Event Notification Report for March 23, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
3/20/2020 - 3/23/2020

** 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: 54594
Facility: QUAD CITIES Region: 3 State: IL Unit: [] [2] [] RX Type: [1] GE-3,[2] GE-3 NRC Notified By: SAMUEL SHAVER HQ OPS Officer: HOWIE CROUCH	Notification Date: 03/20/2020 Notification Time: 17:47 [ET] Event Date: 03/20/2020 Event Time: 10:25 [CDT] Last Update Date: 03/20/2020
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION	Person (Organization): JOHN HANNA (R3DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

Power Operation

Event Text

LOW PRESSURE COOLANT INJECTION UNPLANNED INOPERABILITY

"On March 20, 2020, at 1025 hours [CDT], Unit 2 MCC [motor control center] 28/29-5 failed to transfer to its alternate feed during surveillance testing. This would result in MCC 28/29-5 being de-energized in the event of a DBA LOCA [design basis accident loss of coolant accident] in which the Unit 1 Emergency Diesel Generator fails to energize Bus 29. Consequently, the LPCI [low pressure coolant injection] Injection Valve (MO 2-1001-29A/B) would not have power to open on the loop selected by LPCI Loop Select. This renders both divisions of the LPCI mode of Residual Heat Removal system inoperable. Technical Specification 3.5.1, Condition E had previously been entered during testing, requiring restoration of LPCI in 72 hours. No other ECCS [emergency core cooling] systems were inoperable at the time of the event. Troubleshooting and repairs are in progress.

"This event is reportable under 10 CFR 50.72(b)(3)(v)(D) as an event or condition that could have prevented fulfillment of a safety function."

The plant is still in its 72-hr. LCO action statement.

The licensee has notified the NRC Resident Inspector and the state of Illinois Emergency Management Agency.

Power Reactor	Event Number: 54596
Facility: VOGTLE Region: 2 State: GA Unit: [1] [] [] RX Type: [1] W-4-LP,[2] W-4-LP NRC Notified By: CURT RABUN HQ OPS Officer: OSSY FONT	Notification Date: 03/21/2020 Notification Time: 23:46 [ET] Event Date: 03/21/2020 Event Time: 16:44 [EDT] Last Update Date: 03/22/2020
Emergency Class: NON EMERGENCY 10 CFR Section: 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

Refueling

Event Text

AUTOMATIC ACTUATION OF THE 1B EMERGENCY DIESEL GENERATOR

"At 1644 EDT with Unit 1 in Mode 6 at 0 percent power, an actuation of the Unit 1 Bravo Train Emergency Diesel Generator system (EDG) occurred during Engineered Safety Feature Actuation System (ESFAS) testing. The reason for the EDG auto-start signal was a loss of voltage on the Bravo train safety related electrical bus due to the EDG output breaker opening. The EDG was already running at the time of the loss of voltage on the bus.

"This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the EDG system.

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

There was no impact to Unit 2.

Power Reactor	Event Number: 54597
Facility: BRUNSWICK Region: 2 State: NC Unit: [1] [] [] RX Type: [1] GE-4,[2] GE-4 NRC Notified By: BRIAN MOSCHET HQ OPS Officer: OSSY FONT	Notification Date: 03/22/2020 Notification Time: 16:39 [ET] Event Date: 03/22/2020 Event Time: 12:55 [EDT] Last Update Date: 03/22/2020
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL	Person (Organization): MARK MILLER (R2DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

M/R

Startup

Hot Shutdown

Event Text

MANUAL REACTOR SCRAM

"At 1255 Eastern Daylight Time (EDT) on March 22, 2020, with Unit 1 in Mode 2, stabilized at 2 percent power, coming out of a refueling outage, all 4 main turbine Bypass Valves (BPVs) opened unexpectedly. As a result, the main control room inserted a manual reactor scram. All control rods inserted as expected during the scram.

"In accordance with plant procedures, the main control room closed all Main Steam Line Isolation Valves (MSIVs) to arrest the cooldown resulting from BPVs remaining open. The condensate system remained aligned for injection and pressure control was initially via main steam line drains. RHR [residual heat removal] shutdown cooling was placed in operation for decay heat removal and pressure control once the MSIVs were closed.

"All systems responded as designed, with the exception of the BPVs.

"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."

There was no impact to Unit 2.

Page Last Reviewed/Updated Wednesday, March 24, 2021