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Event Notification Report for July 03, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
7/2/2018 - 7/3/2018

** EVENT NUMBERS **


53468 53470 53484 53485 53486

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Agreement State Event Number: 53468
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: EMORY UNIVERSITY
Region: 1
City: Atlanta   State: GA
County:
License #: GA 153-1
Agreement: Y
Docket:
NRC Notified By: IRENE BENNETT
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 06/22/2018
Notification Time: 14:26 [ET]
Event Date: 06/21/2018
Event Time: 00:00 [EDT]
Last Update Date: 07/02/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ART BURRITT (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DOSE MISADMINISTRATION

The following information was received from the State of Georgia via email;

"RMP [Georgia Radioactive Materials Program] received a call regarding an event that occurred at the main Emory Campus. A 57 year old male was treated on June 21, 2018 with 81.1 mCi of Y-90 Therasphere. The treatment site was the right lobe of the liver. Approximately an hour after the treatment the patient was scanned. The scan indicated that approximately 80% of the administered dose went to the left lobe, 10% went to the right lobe and some went to the stomach and some went to the 1st portion of the duodenum. It was determined there was a vessel spasm during the treatment that caused the theraspheres to shunt to the left lobe of the liver."

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.

Georgia Incident Report # 3.

* * * UPDATE FROM IRENE BENNETT TO VINCE KLCO ON 6/2/2018 AT 1426 EDT * * *

The following information was received from the State of Georgia via email:

"[The Georgia Radioactive Materials Program] received Emory's report regarding the Y-90 procedure and verified the backflow to the left lobe was due to shunting. Based on this information, [Georgia has] determined that this is not a medical event. All documentation will be filed in the licensee's file and electronically."

Notified the R1DO (Powell) and the NMSS Events Group via email.

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Agreement State Event Number: 53470
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: GOOD SAMARITAN HOSPITAL
Region: 3
City: CINCINNATI   State: OH
County:
License #: 02120310022
Agreement: Y
Docket:
NRC Notified By: MICHAEL RUBADUE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 06/25/2018
Notification Time: 11:11 [ET]
Event Date: 06/25/2018
Event Time: 00:00 [EDT]
Last Update Date: 06/25/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
AARON McCRAW (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

OHIO AGREEMENT STATE REPORT - LOST IODINE-125 SEED

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

"An I-125 seed, approximately 127 microCi, was retrieved from a breast seed localization patient on 6/20/18. A gamma probe was used during surgery to verify it was present in the tissue sample. After surgery the sample was x-rayed and surveyed to verify the seed was still present in the sample; the tissue was placed in a formalin tray and locked in a cabinet. Pathology dissected the tissue on 6/21/18 and did not find the seed. The licensee believes the seed was loosely attached to the tissue and was thrown away with the rest of the materials after it was x-rayed. The licensee performed surveys and did not locate the source. Due to the low activity of the source, it is not expected that the public dose limit would be exceeded."

Ohio NMED Report No.: OH180005

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Power Reactor Event Number: 53484
Facility: VOGTLE
Region: 2     State: GA
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: KEVIN LOWE
HQ OPS Officer: VINCE KLCO
Notification Date: 07/03/2018
Notification Time: 12:00 [ET]
Event Date: 07/03/2018
Event Time: 09:54 [EDT]
Last Update Date: 07/03/2018
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):
RANDY MUSSER (R2DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 100 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP DUE TO HIGH STEAM GENERATOR WATER LEVEL

"At 0954 [EDT] on July 3, 2018, with Unit 1 in Mode 1 at 100 percent power, the reactor was manually tripped due to high steam generator water level. The trip was not complex, with all systems responding normally. Operations stabilized the plant in Mode 3. Decay heat is being removed through the main steam lines through the steam dumps and into the condenser.

"The expected 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).

"Unit 2 was not affected.

"There was no impact to the health and safety of the public or plant personnel.

"The NRC Resident Inspectors have been notified."

All control rods inserted and Unit 1 is in an electrical shutdown lineup. The cause of the high steam generator water level transient is being investigated.

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!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 53485
Facility: CALLAWAY
Region: 4     State: MO
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: JEREMY CZESCHIN
HQ OPS Officer: VINCE KLCO
Notification Date: 07/03/2018
Notification Time: 19:07 [ET]
Event Date: 07/03/2018
Event Time: 15:15 [CDT]
Last Update Date: 07/31/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
GEOFFREY MILLER (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 AN UNANALYZED CONDITION THAT SIGNIFICANTLY DEGRADES PLANT SAFETY

"On July 3, 2018, while performing a review of Emergency Operating Procedures, a concern was identified regarding the potential for excessive loss of ultimate heat sink inventory (UHS) through the auxiliary feedwater (AFW) system mini-flow recirculation pathway. This condition would have the potential to prevent the ultimate heat sink from providing an adequate inventory of water for a 30-day mission time.

"The normal water supply for the Callaway AFW system is the condensate storage tank (CST). The CST is a non-safety grade component. The safety-grade supply for AFW is the essential service water (ESW) system. The ESW system is supplied by the UHS. The UHS thermal performance analysis accounts for a loss of UHS inventory to the AFW system up until the point of the accident sequence that the AFW pumps would be secured. The analysis did not include an allowance for loss of UHS inventory through the AFW mini-flow recirculation pathway following the AFW pumps being secured. The EOP guidance that secures the AFW pumps does not isolate the mini-flow recirculation pathway.

"Initial estimates indicate that loss of UHS inventory through the mini-flow recirculation pathway, if not isolated, would preclude the UHS from completing its 30-day mission time. This potential for depletion of the UHS placed the plant in an unanalyzed condition that significantly degraded safety.

"Callaway has issued interim guidance to the on-shift personnel regarding this concern to ensure that the ultimate heat sink water level is maintained at a level that will be adequate to mitigate the potential loss of inventory.

"This condition is reportable per 10 CFR 50.72(b)(3)(ii)(B) for an unanalyzed condition that significantly degrades safety.

"The NRC Resident Inspectors have been notified of this condition."

* * * RETRACTION ON 07/31/2018 AT 1430 EDT FROM LEE YOUNG TO ANDREW WAUGH * * *

"Event Notification (EN) 53485, made on July 3, 2018, is being retracted because re-evaluation performed subsequent to the notification has demonstrated, based on actual plant equipment and environmental conditions, that the unanalyzed inventory losses previously reported by EN 53485 would not have depleted the UHS inventory to an unacceptable level during its 30-day mission time.

"The re-evaluation has led to the conclusion that the previously unanalyzed losses of UHS inventory would not have prevented the UHS from performing its specified safety functions and meeting its 30-day mission time requirements. With the UHS capable of performing its specified safety functions and meeting its 30-day mission time requirements, the systems supported by the UHS would have remained capable of performing their specified safety functions. Based on these considerations, it has been determined that the condition reported in EN 53485 did not result in the plant being in an unanalyzed condition that significantly degraded safety. Consequently, the condition did not meet the criteria for an 8-hour notification per 10 CFR 50.72(b)(3)(ii)(B) for an unanalyzed condition that significantly degrades safety.

"The NRC Resident Inspector has been notified of the Event Notification retraction."

Notified R4DO (Gaddy).

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Power Reactor Event Number: 53486
Facility: HARRIS
Region: 2     State: NC
Unit: [1] [] []
RX Type: [1] W-3-LP
NRC Notified By: DAVID FISHMAN
HQ OPS Officer: STEVEN VITTO
Notification Date: 07/03/2018
Notification Time: 23:27 [ET]
Event Date: 07/03/2018
Event Time: 17:53 [EDT]
Last Update Date: 07/03/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
RANDY MUSSER (R2DO)
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

TURBINE TRIP SOLENOID FAILED TO ACTUATE DURING TESTING

"At 1753 on 7/3/2018 it was discovered that both sets of turbine trip solenoids were previously unable to actuate within allowable time frames; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v). At the time of discovery, one set of turbine trip solenoids had been restored.

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."


Page Last Reviewed/Updated Friday, May 03, 2019
Friday, May 03, 2019