Event Notification Report for October 28, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/27/2021 - 10/28/2021
Power Reactor
Event Number: 55550
Facility: Watts Bar
Region: 2 State: TN
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Rob Collins
HQ OPS Officer: Donald Norwood
Region: 2 State: TN
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Rob Collins
HQ OPS Officer: Donald Norwood
Notification Date: 10/28/2021
Notification Time: 14:19 [ET]
Event Date: 10/28/2021
Event Time: 13:40 [EDT]
Last Update Date: 10/28/2021
Notification Time: 14:19 [ET]
Event Date: 10/28/2021
Event Time: 13:40 [EDT]
Last Update Date: 10/28/2021
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
Person (Organization):
Miller, Mark (R2)
Miller, Mark (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 92 | Power Operation | 92 | Power Operation |
| 2 | N | Y | 95 | Power Operation | 95 | Power Operation |
EN Revision Imported Date: 11/26/2021
EN Revision Text: OFFSITE NOTIFICATION DUE TO TWO MONITORING WELLS EXCEEDING NEI GPI TRITIUM THRESHOLD VALUES
"At 1340 EDT on October 28, 2021, Watts Bar Nuclear Plant (WBN) Units 1 and 2 initiated voluntary communication to the State of Tennessee and local officials as part of the Nuclear Energy Institute (NEI) Groundwater Protection Initiative (GPI), after receiving analysis results for two on-site monitoring wells that indicated tritium activity above the GPI voluntary communication threshold. The suspected source, a permitted release line, has been isolated, and additional corrective actions are in progress. This condition did not exceed any NRC regulations or reporting criteria. This notification is being made solely as a four-hour, non-emergency notification for a Notification of Other Government Agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
EN Revision Text: OFFSITE NOTIFICATION DUE TO TWO MONITORING WELLS EXCEEDING NEI GPI TRITIUM THRESHOLD VALUES
"At 1340 EDT on October 28, 2021, Watts Bar Nuclear Plant (WBN) Units 1 and 2 initiated voluntary communication to the State of Tennessee and local officials as part of the Nuclear Energy Institute (NEI) Groundwater Protection Initiative (GPI), after receiving analysis results for two on-site monitoring wells that indicated tritium activity above the GPI voluntary communication threshold. The suspected source, a permitted release line, has been isolated, and additional corrective actions are in progress. This condition did not exceed any NRC regulations or reporting criteria. This notification is being made solely as a four-hour, non-emergency notification for a Notification of Other Government Agency. This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi). There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
Agreement State
Event Number: 55640
Rep Org: PA Bureau of Radiation Protection
Licensee: UPMC Passavant
Region: 1
City: Pittsburgh State: PA
County:
License #: PA-0310
Agreement: Y
Docket:
NRC Notified By: John S. Chippo
HQ OPS Officer: Lloyd Desotell
Licensee: UPMC Passavant
Region: 1
City: Pittsburgh State: PA
County:
License #: PA-0310
Agreement: Y
Docket:
NRC Notified By: John S. Chippo
HQ OPS Officer: Lloyd Desotell
Notification Date: 12/10/2021
Notification Time: 13:27 [ET]
Event Date: 10/28/2021
Event Time: 00:00 [EST]
Last Update Date: 12/10/2021
Notification Time: 13:27 [ET]
Event Date: 10/28/2021
Event Time: 00:00 [EST]
Last Update Date: 12/10/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Dentel, Glenn (R1DO)
NMSS_Events_Notification, (EMAIL)
Dentel, Glenn (R1DO)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 1/10/2022
EN Revision Text: AGREEMENT STATE REPORT - DOSE TO UNINTENDED ORGAN
The following was received from the Commonwealth of Pennsylvania by email:
"On December 10, 2021, the Radiation Safety Officer for the licensee verbally reported a patient being treated for vaginal cancer was prescribed a 21 Gy total dose, to be delivered in 3 fractions of 7 Gy each via HDR [(high dose rate)]. The first fraction was delivered on October 28, 2021. At some point after that treatment, the patient began experiencing complications from the hysterectomy and ended up going to a different hospital for that issue. The patient did not return to the licensee's facility to complete her treatment. At the other hospital, a different Radiation Oncologist was consulted and was reviewing the patient's treatment and discovered that the treatment in October at the licensee was 3 cm off and the intestine received some fraction of the first treatment dose. It was discovered that the patient required re-suturing of the cervix and that the brachytherapy apparatus (used in the HDR treatment) passed beyond the apex of the vagina. This discovery was made yesterday, December 9, 2021. The licensee's medical physicist is currently calculating dose estimates. The referring physician is also being informed. No further information is available at this time. The Department of Environmental Protection will update this event as soon as more information is provided."
PA Event Report ID No: PA210021
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 - DOSE TO UNINTENDED ORGAN
The following was received from the Commonwealth of Pennsylvania by email:
"On December 10, 2021, the Radiation Safety Officer for the licensee verbally reported a patient being treated for vaginal cancer was prescribed a 21 Gy total dose, to be delivered in 3 fractions of 7 Gy each via HDR [(high dose rate)]. The first fraction was delivered on October 28, 2021. At some point after that treatment, the patient began experiencing complications from the hysterectomy and ended up going to a different hospital for that issue. The patient did not return to the licensee's facility to complete her treatment. At the other hospital, a different Radiation Oncologist was consulted and was reviewing the patient's treatment and discovered that the treatment in October at the licensee was 3 cm off and the intestine received some fraction of the first treatment dose. It was discovered that the patient required re-suturing of the cervix and that the brachytherapy apparatus (used in the HDR treatment) passed beyond the apex of the vagina. This discovery was made yesterday, December 9, 2021. The licensee's medical physicist is currently calculating dose estimates. The referring physician is also being informed. No further information is available at this time. The Department of Environmental Protection will update this event as soon as more information is provided."
PA Event Report ID No: PA210021
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