Event Notification Report for May 12, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/11/2021 - 05/12/2021
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State
Event Number: 55257
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: University of California Davis
Region: 4
City: Sacramento State: CA
County:
License #: CA-RML 1334-57
Agreement: Y
Docket:
NRC Notified By: Robert Greger
HQ OPS Officer: Kerby Scales
Licensee: University of California Davis
Region: 4
City: Sacramento State: CA
County:
License #: CA-RML 1334-57
Agreement: Y
Docket:
NRC Notified By: Robert Greger
HQ OPS Officer: Kerby Scales
Notification Date: 05/13/2021
Notification Time: 20:41 [ET]
Event Date: 05/12/2021
Event Time: 00:00 []
Last Update Date: 06/03/2021
Notification Time: 20:41 [ET]
Event Date: 05/12/2021
Event Time: 00:00 []
Last Update Date: 06/03/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
GADDY, VINCENT (R4DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
Kevin Williams (NMSS/DIR)
GADDY, VINCENT (R4DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
Kevin Williams (NMSS/DIR)
EN Revision Imported Date: 7/2/2021
EN Revision Text: AGREEMENT STATE REPORT - OVERDOSE AND WRONG TREATMENT SITE
The following was received from the California Department of Public Health via email:
"On May 12, 2021, licensee notified the [Radiologic Health Branch] RHB of a possible medical event which occurred on May 10, 2021 involving a Gamma Knife patient who likely received a dose greater than 0.5 Sv (50 rem) to a tissue other than the treatment site and over 50% of the expected dose to that site from the procedure if the administration had been given in accordance with the written directive. No further details have been provided at this time. The licensee is currently investigating and will provide a full report within 15 days. RHB is investigating this event."
California Item Number: 051221
* * * RETRACTION ON 1 JUNE 2021 AT 1454 EDT FROM L. ROBERT GREGER TO JOANNA BRIDGE * * *
The following was received via e-mail from the state of California via e-mail:
"The licensee's initial dose calculation performed on the impacted non-target tissue was made to a non-dimensional point adjacent to the target tissue. Upon further licensee consideration, the non-target dose calculation was performed on the 1.55 cc non-target tissue (muscle) most impacted by a planning error for the gamma knife treatment. The revised calculation resulted in a dose to the non-target muscle tissue of 140 rad (1.4 Gy) compared to the 120 rad (1.2 Gy) that the 1.55 cc non-target muscle tissue would have received had the planning error not occurred. Therefore, the Medical Event criterion was not exceeded."
Notified R4DO (Groom) and NMSS Events (by email).
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 - OVERDOSE AND WRONG TREATMENT SITE
The following was received from the California Department of Public Health via email:
"On May 12, 2021, licensee notified the [Radiologic Health Branch] RHB of a possible medical event which occurred on May 10, 2021 involving a Gamma Knife patient who likely received a dose greater than 0.5 Sv (50 rem) to a tissue other than the treatment site and over 50% of the expected dose to that site from the procedure if the administration had been given in accordance with the written directive. No further details have been provided at this time. The licensee is currently investigating and will provide a full report within 15 days. RHB is investigating this event."
California Item Number: 051221
* * * RETRACTION ON 1 JUNE 2021 AT 1454 EDT FROM L. ROBERT GREGER TO JOANNA BRIDGE * * *
The following was received via e-mail from the state of California via e-mail:
"The licensee's initial dose calculation performed on the impacted non-target tissue was made to a non-dimensional point adjacent to the target tissue. Upon further licensee consideration, the non-target dose calculation was performed on the 1.55 cc non-target tissue (muscle) most impacted by a planning error for the gamma knife treatment. The revised calculation resulted in a dose to the non-target muscle tissue of 140 rad (1.4 Gy) compared to the 120 rad (1.2 Gy) that the 1.55 cc non-target muscle tissue would have received had the planning error not occurred. Therefore, the Medical Event criterion was not exceeded."
Notified R4DO (Groom) and NMSS Events (by email).
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: 55252
Facility: Wolf Creek
Region: 4 State: KS
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: Tyler Greenfield
HQ OPS Officer: Jeffrey Whited
Region: 4 State: KS
Unit: [1] [] []
RX Type: [1] W-4-LP
NRC Notified By: Tyler Greenfield
HQ OPS Officer: Jeffrey Whited
Notification Date: 05/12/2021
Notification Time: 15:41 [ET]
Event Date: 05/12/2021
Event Time: 11:25 [CDT]
Last Update Date: 05/12/2021
Notification Time: 15:41 [ET]
Event Date: 05/12/2021
Event Time: 11:25 [CDT]
Last Update Date: 05/12/2021
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):
GADDY, VINCENT (R4)
GADDY, VINCENT (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | A/R | Y | 8 | Power Operation | 0 | Hot Standby |
EN Revision Imported Date: 6/11/2021
EN Revision Text: AUTOMATIC REACTOR TRIP, MAIN FEED ISOLATION, AND AUXILLIARY FEEDWATER SYSTEM ACTUATION
"With Reactor power at approximately 8 percent following a refueling outage, Steam Generator levels began to oscillate while in automatic control. Manual control of Main Feedwater Regulating Valves was unable to stabilize steam generator levels prior to reaching the "C" Steam Generator Low Level Reactor Trip setpoint. Reactor Trip, Main Feedwater Isolation and Auxiliary Feedwater Actuation automatically actuated.
"The plant is stable in Mode 3 at Hot Standby. All equipment has responded as expected.
"The Resident has been contacted."
EN Revision Text: AUTOMATIC REACTOR TRIP, MAIN FEED ISOLATION, AND AUXILLIARY FEEDWATER SYSTEM ACTUATION
"With Reactor power at approximately 8 percent following a refueling outage, Steam Generator levels began to oscillate while in automatic control. Manual control of Main Feedwater Regulating Valves was unable to stabilize steam generator levels prior to reaching the "C" Steam Generator Low Level Reactor Trip setpoint. Reactor Trip, Main Feedwater Isolation and Auxiliary Feedwater Actuation automatically actuated.
"The plant is stable in Mode 3 at Hot Standby. All equipment has responded as expected.
"The Resident has been contacted."