device (QSA Global model 880 Delta, serial #D13616) and a 3.7 TBq (100 Ci) Ir-192 source. A radiography team arrived at a job site on 12/1/2016 and, during equipment set up, noticed the drive cable connector was bent. Upon obtaining a new crank assembly, the team could not successfully crank out the source. The reel of the crank assembly did not move. After another failed attempt, they detached the crank assembly from the exposure device and noticed that place where the connector attaches to the source pigtail was worn and bent. The team returned to their facility and exchanged exposure devices. Preliminary investigation indicated that either the exposure device was damaged in previous work and had not been reported, or daily inspection and maintenance checks were inadequate or not performed prior to 10/11/2017. Corrective actions included obtaining new equipment.

"No exposures occurred since the source was not able to be cranked out of the device."

"Device/Equipment: Camera/ Radiography
Manufacture: QSA Global, Inc.
Model Number: 880 Delta
Equipment Serial Number: D13616

"Radionuclide: Ir-192
Activity: 100 Ci"

Illinois Item Number: 170517

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Agreement State Event Number: 53103
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: AURORA HEALTH CARE SOUTHERN LAKES, INC
Region: 3
City: KENOSHA State: WI
County:
License #: 059-1019-01
Agreement: Y
Docket:
NRC Notified By: DAVID REINDL
HQ OPS Officer: DONG HWA PARK
Notification Date: 12/04/2017
Notification Time: 16:52 [ET]
Event Date: 12/04/2017
Event Time: 11:00 [CST]
Last Update Date: 12/04/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANN MARIE STONE (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - PATIENT RECEIVED LESS THAN PRESCRIBED Y-90 DOSE

The following was received from the State of Wisconsin via email:

"On December 4, 2017, the department [State of Wisconsin Department of Health Services] received a telephone call and email from the licensee's lead nuclear medicine technologist about a Y-90 TheraSphere dose that was not delivered as prescribed to the patient. The procedure occurred at 11:00 AM on December 4, 2017. The written directive stated that the dose delivered should be 120 Gy. The estimated dose delivered to the liver was 17.7 Gy. The nuclear medicine technologist discovered contamination in the operating room where the procedure took place, which implied that some of the dose did not get into the patient during the treatment. The licensee is suspecting that there was an issue with the administration kit. The licensee has contacted the manufacturer and the manufacturer is planning a site visit. The licensee has removed the contaminated administration kit and placed it in a waste bag for decay in storage. The room where the administration occurred has also been cleaned. The department [State of Wisconsin Department of Health Services] will follow up with a site visit to investigate the incident.

"Event Report ID No.: WI170019"

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: 53110
Facility: CLINTON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: DALE SHELTON
HQ OPS Officer: STEVE SANDIN
Notification Date: 12/09/2017
Notification Time: 18:42 [ET]
Event Date: 12/09/2017
Event Time: 13:48 [CST]
Last Update Date: 12/11/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
ANN MARIE STONE (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 98 Power Operation 0 Hot Shutdown

Event Text

MANUAL REACTOR SCRAM DUE TO LOSS OF DIVISION 1 AC POWER TO NUMEROUS COMPONENTS

"At approximately 1347 [CST] on 12/09/17, the Main Control Room received annunciators that indicated a trip of the 4160 V 1A1 breaker 1AP07EJ, 480V XFMR 1A and A1 breaker. Numerous Division 1 components lost power (powered from unit subs 1A and A1). The Division 1 containment Instrument Air isolation valves had failed closed by design due to the loss of power. Due to the loss of containment instrument air, several control rods began to drift into the core as expected and, by procedure, the reactor mode switch was placed in the shutdown position at 1353 [CST]. All control rods fully inserted.

"Also due to the loss of power, the Fuel Building ventilation dampers failed closed by design. With the normal ventilation system secured, secondary containment differential pressure rose to slightly greater than 0 inches water gauge which exceeded the Technical Specification requirement of greater than 0.25 inches vacuum water gauge at 1348 [CST]. The Control Room entered EOP-8, Secondary Containment Control. Secondary Containment differential pressure was restored within Technical Specification requirements at 1351 [CST] by starting the Division 2 Standby Gas Treatment system.

"This event is being reported as a manual actuation of the Reactor Protection System (RPS) and as a Condition that Could Have Prevented Fulfillment of a Safety Function.

"The cause is currently under investigation. The NRC Resident has been notified."

The licensee informed the NRC Resident Inspector.

* * * UPDATE FROM DALE SHELTON TO VINCE KLCO AT 1658 EST ON 12/10/2017 * * *

"During a review of plant logs it was identified that the primary to secondary containment differential pressure was identified to be outside of Technical Specification 3.6.1.4 limits of 0 plus or minus 0.25 psid at 2009 on 12/9/17 due to the primary containment ventilation system dampers closing as a result of the loss of power. This parameter is an initial safety analysis assumption to ensure that primary containment pressures remain within the design values during a Loss of Coolant Accident (LOCA). As a result, this condition is reportable as an unanalyzed condition that significantly degrades plant safety.

"The NRC Senior Resident Inspector has been notified."

Notified the R3DO (Stone).

* * * UPDATE FROM MICHAEL ANTONELLI TO VINCE KLCO ON 12/11/17 AT 1805 EST * * *

"During the post transient review of the trip of the 4160 V 1A1 breaker 1AP07EJ, 480V XFMR 1A and A1, it was identified that the unplanned INOPERABILITY of the Low Pressure Core Spray (LPCS) system due to the loss of power to the injection valve constitutes an event or condition that could have prevented fulfillment of a safety function and is reportable under 10CFR50.72(b)(3)(v)(D) for Accident Mitigation. The High Pressure Core Spray (HPCS) remained available to perform the core spray function, if necessary, during a design basis Loss of Coolant Accident (LOCA), however HPCS and LPCS are each considered single train safety systems.

"The NRC Senior Resident Inspector has been notified."

Notified the R3DO (Stone).

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Power Reactor Event Number: 53111
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [ ] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: JEFF NOLTE
HQ OPS Officer: ANDREW WAUGH
Notification Date: 12/11/2017
Notification Time: 00:35 [ET]
Event Date: 12/10/2017
Event Time: 23:50 [EST]
Last Update Date: 12/11/2017
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
SHAKUR WALKER (R2DO)
BO PHAM (IRD)
CATHERINE HANEY (R2 R)
BRIAN HOLIAN (NRR)

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

UNUSUAL EVENT DUE TO A SMOKE DETECTOR ALARM RECEIVED INSIDE CONTAINMENT

"St. Lucie Unit 1 declared an Unusual Event due to a smoke detector alarm received in the Unit 1 Containment Building that was unable to be confirmed within 15 minutes. A Containment entry was completed and no evidence of fire was found. The Unusual Event was terminated at 00:26 on 12/11/17.

"State and local officials have been notified by the licensee.

"The NRC Resident Inspector has been notified of this by licensee."

Notified DHS SWO, FEMA Operations Center, DHS NICC, FEMA NWC (email), and DHS Nuclear SSA (email).

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Power Reactor Event Number: 53112
Facility: WATTS BAR
Region: 2 State: TN
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BRIAN McILNAY
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 12/11/2017
Notification Time: 11:06 [ET]
Event Date: 12/11/2017
Event Time: 08:57 [EST]
Last Update Date: 12/11/2017
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):
SHAKUR WALKER (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 97 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP IN RESPONSE TO INDICATION OF MULTIPLE DROPPED CONTROL RODS

"While operating at 97% power, the Watts Bar Unit 2 reactor was manually tripped at 0857 EST on December 11, 2017 due to multiple dropped control rods. All control and shutdown bank rods inserted properly in response to the manual reactor trip. All safety systems including Auxiliary Feedwater actuated as designed. The plant is stable with decay heat removal through Auxiliary Feedwater and the Steam Dump System.

"The cause of the dropped rods is being investigated.

"The manual actuation of the Reactor Protection System (RPS) is being reported as a four hour report under 10 CFR 50.72 (b)(2)(iv)(B). The actuation of the Auxiliary Feedwater System (an engineered safety feature) is being reported as an eight hour report under 10 CFR 50.72 (b)(3)(iv)(A).

"The NRC Senior Resident Inspector has been notified for this event."

No safety or relief valves lifted during this event.

Page Last Reviewed/Updated Tuesday, December 12, 2017
Tuesday, December 12, 2017