Event Notification Report for November 04, 2019
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/03/2019 - 11/04/2019
Agreement State
Event Number: 54372
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: GEISINGER HOLY SPIRIT CANCER CENTER
Region: 1
City: MECHANICSBURG State: PA
County:
License #: PA-0249A
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: ERIC SIMPSON
Licensee: GEISINGER HOLY SPIRIT CANCER CENTER
Region: 1
City: MECHANICSBURG State: PA
County:
License #: PA-0249A
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: ERIC SIMPSON
Notification Date: 11/06/2019
Notification Time: 09:12 [ET]
Event Date: 11/04/2019
Event Time: 00:00 [EST]
Last Update Date: 11/06/2019
Notification Time: 09:12 [ET]
Event Date: 11/04/2019
Event Time: 00:00 [EST]
Last Update Date: 11/06/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN CHERUBINI (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
JOHN CHERUBINI (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - GAMMA KNIFE FAILS TO FUNCTION AS DESIGNED
The following information was received via fax:
"On November 4, 2019 the licensee was performing a mask treatment with the Elekta Gamma Knife Icon containing Cobalt 60. The treatment was interrupted when the High Definition Motion Management tracking system lost communication with 1 minute and 29 seconds remaining from shot B6, (planned for 2 minutes 13 seconds) and 2 minutes 36 seconds remaining for B3 (No treatment was delivered from this shot). The sources safely retracted into their home position and the software message prompted the user to reinitiate the Gamma Knife system; however, an error message occurred on each attempt to reinitiate. The system was then rebooted; however, the same error occurred again. The patient was removed from the treatment vault and a service call was made to Elekta. The onsite service engineer arrived that same day to troubleshoot and new parts were ordered and arrived on November 5, 2019. The intent is to complete the remaining treatment on November 5, 2019 once the Gamma knife repair and subsequent QA is completed. The doctor and patient were informed immediately. No overdose to anyone has occurred and no harm is expected to the patient. The [PA Bureau of Radiation Protection] will update this event as soon as more information is provided."
Pennsylvania Event Report ID No: PA190025
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 information was received via fax:
"On November 4, 2019 the licensee was performing a mask treatment with the Elekta Gamma Knife Icon containing Cobalt 60. The treatment was interrupted when the High Definition Motion Management tracking system lost communication with 1 minute and 29 seconds remaining from shot B6, (planned for 2 minutes 13 seconds) and 2 minutes 36 seconds remaining for B3 (No treatment was delivered from this shot). The sources safely retracted into their home position and the software message prompted the user to reinitiate the Gamma Knife system; however, an error message occurred on each attempt to reinitiate. The system was then rebooted; however, the same error occurred again. The patient was removed from the treatment vault and a service call was made to Elekta. The onsite service engineer arrived that same day to troubleshoot and new parts were ordered and arrived on November 5, 2019. The intent is to complete the remaining treatment on November 5, 2019 once the Gamma knife repair and subsequent QA is completed. The doctor and patient were informed immediately. No overdose to anyone has occurred and no harm is expected to the patient. The [PA Bureau of Radiation Protection] will update this event as soon as more information is provided."
Pennsylvania Event Report ID No: PA190025
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: 54369
Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: MARK BENKOWSKI
HQ OPS Officer: JEFF HERRERA
Region: 1 State: PA
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: MARK BENKOWSKI
HQ OPS Officer: JEFF HERRERA
Notification Date: 11/04/2019
Notification Time: 09:06 [ET]
Event Date: 11/04/2019
Event Time: 05:35 [EST]
Last Update Date: 11/04/2019
Notification Time: 09:06 [ET]
Event Date: 11/04/2019
Event Time: 05:35 [EST]
Last Update Date: 11/04/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
JOHN CHERUBINI (R1DO)
JOHN CHERUBINI (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | M/R | Y | 15 | Power Operation | 0 | Hot Standby |
MANUAL REACTOR TRIP DUE TO STEAM DUMP TRANSIENT
"At 0535 [EST] on November 4, 2019, with Unit 1 in mode 1 at 15 [percent] power, the reactor was manually tripped due to the lifting of an 'A' Main Steamline Safety Valve following a Condenser Steam Dump transient. The trip response was not complex, with all systems responding normally post-trip, and all control rods fully inserted into the core.
"Operations responded and stabilized the plant. Decay heat is being removed by discharging steam to the Main Condenser by using the Condenser Steam Dump Valves. Offsite power is available and is currently supplying Normal and Emergency busses. The plant is currently stable in mode 3. Unit 2 is unaffected by this event and remains at 100 [percent] power in mode 1.
"Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B).
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
"At 0535 [EST] on November 4, 2019, with Unit 1 in mode 1 at 15 [percent] power, the reactor was manually tripped due to the lifting of an 'A' Main Steamline Safety Valve following a Condenser Steam Dump transient. The trip response was not complex, with all systems responding normally post-trip, and all control rods fully inserted into the core.
"Operations responded and stabilized the plant. Decay heat is being removed by discharging steam to the Main Condenser by using the Condenser Steam Dump Valves. Offsite power is available and is currently supplying Normal and Emergency busses. The plant is currently stable in mode 3. Unit 2 is unaffected by this event and remains at 100 [percent] power in mode 1.
"Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B).
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."