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Event Notification Report for August 16, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
8/15/2018 - 8/16/2018

** EVENT NUMBERS **


53539 53548 53551

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Agreement State Event Number: 53539
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: KETTERING MEDICAL CENTER
Region: 3
City: KETTERING   State: OH
County: MONTGOMERY
License #: 02120580021
Agreement: Y
Docket:
NRC Notified By: MICHAEL J RUBADUE
HQ OPS Officer: BRIAN LIN
Notification Date: 08/08/2018
Notification Time: 16:46 [ET]
Event Date: 08/02/2018
Event Time: 00:00 [EDT]
Last Update Date: 08/08/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
PATRICIA MILLIGAN (INES)
DAN COLLINS (EMAIL)

Event Text

AGREEMENT STATE REPORT - PATIENT OVEREXPOSURE

The following information was received via E-mail:

"The licensee reported to the [Ohio] Department [of Health] on 8/3/2018 that a potential medical event had occurred due to a delay in a surgical procedure. The delay was caused by the insurance company rescinding approval to remove a breast tumor until three medical opinions were obtained. The licensee implanted a 472 microCi I-125 seed [radioactive seed localization] (RSL) in the tumor on 5/29/2018 after receiving approval from the insurance company. The surgery was scheduled for 6/4/2018. The expected dose to the patient was 12.65 Rem to the tissue and 1.52 Rem EDE [Effective Dose Equivalent]. The surgery was delayed until approval from the insurance company was obtained, and was performed on 8/2/2018. The delay resulted in a tissue dose of 99.45 Rem and EDE of 11.93 Rem.

"A follow-up will be conducted with the routine inspection in September."

Ohio State Report: OH180006

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: 53548
Facility: BEAVER VALLEY
Region: 1     State: PA
Unit: [] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: ROB KLINDWORTH
HQ OPS Officer: RICHARD SMITH
Notification Date: 08/12/2018
Notification Time: 02:58 [ET]
Event Date: 08/12/2018
Event Time: 01:58 [EDT]
Last Update Date: 08/16/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
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

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN - LOSS OF 480 VOLTAGE EMERGENCY BUS

"On 8-12-18 at 0158 EDT, Beaver Valley Unit 2 experienced a loss of 480 Volt 2P Emergency Bus. This resulted in a Loss of Safety Function due to the 2-2 Emergency Diesel Generator [EDG] being Inoperable coincident with the Residual Heat Release Valve (2SVS-HCV104). A Technical Specification shutdown is required per LCO 3.0.3."

The Licensee also stated they were in an unanalyzed condition due to the EDG and Residual Heat Release Valve being inoperable at the same time.

The Licensee is shutting down to Mode 5 (Cold Shutdown).

The Licensee is notifying the Resident Inspector.

The Licensee will be making a Press Release about the unplanned shutdown.


* * * UPDATE ON 08/16/2018 AT 1424 EDT FROM BLASE BARTKO TO KEN MOTT * * *

"On 8-12-18 at 0158 [EDT] Beaver Valley Unit 2 experienced a loss of 480 Volt 2P Emergency Bus. Per operational guidance, this was determined to be a Loss of Safety Function due to the Unit 2 Emergency Diesel Generator (EDG) being INOPERABLE coincident with the Residual Heat Release Valve (2SVS-HCV104) 10 CFR 50.72(b)(3)(v)(B) and (D). This was also reported as an Unanalyzed Condition 10 CFR 50.72(b)(3)(ii)(b).

"No Press Release was performed for this event.

"The NRC Resident Inspector was notified.

"At 0410 [EDT] a Technical Specification Shutdown was commenced 10 CFR 50.72(b)(2)(i).

"At 2011 [EDT] the 480 Volt 2P Emergency Bus was restored and energized.

"Further evaluation of the event has determined that this event was not an Unanalyzed Condition and did not result in a Loss of Safety Function. The classifications of Unanalyzed Condition and Loss of Safety Function are being retracted.

"The accuracy of the existing guidance relative to Safety Function has been entered in the Corrective Action Program and interim actions have been taken to provide accurate guidance."

Notified R1DO (Young) via email.

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Power Reactor Event Number: 53551
Facility: BYRON
Region: 3     State: IL
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN CONROY
HQ OPS Officer: KENNETH MOTT
Notification Date: 08/16/2018
Notification Time: 12:08 [ET]
Event Date: 08/16/2018
Event Time: 08:40 [CDT]
Last Update Date: 08/16/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
KARLA STOEDTER (R3DO)
FFD GROUP (EMAIL)
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 TEST POSITIVE FOR LICENSED EMPLOYEE

"In accordance with 10 CFR 26.719(b)(2)(ii), this notification reports a licensed Operations employee had a confirmed positive for alcohol during a random fitness for duty test. The individual was not in the protected area and not performing licensed duties at the time of discovery. The employee's access to the plant has been suspended.

"The NRC Resident Inspector has been notified."


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