Event Notification Report for March 03, 2020
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/02/2020 - 03/03/2020
Power Reactor
Event Number: 54559
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [] [] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: MATTHEW SLOUKA
HQ OPS Officer: ANDREW WAUGH
Region: 2 State: AL
Unit: [] [] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: MATTHEW SLOUKA
HQ OPS Officer: ANDREW WAUGH
Notification Date: 03/03/2020
Notification Time: 12:18 [ET]
Event Date: 03/03/2020
Event Time: 04:16 [CST]
Last Update Date: 03/03/2020
Notification Time: 12:18 [ET]
Event Date: 03/03/2020
Event Time: 04:16 [CST]
Last Update Date: 03/03/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
BRADLEY DAVIS (R2DO)
BRADLEY DAVIS (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | N | 0 | Refueling | 0 | Refueling |
EMERGENCY DIESEL GENERATOR ACTUATION
"At 0416 CST on March 3, 2020, with Browns Ferry Unit 3 in Mode 5, there was a partial loss of 161kV power due to a trip and re-closure of the feeder breaker supplying the Common Station Service Transformer (CSST) A. Unit 3 lost power to the 1A Start Bus and the 3A Unit Board, which supplies power to the 3EA and 3EB 4kV Shutdown Boards. The loss of the 4kV Shutdown Boards resulted in an auto actuation of the 3A and 3B Emergency Diesel Generators (EDG). The 3C EDG and 3EC 4kV Shutdown Board were removed from service for maintenance at the time of the loss of power, and the 3ED 4kV Shutdown Board continued to be powered from the 3B Unit Board.
"All systems responded as expected for the loss of power.
"This event requires an 8 hour report per 10 CFR 50.72(b)(3)(iv)(A).
"There was no impact to the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
The partial loss of power was caused by a storm in the area. Offsite power has been restored to the CSST and the EDGs have been secured.
"At 0416 CST on March 3, 2020, with Browns Ferry Unit 3 in Mode 5, there was a partial loss of 161kV power due to a trip and re-closure of the feeder breaker supplying the Common Station Service Transformer (CSST) A. Unit 3 lost power to the 1A Start Bus and the 3A Unit Board, which supplies power to the 3EA and 3EB 4kV Shutdown Boards. The loss of the 4kV Shutdown Boards resulted in an auto actuation of the 3A and 3B Emergency Diesel Generators (EDG). The 3C EDG and 3EC 4kV Shutdown Board were removed from service for maintenance at the time of the loss of power, and the 3ED 4kV Shutdown Board continued to be powered from the 3B Unit Board.
"All systems responded as expected for the loss of power.
"This event requires an 8 hour report per 10 CFR 50.72(b)(3)(iv)(A).
"There was no impact to the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
The partial loss of power was caused by a storm in the area. Offsite power has been restored to the CSST and the EDGs have been secured.
Agreement State
Event Number: 54601
Rep Org: RI DEPT OF RADIOLOGICAL HEALTH
Licensee: RHODE ISLAND HOSPITAL
Region: 1
City: PROVIDENCE State: RI
County:
License #: 7A-051-02
Agreement: Y
Docket:
NRC Notified By: MARIA BARNES
HQ OPS Officer: OSSY FONT
Licensee: RHODE ISLAND HOSPITAL
Region: 1
City: PROVIDENCE State: RI
County:
License #: 7A-051-02
Agreement: Y
Docket:
NRC Notified By: MARIA BARNES
HQ OPS Officer: OSSY FONT
Notification Date: 03/23/2020
Notification Time: 16:58 [ET]
Event Date: 03/03/2020
Event Time: 00:00 [EDT]
Last Update Date: 03/23/2020
Notification Time: 16:58 [ET]
Event Date: 03/03/2020
Event Time: 00:00 [EDT]
Last Update Date: 03/23/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MICHAEL LAYTON (DD)
KEVIN WILLIAMS (EMAIL)
PATRICIA MILLIGAN (EMAIL)
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MICHAEL LAYTON (DD)
KEVIN WILLIAMS (EMAIL)
PATRICIA MILLIGAN (EMAIL)
AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION (ABNORMAL OCCURRENCE)
The following was received from the Rhode Island Department of Health (RIDOH; the Department) via email:
"On March 4, 2020, the Department's staff at RIDOH, Radiation Control Program became aware of a medical event (ME) that occurred at the Rhode Island Hospital, Department of Radiation Oncology in Providence on March 3, 2020. The ME is reportable as per 10 CFR 35.3045(a)(1)(i)(A) and meets the criteria for an Abnormal Occurrence.
"On March 3, 2020, a patient underwent Gamma Knife treatment of a left vestibular schwannoma. At the conclusion of the treatment it was discovered that the location of the anterior screws securing the patient's head in the treatment position had moved. Before the patient was moved from the treatment table, the patient's position was observed by the radiation oncologist, neurosurgeon, and medical physicist. It is unknown at this time what contributed to the event and how the screws securing the patient in the treatment position had shifted from the initial position. Based on information provided by the patient and other participants associated with this event, a delivered dose was estimated using the GammaPlan Treatment Planning System. The estimated delivery to the target coverage area (volume of tissue receiving dose) was 44 percent. The estimated dose to the target was 4 Gy (400 rad). An unintended dose to a region of the left temporal lobe within the brain was estimated to be 13.6 Gy (1,360 rad). On the day of the incident, the attending neurosurgeon spoke directly with the patient informing the patient that the stereotactic frame had disengaged from his head at some point midway through the treatment and resulted in an unclear radiation dose to the tumor. The patient was informed of the estimated dose and told of the licensee's plan to obtain a follow-up brain MRI within 1-2 weeks after treatment and approximately 3 months after treatment."
The licensee is taking a number of corrective actions, including having the radiation therapist ensure that the patient understands that any movement of their head within the headframe is not anticipated and should be communicated immediately.
Event Report ID No: RI2020-01
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 from the Rhode Island Department of Health (RIDOH; the Department) via email:
"On March 4, 2020, the Department's staff at RIDOH, Radiation Control Program became aware of a medical event (ME) that occurred at the Rhode Island Hospital, Department of Radiation Oncology in Providence on March 3, 2020. The ME is reportable as per 10 CFR 35.3045(a)(1)(i)(A) and meets the criteria for an Abnormal Occurrence.
"On March 3, 2020, a patient underwent Gamma Knife treatment of a left vestibular schwannoma. At the conclusion of the treatment it was discovered that the location of the anterior screws securing the patient's head in the treatment position had moved. Before the patient was moved from the treatment table, the patient's position was observed by the radiation oncologist, neurosurgeon, and medical physicist. It is unknown at this time what contributed to the event and how the screws securing the patient in the treatment position had shifted from the initial position. Based on information provided by the patient and other participants associated with this event, a delivered dose was estimated using the GammaPlan Treatment Planning System. The estimated delivery to the target coverage area (volume of tissue receiving dose) was 44 percent. The estimated dose to the target was 4 Gy (400 rad). An unintended dose to a region of the left temporal lobe within the brain was estimated to be 13.6 Gy (1,360 rad). On the day of the incident, the attending neurosurgeon spoke directly with the patient informing the patient that the stereotactic frame had disengaged from his head at some point midway through the treatment and resulted in an unclear radiation dose to the tumor. The patient was informed of the estimated dose and told of the licensee's plan to obtain a follow-up brain MRI within 1-2 weeks after treatment and approximately 3 months after treatment."
The licensee is taking a number of corrective actions, including having the radiation therapist ensure that the patient understands that any movement of their head within the headframe is not anticipated and should be communicated immediately.
Event Report ID No: RI2020-01
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: 54560
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [] [2] []
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: ANTON PESTKA
HQ OPS Officer: JEFFREY WHITED
Region: 4 State: AZ
Unit: [] [2] []
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: ANTON PESTKA
HQ OPS Officer: JEFFREY WHITED
Notification Date: 03/04/2020
Notification Time: 02:07 [ET]
Event Date: 03/03/2020
Event Time: 20:50 [MST]
Last Update Date: 05/04/2020
Notification Time: 02:07 [ET]
Event Date: 03/03/2020
Event Time: 20:50 [MST]
Last Update Date: 05/04/2020
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
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical 50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
RICK DEESE (R4DO)
RICK DEESE (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 |
REACTOR TRIP DUE TO LOW STEAM GENERATOR LEVEL
"At 2050 MST on March 3, 2020, Unit 2 reactor automatically tripped on Low Steam Generator (SG) Number 1 level signal from the Reactor Protection System. The low SG level occurred as the result of a trip of both Main Feedwater Pumps, which tripped during restoration of power to the Main Feedwater Pump Lube oil control panel. Auxiliary Feedwater (AFAS-1 and AFAS-2) actuated due to low SG levels in both SG post reactor trip as designed. This event is being reported as a reactor protection system and a specified system actuation in accordance with the reporting criteria of 10 CFR 50.72(b)(2)(iv)(B) and 10 CFR 50.72(b)(3)(iv)(A).
"Following the reactor trip, all [control element assemblies] CEAs inserted fully into the core. All systems operated as expected. No emergency plan classification was required per the Emergency Plan. Safety related busses remained powered during the event from offsite power and the offsite power grid is stable. Unit 2 is stable and in Mode 3. Steam Generators are being fed via the class 1E powered motor driven auxiliary feedwater pump.
"The NRC Senior Resident Inspector has been informed."
Units 1 and 3 were unaffected by the trip and remain at 100 percent power.
* * * UPDATE FROM ALLAN BRIEFE TO DONALD NORWOOD AT 1231 EDT ON 5/4/2020 * * *
"The event reported on March 4, 2020 (EN 54560) also included actuations of the Emergency Diesel Generators in response to the AFAS-1 and AFAS-2 actuations. The Class 4.16kV buses remained energized from off-site power.
"The NRC Senior Resident Inspector has been informed."
Notified R4DO (Drake).
"At 2050 MST on March 3, 2020, Unit 2 reactor automatically tripped on Low Steam Generator (SG) Number 1 level signal from the Reactor Protection System. The low SG level occurred as the result of a trip of both Main Feedwater Pumps, which tripped during restoration of power to the Main Feedwater Pump Lube oil control panel. Auxiliary Feedwater (AFAS-1 and AFAS-2) actuated due to low SG levels in both SG post reactor trip as designed. This event is being reported as a reactor protection system and a specified system actuation in accordance with the reporting criteria of 10 CFR 50.72(b)(2)(iv)(B) and 10 CFR 50.72(b)(3)(iv)(A).
"Following the reactor trip, all [control element assemblies] CEAs inserted fully into the core. All systems operated as expected. No emergency plan classification was required per the Emergency Plan. Safety related busses remained powered during the event from offsite power and the offsite power grid is stable. Unit 2 is stable and in Mode 3. Steam Generators are being fed via the class 1E powered motor driven auxiliary feedwater pump.
"The NRC Senior Resident Inspector has been informed."
Units 1 and 3 were unaffected by the trip and remain at 100 percent power.
* * * UPDATE FROM ALLAN BRIEFE TO DONALD NORWOOD AT 1231 EDT ON 5/4/2020 * * *
"The event reported on March 4, 2020 (EN 54560) also included actuations of the Emergency Diesel Generators in response to the AFAS-1 and AFAS-2 actuations. The Class 4.16kV buses remained energized from off-site power.
"The NRC Senior Resident Inspector has been informed."
Notified R4DO (Drake).