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Event Notification Report for October 28, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/25/2019 - 10/28/2019

** EVENT NUMBERS **

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.

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

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 Pull-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."

Power Reactor	Event Number: 54355
Facility: QUAD CITIES Region: 3 State: IL Unit: [1] [2] [] RX Type: [1] GE-3,[2] GE-3 NRC Notified By: JEFFREY KOSCIK HQ OPS Officer: OSSY FONT	Notification Date: 10/27/2019 Notification Time: 22:36 [ET] Event Date: 10/27/2019 Event Time: 16:05 [CDT] Last Update Date: 10/27/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION	Person (Organization): KARLA STOEDTER (R3DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

100

Power Operation

100

Power Operation

100

Power Operation

Event Text

WATER FOUND IN CONTROL ROOM EMERGENCY VENTILATION AIR FILTRATION UNIT

"On October 27, 2019, at 1605 CDT, the Control Room Emergency Ventilation (CREV) was declared inoperable due to finding water in the system's Air Filtration Unit (AFU) filter enclosure. Technical Specification 3.7.4, Condition A, was entered which requires the CREV system to be restored to an operable status in seven days. No other systems were out of service at the time this was declared inoperable.

"The CREV system maintains a habitable control room environment and ensures the operability of components in the control room emergency zone during accident conditions.

"This notification is being made in accordance with 10 CFR 50.72(b)(3)(v)(D), "Event or Condition That Could Have Prevented Fulfillment of a Safety Function," because the CREV system is a single train system required to mitigate the consequences of an accident.

"The licensee has notified the NRC Resident Inspector."

Page Last Reviewed/Updated Wednesday, March 24, 2021