Event Notification Report for December 03, 2020
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/02/2020 - 12/03/2020
Power Reactor
Event Number: 55020
Facility: Calvert Cliffs
Region: 1 State: MD
Unit: [1] [] []
RX Type: [1] CE,[2] CE
NRC Notified By: Britain Foster
HQ OPS Officer: Donald Norwood
Region: 1 State: MD
Unit: [1] [] []
RX Type: [1] CE,[2] CE
NRC Notified By: Britain Foster
HQ OPS Officer: Donald Norwood
Notification Date: 12/03/2020
Notification Time: 17:10 [ET]
Event Date: 12/03/2020
Event Time: 09:23 [EST]
Last Update Date: 12/03/2020
Notification Time: 17:10 [ET]
Event Date: 12/03/2020
Event Time: 09:23 [EST]
Last Update Date: 12/03/2020
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):
CHRISTOPHER CAHILL (R1DO)
CHRISTOPHER CAHILL (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
VALID ACTUATION OF AN EMERGENCY DIESEL GENERATOR
"At 0923 EST on December 3, 2020, with Unit 1 in Mode 1 at 100 percent power, an actuation of the Emergency AC Electrical Power System (Emergency Diesel Generator 1A) occurred during normal plant operations. The reason for Emergency Diesel Generator 1A auto start was due to Class 1E 4KV Bus 11 feeder breaker opening.
"The Emergency Diesel Generator 1A automatically started as designed when the loss of voltage signal on 4KV Bus 11 was received. This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that resulted in a valid actuation of the Emergency AC Electrical Power System.
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
The cause of the 4KV Bus 11 Feeder Breaker opening is unknown at the present time and is under investigation.
"At 0923 EST on December 3, 2020, with Unit 1 in Mode 1 at 100 percent power, an actuation of the Emergency AC Electrical Power System (Emergency Diesel Generator 1A) occurred during normal plant operations. The reason for Emergency Diesel Generator 1A auto start was due to Class 1E 4KV Bus 11 feeder breaker opening.
"The Emergency Diesel Generator 1A automatically started as designed when the loss of voltage signal on 4KV Bus 11 was received. This event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that resulted in a valid actuation of the Emergency AC Electrical Power System.
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
The cause of the 4KV Bus 11 Feeder Breaker opening is unknown at the present time and is under investigation.
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State
Event Number: 55021
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: Inova Fairfax Medical Campus
Region: 1
City: Falls Church State: VA
County:
License #: 610-116-1
Agreement: Y
Docket:
NRC Notified By: Asfaw Fenta
HQ OPS Officer: Jeffrey Whited
Licensee: Inova Fairfax Medical Campus
Region: 1
City: Falls Church State: VA
County:
License #: 610-116-1
Agreement: Y
Docket:
NRC Notified By: Asfaw Fenta
HQ OPS Officer: Jeffrey Whited
Notification Date: 12/04/2020
Notification Time: 08:20 [ET]
Event Date: 12/03/2020
Event Time: 00:00 [EST]
Last Update Date: 12/08/2020
Notification Time: 08:20 [ET]
Event Date: 12/03/2020
Event Time: 00:00 [EST]
Last Update Date: 12/08/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 12/8/2020
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT REPORT - UNDERDOSAGE
The following was received from the Virginia Radioactive Materials Program via email:
"On December 3, 2020, at 1540 EST, the Virginia Radioactive Materials Program (VRMP) received a report from the licensee via telephone that a medical event occurred on December 3, 2020, as a result of a therapy procedure using SIR-Spheres Yttrium-90 resin microspheres. The prescribed dosage to the tumor was 27.9 milliCuries. The actual delivered dosage to the tumor was 20.03 milliCuries, which resulted a difference of 28.3 percent (under-dosage). The preliminary report indicated that this difference was determined based on the measurement of the remaining residual activity in the delivery system.
"Referring physician was notified and an Authorized User was requested to contact the patient concerning the event. The VRMP is working with the licensee to obtain additional information and this report will be updated once the licensee's investigation is complete and the information is received."
Event Report ID No.: VA20006
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.
* * * RETRACTION ON 12/08/20 AT 0922 EST FROM ASFAW FENTA TO SOLOMON SAHLE * * *
The following retraction was received from the Commonwealth of Virginia via email:
"On 12/7/2020, VRMP received a report from the licensee re-investigation the event by two independent teams on 12/4/2020 for verification. Both teams found an error on the first measurement of the remaining residual radioactivity in the delivery system. Based on the teams' new measurements, the dosage left over after the procedure was now calculated to be 1.4 milliCuries of Yttrium-90 versus the original value of 8 milliCuries. Those measurements were corrected for the radioactive decay to the time of the procedure. The new value is within the allowed dose deviation of a normal procedure (new estimate 5 percent deviation of prescription). Thus, VRMP requests the NRC Operation Center retract this event report."
Notified R1DO (Bower) and NMSS Event Notification via email.
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT REPORT - UNDERDOSAGE
The following was received from the Virginia Radioactive Materials Program via email:
"On December 3, 2020, at 1540 EST, the Virginia Radioactive Materials Program (VRMP) received a report from the licensee via telephone that a medical event occurred on December 3, 2020, as a result of a therapy procedure using SIR-Spheres Yttrium-90 resin microspheres. The prescribed dosage to the tumor was 27.9 milliCuries. The actual delivered dosage to the tumor was 20.03 milliCuries, which resulted a difference of 28.3 percent (under-dosage). The preliminary report indicated that this difference was determined based on the measurement of the remaining residual activity in the delivery system.
"Referring physician was notified and an Authorized User was requested to contact the patient concerning the event. The VRMP is working with the licensee to obtain additional information and this report will be updated once the licensee's investigation is complete and the information is received."
Event Report ID No.: VA20006
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.
* * * RETRACTION ON 12/08/20 AT 0922 EST FROM ASFAW FENTA TO SOLOMON SAHLE * * *
The following retraction was received from the Commonwealth of Virginia via email:
"On 12/7/2020, VRMP received a report from the licensee re-investigation the event by two independent teams on 12/4/2020 for verification. Both teams found an error on the first measurement of the remaining residual radioactivity in the delivery system. Based on the teams' new measurements, the dosage left over after the procedure was now calculated to be 1.4 milliCuries of Yttrium-90 versus the original value of 8 milliCuries. Those measurements were corrected for the radioactive decay to the time of the procedure. The new value is within the allowed dose deviation of a normal procedure (new estimate 5 percent deviation of prescription). Thus, VRMP requests the NRC Operation Center retract this event report."
Notified R1DO (Bower) and NMSS Event Notification via email.