Home NRC Library Document Collections Events, Reports Associated with Event Notification Reports 2019

Event Notification Report for August 01, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
7/31/2019 - 8/1/2019

** EVENT NUMBERS **

Agreement State	Event Number: 54180
Rep Org: OHIO BUREAU OF RADIATION PROTECTION Licensee: UPA TECHNOLOGY, INC. Region: 3 City: WEST CHESTER State: OH County: License #: 03214090000 Agreement: Y Docket: NRC Notified By: STEPHEN JAMES HQ OPS Officer: HOWIE CROUCH	Notification Date: 07/24/2019 Notification Time: 09:34 [ET] Event Date: 07/12/2019 Event Time: 00:00 [EDT] Last Update Date: 07/24/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): CHARLES NORTON (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - LEAKING RADIOACTIVE SOURCE

The following information was obtained from the state of Ohio via email:

"[Manufacturing and Distribution] licensee received beta back-scatter on a device from customer for repair. Upon receipt, licensee conducted leak test and results indicated >185 Bq (0.005 microCi). Device contained 100 microCi Pm-147 source and is distributed under a general license.

"Upon investigation, licensee determined customer had used probe on wet surface, which clogged aperture, and customer attempted to clear aperture with sharp, pointed object which damaged source. At customer's request, licensee went to customer's location to survey area of use for contamination. No contamination was found."

Ohio report no.: OH190012

Agreement State	Event Number: 54181
Rep Org: OHIO BUREAU OF RADIATION PROTECTION Licensee: GENESIS HOSPITAL Region: 3 City: ZANESVILLE State: OH County: License #: 02120610006 Agreement: Y Docket: NRC Notified By: MICHAEL SNEE HQ OPS Officer: HOWIE CROUCH	Notification Date: 07/24/2019 Notification Time: 10:37 [ET] Event Date: 06/27/2019 Event Time: 00:00 [EDT] Last Update Date: 07/24/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): CHARLES NORTON (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE TO THE LIVER

The following information is summarized from an email received from the state of Ohio:

A patient was undergoing Y-90 Therasphere treatment of both lobes of the liver. The calculations and dose were ordered for the volume of the left lobe which was 230cc. Due to a communication error, that dose was delivered to the right lobe which had a volume of 1600cc. This represents an underdose to the right lobe. The intended dose to the right lobe was 120 Gy. The delivered dose was 17.6 Gy. The licensee is evaluating additional treatment.

The patient and prescribing physician were notified.

The State will be performing an investigation.

Ohio report no.: OH190013

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: 54182
Rep Org: MAINE RADIATION CONTROL PROGRAM Licensee: APPLUS RTD USA Region: 1 City: SOUTH PORTLAND State: ME County: License #: ME 05139 #19 Agreement: Y Docket: NRC Notified By: JAY HYLAND HQ OPS Officer: ANDREW WAUGH	Notification Date: 07/24/2019 Notification Time: 12:58 [ET] Event Date: 02/08/2017 Event Time: 17:30 [EST] Last Update Date: 07/24/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): MEL GRAY (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - DAMAGED RADIOGRAPHY EXPOSURE DEVICE

The following is a synopsis of information received via email from the state of Maine:

At approximately 1730 EST on 2/8/2017, Applus RTD had a source disconnect on a radiography exposure device at Casco Bay Steel in South Portland, Maine. The radiography exposure device was an Amersham Model 880 with an Ir-192 source. The Radiation Safety Officer (RSO) was contacted about the incident, went to the site, and helped secure the area with the help of a radiographer. The RSO replaced the drive cable and retrieved the source back into the radiography camera.

The drive cable and exposure device have been taken to the manufacturer to determine the cause of the problem.

The original notification for this event was made through the Nuclear Materials Event Database (NMED) under the 30-day reporting requirement due to the fact that the State felt it was not an equipment failure. During the State's review it was determined that a notification to NRC was required within 24 hours due to the equipment being disabled during the recovery operations.

Maine Event Report ID No.: ME 17-001

Power Reactor	Event Number: 54190
Facility: SOUTH TEXAS Region: 4 State: TX Unit: [1] [] [] RX Type: [1] W-4-LP,[2] W-4-LP NRC Notified By: KEITH MINK HQ OPS Officer: DONALD NORWOOD	Notification Date: 07/31/2019 Notification Time: 15:55 [ET] Event Date: 07/31/2019 Event Time: 07:41 [CDT] Last Update Date: 07/31/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION	Person (Organization): JEREMY GROOM (R4DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

100

Power Operation

Event Text

DISCOVERY OF CONDITION THAT COULD HAVE PREVENTED FULFILLMENT OF A SAFETY FUNCTION

"South Texas Project (STP) Unit 1 reactor head vent valve B1RCHCV0601 was declared inoperable on December 29, 2018, STP Unit 1 reactor head vent valve B1RCHCV0602 was declared inoperable on July 30, 2019. Technical Specification 3.3.3.5 requires one of two reactor head vent valves to be operable. This issue placed the plant in a 30-day Technical Specification Action.

"At 0741 CDT on July 31, 2019, South Texas Project Electric Generating Station (STPEGS) made a determination based on firm evidence that reactor head vent valve B1RCHCV0602 had been inoperable since June 24, 2019. This results in a condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.

"This report is being made pursuant to 10 CFR 50.72(b)(3)(v)(D), 'any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.

"The inoperable equipment is required for accident conditions and presents no danger to the health and safety of the public or the safe operation of the units.

"The NRC Resident Inspector has been notified."

Power Reactor	Event Number: 54191
Facility: WATERFORD Region: 4 State: LA Unit: [3] [] [] RX Type: [3] CE NRC Notified By: BRIAN BUSCHBAUM HQ OPS Officer: DONALD NORWOOD	Notification Date: 07/31/2019 Notification Time: 16:20 [ET] Event Date: 07/31/2019 Event Time: 12:06 [CDT] Last Update Date: 07/31/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(2)(i) - PLANT S/D REQD BY TS 50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION	Person (Organization): JEREMY GROOM (R4DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

Event Text

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO INOPERABLE BORON INJECTION FLOW PATHS AND CHARGING PUMPS

"On July 31, 2019, at 1206 CDT, Waterford 3 commenced initiation of a plant shutdown as required by Technical Specification (TS) Limiting Condition for Operation (LCO) 3.0.3. Prior to this, on July 31, 2019, at 1108 CDT, the boron injection flow paths were declared inoperable in accordance with LCO 3.1.2.2, 'Flow Paths - Operating,' and the charging pumps were declared inoperable in accordance with LCO 3.1.2.4, 'Charging Pumps-Operating.' This was due to visual examination identifying that propagation had progressed on a previously identified flaw on piping upstream of the header supplying the charging pumps. TS LCO 3.0.3 was entered due to the action statements of LCOs 3.1.2.2 and 3.1.2.4 not being met. LCO 3.0.3 requires that action shall be initiated within one hour to place the unit in a mode in which the specification does not apply by placing it in hot standby within the next 6 hours and cold shutdown within the next 30 hours. At 1206 CDT, Waterford 3 commenced direct boration to the reactor coolant system.

"This condition meets the reporting criteria of 10 CFR 50.72(b)(2)(i) due to the initiation of plant shutdown required by Technical Specifications and 10 CFR 50.72(b)(3)(v)(A) and (D) due to an event or condition that could have prevented fulfillment of a safety function of structures or systems that are needed to (A) shutdown the reactor and maintain it in a safe shutdown condition and (D) mitigate the consequences of an accident."

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