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Event Notification Report for May 11, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
5/10/2018 - 5/11/2018

** EVENT NUMBERS **


53375 53376 53377 53395 53396 53398

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Agreement State Event Number: 53375
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: H.B. FULLER
Region: 4
City: VANCOUVER   State: WA
County:
License #: WN-R-0859
Agreement: Y
Docket:
NRC Notified By: TRISTAN HAY
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/02/2018
Notification Time: 17:05 [ET]
Event Date:
Event Time: [PDT]
Last Update Date: 05/02/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - SHUTTER TEST FAILED

The following information was obtained from the state of Washington via email:

"[The licensee] called on 4-4-2018 to tell the state that their GL [General License] device failed the shutter test. He said the device was placed out of use and is being sent back to the manufacturer."

Washington State Incident Number WA-18-011

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Agreement State Event Number: 53376
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: EARTH SOLUTIONS NW
Region: 4
City: BELLEVUE   State: WA
County:
License #: WA-WN-I0560-1
Agreement: Y
Docket:
NRC Notified By: JAMES KILLINGBECK
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/02/2018
Notification Time: 19:22 [ET]
Event Date:
Event Time: [PDT]
Last Update Date: 05/02/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DAMAGED GAUGE

The following information was obtained from the state of Washington via email:

"Earth Solutions NW (ESNW) reported that a moisture/density gauge (CPN model MC-1-DR, serial #MD60308232) was crushed on 7/2/2013 at temporary jobsite in Mill Creek, Washington. The gauge contained a 1.85 GBq (50 mCi) Am-Be source (model CPN-131, serial #AM8232) and a 0.37 GBq (10 mCi) Cs-137 source (model CPN-131, serial #C8232). The gauge operator had placed the gauge in front of his truck. When asked to move his truck, he forgot about the gauge, moved the truck forward, and crushed the gauge. The source rod was retrieved using a shovel and placed in a bucket of sand. Radiation surveys revealed no radioactive contamination at the jobsite. The source rod and other parts of the gauge were returned to the ESNW facility. On 7/17/2013, Hevly Technical Services (gauge contractor) and Washington Department of Health personnel performed leak tests on the Cs-137 and Am-Be sources. Washington State Public Health Laboratories analyzed the leak test samples and detected no radioactivity. The Cs-137 source rod was reinserted into the gauge body and secured with duct tape. The gauge was then placed into its shipping container. Hevly Technical Services transported the gauge to Qal-Tek Associates (radioactive waste broker) for disposal. To prevent recurrence, ESNW provided additional training to gauge users on proper handling, transporting, storage, and emergency procedures."

NMED Item Number: 130311

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Agreement State Event Number: 53377
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: SWEDISH MEDICAL CENTER
Region: 4
City: SEATTLE   State: WA
County:
License #: WA-WN-M008-1
Agreement: Y
Docket:
NRC Notified By: JAMES KILLINGBECK
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/02/2018
Notification Time: 19:53 [ET]
Event Date: 01/23/2018
Event Time: 11:30 [PDT]
Last Update Date: 05/02/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY AZUA (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - PATIENT RECEIVED DOSE LESS THAN PRESCRIBED DOSE

The following information was obtained from the state of Washington via email:

"Swedish Medical Center (SMC) reported that a patient prescribed to receive 725 MBq (19.59 mCi) of Y-90 microspheres (Sirtex Medical model SIR-Spheres) to the left lobe of the liver, only received 370 MBq (10 mCi). SMC planned a two-artery feed, using 360 MBq (9.73 mCi) per artery per sub lobe. The written directive called for a total of 725 MBq (19.59 mCi) split into two doses. The certified nuclear medicine technologist who drew the dose did not properly review the written directive's instruction to split the total dose into two doses. Instead, the technologist split 370 MBq (10 mCi) into two doses of 190 and 180 MBq (5.14 and 4.86 mCi), respectively. Prior to patient administration, the radiation oncologist also failed to check the drawn doses prior to injecting them. The incident was identified post-injection when the remaining 360 MBq (9.73 mCi) of the original 725 MBq (19.59 mCi) was discovered. The physicians involved believe that the diminished dose may still provide the treatment sought. They will follow up on the patient in six months and will, if deemed necessary, retreat the liver lesions. The referring physician and patient were informed of the incident. SMC's investigation identified several errors: lack of comprehension regarding the dose draw worksheet, miscommunication and failure to review the written directive prior to correcting a dose, and failure to perform a safety pause and properly review the dose to be administered against the written directive prior to administration. Corrective actions included modifying the dose draw spreadsheet, training the nuclear medicine department with regards to the spreadsheet, and modifying the treatment record sheet to include a formal procedural pause prior to administration. The Washington Department of Health, Office of Radiation Protection, did not anticipate conducting an onsite investigation."

NMED Item Number: 180058

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: 53395
Facility: NINE MILE POINT
Region: 1     State: NY
Unit: [] [2] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: CHRIS MOORHEAD
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/10/2018
Notification Time: 08:59 [ET]
Event Date:
Event Time: [EDT]
Last Update Date: 05/11/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
ANNE DeFRANCISCO (R1DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

VALID EMERGENCY DIESEL START ON PARTIAL LOSS OF OFFSITE POWER

"At 0248 [EDT], with the plant shutdown in Mode 4, Nine Mile Point Unit 2 experienced a partial loss of off-site power during relay testing that resulted in an automatic start of the Division 2 Emergency Diesel Generator. All systems responded as expected for the event. The cause is being investigated. The station responded in accordance with appropriate Special Operating Procedures and restored impacted systems.

"This event is being reported in accordance with 10CFR50.72(b)(3)(iv)(A)"

At the time of the report, the emergency diesel generators are loaded and supplying plant safety equipment.

The licensee has notified the state of New York Emergency Management Agency and the NRC Resident Inspector.

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Power Reactor Event Number: 53396
Facility: OCONEE
Region: 2     State: SC
Unit: [] [] [3]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: BEN MCCALL
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 05/10/2018
Notification Time: 17:03 [ET]
Event Date:
Event Time: [EDT]
Last Update Date: 05/11/2018
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
FRANK EHRHARDT (R2DO)
WILLIAM GOTT (IRD)
CHRIS MILLER (NRR EO)
BRIAN HOLIAN (DNRR)
LAURA DUDES (R2DRA)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Refueling 0 Refueling

Event Text

NOTIFICATION OF UNUSUAL EVENT

"Unit 3 experienced a loss of AC power while in Mode 6. Power was regained automatically from Keowee via the underground path.

"Decay heat removal has been restored. Spent fuel cooling has been restored.

"Emergency procedures [are] in progress."

The Licensee notified the senior NRC resident inspector, State of South Carolina and local authorities.

The total loss of 4160 volt AC power was for approximately 30 seconds. The unit is refueled and reactor reassembly complete up to bolting on the reactor head. There was no effect on Units 1 and 2.

Notified DHS SWO, FEMA Ops Center, FEMA NWC, DHS NICC, and NuclearSSA

* * * UPDATE FROM SCOTT HAWKESWORTH TO HOWIE CROUCH AT 0554 EDT ON 5/11/18 * * *

At 0530 EDT, Oconee terminated the notification of unusual event on Unit 3. The basis for termination was that offsite power was restored and the plant is now in its normal shutdown electrical lineup.

The licensee has notified Oconee and Pickens counties and will be notifying the NRC Resident Inspector.

Notified R2DO (Ehrhardt), NRR EO (Miller), IRD MOC (Gott), DHS SWO, FEMA Operations Center, DHS NICC, FEMA NWC (email) and NuclearSSA (email).

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Power Reactor Event Number: 53398
Facility: WATTS BAR
Region: 2     State: TN
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: CHUCK BROESCHE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 05/11/2018
Notification Time: 15:19 [ET]
Event Date:
Event Time: [EDT]
Last Update Date: 05/11/2018
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):
FRANK EHRHARDT (R2DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 58 Power Operation 58 Power Operation

Event Text

CONTAINMENT SHIELD BUILDING INOPERABLE

"At 1011 EDT on May 11, 2018, Containment Shield Building Annulus differential pressure exceeded the required limit. The Shield Building was declared inoperable requiring entry into Technical Specification (TS) 3.6.15 Conditions A and B. The event was initiated by failure of the operating annulus vacuum fan. Main Control Room Operators manually started the stand-by annulus vacuum fan to recover pressure. Shield Building Annulus differential pressure was restored to the required value at 1016 EDT and TS 3.6.15 Condition A and B were exited on May 11, 2018 at 1016 EDT.

"The failure mechanism for the annulus vacuum fan is being investigated.

"The Containment Shield Building ensures the release of radioactive material from the containment atmosphere is restricted to those leakage paths and associated leakage rates assumed in the accident analysis during a Loss of Coolant Accident (LOCA). The Emergency Gas Treatment System (EGTS) would have automatically started and performed its design function to maintain the Shield Building Annulus differential pressure within required limits.

"The event is being reported pursuant to 10 CFR 50.72(b)(3)(v)(C) and 10 CFR 50.72(b)(3)(v)(D). The NRC Resident has been notified."


Page Last Reviewed/Updated Monday, June 18, 2018
Monday, June 18, 2018