Event Notification Report for February 12, 2019
|
U.S. Nuclear Regulatory Commission Event Reports For ** EVENT NUMBERS ** |
| 53815 | 53857 | 53859 | 53867 |
| !!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!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). |
| 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. |
| 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. |
| 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 Wednesday, March 24, 2021
Page Last Reviewed/Updated Wednesday, March 24, 2021