Event Notification Report for January 10, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/09/2023 - 01/10/2023
Power Reactor
Event Number: 56264
Facility: Turkey Point
Region: 2 State: FL
Unit: [3] [] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: Szemei Choi
HQ OPS Officer: Thomas Herrity
Region: 2 State: FL
Unit: [3] [] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: Szemei Choi
HQ OPS Officer: Thomas Herrity
Notification Date: 12/08/2022
Notification Time: 14:39 [ET]
Event Date: 12/08/2022
Event Time: 14:02 [EST]
Last Update Date: 01/09/2023
Notification Time: 14:39 [ET]
Event Date: 12/08/2022
Event Time: 14:02 [EST]
Last Update Date: 01/09/2023
Emergency Class: Unusual Event
10 CFR Section:
50.72(a) (1) (i) - Emergency Declared
10 CFR Section:
50.72(a) (1) (i) - Emergency Declared
Person (Organization):
Miller, Mark (R2DO)
Miller, Chris (NRR EO)
Crouch, Howard (IR)
Dudes, Laura (R2RA)
Andrea Veil (NRR)
Miller, Mark (R2DO)
Miller, Chris (NRR EO)
Crouch, Howard (IR)
Dudes, Laura (R2RA)
Andrea Veil (NRR)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
EN Revision Imported Date: 1/10/2023
EN Revision Text: UNUSUAL EVENT DUE TO EXCESSIVE REACTOR COOLANT SYSTEM LEAKAGE
At 1402 EST Turkey Point Unit 3, while operating at 100 percent, declared an Unusual Event due to unidentified leakage greater than 10 gallons per minute for more than 15 minutes. The abnormal procedure for Reactor Coolant System leakage was entered. The plant remains at 100 percent power. The cause of the leakage is under investigation.
At 1446 EST it was verified that the leak had been isolated. The plant remains at 100 percent power.
Unit 4 was unaffected.
State and local authorities were notified by the licensee.
The NRC Resident Inspector has been notified.
Notified DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), DHS NRCC THD Dest (email), and DHS Nuclear SSA (email).
* * * UPDATE ON 12/08/22 AT 1621 (EST) FROM SZEMEI CHOI TO THOMAS HERRITY * * *
Turkey Point Unit 3 has isolated the leak. The Unusual Event was terminated at 1558 EST.
The NRC Resident Inspector has been notified.
Notified R2DO (Miller), NRR EO (Miller), and IR MOC (Crouch). Notified DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), DHS NRCC THD Dest (email), and DHS Nuclear SSA (email).
* * * RETRACTION FROM BRANDEN NATHE TO DONALD NORWOOD AT 1446 EST ON 1/9/2023 * * *
"Turkey Point Nuclear Unit 3 is retracting this notification based on the following additional information not available at the time of the notification, Following the event for unidentified RCS leakage on 12/8/22 at 1403 EST, additional information demonstrated that an RCS leak did not exist.
"A review of indications showed that the in-service seal water return filter D/P [Differential Pressure] rose from 1 psid to 6 psid with a corresponding rise in VCT [Volume Control Tank] level as would be seen with an increase in excess letdown flowrate. Additionally, the on-contact radiation dose rate from the excess letdown piping in the U3 Pipe and Valve Room was measured by RP [Radiation Personnel] to be significantly higher than normal with no other sources of elevated radiation levels noted.
"Following the closure of CV-3-387, RCS To Excess Letdown HX [Heat Exchanger] Control Valve, a nominal input/output flow balance was able to be restored. Containment parameters including pressure, temperature, sump level and radiation level did not change during the event. Due to the shared nature of piping between excess letdown and seal water return, a challenge to system integrity would not allow RCP [Reactor Coolant Pump] controlled bleed-off to remain in service with a normal flow balance which it has at all times subsequent to the event.
"Turkey Point Nuclear reported initially based on the available information at the time and to ensure timeliness with emergency declaration and reporting notification requirements. The NRC Resident Inspector has been notified."
Notified R2DO (Miller).
EN Revision Text: UNUSUAL EVENT DUE TO EXCESSIVE REACTOR COOLANT SYSTEM LEAKAGE
At 1402 EST Turkey Point Unit 3, while operating at 100 percent, declared an Unusual Event due to unidentified leakage greater than 10 gallons per minute for more than 15 minutes. The abnormal procedure for Reactor Coolant System leakage was entered. The plant remains at 100 percent power. The cause of the leakage is under investigation.
At 1446 EST it was verified that the leak had been isolated. The plant remains at 100 percent power.
Unit 4 was unaffected.
State and local authorities were notified by the licensee.
The NRC Resident Inspector has been notified.
Notified DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), DHS NRCC THD Dest (email), and DHS Nuclear SSA (email).
* * * UPDATE ON 12/08/22 AT 1621 (EST) FROM SZEMEI CHOI TO THOMAS HERRITY * * *
Turkey Point Unit 3 has isolated the leak. The Unusual Event was terminated at 1558 EST.
The NRC Resident Inspector has been notified.
Notified R2DO (Miller), NRR EO (Miller), and IR MOC (Crouch). Notified DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), DHS NRCC THD Dest (email), and DHS Nuclear SSA (email).
* * * RETRACTION FROM BRANDEN NATHE TO DONALD NORWOOD AT 1446 EST ON 1/9/2023 * * *
"Turkey Point Nuclear Unit 3 is retracting this notification based on the following additional information not available at the time of the notification, Following the event for unidentified RCS leakage on 12/8/22 at 1403 EST, additional information demonstrated that an RCS leak did not exist.
"A review of indications showed that the in-service seal water return filter D/P [Differential Pressure] rose from 1 psid to 6 psid with a corresponding rise in VCT [Volume Control Tank] level as would be seen with an increase in excess letdown flowrate. Additionally, the on-contact radiation dose rate from the excess letdown piping in the U3 Pipe and Valve Room was measured by RP [Radiation Personnel] to be significantly higher than normal with no other sources of elevated radiation levels noted.
"Following the closure of CV-3-387, RCS To Excess Letdown HX [Heat Exchanger] Control Valve, a nominal input/output flow balance was able to be restored. Containment parameters including pressure, temperature, sump level and radiation level did not change during the event. Due to the shared nature of piping between excess letdown and seal water return, a challenge to system integrity would not allow RCP [Reactor Coolant Pump] controlled bleed-off to remain in service with a normal flow balance which it has at all times subsequent to the event.
"Turkey Point Nuclear reported initially based on the available information at the time and to ensure timeliness with emergency declaration and reporting notification requirements. The NRC Resident Inspector has been notified."
Notified R2DO (Miller).
Agreement State
Event Number: 56272
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Alexian Brothers Medical Center
Region: 3
City: Elk Grove Village State: IL
County:
License #: IL-01418-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Adam Koziol
Licensee: Alexian Brothers Medical Center
Region: 3
City: Elk Grove Village State: IL
County:
License #: IL-01418-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Adam Koziol
Notification Date: 12/14/2022
Notification Time: 17:00 [ET]
Event Date: 12/14/2022
Event Time: 00:00 [CST]
Last Update Date: 01/10/2023
Notification Time: 17:00 [ET]
Event Date: 12/14/2022
Event Time: 00:00 [CST]
Last Update Date: 01/10/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Ruiz, Robert (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Ruiz, Robert (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 1/11/2023
EN Revision Text: AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following information was provided by the Illinois Emergency Management Agency (The Agency) via email:
"The Agency was contacted on 12/14/22 by the medical physicist for Alexian Brothers Medical Center to advise that a Y-90 microsphere administration conducted that morning resulted in a reportable under dose. The administered amount was 20.4 percent lower than that specified in the written directive. This was not a stasis case. The licensee has tried multiple times, but has so far been unable to reach the patient for notification. The referring physician has been notified. Agency inspectors have gathered preliminary information but will conduct a reactionary site visit on Tuesday, 12/20/2022. More information will be provided once it becomes available."
Illinois Event Number: IL220043
* * * UPDATE ON 01/10/2023 AT 1535 EST FROM GARY FORSEE TO ERNEST WEST * * *
"When initially reported, this was not identified as a stasis case. Both the patient and the referring physician were notified within 24 hours. Agency inspectors conducted a reactionary site visit on 12/20/2022. Upon further discussion and investigation, the authorized user (AU) and authorized medical physicist (AMP) believe the procedure may have reached stasis. The AMP acknowledged that additional training needed to be provided to the treatment team regarding procedures reaching stasis. The licensee determined the root cause to be failure to identify stasis. Agency inspectors determined the potential root cause as a failure to follow procedures and lack of sufficient training to the newly hired AU regarding stasis. This incident and the licensee's procedures will be reviewed during the next routine inspection. This matter may be considered closed."
Notified R3DO (Edwards) and NMSS Event Notifications via email.
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 - PATIENT UNDERDOSE
The following information was provided by the Illinois Emergency Management Agency (The Agency) via email:
"The Agency was contacted on 12/14/22 by the medical physicist for Alexian Brothers Medical Center to advise that a Y-90 microsphere administration conducted that morning resulted in a reportable under dose. The administered amount was 20.4 percent lower than that specified in the written directive. This was not a stasis case. The licensee has tried multiple times, but has so far been unable to reach the patient for notification. The referring physician has been notified. Agency inspectors have gathered preliminary information but will conduct a reactionary site visit on Tuesday, 12/20/2022. More information will be provided once it becomes available."
Illinois Event Number: IL220043
* * * UPDATE ON 01/10/2023 AT 1535 EST FROM GARY FORSEE TO ERNEST WEST * * *
"When initially reported, this was not identified as a stasis case. Both the patient and the referring physician were notified within 24 hours. Agency inspectors conducted a reactionary site visit on 12/20/2022. Upon further discussion and investigation, the authorized user (AU) and authorized medical physicist (AMP) believe the procedure may have reached stasis. The AMP acknowledged that additional training needed to be provided to the treatment team regarding procedures reaching stasis. The licensee determined the root cause to be failure to identify stasis. Agency inspectors determined the potential root cause as a failure to follow procedures and lack of sufficient training to the newly hired AU regarding stasis. This incident and the licensee's procedures will be reviewed during the next routine inspection. This matter may be considered closed."
Notified R3DO (Edwards) and NMSS Event Notifications via email.
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.