Event Notification Report for November 12, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/11/2021 - 11/12/2021
Power Reactor
Event Number: 55572
Facility: Beaver Valley
Region: 1 State: PA
Unit: [2] [] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: Sean McGee
HQ OPS Officer: Donald Norwood
Region: 1 State: PA
Unit: [2] [] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: Sean McGee
HQ OPS Officer: Donald Norwood
Notification Date: 11/12/2021
Notification Time: 13:52 [ET]
Event Date: 11/12/2021
Event Time: 10:07 [EST]
Last Update Date: 11/12/2021
Notification Time: 13:52 [ET]
Event Date: 11/12/2021
Event Time: 10:07 [EST]
Last Update Date: 11/12/2021
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical
Person (Organization):
Henrion, Mark (R1)
Henrion, Mark (R1)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | M/R | Y | 17 | Power Operation | 0 | Power Operation |
EN Revision Imported Date: 12/10/2021
EN Revision Text: MANUAL REACTOR TRIP DUE TO INCREASING STEAM GENERATOR WATER LEVELS
"At 1007 EST on November 12, 2021, with Unit 2 in Mode 1 at approximately 17 percent power following a refueling outage, the reactor was manually tripped due to increasing steam generator water levels due to an oscillating Main Feedwater Pump Recirculation Valve. Additionally, the Main Steam Isolation Valves were manually closed to prevent excessive reactor coolant system cooldown. Decay heat is being removed by discharging steam to the atmosphere using the Atmospheric Dump Valves.
"The trip was not complex, with all systems responding normally post-trip. There was no equipment inoperable prior to the event that contributed to the reactor trip or adversely impacted plant response. Operations responded and stabilized the plant.
"Beaver Valley Power Station Unit 1 is unaffected and remains at 100 percent power in Mode 1.
"Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour, non-emergency notification, per 10 CFR 50.72(b)(2)(iv)(B).
"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: MANUAL REACTOR TRIP DUE TO INCREASING STEAM GENERATOR WATER LEVELS
"At 1007 EST on November 12, 2021, with Unit 2 in Mode 1 at approximately 17 percent power following a refueling outage, the reactor was manually tripped due to increasing steam generator water levels due to an oscillating Main Feedwater Pump Recirculation Valve. Additionally, the Main Steam Isolation Valves were manually closed to prevent excessive reactor coolant system cooldown. Decay heat is being removed by discharging steam to the atmosphere using the Atmospheric Dump Valves.
"The trip was not complex, with all systems responding normally post-trip. There was no equipment inoperable prior to the event that contributed to the reactor trip or adversely impacted plant response. Operations responded and stabilized the plant.
"Beaver Valley Power Station Unit 1 is unaffected and remains at 100 percent power in Mode 1.
"Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour, non-emergency notification, per 10 CFR 50.72(b)(2)(iv)(B).
"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: 55573
Rep Org: Arizona Dept of Health Services
Licensee: Western Regional Medical Center
Region: 4
City: Goodyear State: AZ
County:
License #: 07-629
Agreement: Y
Docket:
NRC Notified By: Brian Goretzki
HQ OPS Officer: Donald Norwood
Licensee: Western Regional Medical Center
Region: 4
City: Goodyear State: AZ
County:
License #: 07-629
Agreement: Y
Docket:
NRC Notified By: Brian Goretzki
HQ OPS Officer: Donald Norwood
Notification Date: 11/12/2021
Notification Time: 19:08 [ET]
Event Date: 11/12/2021
Event Time: 00:00 [MST]
Last Update Date: 11/12/2021
Notification Time: 19:08 [ET]
Event Date: 11/12/2021
Event Time: 00:00 [MST]
Last Update Date: 11/12/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Gaddy, Vincent (R4)
NMSS_Events_Notification, (EMAIL)
Gaddy, Vincent (R4)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 12/10/2021
EN Revision Text: MEDICAL EVENT - UNDERDOSAGE DUE TO HDR AFTERLOADER MALFUNCTION
The following information was received via E-mail:
"On November 12, 2021, the Department (Arizona Department of Health Services) was notified by the licensee that during an HDR treatment, an error message showed up after the first 15 channels were delivered. The error message was '8C:2 Dummy park switch or drive failure.' The Varian Medical System help desk was contacted for the error message without resolution. The field service engineer was called and suggested to power down the afterloader unit and reboot it, which did not resolve the problem. To avoid putting the patient under general anesthesia any longer, the Authorized User decided to stop the treatment and left the remaining four (4) channels untreated. The prescribed dose was 14 Gy and the estimated dose given was 10.2 Gy. The afterloader unit was a Varian Varisource iX, with an activity of 7.5 Ci of Iridium-192. The Department has requested additional information and continues to investigate the event."
Arizona Incident: 21-010
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: MEDICAL EVENT - UNDERDOSAGE DUE TO HDR AFTERLOADER MALFUNCTION
The following information was received via E-mail:
"On November 12, 2021, the Department (Arizona Department of Health Services) was notified by the licensee that during an HDR treatment, an error message showed up after the first 15 channels were delivered. The error message was '8C:2 Dummy park switch or drive failure.' The Varian Medical System help desk was contacted for the error message without resolution. The field service engineer was called and suggested to power down the afterloader unit and reboot it, which did not resolve the problem. To avoid putting the patient under general anesthesia any longer, the Authorized User decided to stop the treatment and left the remaining four (4) channels untreated. The prescribed dose was 14 Gy and the estimated dose given was 10.2 Gy. The afterloader unit was a Varian Varisource iX, with an activity of 7.5 Ci of Iridium-192. The Department has requested additional information and continues to investigate the event."
Arizona Incident: 21-010
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.
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 55574
Facility: Turkey Point
Region: 2 State: FL
Unit: [3] [] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: Humberto Benitez
HQ OPS Officer: Donald Norwood
Region: 2 State: FL
Unit: [3] [] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: Humberto Benitez
HQ OPS Officer: Donald Norwood
Notification Date: 11/12/2021
Notification Time: 20:47 [ET]
Event Date: 11/12/2021
Event Time: 16:05 [EST]
Last Update Date: 03/28/2022
Notification Time: 20:47 [ET]
Event Date: 11/12/2021
Event Time: 16:05 [EST]
Last Update Date: 03/28/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(ii)(A) - Degraded Condition
10 CFR Section:
50.72(b)(3)(ii)(A) - Degraded Condition
Person (Organization):
Miller, Mark (R2)
Miller, Mark (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | N | 0 | Hot Standby | 0 | Hot Standby |
EN Revision Imported Date: 4/15/2022
EN Revision Text: REACTOR COOLANT SYSTEM PRESSURE BOUNDARY DEGRADED
"At 1605 EST on 11/12/21, it was determined that the RCS Pressure Boundary does not meet ASME Section XI, Table IWB-341 0-1, 'Acceptable Standards' due to a through wall leak of the Core Exit Thermocouple Nozzle Assembly.
"Measures have been taken to establish Mode 5 for corrective actions.
"This event is being reported pursuant to 10 CFR 50.72(b)(3)(ii)(A).
"The NRC Resident Inspector has been notified.
* * * RETRACTION ON 3/28/2022 AT 0849 EDT FROM DAVID STOIA TO MIKE STAFFORD * * *
The following information was provided by the licensee via email:
"On 11/12/2021 EN 55574 reported possible evidence of pressure boundary through-wall leakage observed on a Core Exit Thermocouple (CET) tube. On 3/10/2022, based on laboratory analysis of the affected CET tube section, FPL Engineering determined that there was no pressure boundary through-wall leakage associated with this event. Analysis identified that the leakage likely originated from an adjacent threaded compression fitting on a tubing joint. This condition complies with ASME Section XI requirements and is therefore not reportable. This follow-up NRCOC notification is a retraction of EN 55574."
The NRC Resident Inspector has been notified.
Notified R2DO (Miller).
EN Revision Text: REACTOR COOLANT SYSTEM PRESSURE BOUNDARY DEGRADED
"At 1605 EST on 11/12/21, it was determined that the RCS Pressure Boundary does not meet ASME Section XI, Table IWB-341 0-1, 'Acceptable Standards' due to a through wall leak of the Core Exit Thermocouple Nozzle Assembly.
"Measures have been taken to establish Mode 5 for corrective actions.
"This event is being reported pursuant to 10 CFR 50.72(b)(3)(ii)(A).
"The NRC Resident Inspector has been notified.
* * * RETRACTION ON 3/28/2022 AT 0849 EDT FROM DAVID STOIA TO MIKE STAFFORD * * *
The following information was provided by the licensee via email:
"On 11/12/2021 EN 55574 reported possible evidence of pressure boundary through-wall leakage observed on a Core Exit Thermocouple (CET) tube. On 3/10/2022, based on laboratory analysis of the affected CET tube section, FPL Engineering determined that there was no pressure boundary through-wall leakage associated with this event. Analysis identified that the leakage likely originated from an adjacent threaded compression fitting on a tubing joint. This condition complies with ASME Section XI requirements and is therefore not reportable. This follow-up NRCOC notification is a retraction of EN 55574."
The NRC Resident Inspector has been notified.
Notified R2DO (Miller).
Agreement State
Event Number: 55579
Rep Org: California Radiation Control Prgm
Licensee: Regents of the University of California - Los Angeles
Region: 4
City: Los Angeles State: CA
County:
License #: 1335-19
Agreement: Y
Docket:
NRC Notified By: Donald Oesterle
HQ OPS Officer: Donald Norwood
Licensee: Regents of the University of California - Los Angeles
Region: 4
City: Los Angeles State: CA
County:
License #: 1335-19
Agreement: Y
Docket:
NRC Notified By: Donald Oesterle
HQ OPS Officer: Donald Norwood
Notification Date: 11/15/2021
Notification Time: 15:12 [ET]
Event Date: 11/12/2021
Event Time: 00:00 [PST]
Last Update Date: 11/15/2021
Notification Time: 15:12 [ET]
Event Date: 11/12/2021
Event Time: 00:00 [PST]
Last Update Date: 11/15/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Drake, James (R4)
NMSS_Events_Notification, (EMAIL)
Drake, James (R4)
NMSS_Events_Notification, (EMAIL)
EN Revision Imported Date: 12/15/2021
EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE DURING Y-90 ADMINISTRATION
The following information was received via E-mail:
"On Saturday, November 13, 2021 at 1420 PST, a CDPH-Radiologic Health Branch inspector was notified by E-mail that a medical event had occurred on November 12, 2021, at UCLA during a Y-90 liver cancer treatment. The signed written directive was included in the notification.
"The prescribed dose for 'Segment Left' was 70 Gy (6 GBq) and the dose delivered was 68.8 Gy (or 98.29 percent of the prescribed dose). The prescribed dose for 'Segment Right' was 120 Gy (3 GBq) and the dose delivered was 78.3 Gy (or 65.25 percent of the prescribed dose).
"The authorized user administered two vials of BTG Nordion Inc. TheraSphere Y-90 glass microspheres beginning approximately 1200 PST. Vial number 101 went to the right lobe and vial number 30 went to the left lobe of the liver.
"Radiation surveys of the waste containers occurred at 1516 PST and 1519 PST respectively, and the radiation level from vial number 30 was higher than expected. UCLA's medical physicist was consulted at 1630 PST November 12, 2021, who determined that a medical event had occurred.
"UCLA will be investigating the cause of the underdose and make a 15-day written report."
California 5010 Number: 111221
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 - UNDERDOSE DURING Y-90 ADMINISTRATION
The following information was received via E-mail:
"On Saturday, November 13, 2021 at 1420 PST, a CDPH-Radiologic Health Branch inspector was notified by E-mail that a medical event had occurred on November 12, 2021, at UCLA during a Y-90 liver cancer treatment. The signed written directive was included in the notification.
"The prescribed dose for 'Segment Left' was 70 Gy (6 GBq) and the dose delivered was 68.8 Gy (or 98.29 percent of the prescribed dose). The prescribed dose for 'Segment Right' was 120 Gy (3 GBq) and the dose delivered was 78.3 Gy (or 65.25 percent of the prescribed dose).
"The authorized user administered two vials of BTG Nordion Inc. TheraSphere Y-90 glass microspheres beginning approximately 1200 PST. Vial number 101 went to the right lobe and vial number 30 went to the left lobe of the liver.
"Radiation surveys of the waste containers occurred at 1516 PST and 1519 PST respectively, and the radiation level from vial number 30 was higher than expected. UCLA's medical physicist was consulted at 1630 PST November 12, 2021, who determined that a medical event had occurred.
"UCLA will be investigating the cause of the underdose and make a 15-day written report."
California 5010 Number: 111221
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: 56919
Rep Org: V. C. Summer
Licensee: V. C. Summer
Region: 2
City: Jenkinsville State: SC
County: Fairfield
License #:
Agreement: Y
Docket:
NRC Notified By: Justin Bouknight
HQ OPS Officer: Thomas Herrity
Licensee: V. C. Summer
Region: 2
City: Jenkinsville State: SC
County: Fairfield
License #:
Agreement: Y
Docket:
NRC Notified By: Justin Bouknight
HQ OPS Officer: Thomas Herrity
Notification Date: 01/10/2024
Notification Time: 08:18 [ET]
Event Date: 11/12/2021
Event Time: 00:00 [EST]
Last Update Date: 01/17/2024
Notification Time: 08:18 [ET]
Event Date: 11/12/2021
Event Time: 00:00 [EST]
Last Update Date: 01/17/2024
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):
Miller, Mark (R2DO)
Part 21/50.55 Reactors, - (EMAIL)
Miller, Mark (R2DO)
Part 21/50.55 Reactors, - (EMAIL)
EN Revision Imported Date: 1/18/2024
EN Revision Text: PART 21 - EATON-CUTLER HAMMER RELAY ON EMERGENCY DIESEL FAILED
The following information was provided by the licensee via email and phone call:
"On January 9, 2024, VC Summer Nuclear Station (VCSNS) determined a manufacturing defect affecting a control power circuit monitor (CP1) relay on its 'B' emergency diesel generator (EDG) was reportable under Part 21.
"On November 12, 2021, the 'B' EDG was rendered inoperable when its CP1 relay de-energized due to mechanical binding of the magnet carrier assembly. The binding was caused by a manufacturing defect that allowed heat-induced shrinkage to reduce the clearance between the magnet carrier and adjacent coil housing and base, preventing it from moving freely. VCSNS replaced the affected relay and restored operability of its 'B' EDG.
"Manufacturer/Model: Eaton-Cutler Hammer D26MRD30A1
"A written notification in accordance with 10 CFR 21.21(d)(3)(ii) will be provided within 30 days. The NRC Senior Resident Inspector has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The plant has notified the manufacturer. It is not known if any other plants are affected by this defect.
EN Revision Text: PART 21 - EATON-CUTLER HAMMER RELAY ON EMERGENCY DIESEL FAILED
The following information was provided by the licensee via email and phone call:
"On January 9, 2024, VC Summer Nuclear Station (VCSNS) determined a manufacturing defect affecting a control power circuit monitor (CP1) relay on its 'B' emergency diesel generator (EDG) was reportable under Part 21.
"On November 12, 2021, the 'B' EDG was rendered inoperable when its CP1 relay de-energized due to mechanical binding of the magnet carrier assembly. The binding was caused by a manufacturing defect that allowed heat-induced shrinkage to reduce the clearance between the magnet carrier and adjacent coil housing and base, preventing it from moving freely. VCSNS replaced the affected relay and restored operability of its 'B' EDG.
"Manufacturer/Model: Eaton-Cutler Hammer D26MRD30A1
"A written notification in accordance with 10 CFR 21.21(d)(3)(ii) will be provided within 30 days. The NRC Senior Resident Inspector has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The plant has notified the manufacturer. It is not known if any other plants are affected by this defect.