Event Notification Report for February 15, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/14/2021 - 02/15/2021
Power Reactor
Event Number: 55104
Facility: South Texas
Region: 4 State: TX
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Ron Rohan
HQ OPS Officer: Thomas Kendzia
Region: 4 State: TX
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Ron Rohan
HQ OPS Officer: Thomas Kendzia
Notification Date: 02/15/2021
Notification Time: 10:06 [ET]
Event Date: 02/15/2021
Event Time: 05:26 [CST]
Last Update Date: 02/15/2021
Notification Time: 10:06 [ET]
Event Date: 02/15/2021
Event Time: 05:26 [CST]
Last Update Date: 02/15/2021
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):
DIXON, JOHN (R4)
DIXON, JOHN (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | A/R | Y | 100 | Power Operation | 0 | Hot Standby |
EN Revision Imported Date: 2/17/2021
EN Revision Text: AUTOMATIC REACTOR TRIP DUE TO LOW STEAM GENERATOR LEVEL
"At 0526 [CST] on 02/15/2021, Unit 1 automatically tripped due to low steam generator levels. The low steam generator levels were due to loss of Feedwater pumps 11 and 13 (cause unknown).
"Auxiliary Feedwater and Feedwater Isolation actuated as designed. All Control and Shutdown Rods fully inserted. No primary or secondary relief valves opened. There were no electrical problems. Normal operating temperature and pressure (NOT/NOP) is 567 degrees F and 2235 psig.
"There were no significant TS LCOs entered.
"This event was not significant to the health and safety of the public based on all safety systems performed as designed. Unit 2 was not affected. Decay heat removal is being controlled via Steam Dumps. [Auxiliary Feedwater is supplying water to the Steam Generators.] Offsite power is in the normal electrical lineup.
"The NRC Resident inspector has been notified."
Unit 2 was not affected and remains at 100% power.
EN Revision Text: AUTOMATIC REACTOR TRIP DUE TO LOW STEAM GENERATOR LEVEL
"At 0526 [CST] on 02/15/2021, Unit 1 automatically tripped due to low steam generator levels. The low steam generator levels were due to loss of Feedwater pumps 11 and 13 (cause unknown).
"Auxiliary Feedwater and Feedwater Isolation actuated as designed. All Control and Shutdown Rods fully inserted. No primary or secondary relief valves opened. There were no electrical problems. Normal operating temperature and pressure (NOT/NOP) is 567 degrees F and 2235 psig.
"There were no significant TS LCOs entered.
"This event was not significant to the health and safety of the public based on all safety systems performed as designed. Unit 2 was not affected. Decay heat removal is being controlled via Steam Dumps. [Auxiliary Feedwater is supplying water to the Steam Generators.] Offsite power is in the normal electrical lineup.
"The NRC Resident inspector has been notified."
Unit 2 was not affected and remains at 100% power.
Agreement State
Event Number: 55704
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Northwestern Memorial Hospital
Region: 3
City: Chicago State: IL
County:
License #: IL-01037-02
Agreement: Y
Docket:
NRC Notified By: Robin G. Muzzalupo
HQ OPS Officer: Lloyd Desotell
Licensee: Northwestern Memorial Hospital
Region: 3
City: Chicago State: IL
County:
License #: IL-01037-02
Agreement: Y
Docket:
NRC Notified By: Robin G. Muzzalupo
HQ OPS Officer: Lloyd Desotell
Notification Date: 01/13/2022
Notification Time: 17:15 [ET]
Event Date: 02/15/2021
Event Time: 00:00 [CST]
Last Update Date: 01/13/2022
Notification Time: 17:15 [ET]
Event Date: 02/15/2021
Event Time: 00:00 [CST]
Last Update Date: 01/13/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Skokowski, Richard (R3)
NMSS_Events_Notification, (EMAIL)
Skokowski, Richard (R3)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 2/11/2022
EN Revision Text: AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following information was received from Illinois Emergency Management Agency (Agency) via E-mail:
"Agency inspectors performed a routine inspection on 1/6/2022. During a review of Y-90 TheraSphere procedures, inspectors noted an unreported medical event which occurred on 2/15/2021.
"On 2/15/2021, a written directive to deliver 1.93 GBq Y-90 TheraSpheres to the right hepatic artery was prepared. The procedure performed that same day was halted prematurely due to an unwinding of the male luer lock connector and only 0.49 GBq were administered. To compensate for the underdose, the licensee created an additional written directive and administered 1.17 GBq Y-90 TheraSpheres without incident [on the same day as the initial procedure].
"The licensee was under the impression that this was not a reportable medical event since they were able to compensate the dose with an additional vial they had on hand and were ultimately able to deliver the intended dose."
Item Number: IL220001
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.
EN Revision Text: AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following information was received from Illinois Emergency Management Agency (Agency) via E-mail:
"Agency inspectors performed a routine inspection on 1/6/2022. During a review of Y-90 TheraSphere procedures, inspectors noted an unreported medical event which occurred on 2/15/2021.
"On 2/15/2021, a written directive to deliver 1.93 GBq Y-90 TheraSpheres to the right hepatic artery was prepared. The procedure performed that same day was halted prematurely due to an unwinding of the male luer lock connector and only 0.49 GBq were administered. To compensate for the underdose, the licensee created an additional written directive and administered 1.17 GBq Y-90 TheraSpheres without incident [on the same day as the initial procedure].
"The licensee was under the impression that this was not a reportable medical event since they were able to compensate the dose with an additional vial they had on hand and were ultimately able to deliver the intended dose."
Item Number: IL220001
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.