Event Notification Report for March 28, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/27/2023 - 03/28/2023
Agreement State
Event Number: 56423
Rep Org: Arkansas Department of Health
Licensee: Baptist Health Medical Center
Region: 4
City: Little Rock State: AR
County:
License #: ARK-0058-02120
Agreement: Y
Docket:
NRC Notified By: Susan Elliott
HQ OPS Officer: Donald Norwood
Notification Date: 03/21/2023
Notification Time: 13:57 [ET]
Event Date: 03/14/2023
Event Time: 00:00 [CDT]
Last Update Date: 03/22/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
O'Keefe, Neil (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Einberg, Christian (NMSS)
Event Text
AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was received via email:
"On March 21, 2023, a report of misadministration was received by the Arkansas Department of Health from Baptist Health Medical Center, Little Rock at 0945 CDT.
"A 72 year old female came to the Baptist Health Little Rock Nuclear Medicine department for a radioactive iodine thyroid scan. The patient had been scheduled in our [Electronic Medical Record system] as a Total Body Iodine [TBI] Scan with Thyrogen. The patient was given the first dose of Thyrogen on Monday, March 13th. She came in the following day for her second dose of Thyrogen. At this time, the nuclear medicine technologist was informed that the patient still had her thyroid. The technologist called the radiologist and asked how long the patient needed to be off of Thyrogen to have an I-123 scan. The technologist was told to call the radiopharmacy and ask. The technologist was also told to call the ordering provider to clarify the order. The technologist communicated with the ordering provider's nurse. The ordering provider did not know what to do at this point other than to continue with the study. No explanation was given to the ordering provider about the TBI scan or the effects of I-131 on their patient. The technologist proceeded with dosing the patient on March 15th with 4.4 mCi of I-131. The patient came back on Friday, March 17th for imaging. At this point, the radiologist realized that the technologist had performed the incorrect study and misadministered I-131. The health physicist was notified, and on Monday, March 20th, estimated that since no uptake was performed, that the patient received, at minimum, 14,000 rads/500 Rem to her thyroid gland from the dose of I-131."
Arkansas Event Report ID No.: AR-2023-002
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: 56429
Facility: Fermi
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: Justin Wilhelm
HQ OPS Officer: Donald Norwood
Notification Date: 03/23/2023
Notification Time: 18:30 [ET]
Event Date: 03/23/2023
Event Time: 11:45 [EDT]
Last Update Date: 03/27/2023
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(A) - Pot Unable To Safe Sd
50.72(b)(3)(v)(B) - Pot Rhr Inop
50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
McCraw, Aaron (R3DO)
Power Reactor Unit Info
| 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
EN Revision Imported Date: 3/27/2023
EN Revision Text: DESIGN FLAW DISCOVERED IN MECHANICAL DRAFT COOLING TOWER FAN BRAKES
The following information was provided by the licensee via fax:
"While in Mode 1 at 100 percent power at 1145 EDT on March 23, 2023, it was determined that all mechanical draft cooling Tower (MDCT) fan brakes would not perform their design function during a tornado due to a design flaw with the control system. The MDCT fan brakes are required to prevent fan overspeed from a design basis tornado. The MDCT fans are required to support the operability of the ultimate heat sink (UHS).
"At the time of discovery, the provisions of LCO 3.0.9 were being utilized for loss of the 'D' MDCT fan brake (barrier loss). When it was identified the condition was a design flaw common to all MDCT fan brakes, the 24-hour allowance for restoration was entered.
"A design change is currently being implemented to restore MDCT fan brake operability.
"This condition is reportable per 10 CFR 50.72(b)(3)(v)(A), (B), & (D).
"The NRC Resident Inspector has been notified."
Power Reactor
Event Number: 56430
Facility: Susquehanna
Region: 1 State: PA
Unit: [2] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Robert Bingman
HQ OPS Officer: Brian P. Smith
Notification Date: 03/23/2023
Notification Time: 20:40 [ET]
Event Date: 03/23/2023
Event Time: 17:36 [EDT]
Last Update Date: 03/27/2023
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
Werkheiser, Dave (R1DO)
Power Reactor Unit Info
| Unit |
SCRAM Code |
RX Crit |
Initial PWR |
Initial RX Mode |
Current PWR |
Current RX Mode |
| 2 |
N |
N |
0 |
Cold Shutdown |
0 |
Cold Shutdown |
Event Text
EN Revision Imported Date: 3/27/2023
EN Revision Text: EMERGENCY DIESEL GENERATOR ACTUATION
The following information was provided by the licensee via email:
"At 1736 EDT on March 23, 2023, during overcurrent testing of the '2B' [Emergency Safeguards System] ESS Bus, the work group was re-installing tested relays and inadvertently caused a '2B' ESS Bus lockout. This resulted in the '2B' ESS Bus deenergizing and a valid start signal provided to the 'B' Emergency Diesel Generator [EDG]. The 'B' EDG started and functioned as designed.
"This is being reported as an unplanned actuation of systems that mitigate the consequences of significant events in accordance with 10 CFR 50.72(b)(3)(iv)(A).
"The NRC Resident Inspector has been notified."
Power Reactor
Event Number: 56434
Facility: Susquehanna
Region: 1 State: PA
Unit: [2] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Robert Bingman
HQ OPS Officer: Eric Simpson
Notification Date: 03/26/2023
Notification Time: 19:41 [ET]
Event Date: 03/26/2023
Event Time: 16:03 [EDT]
Last Update Date: 03/26/2023
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(ii)(A) - Degraded Condition
Person (Organization):
Werkheiser, Dave (R1DO)
Power Reactor Unit Info
| Unit |
SCRAM Code |
RX Crit |
Initial PWR |
Initial RX Mode |
Current PWR |
Current RX Mode |
| 2 |
N |
N |
0 |
Cold Shutdown |
0 |
Cold Shutdown |
Event Text
DEGRADED CONDITION - LEAK RATE LIMITS EXCEEDED
The following information was provided by the licensee via email:
"On 03/26/2023 at 1603 EDT, while performing Appendix J local leak rate testing, it was determined that the Secondary Containment Bypass Leakage (SCBL) limit had been exceeded for Unit 2. During performance of the leak rate test, SE-259-027 for X-9B penetration, it was determined that the combined SCBL limit of 15 standard cubic feet per hour for the as-found minimum pathway was exceeded, as specified in Technical Specification, Surveillance Requirement 3.6.1.3.11.
"This event is being reported pursuant to 10CFR50.72(b)(3)(ii).
"The Resident Inspector has been notified."