Event Notification Report for August 16, 2019
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/15/2019 - 08/16/2019
Agreement State
Event Number: 54230
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: THOMAS JEFFERSON UNIVERSITY HOSPITALS
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0130
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: JEFFREY WHITED
Licensee: THOMAS JEFFERSON UNIVERSITY HOSPITALS
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0130
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: JEFFREY WHITED
Notification Date: 08/19/2019
Notification Time: 14:17 [ET]
Event Date: 08/16/2019
Event Time: 00:00 [EDT]
Last Update Date: 08/19/2019
Notification Time: 14:17 [ET]
Event Date: 08/16/2019
Event Time: 00:00 [EDT]
Last Update Date: 08/19/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVE WERKHEISER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
DAVE WERKHEISER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - PATIENT UNDER-DOSAGE
The following was received via fax:
"On August 16, 2019, a patient underwent a Y-90 SIR-Sphere treatment. The treatment plan was for 2 administrations of Y-90. The first administration was delivered without incident. The second administration was to be a total dosage of 12.27 mCi delivered to the right lobe of the liver. During this second administration, it was observed that the team had backflow into the administration vile. The administration was immediately halted, and the team took readings to ascertain the amount of material delivered. It was estimated that only 28 percent of the dose was delivered to the patient. The patient was verbally informed the day of the event. The referring physician was left a voicemail on the day of the event, however further attempts will be made to contact him directly."
Event Report ID No.: PA190019
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.
The following was received via fax:
"On August 16, 2019, a patient underwent a Y-90 SIR-Sphere treatment. The treatment plan was for 2 administrations of Y-90. The first administration was delivered without incident. The second administration was to be a total dosage of 12.27 mCi delivered to the right lobe of the liver. During this second administration, it was observed that the team had backflow into the administration vile. The administration was immediately halted, and the team took readings to ascertain the amount of material delivered. It was estimated that only 28 percent of the dose was delivered to the patient. The patient was verbally informed the day of the event. The referring physician was left a voicemail on the day of the event, however further attempts will be made to contact him directly."
Event Report ID No.: PA190019
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: 54224
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [] [2] []
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: SEAN MCCORMACK
HQ OPS Officer: KERBY SCALES
Region: 4 State: AZ
Unit: [] [2] []
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: SEAN MCCORMACK
HQ OPS Officer: KERBY SCALES
Notification Date: 08/16/2019
Notification Time: 15:05 [ET]
Event Date: 08/16/2019
Event Time: 08:21 [MST]
Last Update Date: 08/16/2019
Notification Time: 15:05 [ET]
Event Date: 08/16/2019
Event Time: 08:21 [MST]
Last Update Date: 08/16/2019
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
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
RAY KELLAR (R4DO)
RAY KELLAR (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | A/R | Y | 100 | Power Operation | 0 | Hot Standby |
AUTOMATIC REACTOR TRIP DUE TO TURBINE TRIP
"At 0821 MST, on August 16, 2019, a main turbine trip occurred followed by a loss of power to all reactor coolant pumps. The Palo Verde Nuclear Generating Station (PVNGS) Unit 2 control room then received reactor protection system alarms for low departure from nucleate boiling ratio and an automatic reactor trip occurred. Following the reactor trip, auxiliary feedwater was manually started to maintain steam generator levels. A Main Steam Isolation Signal was manually initiated as directed by the Emergency Operating Procedures. Unit 2 is currently stable in Mode 3. Prior to the reactor trip, Unit 2 was operating normally at 100 percent power.
"No major equipment was inoperable prior to the event that contributed to the event or challenged operator response. All control element assemblies fully inserted into the core and no emergency classification was required per the PVNGS Emergency Plan. The cause of the reactor trip is under investigation.
"The event did not result in any challenges to fission product barriers and there were no adverse safety consequences as a result of this event. The event did not adversely affect the safe operation of the plant or the health and safety of the public.
"The NRC Resident Inspector has been informed of the Unit 2 reactor trip."
Decay heat is being removed via the atmospheric steam dump valves.
Units 1 and 3 were unaffected by this event.
"At 0821 MST, on August 16, 2019, a main turbine trip occurred followed by a loss of power to all reactor coolant pumps. The Palo Verde Nuclear Generating Station (PVNGS) Unit 2 control room then received reactor protection system alarms for low departure from nucleate boiling ratio and an automatic reactor trip occurred. Following the reactor trip, auxiliary feedwater was manually started to maintain steam generator levels. A Main Steam Isolation Signal was manually initiated as directed by the Emergency Operating Procedures. Unit 2 is currently stable in Mode 3. Prior to the reactor trip, Unit 2 was operating normally at 100 percent power.
"No major equipment was inoperable prior to the event that contributed to the event or challenged operator response. All control element assemblies fully inserted into the core and no emergency classification was required per the PVNGS Emergency Plan. The cause of the reactor trip is under investigation.
"The event did not result in any challenges to fission product barriers and there were no adverse safety consequences as a result of this event. The event did not adversely affect the safe operation of the plant or the health and safety of the public.
"The NRC Resident Inspector has been informed of the Unit 2 reactor trip."
Decay heat is being removed via the atmospheric steam dump valves.
Units 1 and 3 were unaffected by this event.