Event Notification Report for February 18, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/17/2021 - 02/18/2021
Non-Agreement State
Event Number: 55107
Rep Org: Kootenai Health
Licensee: Kootenai Health
Region: 4
City: Coeur d`Alene State: ID
County:
License #: 11-27307-01
Agreement: N
Docket:
NRC Notified By: Rhonda Powell
HQ OPS Officer: Bethany Cecere
Licensee: Kootenai Health
Region: 4
City: Coeur d`Alene State: ID
County:
License #: 11-27307-01
Agreement: N
Docket:
NRC Notified By: Rhonda Powell
HQ OPS Officer: Bethany Cecere
Notification Date: 02/18/2021
Notification Time: 17:02 [ET]
Event Date: 02/18/2021
Event Time: 10:40 [MST]
Last Update Date: 02/18/2021
Notification Time: 17:02 [ET]
Event Date: 02/18/2021
Event Time: 10:40 [MST]
Last Update Date: 02/18/2021
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
Person (Organization):
DIXON, JOHN (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
DIXON, JOHN (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
NON-AGREEMENT STATE REPORT - RADIOPHARMECEUTICAL UNDER DOSE
The following was received via phone from the licensee:
At 1040 MST, on 2/18/21, a patient received less than the prescribed dose of 130 gray to the liver due to the catheter and device connection coming apart. The isotope was Y-90 glass microspheres. The calculated dose to the patient was 62.2 gray (47.9 percent of the prescribed dose). All non-delivered material was collected in the catheter and on absorbent material for decay and return to the manufacturer. The patient was notified of the under dose.
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 via phone from the licensee:
At 1040 MST, on 2/18/21, a patient received less than the prescribed dose of 130 gray to the liver due to the catheter and device connection coming apart. The isotope was Y-90 glass microspheres. The calculated dose to the patient was 62.2 gray (47.9 percent of the prescribed dose). All non-delivered material was collected in the catheter and on absorbent material for decay and return to the manufacturer. The patient was notified of the under dose.
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.
Part 21
Event Number: 55314
Rep Org: GE HITACHI NUCLEAR ENERGY
Licensee: GE Hitachi Nuclear Energy
Region: 1
City: Wilmington State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Jim Harrison
HQ OPS Officer: Jeffrey Whited
Licensee: GE Hitachi Nuclear Energy
Region: 1
City: Wilmington State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Jim Harrison
HQ OPS Officer: Jeffrey Whited
Notification Date: 06/17/2021
Notification Time: 14:26 [ET]
Event Date: 02/18/2021
Event Time: 00:00 [EDT]
Last Update Date: 06/17/2021
Notification Time: 14:26 [ET]
Event Date: 02/18/2021
Event Time: 00:00 [EDT]
Last Update Date: 06/17/2021
Emergency Class: Non Emergency
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
Person (Organization):
HILLS, DAVID (R3DO)
JOSEY, JEFFREY (R4DO)
PART 21/50.55 REACTORS, - (EMAIL)
HILLS, DAVID (R3DO)
JOSEY, JEFFREY (R4DO)
PART 21/50.55 REACTORS, - (EMAIL)
EN Revision Imported Date: 7/16/2021
EN Revision Text: PART 21 REPORT
The following is a summary of a report received from the vendor via email:
The vendor notified the NRC that the hydraulic loss coefficient used to calculate the pressure loss and flow rate into the Side Entry Orifice (SEO) at the fuel bundle entrance in BWR/6 plants may have been underpredicted. The SEO loss coefficient was underpredicted for some fuel bundle locations, which could result in an overprediction of MCPR margin in core monitoring applications. The overprediction was a result of not originally including in the assessment flow area restrictions associated with instrument support structures in the cross beams (structural supports underneath the core plate) in BWR/6 plant designs. BWR/2-5 plants built by GE have a different core support structure that is more open so that multiple SEO losses are not applied to evaluations for those plants.
However, there are currently no US ABWR plants in operation that would potentially be affected by this evaluation. The potential error in the core monitoring system does not affect the NRC certified design of the ABWR or the GEH ABWR design certification renewal application currently under review. The unique core support structure design of the BWR6 and ABWR is not shared by earlier BWR plants or the ESBWR.
Potentially Affected Plants:
Grand Gulf, River Bend, Clinton, Perry
Point of Contact: Michelle Catts
GE Hitachi Nuclear Energy
Safety Evaluation Program Manager
3901 Castle Hayne Road, Wilmington, NC 28401
EN Revision Text: PART 21 REPORT
The following is a summary of a report received from the vendor via email:
The vendor notified the NRC that the hydraulic loss coefficient used to calculate the pressure loss and flow rate into the Side Entry Orifice (SEO) at the fuel bundle entrance in BWR/6 plants may have been underpredicted. The SEO loss coefficient was underpredicted for some fuel bundle locations, which could result in an overprediction of MCPR margin in core monitoring applications. The overprediction was a result of not originally including in the assessment flow area restrictions associated with instrument support structures in the cross beams (structural supports underneath the core plate) in BWR/6 plant designs. BWR/2-5 plants built by GE have a different core support structure that is more open so that multiple SEO losses are not applied to evaluations for those plants.
However, there are currently no US ABWR plants in operation that would potentially be affected by this evaluation. The potential error in the core monitoring system does not affect the NRC certified design of the ABWR or the GEH ABWR design certification renewal application currently under review. The unique core support structure design of the BWR6 and ABWR is not shared by earlier BWR plants or the ESBWR.
Potentially Affected Plants:
Grand Gulf, River Bend, Clinton, Perry
Point of Contact: Michelle Catts
GE Hitachi Nuclear Energy
Safety Evaluation Program Manager
3901 Castle Hayne Road, Wilmington, NC 28401