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Event Notification Report for March 24, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
3/23/2020 - 3/24/2020

** EVENT NUMBERS **

Agreement State	Event Number: 54585
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES Licensee: THE HOUSTON METHODIST HOSPITAL Region: 4 City: HOUSTON State: TX County: License #: RAM-L00457 Agreement: Y Docket: NRC Notified By: RANDALL REDD HQ OPS Officer: JEFFREY WHITED	Notification Date: 03/13/2020 Notification Time: 19:28 [ET] Event Date: 03/13/2020 Event Time: 00:00 [CDT] Last Update Date: 03/13/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): DAVID PROULX (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The following was received from the State of Texas via email:

"On March 13, 2020, [the Texas Department of State Health Services] was notified by the Houston Methodist Hospital of a medical event. The patient was to receive 18.4 Gy of therapeutic dose from a Novoste Beta-Cath system Sr-90 source (system serial no. 89670, source train serial no. za925). When the procedure began, the command was sent to the system to deliver the source. The source did not appear within the fluoro field as expected after 10 seconds and the command was sent to the system to retract the source. The source failed to retract. The oncologist manually removed the catheter from the patient and found the source stuck inside. It is now back in the system. The licensee has been reminded that they need to notify the referring physician within 24 hours. An investigation into this event is ongoing. More information will be provided when obtained in accordance with SA-300."

Texas Incident Number: 9751

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: 54599
Facility: HARRIS Region: 2 State: NC Unit: [1] [] [] RX Type: [1] W-3-LP NRC Notified By: ADAM ZIMANDY HQ OPS Officer: OSSY FONT	Notification Date: 03/23/2020 Notification Time: 13:36 [ET] Event Date: 03/23/2020 Event Time: 10:13 [EDT] Last Update Date: 03/23/2020
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION	Person (Organization): MARK MILLER (R2DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

A/R

100

Power Operation

Hot Standby

Event Text

AUTOMATIC REACTOR TRIP

"On March 23, 2020, at 1013 EDT, with Harris Nuclear Plant Unit 1 in Mode 1, at 100 percent power, an unplanned actuation of the reactor protection system occurred. This resulted in an automatic reactor trip. The trip occurred during the restoration of the auto-stop turbine trip function during a planned maintenance evolution.

"All safety systems functioned as expected. Auxiliary Feedwater started as designed and was secured. Steam generator levels are being maintained by normal feedwater through the feedwater regulator bypass valves. Decay heat is being removed by using the condenser steam dump flow path.

"Due to the unplanned Reactor Protection System actuation while critical and the expected Auxiliary Feedwater actuation, this event is being reported as a four hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B) and an eight hour, non-emergency notification per 10 CFR 50.72(b)(3)(iv)(A).

"There was no impact on the health and safety of the public or plant personnel.

"The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Wednesday, March 24, 2021