| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
02/23/2018 - 02/26/2018 ** EVENT NUMBERS ** |
 | Non-Agreement State | Event Number: 53200 | Rep Org: CENTRO DE RADIOTERAPIA
Licensee: CENTRO DE RADIOTERAPIA
Region: 1
City: HATO REY State: PR
County:
License #: 52-30937-01
Agreement: N
Docket:
NRC Notified By: LUIS RIVERA
HQ OPS Officer: ANDREW WAUGH | Notification Date: 02/08/2018
Notification Time: 14:47 [ET]
Event Date: 02/06/2018
Event Time: [EST]
Last Update Date: 02/23/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(b) - PATIENT INTERVENTION DAMAGE
| Person (Organization):
RAY POWELL (R1DO)
DOUGLAS BOLLOCK (NMSS)
NMSS_EVENTS_NOTIFICA (EMAI)
| Event Text SKIN REACTION RESULTING FROM RADIATION THERAPY
The following event was received from Auxilio Mutuo Radiation Therapy Center via phone:
A patient who had undergone three gynecological intracavitary brachytherapy procedures was noticed to have a skin reaction. The skin reaction was noticed on the third of the three treatments occurring on 1/24/2018. At this point, it was unclear if the skin reaction was related to the treatments. On 2/6/2018, the attending physician saw the patient and declared that the skin reaction was caused by the radiation treatments, because it had progressed to moist desquamation.
The prescribed dose was 400 cGy per fraction for 3 fractions for a total of 1,200 cGy to a depth of 5 cm.
This event is under further investigation.
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.
* * * UPDATE ON 02/23/2018 AT 1245 EST FROM LUIS RIVERA TO STEVEN VITTO * * *
The following is an excerpt from the licensees submittal received via email:
"Following review of the aforementioned information, it was now clear that the reaction was radiation related, and the incident report was carried out on that same day as per protocol.
"The dose estimate for skin directly in contact with the surface of the 'internal catheter' is between 51.54 Gy and 85.55 Gy."
Notified R1DO (Burritt), NMSS (Bollock), and NMSS Events Notification via email. |
| !!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!! | | Agreement State | Event Number: 53218 | Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: VERSO MINNESOTA WISCONSIN LLC
Region: 3
City: Stevens Point State: WI
County:
License #: 141-1258-01
Agreement: Y
Docket:
NRC Notified By: KRISTA KUHLMAN
HQ OPS Officer: THOMAS KENDZIA | Notification Date: 02/16/2018
Notification Time: 15:46 [ET]
Event Date: 01/28/2018
Event Time: [CST]
Last Update Date: 02/21/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
AARON McCRAW (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
| Event Text AGREEMENT STATE REPORT - SHUTTER WOULD NOT OPEN
The following was received from the State of Wisconsin:
"On February 16, 2018 WI DHS [Wisconsin Department of Health Services] was notified that at the licensee's Stevens Point facility a scanning gauge had a malfunction with the automatic control mechanism and the shutter would not open. The issue was originally identified by the licensee's on-site [personnel] on January 28, 2018 and a service provider was able to fix the issue on January 31, 2018. The corporate RSO [Radiation Safety Officer] became aware of the issue after an on-site visit on February 15, 2018 and reported it to WI DHS the next day. The department will follow-up with the licensee to determine the cause of the shutter control mechanism failure and delay in reporting issues to the corporate RSO."
Wisconsin Event: WI 180006
* * * RETRACTION FROM KRISTA KUHLMAN TO DONALD NORWOOD AT 1437 EST ON 2/21/2018 * * *
This event has been determined to not be reportable. This OPS notice should be retracted.
Notified R3DO (Peterson) and via E-mail NMSS Events Notification group. |
| Power Reactor | Event Number: 53227 | Facility: GRAND GULF
Region: 4 State: MS
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: JAY COMFORT
HQ OPS Officer: STEVEN VITTO | Notification Date: 02/23/2018
Notification Time: 18:04 [ET]
Event Date: 02/18/2018
Event Time: 00:06 [CST]
Last Update Date: 02/23/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
| Person (Organization):
GREG PICK (R4DO)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | N | Y | 97 | Power Operation | 97 | Power Operation | Event Text EMERGENCY DIESEL GENERATORS INOPERABLE
"On February 18, 2018, Grand Gulf Nuclear Station experienced the concurrent inoperability of two Emergency Diesel Generators [DG]. This event is being reported as a late 8-hour non-emergency notification per 10 CFR 50.72(b)(3)(v)(D) as an 'Event or Condition that Could Have Prevented Fulfillment of a Safety Function (Accident Mitigation).'
"On February 14, 2018 at 0100 [CST], the Division 2 Diesel Generator was declared inoperable, and subsequently removed from service for maintenance. On February 18, 2018 at 0006 [CST], the Division 3 Diesel Generator Jacket Water temperature exceeded the trip setpoint and Division 3 Diesel Generator was declared inoperable. The Division 2 Diesel Generator was restored and declared operable on February 18, 2018 at 0355 [CST], and the Division 3 Diesel Generator was restored and declared operable on February 18, 2018 at 1240 [CST]. As a result, Technical Specification Condition 3.8.1.E was entered at 0006 [CST] on February 18, 2018 and exited at 0355 [CST] on February 18, 2018.
"Technical Specification Bases 3.8.1.E.1 states 'With two DGs inoperable, there is one remaining standby AC source. Thus, with an assumed loss of offsite electrical power, insufficient standby AC sources are available to power the minimum required ESF functions.'
"Offsite power was available throughout this event and there was no impact to the health and safety of the public or plant personnel.
"The NRC Resident Inspector has been notified." |
| Power Reactor | Event Number: 53228 | Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: MICHAEL SMITH
HQ OPS Officer: STEVEN VITTO | Notification Date: 02/23/2018
Notification Time: 20:29 [ET]
Event Date: 02/23/2018
Event Time: 17:50 [EST]
Last Update Date: 02/23/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
| Person (Organization):
ART BURRITT (R1DO)
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 | | 2 | N | Y | 100 | Power Operation | 100 | Power Operation | Event Text FITNESS FOR DUTY - MISUSE OF A CONTROLLED SUBSTANCE BY SUPERVISORY PERSONNEL
"At 1750 [EST] on 2/23/2018 credible information was obtained that a non-licensed supervisory person had intentionally misused a controlled substance. Unescorted access has been withdrawn. Per 10 CFR 26.719(b)(2)(i) this is a 24 hour reportable event.
"The NRC Resident Inspector has been notified." |
| Power Reactor | Event Number: 53229 | Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [ ] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: RYAN ROBILLARD
HQ OPS Officer: DAN LIVERMORE | Notification Date: 02/25/2018
Notification Time: 11:24 [ET]
Event Date: 02/25/2018
Event Time: 03:30 [EST]
Last Update Date: 02/25/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
| Person (Organization):
ART BURRITT (R1DO)
FFD GROUP (EMAI)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 3 | N | Y | 100 | Power Operation | 100 | Power Operation | Event Text VIOLATION OF FITNESS FOR DUTY POLICY
A non-licensed employee was found in violation of the sites Fitness for Duty Policy. The employee's access authorization to the plant has been terminated.
The NRC Resident Inspector has been notified. | |