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

Event Notification Report for August 15, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
8/14/2019 - 8/15/2019

** EVENT NUMBERS **

Non-Agreement State	Event Number: 54202
Rep Org: YALE NEW HAVEN HOSPITAL Licensee: YALE NEW HAVEN HOSPITAL Region: 1 City: NEW HAVEN State: CT County: License #: 06-00819-03 Agreement: N Docket: NRC Notified By: MIKE BOHAN HQ OPS Officer: KERBY SCALES	Notification Date: 08/06/2019 Notification Time: 13:39 [ET] Event Date: 07/02/2019 Event Time: 00:00 [EDT] Last Update Date: 08/06/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE	Person (Organization): BRIAN LIN (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

WRITTEN DIRECTIVE FOR MICRO-SPHERE LIVER TREATMENT WAS INCORRECT

On 7/24/19 while preparing to administer micro-sphere liver treatment the health physicist discovered that the paperwork for a previous treatment on a different patient was incorrect. The paperwork indicated that the treatment was for the left lobe of the liver. The patient's left liver was removed in a previous surgery. The prescribing physician realized that the treatment was for the right lobe of the liver and administered treatment to the right lobe. The physician failed to correct the paperwork. The treatment was on 7/2/19. The prescribed dose was 0.77 GBq and the administered dose was 0.78 GBq. There was no harm to the patient.

The licensee notified the NRC R1 Office (Tara Weidner, Penny Lanzisera).

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.

Power Reactor	Event Number: 54219
Facility: DAVIS BESSE Region: 3 State: OH Unit: [1] [] [] RX Type: [1] B&W-R-LP NRC Notified By: TOM COBBLEDICK HQ OPS Officer: THOMAS KENDZIA	Notification Date: 08/14/2019 Notification Time: 14:47 [ET] Event Date: 08/14/2019 Event Time: 12:01 [EDT] Last Update Date: 08/14/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(2)(xi) - OFFSITE NOTIFICATION	Person (Organization): HIRONORI PETERSON (R3DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

100

Power Operation

Event Text

INADVERTANT ACTIVATION OF EMERGENCY SIRENS

"At 12:01 PM (EDT), on August 14, 2019, all fifty-four (54) of the Davis-Besse Nuclear Power Station Offsite Emergency Notification sirens were inadvertently activated for one minute during a planned silent test. The County Sheriff's Dispatch Office notified FirstEnergy Nuclear Operating Company of the inadvertent actuation. This notification is being made solely as a four-hour, non-emergency notification for a Notification of Other Government Agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi).

"All sirens remain functional, and the NRC Resident Inspector has been notified of the issue."

The Licensee will be notifying Ottawa and Lucas counties and the state of Ohio.

The inadvertent activation was by the county dispatcher.

Power Reactor	Event Number: 54220
Facility: WATTS BAR Region: 2 State: TN Unit: [] [2] [] RX Type: [1] W-4-LP,[2] W-4-LP NRC Notified By: DAVIS ALLEN HQ OPS Officer: THOMAS KENDZIA	Notification Date: 08/14/2019 Notification Time: 20:00 [ET] Event Date: 07/26/2019 Event Time: 10:03 [EDT] Last Update Date: 08/14/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION	Person (Organization): ERIC MICHEL (R2DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

100

Power Operation

Event Text

INVALID CONTAINMENT VENTILATION ISOLATION ACTUATION

"This 60-day telephone notification is being submitted in accordance with paragraphs 10 CFR 50.73(a)(1) and 50.73(a)(2)(iv)(A) to report an invalid Containment Ventilation Isolation (CVI) actuation at Watts Bar Nuclear Plant (WBN) Unit 2.

"On July 26, 2019, at 1003 Eastern Daylight Time (EDT), the Train A CVI actuated due to an invalid High Radiation signal from 2-RM-90-130, Containment Purge Air Exhaust Monitor. Prior to and following the invalid High Radiation alarm, all radiation monitors except 2-RM-90-130 were stable at their normal values. All required automatic actuations occurred as designed. Upon investigation, the cause of the invalid High Radiation alarm was due to a failed ratemeter for 2-RM-90-130.

"Control room operators performed appropriate checks and confirmed that the subject indication was an invalid high radiation signal. The ratemeter for 2-RM-90-130 was replaced and the monitor returned to service. At the time of the event, plant conditions for a High Radiation alarm did not exist; therefore, the CVI was invalid.

"The NRC Resident Inspector was notified."

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