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Event Notification Report for October 25, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/24/2019 - 10/25/2019

** EVENT NUMBERS **


54334 54336 54339 54347 54348 54350 54351

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Agreement State Event Number: 54334
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: GRADY HOSPITAL
Region: 1
City: ATLANTA   State: GA
County:
License #: GA 258-2
Agreement: Y
Docket:
NRC Notified By: IRENE BENNETT
HQ OPS Officer: JEFF HERRERA
Notification Date: 10/16/2019
Notification Time: 17:20 [ET]
Event Date: 10/15/2019
Event Time: 00:00 [EDT]
Last Update Date: 10/16/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DON JACKSON (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

CONTAMINATINON OF HOT LAB DUE TO BREAKING CAPSULE

The following report was received from the Georgia Radioactive Materials Program via email:

"A patient diagnosed with hyperthyroidism was scheduled to receive 30 mCi of Iodine-131 on Oct 15, 2019. The patient informed the AU [authorized user] that they could not swallow the capsule, so the AU proceeded to break the capsule in half and pour the contents in water to easily administer to the patient. The patient and AU were in the treatment room when the AU began to break the capsule. The AU then went to the hot lab where he successfully broke the capsule using a syringe needle. The nuclear technician inquired as to what was happening in the hot lab and realized that there may be a potential contamination issue and contacted the RSO [Radiation Safety Officer]. The areas were surveyed and determined to be contaminated with Iodine-131 was the hot lab, hallway in front of the hot lab, counter of the treatment room, scrub pants, shoes and socks.

"The RSO took the scrub pants and sock and shoes and placed them in an area for DIS [decay in storage]. He proceeded to clean the area from least contaminated, the hallway and treatment room, but could not get it completely clean. The treatment room is a less used room and isolated so that room could be sealed off and secured. The hallway is posted and cordon off. Currently, the RSO is uncertain as to how much contamination is in the hot lab and has the room sealed and secured until he can further assess the area.

"The staff who were working in the area consisted of the RSO, Assistant RSO, nuclear technician, and AU were monitored for thyroid uptake. Results were negative. The patient was not monitored for thyroid uptake since the patient was sitting at the opposite side of the treatment room opposite of where the contamination occurred. The floor of the room and adjacent hallway was free of contamination. In addition, the patient had a Iodine-123 uptake one week prior. So they would have had some residual Iodine-123 still in the body. The patient was never administered the Iodine-131 in water.

"The RSO will prepare a full report discussing the incident, root cause and correction plan within 15 days. An associate will be assigned to the event."

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Agreement State Event Number: 54336
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: CHARLOTTE MECKLENBURG
Region: 1
City: CHARLOTTE   State: NC
County:
License #: 060-0014-3
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: ANDREW WAUGH
Notification Date: 10/17/2019
Notification Time: 16:56 [ET]
Event Date: 10/16/2019
Event Time: 00:00 [EDT]
Last Update Date: 10/17/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DON JACKSON (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The following is the summary of an email received from the state of North Carolina:

A patient was scheduled for an intravascular brachytherapy treatment on 10/16/2019. The treatment utilized a Novoste transfer device with an Sr-90 source. The prescribed dose for the treatment was 23.0 Gy, which corresponds to a planned treatment time of 5 minutes and 47 seconds.

The treatment was delivered and the source return process was initiated. Resistance was encountered returning the source to the transfer device and the team had to commence the emergency bail-out procedure. The catheter was extracted while it was still attached to the device and both were placed in the bail-out box. The patient, room, and box were all surveyed. The survey confirmed that the source was in the bail-out box. The box was then transferred to a designated secure location.

Because of the additional time elapsed between the expected return of the source to the transfer device and the securing of the source in the bail-out box it is possible that the patient could have received an additional dose of up to 6.98 Gy.

The manufacturer of the transfer device was notified of this event on 10/16/2019. The patient and referring physician were both notified on 10/17/2019.

Device Information:
Transfer Device
Manufacturer: Novoste (Best Medical)
Model: Beta Cath System
Serial: 91806

Source Information:
Sr-90
Manufacturer: Novoste
Activity: 2.01 GBq (4/16/03)
Serial: ZB607

NC Tracking Number: NC 190036

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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!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 54339
Facility: ARKANSAS NUCLEAR
Region: 4     State: AR
Unit: [] [2] []
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: REX KNIGHT
HQ OPS Officer: OSSY FONT
Notification Date: 10/20/2019
Notification Time: 19:21 [ET]
Event Date: 10/20/2019
Event Time: 10:30 [CDT]
Last Update Date: 10/24/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
HEATHER GEPFORD (R4DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation

Event Text

CONTROL ROOM ENVELOPE BREACH

"At 1030 CDT, it was discovered that the loop seal on the condensate drain was empty for VUC-9 Control Room AC Unit. This creates a breach in the Control Room envelope. Unit 2 entered [Technical Specification] T.S. 3.7.6.1 Action D. Unit 1 is in Mode 6; therefore, not in a mode of applicability."

Compensatory action were being performed and the licensee was in the process of sealing the loop.

The licensee will notify the NRC Resident Inspector.


* * * RETRACTION FROM DONNA BOYD TO DONALD NORWOOD AT 1336 EDT ON 10/24/2019 * * *

"This report is being retracted. The Control Room Envelope (CRE) provides a safety function which limits radiological dose to occupants to no more than 5 rem for 30 days post-accident. The dose limitation assumes the occupants are stationed within the CRE 24 hours a day for the entire 30-day period. The CRE also functions to protect occupants from potential hazards such as smoke or toxic chemicals.

"The CRE is declared inoperable when a potential breach is identified, regardless of the ability to seal the breach. With respect to the event of October 20, 2019, the water level in a loop seal could not be maintained at the desired level. Subsequent evaluation determined that sufficient water was maintained in the loop seal to prevent a breach of the CRE.

"The subject reporting criterion is based on the assumption that safety-related systems, structures, and components (SSCs) may no longer be capable of mitigating the consequences of an accident. In accordance with NUREG 1022, 'Event Report Guidelines 10 CFR 50.72 and 50.73,' a report may be retracted based on a revised operability determination. The CRE remained operable; therefore, this report may be retracted."

The licensee notified the NRC Resident Inspector.

Notified R4DO (Young).

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Power Reactor Event Number: 54347
Facility: OYSTER CREEK
Region: 1     State: NJ
Unit: [1] [] []
RX Type: [1] GE-2
NRC Notified By: JERONIMO JIMENEZ
HQ OPS Officer: CATY NOLAN
Notification Date: 10/24/2019
Notification Time: 16:24 [ET]
Event Date: 10/24/2019
Event Time: 15:24 [EDT]
Last Update Date: 10/24/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
BRICE BICKETT (R1DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Defueled 0 Defueled

Event Text

OFFSITE NOTIFICATION

"Holtec Decommissioning International has notified the State of New Jersey that during the conduct of Industrial Site Remediation Act (ISRA) non-radiological site investigation field sampling and analysis activities at the Oyster Creek site, soil and groundwater exceedances to New Jersey Default Impact to Groundwater Soil Levels, Residential Direct Contact Soil Remediation, Non-Residential Direct Contact Soil Remediation and Class IIA Groundwater Quality Standards were identified. These exceedances are reportable under New Jersey Administrative Code NJAC 7:26C. That notification was made at 1524 EDT."

The NRC Regional Inspector and the State of New Jersey were notified.

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Power Reactor Event Number: 54348
Facility: RIVER BEND
Region: 4     State: LA
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: ALFONSO CROEZE
HQ OPS Officer: DONALD NORWOOD
Notification Date: 10/24/2019
Notification Time: 16:25 [ET]
Event Date: 10/24/2019
Event Time: 10:35 [CDT]
Last Update Date: 10/24/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
CALE YOUNG (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

AUTOMATIC DEPRESSURIZATION SYSTEM INOPERABLE

"At 1035 CDT the Automatic Depressurization System (ADS) was rendered inoperable due to the failure of the 'A' Safety Vent Valve (SVV) Compressor (SVV-C4A) to manually start with SVV-C4B tagged out. System pressure slowly dropped below 131 psig (normal pressure is 165 psig). This caused the ADS safety relief valves to be declared inoperable. The station entered Technical Specification 3.5.1 Condition G. The Required Action was to be in Mode 3 in 12 hours. As a result, the station was in a condition that could have prevented the fulfillment of a safety function.

"The breaker for SVV-C4B was reset and the clearance for SVV-V4B was released. System pressure was restored to greater than 131 psig at 1116 CDT which allowed exit of the action statement to be in Mode 3 in 12 hours. System parameters are currently stable in the normal pressure range. Investigation for the cause of the system failure is ongoing.

"No radiological releases have occurred due to this event from the unit."

The licensee notified the NRC Resident Inspector.

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Part 21 Event Number: 54350
Rep Org: ENGINE SYSTEMS, INC
Licensee: ENGINE SYSTEMS, INC
Region: 1
City: ROCKY MOUNT   State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DAN ROBERTS
HQ OPS Officer: CATY NOLAN
Notification Date: 10/24/2019
Notification Time: 17:04 [ET]
Event Date: 09/06/2019
Event Time: 00:00 [EDT]
Last Update Date: 10/24/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
BRICE BICKETT (R1DO)
OMAR LOPEZ (R2DO)
KARLA STOEDTER (R3DO)
CALE YOUNG (R4DO)
- PART 21/50.55 REACTORS (EMAIL)

Event Text

PART 21 - EMD FUEL INJECTORS SEIZED PLUNGER AND BUSHING

The following is a summary of information that was received via facsimile:

Engine Systems, Inc. (ESI) was notified by a nuclear customer that three of 20 recently installed fuel injectors seized after a short amount of engine run time. Examination of the plunger and bushing (P&B) from each injector identified particles consistent with the base material of the P&B embedded in the scar marks associated with seizures. The root cause of the seizures is attributed to residual machining debris from the manufacturing process. This batch of injectors had been refurbished in 2013 and the P&Bs were replaced as part of the rework activity.

These part number mechanical unit fuel injectors are used on various model EMD 645 diesel engines. The engine utilizes one injector per cylinder; therefore, failure of one injector will render the associated cylinder inoperable. An EMD 645 engine will typically tolerate one inoperable cylinder and maintain rated load; however, multiple inoperable cylinders (as in the case of multiple fuel injectors) will further decrease engine output and likely prevent the engine from carrying out its required load. This adversely affects the ability of the emergency diesel generator set to perform its safety-related function.

This issue only applies to injectors in inventory that have not been installed, which should be returned to ESI. For injectors that have been installed in an engine and have accumulated more than two hours of run time, then the injector is not susceptible to seizure from this type of issue and no further action is required. It has been shown that P&B seizures related to foreign material occur within the first two hours of engine operation.

The affected part numbers are 40084714, 40084715, 40084720, 40084724, 40084725, 40099335, 5228895-RR, 5229250-RR, 5229315-RR, 5229325-RR, 40084714-RR, 40084720-RR, 40084723-RR, 40084724-RR, 40099335-RR. A list of affected customers by injector part number is contained in Appendix A of the Part 21 report, which include Crystal River, Turkey Point, Exelon Generation Company, Beaver Valley, Watts Bar, Clinton, Saint Lucie, Sequoyah, Cooper, Southern California Edison, Davis-Besse, Oconee, Point Beach, Kewaunee, Dresden, Surry, GE Company, Browns Ferry, Energy Northwest, Oyster Creek, Arkansas Nuclear One, Monticello, Nine Mile Point, Entergy Operations Inc., Tennessee Valley Authority, LaSalle, Perry, Quad Cities, Fitzpatrick, and River Bend.

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Power Reactor Event Number: 54351
Facility: SOUTH TEXAS
Region: 4     State: TX
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: SCOTT SAYLORS
HQ OPS Officer: JEFF HERRERA
Notification Date: 10/25/2019
Notification Time: 03:24 [ET]
Event Date: 10/24/2019
Event Time: 20:51 [CDT]
Last Update Date: 10/25/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
CALE YOUNG (R4DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling

Event Text

VALID UNDERVOLTAGE ACTUATION DURING EDG SEQUENCER MAINTENANCE

"On October 24, 2019, at 2051 Central Time, while performing Train C Sequencer maintenance, a valid undervoltage actuation signal was sent to Unit 2 Emergency Diesel Generator (EDG) 23. The ESF Train C bus loads were shed but EDG 23 did not automatically start because it had been placed in Pull-To-Stop to support the sequencer maintenance activities. EDG 23 was taken out of Puil-To-Stop by Control Room staff to allow it to auto start and load the bus. As a result of the bus strip signal, the in service Spent Fuel Pool Cooling Pump secured. Spent Fuel Pool Cooling was restored with no measurable increase in pool temperature.

"The reactor was not critical and reactor decay heat removal was not challenged throughout the event.

"This actuation is reportable per 10 CFR 50.72(b)(3)(iv)(A) due to the automatic actuation of a system listed in 10 CFR 50.72(b)(3)(iv)(B).

"The NRC Resident inspector has been notified."


Page Last Reviewed/Updated Friday, October 25, 2019
Friday, October 25, 2019