Event Notification Report for March 09, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/08/2022 - 03/09/2022
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 55780
Facility: Brunswick
Region: 2 State: NC
Unit: [2] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Jason Krupp
HQ OPS Officer: Dan Livermore
Region: 2 State: NC
Unit: [2] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Jason Krupp
HQ OPS Officer: Dan Livermore
Notification Date: 03/09/2022
Notification Time: 23:20 [ET]
Event Date: 03/09/2022
Event Time: 20:13 [EST]
Last Update Date: 05/04/2022
Notification Time: 23:20 [ET]
Event Date: 03/09/2022
Event Time: 20:13 [EST]
Last Update Date: 05/04/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
Miller, Mark (R2DO)
Miller, Mark (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
EN Revision Imported Date: 5/5/2022
EN Revision Text: HIGH PRESSURE COOLANT INJECTION (HPCI) INOPERABLE
The following information was provided by the licensee:
"At 2013 EST on March 9, 2022, the HPCI System was declared inoperable following evaluation of routine HPCI surveillance testing data indicating that the required response time for reaching rated conditions was not met. Therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D). The Reactor Core Isolation Cooling (RCIC) System and Automatic Depressurization System (ADS) are operable.
"There was no impact on the health and safety of the public or plant personnel. Investigation is in-progress to determine the cause.
"Unit 1 is not affected by this event. Unit 1 is in a refueling outage.
"The NRC Resident Inspector has been notified."
* * * RETRACTION ON 05/04/22 AT 1135 EDT FROM CHARLIE BROOKSHIRE TO DAN LIVERMORE * * *
The following information was provided by the licensee via email:
"At 20:13 EST on March 9, 2022, the HPCI System was declared inoperable following evaluation of routine HPCI surveillance testing data indicating that the required response time for reaching rated flow and pressure was not met. Subsequent to this, it was determined that the required response time was overly conservative for assuring the safety function of the system could be fulfilled. The required response time was revised. The operability determination for this event has been updated indicating that system operability was never lost for this event. There was not a condition that could have prevented the system from fulfilling the safety function.
"The NRC Resident Inspector has been notified."
Notified R2DO (Miller).
EN Revision Text: HIGH PRESSURE COOLANT INJECTION (HPCI) INOPERABLE
The following information was provided by the licensee:
"At 2013 EST on March 9, 2022, the HPCI System was declared inoperable following evaluation of routine HPCI surveillance testing data indicating that the required response time for reaching rated conditions was not met. Therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D). The Reactor Core Isolation Cooling (RCIC) System and Automatic Depressurization System (ADS) are operable.
"There was no impact on the health and safety of the public or plant personnel. Investigation is in-progress to determine the cause.
"Unit 1 is not affected by this event. Unit 1 is in a refueling outage.
"The NRC Resident Inspector has been notified."
* * * RETRACTION ON 05/04/22 AT 1135 EDT FROM CHARLIE BROOKSHIRE TO DAN LIVERMORE * * *
The following information was provided by the licensee via email:
"At 20:13 EST on March 9, 2022, the HPCI System was declared inoperable following evaluation of routine HPCI surveillance testing data indicating that the required response time for reaching rated flow and pressure was not met. Subsequent to this, it was determined that the required response time was overly conservative for assuring the safety function of the system could be fulfilled. The required response time was revised. The operability determination for this event has been updated indicating that system operability was never lost for this event. There was not a condition that could have prevented the system from fulfilling the safety function.
"The NRC Resident Inspector has been notified."
Notified R2DO (Miller).
Agreement State
Event Number: 55781
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Elmhurst Hospital
Region: 3
City: Elmhurst State: IL
County: DuPage
License #: IL-01612-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Dan Livermore
Licensee: Elmhurst Hospital
Region: 3
City: Elmhurst State: IL
County: DuPage
License #: IL-01612-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Dan Livermore
Notification Date: 03/10/2022
Notification Time: 17:10 [ET]
Event Date: 03/09/2022
Event Time: 00:00 [CST]
Last Update Date: 03/10/2022
Notification Time: 17:10 [ET]
Event Date: 03/09/2022
Event Time: 00:00 [CST]
Last Update Date: 03/10/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Hanna, John (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Hanna, John (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 4/8/2022
EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT
The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:
"The radiation safety officer (RSO) for Elmhurst Hospital contacted the Agency on 3/10/22 to advise of a Y-90 microsphere administration in which the patient received only 54 percent of the prescribed dose. The administration occurred on the morning of 3/9/22. The physician felt the delivered dose was clinically effective and no further treatment is planned. No adverse patient impacts are expected.
"The referring physician and patient were notified as required. Agency staff have requested copies of the written directive and associated documentation as details regarding the prescribed activity were not immediately available. Of note, the RSO advised that the authorized user felt resistance during administration and discontinued the procedure. Microspheres were reportedly observed `clumped' within the first two inches of the delivery catheter. A second, smaller vial was obtained and the written directive modified. No contamination or other issues were identified. The Agency will dispatch inspectors, likely at the beginning of next week, to review the procedure and determine root cause. Compliance with Agency regulations regarding modification to a written directive will be reviewed.
"This matter will be reported under NMED number IL220008."
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 TO PATIENT
The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:
"The radiation safety officer (RSO) for Elmhurst Hospital contacted the Agency on 3/10/22 to advise of a Y-90 microsphere administration in which the patient received only 54 percent of the prescribed dose. The administration occurred on the morning of 3/9/22. The physician felt the delivered dose was clinically effective and no further treatment is planned. No adverse patient impacts are expected.
"The referring physician and patient were notified as required. Agency staff have requested copies of the written directive and associated documentation as details regarding the prescribed activity were not immediately available. Of note, the RSO advised that the authorized user felt resistance during administration and discontinued the procedure. Microspheres were reportedly observed `clumped' within the first two inches of the delivery catheter. A second, smaller vial was obtained and the written directive modified. No contamination or other issues were identified. The Agency will dispatch inspectors, likely at the beginning of next week, to review the procedure and determine root cause. Compliance with Agency regulations regarding modification to a written directive will be reviewed.
"This matter will be reported under NMED number IL220008."
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.