Event Notification Report for June 21, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/20/2021 - 06/21/2021
Agreement State
Event Number: 55869
Rep Org: Wisconsin Radiation Protection
Licensee: Aurora Medical Center of Oshkosh
Region: 3
City: Oshkosh State: WI
County:
License #: 139-1025-01
Agreement: Y
Docket:
NRC Notified By: Luther S. Loehrke
HQ OPS Officer: Ossy Font
Licensee: Aurora Medical Center of Oshkosh
Region: 3
City: Oshkosh State: WI
County:
License #: 139-1025-01
Agreement: Y
Docket:
NRC Notified By: Luther S. Loehrke
HQ OPS Officer: Ossy Font
Notification Date: 04/29/2022
Notification Time: 10:07 [ET]
Event Date: 06/21/2021
Event Time: 00:00 [CDT]
Last Update Date: 04/29/2022
Notification Time: 10:07 [ET]
Event Date: 06/21/2021
Event Time: 00:00 [CDT]
Last Update Date: 04/29/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
Ziolkowski, Michael (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Ziolkowski, Michael (R3DO)
AGREEMENT STATE REPORT - MEDICAL EVENT DUE TO DISCREPENCY WITH WRITTEN DIRECTIVE
The following summary was received from the Wisconsin Department of Public Health (the Department) via email:
On April 28, 2022, during an inspection, the Department became aware of a medical event involving Y-90 TheraSphere which occurred on June 21, 2021. A patient's procedure planned for two vials and an activity of 2.81 GBq, which were administered. The written directive erroneously only accounted for one vial and a prescribed activity of 1.94 GBq; therefore, the administered activity was 138.4 percent of the activity specified on the written directive. The administered activity was within 2 percent of the planned activity.
Wisconsin Event Report ID No.: WI220010
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 summary was received from the Wisconsin Department of Public Health (the Department) via email:
On April 28, 2022, during an inspection, the Department became aware of a medical event involving Y-90 TheraSphere which occurred on June 21, 2021. A patient's procedure planned for two vials and an activity of 2.81 GBq, which were administered. The written directive erroneously only accounted for one vial and a prescribed activity of 1.94 GBq; therefore, the administered activity was 138.4 percent of the activity specified on the written directive. The administered activity was within 2 percent of the planned activity.
Wisconsin Event Report ID No.: WI220010
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: 55320
Facility: Braidwood
Region: 3 State: IL
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Matthew Marzano
HQ OPS Officer: Thomas Herrity
Region: 3 State: IL
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Matthew Marzano
HQ OPS Officer: Thomas Herrity
Notification Date: 06/21/2021
Notification Time: 03:06 [ET]
Event Date: 06/21/2021
Event Time: 00:51 [CDT]
Last Update Date: 06/21/2021
Notification Time: 03:06 [ET]
Event Date: 06/21/2021
Event Time: 00:51 [CDT]
Last Update Date: 06/21/2021
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):
HILLS, DAVID (R3)
HILLS, DAVID (R3)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | A/R | N | 100 | Power Operation | 0 | Hot Standby |
EN Revision Imported Date: 7/20/2021
EN Revision Text: REACTOR TRIP ON GENERATOR LOCKOUT RELAY TRIP
"At 0051 CDT Braidwood Unit 1 experienced an automatic reactor trip due to a generator lockout relay trip and subsequent turbine trip and reactor trip.
"The cause of the generator lockout relay trip is unknown at this time and is under investigation. Numerous lightning strikes were present in the area during the time of the generator lockout relay trip.
"Both trains of auxiliary feedwater started automatically following the reactor trip to maintain steam generator water levels.
"All systems responded as expected with the exception of failure of source range nuclear instruments to automatically re-energize following the reactor trip. Both source range nuclear instruments were manually energized in accordance with station procedures. The main steam dump valves are in service to the main condenser to provide heat sink cooling. The plant is being maintained at normal operating pressure and temperature. AC power is being provided by Offsite Power with the 1B Diesel Generator in standby. 1A Diesel Generator is out of service for planned maintenance. All other safety systems are available. There is no impact to Unit 2.
"This report is being made per 10 CFR 50.72(b)(2)(iv)(B) for a RPS actuation, 4 hr. notification, and per 10 CFR 50.72(b)(3)(iv)(A) for an automatic actuation of the Auxiliary Feedwater system, 8 hr. notification.
"The NRC Resident Inspector and Illinois Emergency Management Agency have been informed."
EN Revision Text: REACTOR TRIP ON GENERATOR LOCKOUT RELAY TRIP
"At 0051 CDT Braidwood Unit 1 experienced an automatic reactor trip due to a generator lockout relay trip and subsequent turbine trip and reactor trip.
"The cause of the generator lockout relay trip is unknown at this time and is under investigation. Numerous lightning strikes were present in the area during the time of the generator lockout relay trip.
"Both trains of auxiliary feedwater started automatically following the reactor trip to maintain steam generator water levels.
"All systems responded as expected with the exception of failure of source range nuclear instruments to automatically re-energize following the reactor trip. Both source range nuclear instruments were manually energized in accordance with station procedures. The main steam dump valves are in service to the main condenser to provide heat sink cooling. The plant is being maintained at normal operating pressure and temperature. AC power is being provided by Offsite Power with the 1B Diesel Generator in standby. 1A Diesel Generator is out of service for planned maintenance. All other safety systems are available. There is no impact to Unit 2.
"This report is being made per 10 CFR 50.72(b)(2)(iv)(B) for a RPS actuation, 4 hr. notification, and per 10 CFR 50.72(b)(3)(iv)(A) for an automatic actuation of the Auxiliary Feedwater system, 8 hr. notification.
"The NRC Resident Inspector and Illinois Emergency Management Agency have been informed."