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Event Notification Report for February 12, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
2/11/2019 - 2/12/2019

** EVENT NUMBERS **


53815 53857 53859 53867

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!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 53815
Facility: PILGRIM
Region: 1     State: MA
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: PAUL GALLANT
HQ OPS Officer: DONALD NORWOOD
Notification Date: 01/05/2019
Notification Time: 17:30 [ET]
Event Date: 01/05/2019
Event Time: 10:40 [EST]
Last Update Date: 02/11/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 31 Power Operation 31 Power Operation

Event Text



EN Revision Imported Date : 2/12/2019

EN Revision Text: POTENTIAL LOSS OF MSIV SCRAM FUNCTION DURING MAIN STEAM LINE ISOLATION VALVE TESTING

"At approximately 1040 EST on January 5, 2019, during evaluation of test results for the 'C' Main Steam Isolation Valve (MSIV), it was determined that closure of three of four Main Steam Lines would not necessarily have resulted in a full scram during testing due to failure of a limit switch (LS-6) associated with MSIV-1C while in the test configuration. This condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v), 'Any event or condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to: (A) Shut down the reactor and maintain it in a safe shutdown condition.'

"The system was restored from the testing configuration at 1057 EST and the failed trip channel was placed in the tripped condition at 1326 EST thus restoring the design function. There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

* * * RETRACTION AT 1529 EST ON 02/11/19 FROM JOSEPH FRATTASIO TO JEFF HERRERA * * *

"The purpose of the notification is to retract ENS Notification 53815 made on 01/05/19 for Pilgrim Nuclear Power Station. The previous notification reported that there was a potential loss of Main Steam Isolation Valve (MSIV) scram function during main steam line isolation valve testing, at the time of discovery, due to failure of a limit switch (LS-6) associated with MSIV-1C while in the test configuration. Subsequent evaluation has demonstrated that the scram function credited in the design basis was not lost.
"Specifically, after an Engineering Evaluation, it has been determined that the MSIV position RPS logic was not lost for those functions within the design basis and, as such, was capable of performing its intended safety function."

The NRC Resident Inspector has been notified.

Notified the R1DO (Cahill).

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Agreement State Event Number: 53857
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: MIDWEST REGIONAL MEDICAL CENTER
Region: 3
City: ZION   State: IL
County:
License #: IL-01104-01
Agreement: Y
Docket:
NRC Notified By: C. GIBB VINSON
HQ OPS Officer: OSSY FONT
Notification Date: 02/01/2019
Notification Time: 17:22 [ET]
Event Date: 02/01/2019
Event Time: 12:00 [CST]
Last Update Date: 02/01/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMNES CAMERON (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNDER DOSE ADMINISTRATION OF Y-90 SIR-SPHERES

The following was received via email from the state of Illinois:

"Midwestern Regional Medical Center, Inc. (Zion, IL) administered an under dose of Y-90 SIR-Spheres to a patient. The intended dose was 21.06 mCi but only 10.10 mCi was administered. The imaging supervisor called on 02/01/19 to report a possible medical event. The event occurred today at 1200 CST. During the administration the licensee began to feel pressure in the syringe. A smaller gauge syringe was used but made no difference so the treatment was aborted. Clumping of the microspheres in the catheter is suspected as the cause. Only about 52 percent of the dose was delivered. The licensee is still working on the dosimetry, but it appears that a medical event has occurred in any case.

"They intend to treat the patient again after an investigation."

Illinois Item Number: IL 190005

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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Agreement State Event Number: 53859
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: ALEXIAN BROTHERS MEDICAL CENTER
Region: 3
City: ELK GROVE VILLAGE   State: IL
County:
License #: !L-01418-01
Agreement: Y
Docket:
NRC Notified By: GARY FORSEE
HQ OPS Officer: OSSY FONT
Notification Date: 02/04/2019
Notification Time: 17:32 [ET]
Event Date: 02/04/2019
Event Time: 00:00 [CST]
Last Update Date: 02/04/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ROBERT DALEY (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE EXCEEDING 20 PERCENT OF THE PRESCRIBED DOSE

The following was received via email from the state of Illinois:

"Alexian Brothers Medical Center has advised that an attempted intravascular brachytherapy procedure utilizing a Novoste BetaCath System [containing a sealed source of Sr-90] appears to have resulted in a medical event with an underdose exceeding 20 percent of the prescribed dose. The source train was unable to reach the target location after three attempts, stopping approximately 60mm proximal. The source train was retracted without complication after a 'few seconds' during each attempt. The prescribed exposure was 18.4 Gy. The licensee estimates the unintended area receiving dose (aorta) received 0.006 Sv, less than the 0.5 Sv reporting requirement. This matter is being reported due to the fact the intended tissue received less than 20 percent of the intended dose. This event is ongoing and the report will be amended as details become available. This will be reported to NMED today.

"There is no adverse medical consequence expected for the patient."

Item Number: IL 190006

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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Part 21 Event Number: 53867
Rep Org: AZZ NUCLEAR
Licensee: AZZ NUCLEAR
Region: 3
City: CINCINNATI   State: OH
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TRACY BOLT
HQ OPS Officer: BRIAN P. SMITH
Notification Date: 02/08/2019
Notification Time: 18:31 [ET]
Event Date: 10/01/2015
Event Time: 00:00 [EST]
Last Update Date: 02/11/2019
Emergency Class:
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
ANTHONY MASTERS (R2DO)
VINCENT GADDY (R4DO)
- PART 21/50.55 REACTORS (EMAIL)

Event Text

PART 21 - EATON A200 STARTERS DID NOT OPEN WHEN POWER WAS REMOVED

The following is a synopsis of the Part 21 received:

"Pursuant to l0CFR 21.21(d)(3)(ii), AZZ Nuclear is providing initial written notification of the identification of a deviation.

"PDMS material has been identified in the Eaton A200 series starters/contactors with date code T4115 (41st week of 2015) which is outside the range of May 2008 to December 2012 that were originally identified in NRC Event Number 51611 from 2015. This resulted in a few instances where the starter did not immediately open when the power was removed."

Point of contact for additional information:
Tracy Bolt, Director of Quality Assurance
AZZ Nuclear
7410 Pebble Drive
Ft. Worth, TX 76118


Page Last Reviewed/Updated Tuesday, February 12, 2019
Tuesday, February 12, 2019