Event Notification Report for April 05, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/04/2022 - 04/05/2022
Power Reactor
Event Number: 55821
Facility: Nine Mile Point
Region: 1 State: NY
Unit: [2] [] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: Roman Arnold
HQ OPS Officer: Ossy Font
Region: 1 State: NY
Unit: [2] [] []
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: Roman Arnold
HQ OPS Officer: Ossy Font
Notification Date: 04/05/2022
Notification Time: 06:08 [ET]
Event Date: 04/05/2022
Event Time: 02:23 [EDT]
Last Update Date: 04/05/2022
Notification Time: 06:08 [ET]
Event Date: 04/05/2022
Event Time: 02:23 [EDT]
Last Update Date: 04/05/2022
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(iv)(A) - Eccs Injection 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)(A) - Eccs Injection 50.72(b)(2)(iv)(B) - RPS Actuation - Critical 50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
Defrancisco, Anne (R1DO)
Defrancisco, Anne (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | A/R | Y | 100 | Power Operation | 0 | Hot Standby |
EN Revision Imported Date: 4/15/2022
EN Revision Text: SCRAM ON LOW LEVEL
The following information was provided by the licensee via telephone and email:
"On 4/5/2022, at time 0223 EDT, during maintenance on Feedwater Level Control Valve 2FWS-LV10B, a Feedwater transient occurred resulting in an RPS Automatic Reactor Scram on Low Level (Level 3, 159.3 inches). Following the scram, reactor water level dropped below Level 2 (108.8 inches) resulting in a Group 2 Recirculation Sample System Isolation, Group 3 TIP [(Traversing Incore Probe)] Isolation Valve Isolation, Group 6 and 7 Reactor Water Cleanup Isolation and Group 9 Containment Purge Isolations.
"All control rods inserted as expected. High Pressure Core Spray and Reactor Core Isolation Cooling initiated and injected as expected. ECCS Systems have been secured and normal reactor pressure and level control has been established for hot shutdown. Nine Mile Point Unit 2 is stable in Mode 3.
"These 4 hour and 8-hour non-emergency ENS [(Emergency Notification System)] reports are being made in accordance with 10 CFR 50.72(b)(2)(iv)(A), 10 CFR 50.72(b)(2)(iv)(B), and 10 CFR 50.72(b)(3)(iv)(A).
"The NRC Resident was informed."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
There was no impact on Unit 1.
EN Revision Text: SCRAM ON LOW LEVEL
The following information was provided by the licensee via telephone and email:
"On 4/5/2022, at time 0223 EDT, during maintenance on Feedwater Level Control Valve 2FWS-LV10B, a Feedwater transient occurred resulting in an RPS Automatic Reactor Scram on Low Level (Level 3, 159.3 inches). Following the scram, reactor water level dropped below Level 2 (108.8 inches) resulting in a Group 2 Recirculation Sample System Isolation, Group 3 TIP [(Traversing Incore Probe)] Isolation Valve Isolation, Group 6 and 7 Reactor Water Cleanup Isolation and Group 9 Containment Purge Isolations.
"All control rods inserted as expected. High Pressure Core Spray and Reactor Core Isolation Cooling initiated and injected as expected. ECCS Systems have been secured and normal reactor pressure and level control has been established for hot shutdown. Nine Mile Point Unit 2 is stable in Mode 3.
"These 4 hour and 8-hour non-emergency ENS [(Emergency Notification System)] reports are being made in accordance with 10 CFR 50.72(b)(2)(iv)(A), 10 CFR 50.72(b)(2)(iv)(B), and 10 CFR 50.72(b)(3)(iv)(A).
"The NRC Resident was informed."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
There was no impact on Unit 1.
Agreement State
Event Number: 55823
Rep Org: Nevada Radiological Health
Licensee: Comprehensive Cancer Centers, NV
Region: 4
City: Las Vegas State: NV
County:
License #: 03-12-0491-01
Agreement: Y
Docket:
NRC Notified By: Corey Creveling
HQ OPS Officer: Thomas Herrity
Licensee: Comprehensive Cancer Centers, NV
Region: 4
City: Las Vegas State: NV
County:
License #: 03-12-0491-01
Agreement: Y
Docket:
NRC Notified By: Corey Creveling
HQ OPS Officer: Thomas Herrity
Notification Date: 04/05/2022
Notification Time: 18:37 [ET]
Event Date: 04/05/2022
Event Time: 00:00 [PDT]
Last Update Date: 04/05/2022
Notification Time: 18:37 [ET]
Event Date: 04/05/2022
Event Time: 00:00 [PDT]
Last Update Date: 04/05/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 4/15/2022
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT, EXCEEDED PRESCRIBED DOSE
The following was received from the State of Nevada via email:
"The patient was prescribed ten [High Dose Rate Brachytherapy] treatments [with a 9.0 curie Ir-192 source]. After four treatments, it was discovered that some of the catheters had been incorrectly labeled. This altered the dose distribution resulting in a higher skin dose than anticipated, however the target dose difference did NOT exceed 50 percent from the prescription. The remainder of the patient's treatment was re-planned to compensate for the dose already given. The total doses once complete will be within limits for the skin and the target dose will be within 20 percent of the prescription. All treatments were to the correct patient and correct site.
"The treatment area for this patient is adjacent to the skin, so the intended prescription would have given a skin max dose of nearly 100 percent of the prescribed treatment dose.
"For the four treatments given with the incorrectly labeled catheters, the dose to skin is estimated to be 3 times the initially expected dose, exceeding 50 rem.
"However, the patient's treatment was re-planned to provide additional skin sparing for the remaining treatments while maintaining minimum target coverage to compensate for the dose already given. We estimate the total skin dose from the entire treatment will exceed the initially anticipated skin dose by 41 percent. This total skin dose is still within standard protocol limits, and the written directive has been updated to be inclusive of the initial and new treatment plans and organ at risk (OAR) doses.
"The patient and referring physician were notified the day the event was discovered before the determination that a medical event took place."
Nevada Event Number: NV220002
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT, EXCEEDED PRESCRIBED DOSE
The following was received from the State of Nevada via email:
"The patient was prescribed ten [High Dose Rate Brachytherapy] treatments [with a 9.0 curie Ir-192 source]. After four treatments, it was discovered that some of the catheters had been incorrectly labeled. This altered the dose distribution resulting in a higher skin dose than anticipated, however the target dose difference did NOT exceed 50 percent from the prescription. The remainder of the patient's treatment was re-planned to compensate for the dose already given. The total doses once complete will be within limits for the skin and the target dose will be within 20 percent of the prescription. All treatments were to the correct patient and correct site.
"The treatment area for this patient is adjacent to the skin, so the intended prescription would have given a skin max dose of nearly 100 percent of the prescribed treatment dose.
"For the four treatments given with the incorrectly labeled catheters, the dose to skin is estimated to be 3 times the initially expected dose, exceeding 50 rem.
"However, the patient's treatment was re-planned to provide additional skin sparing for the remaining treatments while maintaining minimum target coverage to compensate for the dose already given. We estimate the total skin dose from the entire treatment will exceed the initially anticipated skin dose by 41 percent. This total skin dose is still within standard protocol limits, and the written directive has been updated to be inclusive of the initial and new treatment plans and organ at risk (OAR) doses.
"The patient and referring physician were notified the day the event was discovered before the determination that a medical event took place."
Nevada Event Number: NV220002