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Event Notification Report for July 04, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
7/3/2019 - 7/4/2019

** EVENT NUMBERS **


54132 54144 54145 54147

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Agreement State Event Number: 54132
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: CONE HEALTH WESLEY LONG HOSPITAL
Region: 1
City: GREENSBORO   State: NC
County:
License #: 041-0153-1
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: CATY NOLAN
Notification Date: 06/26/2019
Notification Time: 15:45 [ET]
Event Date: 06/24/2019
Event Time: 00:00 [EDT]
Last Update Date: 06/26/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DONNA JANDA (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - ADMINISTERED DOSE DIFFERENT THAN PRESCRIBED

The following was received from the North Carolina Radioactive Materials Branch via email:

"On 6/24/19, a patient underwent a Xofigo therapy treatment and did not receive the full dose as prescribed but had to return the following day to receive the full dose on 6/25/19. Due to the size of the patient and the fact that Xofigo doses typically arrive to the licensee in 10cc syringes, [in order] to accommodate the patient with the correct dose, the dose prescribed to the patient was split between two doses/syringes. On 6/24/19, licensee personnel delivered the first dose of 119.19 microCuries (Ra-223) which was approximately 50 percent of the prescribed dose. It was discovered after the patient was discharged that the remaining dose was still in the hot lab. The prescribing physician was immediately notified and the patient returned the following day, 6/25/19, and received the second dose of 114.5 microCuries (Ra-223). NC Radiation protection is currently investigation this incident and will follow up to close and complete this report."

NC tracking number: 190021

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: 54144
Facility: BRUNSWICK
Region: 2     State: NC
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: STEPHEN YODERSMITH
HQ OPS Officer: ANDREW WAUGH
Notification Date: 07/03/2019
Notification Time: 12:42 [ET]
Event Date: 05/09/2019
Event Time: 20:00 [EDT]
Last Update Date: 07/03/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
ROBERT WILLIAMS (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

60 DAY OPTIONAL NOTIFICATION DUE TO ACTUATION OF AN EMERGENCY DIESEL GENERATOR

"This 60-day optional telephone notification is being made in lieu of an LER submittal, as allowed by 10 CFR 50.73(a)(1). This notification is made pursuant to the reporting requirements specified in 10 CFR 50.73(a)(2)(iv)(A) for an invalid actuation of one of the systems listed in 10 CFR 50.73(a)(2)(iv)(B).

"At approximately 2000 EDT on May 9, 2019, an invalid actuation of emergency diesel generator (EDG) 1 occurred. At the time, EDG 1 was removed from service for planned maintenance. The invalid actuation occurred when the starting air clearance was being lifted while simultaneously performing a Post Maintenance Test (PMT) where an external DC power source was applied to a relay that provided continuity directly to the starting air solenoids. As a result, the air start solenoids were energized causing EDG 1 to start.

"EDG 1 started and functioned successfully. The actuation was complete; EDG 1 successfully started and ran unloaded. The actuation was not initiated in response to actual plant conditions, it was not an intentional manual initiation, and there were no parameters satisfying the requirements for initiation of the system. Therefore, this event has been determined to be an invalid actuation.

"This event did not result in any adverse impact to the health and safety of the public."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 54145
Facility: SOUTH TEXAS
Region: 4     State: TX
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ROBERT TATRO
HQ OPS Officer: ANDREW WAUGH
Notification Date: 07/03/2019
Notification Time: 15:24 [ET]
Event Date: 07/03/2019
Event Time: 10:26 [CDT]
Last Update Date: 07/03/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MARK HAIRE (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION DUE TO RADIO TRANSMITTER OUT OF SERVICE

"At 1026 CDT on July 3, 2019, the National Weather Service notified the South Texas Project (STP) that the Bay City NOAA radio transmitter was out of service. This affects the tone alert radios used to notify the public in the event of an emergency condition.

"This condition impacts the ability to readily notify a portion of the Emergency Planning Zone (EPZ) population for the STP Electric Generating Station. The loss of the alert radio system meets the reporting criterion for 10 CFR 50.72(b)(3)(xiii).

"The Matagorda County alert sirens, which are also part of the Public Prompt Notification System, remain operable.

"Compensatory measures have been verified to be available should the Prompt Notification System be needed. These measures consist of a reverse 911 system available from Matagorda County as well as local law enforcement personnel who would perform route alerting for the affected areas of the EPZ.

"The event has been entered into the Corrective Action Program and the NRC Resident Inspector has been notified.

"A return to service time for the radio transmitter is not currently available.

"Matagorda County was also notified by the National Weather Service and STP. This meets the reporting requirement for notification of an offsite agency, 10 CFR 50.72(b)(2)(xi)."

* * * UPDATE FROM ROBERT TATRO TO HOWIE CROUCH @ 1615 EDT ON 7/3/19 * * *

At 1321 CDT, the National Weather Service communication tower was returned to service. South Texas Project verified that the automatic notification radios have been returned to service.

The licensee has notified the NRC Resident Inspector.

Notified R4DO (Haire).

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Power Reactor Event Number: 54147
Facility: ARKANSAS NUCLEAR
Region: 4     State: AR
Unit: [1] [] []
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: DONNA BOYD
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/03/2019
Notification Time: 18:32 [ET]
Event Date: 05/09/2019
Event Time: 12:05 [CDT]
Last Update Date: 07/03/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
MARK HAIRE (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

60-DAY TELEPHONIC NOTIFICATION OF INVALID ENGINEERED SAFETY FEATURE ACTUATION SIGNAL

"This 60-day telephone notification is being made in accordance with 10 CFR 50.73(a)(1) and 10 CFR 50.73(a)(2)(iv)(A) to provide information pertaining to an invalid Engineered Safety Feature actuation signal.

"On May 9, 2019, at Arkansas Nuclear One (ANO) Unit 1, while performing an Emergency Feedwater Initiation and Control (EFIC) Channel B monthly test, a test pushbutton was mispositioned, resulting in an inadvertent initiation of the Emergency Feedwater (EFW) System.

"In accordance with the Engineered Safeguards Actuation System (ESAS) Trip Test portion of the surveillance, the first technician placed EFIC Train B in the tripped condition. The second technician then went to the front of the control room to verify Remote Switch Matrix (RSM) indications. The first technician recalls thinking he was given the order to reset Train B EFW Bus 1 Trip. Therefore, the first technician performed the step using three-part communication, but there is uncertainty about what was said.

"Due to the amount of time the second technician spent in front of the control room, the first technician assumed Operations reset the RSM to complete the Train B reset.

"The second technician returned to the ESAS cabinet and directed the first technician to perform the reset of Train B EFW Bus 1 Trip. The first technician, expecting his next action to be the trip of Train B EFW Bus 2, placed Bus 2 in the tripped condition. This put both buses of Train B EFW in trip and caused the actuation of P-7A EFW Pump.

"This inadvertent actuation was caused by human error and was not a valid signal resulting from parameter inputs. The 1992 Statements of Consideration define an invalid signal to include human error. Therefore, this actuation is considered invalid.

"This event was entered into ANO's corrective action program for resolution. This event did not result in any adverse impact to the health and safety of the public. The plant responded as expected.

"In accordance with 10 CFR 50.73(a)(i) a telephone notification is being made in lieu of submitting a written Licensee Event Report.

"The licensee has notified the NRC Resident Inspector."


Page Last Reviewed/Updated Thursday, July 04, 2019
Thursday, July 04, 2019