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Event Notification Report for October 15, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/12/2018 - 10/15/2018

** EVENT NUMBERS **


53430 53649 53662 53663 53664 53665 53666

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Agreement State Event Number: 53430
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSITY OF PENNSYLVANIA
Region: 1
City: PHILADELPHIA   State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: STEVEN VITTO
Notification Date: 05/29/2018
Notification Time: 14:48 [ET]
Event Date: 05/25/2018
Event Time: 00:00 [EDT]
Last Update Date: 10/12/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GLENN DENTEL (R1DO)
GRETCHEN RIVERA-CAPELLA (NMSS DAY)
NMSS_EVENTS_NOTIFICATION (EMAIL)
PATRICIA MILLIGAN (INES)

Event Text

AGREEMENT STATE REPORT - PATIENT SKIN CONTAMINATION

The following was received from the Commonwealth of Pennsylvania via email:

"On May 29, 2018, the Department's [Bureau of Radiation Protection] staff in Central Office became aware of a medical event (ME) at U PENN hospital in Philadelphia. The ME is reportable as per 10 CFR 35.3045(a)(1)(i) and also meets criteria for an Abnormal Occurrence.

"On May 25, 2018, a 17 year old pediatric patient underwent an 834 millicurie metaiodobenzylguanidine (MIBG) lodine-131 (I-131) treatment for brain cancer. The dose was delivered in a 30 ml syringe and infused via an automatic pump. The nuclear medical technician present during the infusion reported seeing a small amount of blood, but other than that, nothing unusual was noted. However, upon completion of the infusion, meter readings noted high activities on the patient's clothing and bed linen. The possible reason given being a faulty connection line on the automatic pump. The contamination is believed to have also been present on the skin all weekend. Due to the large dose of I-131 infused, the licensee's staff were not able to see the contamination on the patient's skin until he developed erythema. The licensee is in the process of doing a dose reconstruction for the skin contamination. Based on the reading from the patient and estimated activity in the various contaminated items, the licensee currently estimates that approximately 50% of the intended dosage was successfully infused. The authorized user has been informed and is currently notifying the patient's parents and the referring physician.

"A reactive inspection is planned by the Department. More information will be provided upon receipt."

PA Event Report ID No: PA 180012

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 FROM JOHN CHIPPO TO DONALD NORWOOD AT 1451 EDT ON 7/12/2018 * * *

"The University of Pennsylvania (U Penn) reported that a patient's skin became contaminated during medical treatment on 5/25/2018. The 17-year-old pediatric patient was scheduled to receive 30.86 GBq (834 mCi) of I-131 metaiodobenzylguanidine (MIBG) for treatment of brain cancer. The dosage was delivered in a 30 ml syringe and infused via an automatic pump. The nuclear medicine technician present during the infusion saw a small amount of blood, but nothing unusual other than that was noted. However, upon completion of the infusion, radiation surveys revealed high activities of I-131 on the patient's clothing and bed linen.

"U Penn stated that the patient's upper right thigh was cleaned. On 5/27/2018, the patient reported discomfort and reddening (i.e. erythema) on the skin of his upper right thigh, which developed into a lesion and further into desquamation (grade 3) the next day. Radioactive contamination is believed to have been present on the patient's skin for 24 to 48 hours.

"Based on U Penn measurements, nuclear medicine imaging, and the patient's clinical symptoms, the dose to the skin was estimated to be between 50,000 and 120,000 cGy (rad) to a 15 cm2 area. Radiation safety staff consulted with U.S. DOE's REAC/TS in Oak Ridge TN, to verify dose calculations. Calculations of the activity in the waste and the exposure rate from the patient in previous treatments estimated the activity delivered at 15.54 GBq (420 mCi). It was calculated that approximately 7.77 GBq (210 mCi) went to the waste.

"The cause of the incident is believed to be a faulty connection line on the automatic pump. The patient was also disconnected from the infusion pump at the 'Spiros tube' to use the lavatory part way through the procedure. Due to the large dosage of I-131 infused, U Penn staff were unable to detect the contamination on the patient's skin until he developed erythema.

"The authorized user was informed and notified the patient's parents and referring physician. Pennsylvania DEP, Bureau of Radiation Protection, performed a reactive inspection on 6/7 and 6/13/2018. U Penn is conducting a full root cause analysis to develop and implement corrective actions. Procedures that have already been implemented for I-131 MIBG patients included placing absorbent chucks between all parts of the infusion line and the patient's body and requiring an authorized user to be contacted for approval if it is necessary to disconnect a patient during the infusion.

"Root Cause(s): possible equipment failure, training, and/or human error in connecting the line to the infusion pump.

"Actions: A reactive inspection has been completed by the Department. More information will be provided upon receipt from U Penn."

Notified R1DO (Bower), NMSS Events Notification E-mail Group, and INES Coordinator (Milligan).

* * * UPDATE FROM JOHN CHIPPO TO HOWIE CROUCH AT 1102 EDT ON 8/7/18 * * *

The following update was received from the Commonwealth via fax:

"Licensee has provided additional information; Corrective Actions include:

"A complete evaluation is being performed of the infusion system used for this treatment to identify any deficiencies, including comparison of CT imaging of the Spiros connection used in this treatment and an unused one.

"A multidisciplinary I-131 MIBG team with representatives from Nuclear Medicine, Radiation Safety, Nursing and Oncology has been established. The team will meet regularly to review and update policies and procedures for I-131 MIBG therapies. Some immediate steps have included:
(1) use of absorbent material under the administration line over the patient's body,
(2) a change to the administration procedure to require that the infusion not be stopped unless medically necessary and determined by the Authorized User,
(3) planned implementation of continuous patient observation during administration including evaluation of the use of portable video monitoring,
(4) a new procedure has been implemented to address patient fluid management prior to and during infusion,
(5) a review of the infusion system has commenced with focus on the Spiros connector, including additional training on their use.

"Patient specific decontamination procedures have been developed for each treatment treated since the incident. Since decontamination procedures must take into account the patient's age and medical condition, it has been necessary that the medical staff have major input into the procedures for these patients. The knowledge gained from the patient-specific decontamination procedures will be used to refine the decontamination SOP.

"For therapeutic doses in which an activity on the skin that would result in desquamation can be two thousandths of a percent of the dose. It is important to be able to make measurements in these difficult environments. Testing has begun to determine the capabilities of systems that might be used to measure betas in environments in which gammas are several orders of magnitude more abundant than betas.

"Radiation Safety incident response procedures have been revised to include a time out and immediate involvement of additional Health Physics staff during incidents, including during possible Medical Events. The procedure is aimed at refocusing the attention of Health Physicists on all aspects of the incident response, and to prevent the Medical Event reporting requirements from distracting attention from other aspects of the response.

"CAUSE OF THE EVENT:
a) A leak in the system caused by a failure of the Spiros connection in the infusion line.
b) Policies and procedures relating to I-131 MIBG dose administration lacked coordination and oversight. SOPs have been managed separately by each Department (Nursing, Nuclear Medicine, Oncology, and EHRS).
c) Policies and procedures relating to patient contamination and decontamination during dose administration were incomplete.

"ACTIONS: A reactive inspection has been completed by the Department."

Notified R1DO (Cahill), NMSS Events Notification (email), and INES Coordinator (Milligan).

* * * UPDATE FROM JOHN CHIPPO TO OSSY FONT AT 0833 EDT ON 10/12/2018 * * *

The following was received from the Commonwealth of Pennsylvania via email:

"UPDATE 3, clarifications:

"The written directive prescribed 30.23 GBq (817 mCi) of I-131. The dosage administered measured 30.86 GBq (834 mCi) and was delivered over the course of 90 minutes.

"The estimated activity delivered to the correct treatment site was determined to be 22.68 GBq (613 mCi), not 15.54 GBq (420 mCi) as previously reported.

"No decontamination of the patient (right upper thigh) was performed at the time the contamination of bed linens and pants was discovered. This wasn't completed until signs of erythema were present."

PA Event Report ID No: PA 180012

NRC Item# 180252

Notified R1DO (Dentel), and NMSS Events Notification and INES Coordinator (Milligan) via email.

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Agreement State Event Number: 53649
Rep Org: NV DIV OF RAD HEALTH
Licensee: RENOWN REGIONAL MEDICAL CENTER
Region: 4
City: RENO   State: NV
County:
License #: 16-12-0016-01
Agreement: Y
Docket:
NRC Notified By: FAYNE MARTINI
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/05/2018
Notification Time: 17:33 [ET]
Event Date: 10/05/2018
Event Time: 00:00 [PDT]
Last Update Date: 10/05/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - PATIENT UNDERDOSE

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

"This is an email to report a possible medical event. The licensee is Renown Regional Medical Center, the license number is 16-12-0016-01. Occurrence was 10/5/2018 and reported the same day by Renown's RSO. The administration of Y-90 was given, prescribed dose was 15.66mCi and the delivered dose was 9.86mCi. The reason for this was due to patient intervention, apparently the patient moved and pulled the IV [Intravenous therapy] out. A full report from Renown's RSO has not been received, just the initial report."

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: 53662
Facility: SURRY
Region: 2     State: VA
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: JEREMY RIDDICK
HQ OPS Officer: OSSY FONT
Notification Date: 10/12/2018
Notification Time: 01:14 [ET]
Event Date: 10/11/2018
Event Time: 00:00 [EDT]
Last Update Date: 10/12/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
ANTHONY MASTERS (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

ACTUATION OF EMERGENCY DIESEL GENERATOR DUE TO TRANSFORMER TRIP

"On 10/11/18 at 2304, with both Surry Units at 100% power, the 'A' Reserve Station Service Transformer (RSST) tripped on a pilot wire lockout. This resulted in electrical isolation of the 'A' RSST, the 'D' Transfer Bus and the Unit 1 'J' Emergency Bus. The #3 Emergency Diesel Generator (EDG) started and loaded on the Emergency Bus, as designed. Operations entered the appropriate Abnormal Procedures and stabilized the unit. All equipment operated as expected during the event.

"A report of a flash at the 'A' RSST was received (at approximately the time of the initiating event) but there were no reports of visible damage, smoke or fire from the RSST or any associated breakers on subsequent investigation. The #3 EDG is running with normal parameters.

"There was heavy wind/rain in the area associated with Tropical Storm Michael.

"All other electrical distribution systems are in a normal alignment.

"The organization is staffing to evaluate the lockout and required actions for recovery.

"No radiological consequences resulted from this event.

"This event is being reported IAW [in accordance with] 10 CFR 50.52(b)(3)(iv)(A) due to the actuation of the #3 EDG.

"The NRC Resident [Inspector] was notified"

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Power Reactor Event Number: 53663
Facility: CALVERT CLIFFS
Region: 1     State: MD
Unit: [] [2] []
RX Type: [1] CE,[2] CE
NRC Notified By: KEVIN DOUGHERTY
HQ OPS Officer: KAREN COTTON
Notification Date: 10/12/2018
Notification Time: 03:58 [ET]
Event Date: 10/11/2018
Event Time: 00:00 [EDT]
Last Update Date: 10/12/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
GLENN DENTEL (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

AIR START SOLENOID CLOSURE FAILURE

"During a post maintenance start of the 1B diesel generator, the air start solenoid valves did not close as expected. This resulted in lowering air pressure in the common air start headers causing inoperability of the 2A and 2B diesel generators at time 23:03. The 1B diesel generator was isolated from the common air start header, which restored the air start header pressure to the 2A and 2B diesel generators. The 2A and 2B diesel generators were declared operable at 23:34."

The NRC Resident Inspector was notified.

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Part 21 Event Number: 53664
Rep Org: ABB MOTORS AND MECHANICAL
Licensee: ABB MOTORS AND MECHANICAL
Region: 1
City: FLOWERY BRANCH   State: GA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: SHELDON THOMAS
HQ OPS Officer: BETHANY CECERE
Notification Date: 10/12/2018
Notification Time: 15:04 [ET]
Event Date: 08/02/2018
Event Time: 00:00 [EDT]
Last Update Date: 03/04/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
Person (Organization):
GLENN DENTEL (R1DO)
PART 21/50.55 REACTORS (EMAIL)

Event Text

INTERIM PART 21 REPORT - EVALUATION OF MOTORS

The following information was received by from ABB Motors and Mechanical INC by facsimile:

"Pursuant to 10 CFR 21.21(a)(2) this letter provides an interim report concerning an evaluation being performed by ABB Motors and Mechanical Inc. (formerly Baldor Electric Company) on three 40 ft-lb, 56 frame, 2-pole AC electric motors. The issue being evaluated pertains to the abnormal appearance of cracked paint and minor deformation around the stator pin which is located in the motor housing shell.

"The three motors were supplied to Flowserve - Limitorque on a single purchase order in April 2013. The issue being evaluated was identified after MOV production set-up and testing at the valve manufacturing facility. The equipment had not been supplied to a nuclear power plant and thus had not been placed into service.

"The discovery date of the condition being evaluated is August 2, 2018. Evaluation of reportability cannot be completed within the initial evaluation period due to the need to perform additional inspections of motors manufactured in the same period. ABB is working with Flowserve - Limitorque to expedite the additional inspections and testing. It is anticipated that this will be completed by 01/11/2019.

"An initial review of ABB's records indicate that since 1998 ABB has supplied approximately 670, 56-frame AC electric motors of 40 and 60 ft-lb. to Flowserve - Limitorque. Flowserve - Limitorque communicated to ABB that there have been no previously reported occurrences of this issue nor any reported motor failures related to this issue.

"(i) Name and address of the individual or individuals informing the Commission.

"Sheldon Thomas
QA Manager
ABB Motors and Mechanical Inc.
Flowery Branch, GA 30542
(678) 947 7350

"(ii) Identification of the facility, the activity, or the basic component supplied for such facility which fails to comply or contains a defect.

"The basic components being evaluated are Class 1E 40 ft-lb, 56 frame, 2-pole motors supplied to Flowserve - Limitorque for installation on valve actuators to be supplied into nuclear plant applications, to date, no basic components have been determined to contain a defect.

"(iii) Identification of the firm constructing the facility or supplying the basic component which fails to comply or contains a defect.

"The basic components being evaluated were supplied by ABB Motors and Mechanical Inc. (formerly Baldor Electric Company) ("ABB"), No basic components have been determined to contain a defect. This is an interim report.

"(iv) Nature of the defect or failure to comply and the safety hazard which is created or could be created by such defect or failure to comply

"ABB was contacted by our customer Flowserve - Limitorque regarding three 40 ft-lb, 56 frame, 2-pole AC electric motors which were reported to have an abnormal visual appearance of cracked paint and minor deformation of the motor housing material around the stator pin. The motor stator pin is installed through the motor housing shell into the stator assembly. ABB's initial inspection of the three motors suggested that the deformation around the pin may have occurred when the motor was operated during actuator and/or MOV production testing. ABB is evaluating whether this abnormal condition of the stator pin interface with the motor frame constitutes a defect that could potentially affect the safety related function of the motor. To date, no basic components have been determined to contain a defect. This is an interim report.

"(v) The date on which the information of such defect or failure to comply was obtained.

"The discovery date of the condition being evaluated is August 2, 2018,

"(vi) In the case of a basic component which contains a defect or fails to comply, the number and location of these components in use at, supplied for, being supplied for, or may be supplied for, manufactured, or being manufactured for one or more facilities or activities subject to the regulations in this part.

"At this time, no basic components have been determined to contain a defect.

"(vii) The corrective action, which has been, is being, or will be taken; the name of the individual or organization responsible for the action; and the length of time that has been or will be taken to complete the action.

"None at this time,

"(viii) Any advice related to the defect or failure to comply about the facility, activity, or basic component that has been, is being, or will be given to purchasers or licensees.

"None at this time."

* * * UPDATE AT 0815 EST ON 1/11/2019 FROM SHELDON THOMAS TO MARK ABRAMOVITZ * * *

The following information was received via fax:

"This letter is a follow-up to the initial Interim Notification dated October 12, 2018 (Ref. ML18302A229).
ABB continues to work with Flowserve-Limitorque to expedite the additional inspections of motors in the field and testing of motors pulled from inventory. The testing is necessary to assist in determination if the abnormal appearance and deformation constitutes a defect which would cause a substantial safety hazard.

"It is anticipated that this will be completed by February 28, 2019. At that time, motor testing should be complete and analysis of results conducted. ABB will then be able to determine if the nature of the condition is a substantial safety hazard and reportable. If further time is necessary for evaluation, a follow-up to this report will be filed.

"Since discovery of the condition, and to the date of this report, ABB and Flowserve-Limitorque are not aware of any confirmed field inspections by Flowserve-Limitorque's customer or the results of such inspections."

Notified the R1DO (Bower) and Part 21 Reactors Group (via e-mail).

* * * CLOSEOUT RECEIVED AT 1642 EST ON 3/4/20119 FROM SHELDON THOMAS TO MARK ABRAMOVITZ * * *

The following closeout was received by fax:

"ABB has completed the evaluation of the abnormal appearance of the three motors identified in this notification with the determination that this condition does not constitute a defect that would affect the safety related function of the motor."

Notified the R1DO (Werkheiser) and Part 21 Reactors Group (via e-mail).

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Power Reactor Event Number: 53665
Facility: SAINT LUCIE
Region: 2     State: FL
Unit: [] [2] []
RX Type: [1] CE,[2] CE
NRC Notified By: CHARLES PIKE
HQ OPS Officer: BETHANY CECERE
Notification Date: 10/12/2018
Notification Time: 16:54 [ET]
Event Date: 10/12/2018
Event Time: 00:00 [EDT]
Last Update Date: 10/12/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
ANTHONY MASTERS (R2DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 100 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP

"On October 12, 2018 at 1353 EDT, St. Lucie Unit 2 experienced an automatic RPS actuation and Reactor Trip due to a fault on the 2A1 6.9kv bus during a transfer of the bus power supply from the 2A Auxiliary Transformer to the 2A Startup Transformer. The bus fault caused a fire in the 2A1 6.9kv switchgear that has been extinguished. Offsite support was not required to extinguish the fire. The specific cause of the fault is currently under investigation.

"Following the reactor trip, both Steam Generators are being supplied by main feedwater. All [Control Element Assemblies] (CEAs) fully inserted into the core. Decay Heat removal is being accomplished through forced circulation. Main Feedwater and Steam Bypass Control Systems are maintaining stable conditions in Mode 3.

"St. Lucie Unit 1 was unaffected and remains in Mode 1 at 100 percent power.

"This report is submitted in accordance with 10 CFR 50.72(b)(2)(iv)(B) for the Reactor Trip."

The fire was extinguished within 28 minutes. Plant loads are being supplied by the 2B Auxiliary Transformer.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 53666
Facility: GINNA
Region: 1     State: NY
Unit: [1] [] []
RX Type: [1] W-2-LP
NRC Notified By: THOMAS JOACHINCZYK
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 10/14/2018
Notification Time: 07:35 [ET]
Event Date: 10/14/2018
Event Time: 00:00 [EDT]
Last Update Date: 10/14/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
GLENN DENTEL (R1DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 88 Power Operation 88 Power Operation

Event Text

OFFSITE NOTIFICATION DUE TO A SODIUM HYPOCHLORITE LEAK

"Notified New York State Department of Environmental Conservation for draining of sodium hypochlorite (12-15% by weight) from the storage tank into it's engineered secondary containment of approximately 1300 gallons. Reportable per regulation 6 NYCRR Part 597."

The NRC Resident Inspector will be notified by the licensee.

Licensee investigation into the cause of the leak is ongoing.


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Friday, May 03, 2019