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Event Notification Report for October 27, 2018

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/26/2018 - 10/27/2018

** EVENT NUMBERS **


53672 53696 53697

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Agreement State Event Number: 53672
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: CLEVELAND CLINIC FOUNDATION
Region: 3
City: CLEVELAND   State: OH
County:
License #: 02110180013
Agreement: Y
Docket:
NRC Notified By: MICHAEL RUBADUE
HQ OPS Officer: ANDREW WAUGH
Notification Date: 10/18/2018
Notification Time: 13:08 [ET]
Event Date: 10/16/2018
Event Time: 00:00 [EDT]
Last Update Date: 10/18/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID HILLS (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - ADMINISTERED DOSE LOWER THAN PRESCRIBED DOSE

The following information was obtained from the State of Ohio via email:

"On October 16, 2018, a suspected medical event occurred. A patient was prescribed a dose of 120 Gy for segment 4 of the left lobe of the liver involving Y-90 TheraSpheres. All the pre-procedural safety checks were made and appropriate imaging (cone beam CT) was performed to check the catheter position and lesion location. During the first set of infusions, there was high resistance felt on the syringe which continued for the next few infusions. It was decided to stop the treatment as there was risk of inadequate delivery of the microspheres due to possibility of stasis and concern for non-target embolization to other sites. The residual was calculated and it was noted that estimated dose delivered was 6.4 Gy to the target lesion. Post-procedure, the patient had a PET CT to check the Y-90 microspheres distribution and it did not demonstrate any non-targeted deposition.

"The administered dose was 6.4 Gy to segment 4 of the left lobe of the liver. The dose was therefore 5% of the prescribed dose, a 95% difference.

"The microspheres not delivered to the target were contained in the catheter. No contamination occurred as a result of this event.

"The referring physician has been notified as well as the patient.

"A follow-up inspection will be conducted during the week of Oct. 22, 2018."

Ohio NMED Report No.: OH180010

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.

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Power Reactor Event Number: 53696
Facility: GINNA
Region: 1     State: NY
Unit: [1] [] []
RX Type: [1] W-2-LP
NRC Notified By: WADE WEBER
HQ OPS Officer: OSSY FONT
Notification Date: 10/27/2018
Notification Time: 01:50 [ET]
Event Date: 10/26/2018
Event Time: 00:00 [EDT]
Last Update Date: 10/27/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DONNA JANDA (R1DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling

Event Text

AUTOMATIC START OF THE EMERGENCY DIESEL GENERATOR AND LOSS OF RADIATION MONITOR

"RCS [Reactor Coolant System] Pressure: vented to containment, refueling cavity greater than 23ft. [above reactor vessel]. RCS temperature: 96 degrees Fahrenheit.

"The 12A bus de-energized, 'A' EDG [Emergency Diesel Generator] automatically started and loaded on [emergency] buses 14 and 18. The RCS configuration is refueling cavity level greater than 23ft. above the reactor flange with no impact to shutdown cooling.

"Radiation monitor R-1, Control Room radiation monitor, lost power for 2 hrs 10 min. This placed Ginna in a major loss of emergency preparedness capabilities. A temporary radiation monitor has been installed in the Control Room."

Prior to the notification, the licensee had restored the 12A bus from offsite power and the R-1 monitor was re-energized.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 53697
Facility: WATTS BAR
Region: 2     State: TN
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DAVID ALLEN
HQ OPS Officer: DONG HWA PARK
Notification Date: 10/27/2018
Notification Time: 16:52 [ET]
Event Date: 10/27/2018
Event Time: 00:00 [EDT]
Last Update Date: 10/27/2018
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):
ERIC MICHEL (R2DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 21 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP FOLLOWING STARTUP

"On October 27, 2018, at 1533 EDT, Watts Bar Nuclear (WBN) Plant Unit 1 reactor was manually tripped due to a failure of the #3 Reactor Coolant Pump normal feeder breaker to close during the planned power transfer to unit power following startup. Concurrent with the reactor trip, the Auxiliary Feedwater system actuated as designed.

"All Control and Shutdown rods fully inserted. [Main Steam Isolation Valves] MSIVs were required to be isolated due to cooldown. All safety systems responded as designed. The unit is currently stable in Mode 3, with decay heat removal via Auxiliary Feedwater and Steam Generator Atmospheric Dump Valves. Unit 1 is in a normal shutdown electrical alignment.

"This reactor trip and system actuation is being reported under 10CFR 50.72(b)(3)(iv)(A) and 10CFR 50.72 (b)(2)(iv)(B).

"There was no effect on WBN Unit 2.

"The NRC Senior Resident has been notified."


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