Event Notification Report for June 24, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/23/2022 - 06/24/2022
Agreement State
Event Number: 55966
Rep Org: Colorado Dept of Health
Licensee: HCA-HealthONE, LLC dba The Medical Center of Aurora
Region: 4
City: Aurora State: CO
County:
License #: CO 305-03
Agreement: Y
Docket:
NRC Notified By: Phillip Peterson
HQ OPS Officer: Donald Norwood
Licensee: HCA-HealthONE, LLC dba The Medical Center of Aurora
Region: 4
City: Aurora State: CO
County:
License #: CO 305-03
Agreement: Y
Docket:
NRC Notified By: Phillip Peterson
HQ OPS Officer: Donald Norwood
Notification Date: 06/27/2022
Notification Time: 17:07 [ET]
Event Date: 06/24/2022
Event Time: 00:00 [MDT]
Last Update Date: 06/27/2022
Notification Time: 17:07 [ET]
Event Date: 06/24/2022
Event Time: 00:00 [MDT]
Last Update Date: 06/27/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Warnick, Greg (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Williams, Kevin (NMSS)
Warnick, Greg (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Williams, Kevin (NMSS)
AGREEMENT STATE REPORT - DOSE DELIVERED TO WRONG LOCATION
The following information was received from the state of Colorado via facsimile:
"On June 24, 2022, a patient was prescribed 1.45 GBq (39.2 mCi) of Y-90 microspheres (TheraSphere) to the right lobe of the liver, lobe estimated size of 474 grams, for a target dose of 148 Gy. However, imaging after the administration indicates that the dose was incorrectly delivered to the left lobe of the liver, lobe estimated size of 283 grams, for an estimated delivered dose of 240 Gy. The preliminary cause is based on the patient's anatomy with the left hepatic branch close to the intended treatment site. The physician's office is reaching out to the patient to notify them but has not been able to at the time of this initial notification."
Colorado Event Report ID No.: CO220019
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 information was received from the state of Colorado via facsimile:
"On June 24, 2022, a patient was prescribed 1.45 GBq (39.2 mCi) of Y-90 microspheres (TheraSphere) to the right lobe of the liver, lobe estimated size of 474 grams, for a target dose of 148 Gy. However, imaging after the administration indicates that the dose was incorrectly delivered to the left lobe of the liver, lobe estimated size of 283 grams, for an estimated delivered dose of 240 Gy. The preliminary cause is based on the patient's anatomy with the left hepatic branch close to the intended treatment site. The physician's office is reaching out to the patient to notify them but has not been able to at the time of this initial notification."
Colorado Event Report ID No.: CO220019
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: 55962
Facility: Perry
Region: 3 State: OH
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: Clifford Jones
HQ OPS Officer: Ossy Font
Region: 3 State: OH
Unit: [1] [] []
RX Type: [1] GE-6
NRC Notified By: Clifford Jones
HQ OPS Officer: Ossy Font
Notification Date: 06/24/2022
Notification Time: 16:28 [ET]
Event Date: 06/24/2022
Event Time: 12:57 [EDT]
Last Update Date: 06/24/2022
Notification Time: 16:28 [ET]
Event Date: 06/24/2022
Event Time: 12:57 [EDT]
Last Update Date: 06/24/2022
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):
Dickson, Billy (R3DO)
Dickson, Billy (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
EN Revision Imported Date: 6/27/2022
EN Revision Text: LOW PRESSURE CORE SPRAY INOPERABLE
The following information was provided by the licensee via telephone:
"At 1257 EDT on June 24, 2022, it was discovered the Low Pressure Core Spray System (LPCS) was inoperable. At Perry, the Low Pressure Core Spray System is considered a single train system in Modes 1, 2, and 3; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D). Inoperability of the Low Pressure Core Spray system was caused by a loss of power to the LPCS Minimum Flow Valve during surveillance activities.
"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: LOW PRESSURE CORE SPRAY INOPERABLE
The following information was provided by the licensee via telephone:
"At 1257 EDT on June 24, 2022, it was discovered the Low Pressure Core Spray System (LPCS) was inoperable. At Perry, the Low Pressure Core Spray System is considered a single train system in Modes 1, 2, and 3; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D). Inoperability of the Low Pressure Core Spray system was caused by a loss of power to the LPCS Minimum Flow Valve during surveillance activities.
"There was no impact on the health and safety of the public or plant personnel.
"The NRC Resident Inspector has been notified."
Power Reactor
Event Number: 55963
Facility: Waterford
Region: 4 State: LA
Unit: [3] [] []
RX Type: [3] CE
NRC Notified By: William Crowley
HQ OPS Officer: Michael Bloodgood
Region: 4 State: LA
Unit: [3] [] []
RX Type: [3] CE
NRC Notified By: William Crowley
HQ OPS Officer: Michael Bloodgood
Notification Date: 06/25/2022
Notification Time: 00:44 [ET]
Event Date: 06/24/2022
Event Time: 20:12 [CDT]
Last Update Date: 06/25/2022
Notification Time: 00:44 [ET]
Event Date: 06/24/2022
Event Time: 20:12 [CDT]
Last Update Date: 06/25/2022
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):
Kozal, Jason (R4DO)
Kozal, Jason (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | A/R | Y | 100 | Power Operation | 0 | Hot Standby |
EN Revision Imported Date: 6/27/2022
EN Revision Text: AUTOMATIC REACTOR TRIP DUE TO MAIN STEAM ISOLATION VALVE CLOSURE
The following information was provided by the licensee via email:
"At 2012 CDT, Waterford 3 Steam Electric Station, Unit 3 was operating at 100 percent power when an automatic reactor trip occurred due to Main Steam Isolation Valve MS-124B going closed unexpectedly. Subsequently, both main feedwater isolation valves shut. Emergency Feedwater (EFW) was automatically actuated. Preliminary evaluation indicates that all plant systems functioned normally after the reactor trip. The unit is currently stable in Mode 3. All control rods fully inserted as expected and all other plant equipment functioned as expected. This was an uncomplicated trip.
"This event is being reported as a 4-hour non-emergency notification in accordance with 10 CFR 50.72(b)(2)(iv)(B) as an actuation of the reactor protection system (RPS) when the reactor is critical and as an 8-hour non-emergency notification in accordance with 10 CFR 50.72(b)(3)(iv)(A) as valid actuation of the EFW system.
"The NRC Resident Inspector has been notified."
EN Revision Text: AUTOMATIC REACTOR TRIP DUE TO MAIN STEAM ISOLATION VALVE CLOSURE
The following information was provided by the licensee via email:
"At 2012 CDT, Waterford 3 Steam Electric Station, Unit 3 was operating at 100 percent power when an automatic reactor trip occurred due to Main Steam Isolation Valve MS-124B going closed unexpectedly. Subsequently, both main feedwater isolation valves shut. Emergency Feedwater (EFW) was automatically actuated. Preliminary evaluation indicates that all plant systems functioned normally after the reactor trip. The unit is currently stable in Mode 3. All control rods fully inserted as expected and all other plant equipment functioned as expected. This was an uncomplicated trip.
"This event is being reported as a 4-hour non-emergency notification in accordance with 10 CFR 50.72(b)(2)(iv)(B) as an actuation of the reactor protection system (RPS) when the reactor is critical and as an 8-hour non-emergency notification in accordance with 10 CFR 50.72(b)(3)(iv)(A) as valid actuation of the EFW system.
"The NRC Resident Inspector has been notified."
Power Reactor
Event Number: 55964
Facility: Fermi
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: Whitney Hemingway
HQ OPS Officer: Bethany Cecere
Region: 3 State: MI
Unit: [2] [] []
RX Type: [2] GE-4
NRC Notified By: Whitney Hemingway
HQ OPS Officer: Bethany Cecere
Notification Date: 06/25/2022
Notification Time: 01:00 [ET]
Event Date: 06/24/2022
Event Time: 23:38 [EDT]
Last Update Date: 06/25/2022
Notification Time: 01:00 [ET]
Event Date: 06/24/2022
Event Time: 23:38 [EDT]
Last Update Date: 06/25/2022
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):
Dickson, Billy (R3DO)
Dickson, Billy (R3DO)
| 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 |
AUTOMATIC REACTOR SCRAM DUE TO MAIN TURBINE TRIP
The following information was provided by the licensee via email:
"At 2338 EDT, on June 24, 2022, with the unit in Mode 1 at 100 percent power, the reactor automatically scrammed due to an RPS actuation following a Main Turbine Trip. The cause of the turbine trip is not known at this time. The scram was not complex, with systems responding normally post-scram.
"Operations responded and stabilized the plant. Reactor water level has been recovered and maintained at the normal level. Decay Heat is being removed by the Main Steam system to the main condenser using the Turbine Bypass Valves. All Control Rods inserted into the core. The transient occurred with no surveillances or activities in progress. Investigation into the cause of the Turbine Trip is in progress.
"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). The low reactor water level caused an isolation of Primary Containment (Groups 4/13/15) as expected. The Primary Containment Isolation Event is being reported under 10 CFR 50.72(b)(3)(iv)(A). There was no impact to the health and safety of the public or plant personnel. The NRC resident has been notified."
The following information was provided by the licensee via email:
"At 2338 EDT, on June 24, 2022, with the unit in Mode 1 at 100 percent power, the reactor automatically scrammed due to an RPS actuation following a Main Turbine Trip. The cause of the turbine trip is not known at this time. The scram was not complex, with systems responding normally post-scram.
"Operations responded and stabilized the plant. Reactor water level has been recovered and maintained at the normal level. Decay Heat is being removed by the Main Steam system to the main condenser using the Turbine Bypass Valves. All Control Rods inserted into the core. The transient occurred with no surveillances or activities in progress. Investigation into the cause of the Turbine Trip is in progress.
"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). The low reactor water level caused an isolation of Primary Containment (Groups 4/13/15) as expected. The Primary Containment Isolation Event is being reported under 10 CFR 50.72(b)(3)(iv)(A). There was no impact to the health and safety of the public or plant personnel. The NRC resident has been notified."