Event Notification Report for June 02, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/01/2023 - 06/02/2023
Agreement State
Event Number: 56540
Rep Org: Colorado Dept of Health
Licensee: University of Colorado Hospital
Region: 4
City: Aurora State: CO
County:
License #: CO 828-01
Agreement: Y
Docket:
NRC Notified By: Heather Gilbert
HQ OPS Officer: Ian Howard
Licensee: University of Colorado Hospital
Region: 4
City: Aurora State: CO
County:
License #: CO 828-01
Agreement: Y
Docket:
NRC Notified By: Heather Gilbert
HQ OPS Officer: Ian Howard
Notification Date: 05/25/2023
Notification Time: 16:40 [ET]
Event Date: 05/24/2023
Event Time: 13:00 [MDT]
Last Update Date: 05/25/2023
Notification Time: 16:40 [ET]
Event Date: 05/24/2023
Event Time: 13:00 [MDT]
Last Update Date: 05/25/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Vossmar, Patricia (R4DO)
NMSS_Events_Notification, (EMAIL)
Vossmar, Patricia (R4DO)
NMSS_Events_Notification, (EMAIL)
AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following information was provided by the Colorado Department of Health via email:
"On May 24, 2023, the Radiation Safety Officer of the University of Colorado Hospital (RAML [Radioactive Material License] 828-01) reported a medical event. The medical event occurred during the administration of Y-90 TheraSphere treatment that took place in the afternoon on Wednesday, May 24, 2023. During the administration, there appeared to be an obstruction in the catheter's line preventing the target from receiving the intended dose. The obstruction was noticed early in the procedure and it's estimated only 5 to10 percent of dose went to the target organ. After the obstruction was observed, the catheter was removed from the patient and the rest of the dose was not administered. This event is similar to an event at the same hospital on May 18, 2023 (CO230012) which occurred with a different AU [authorized user]. The TheraSpheres were from the same batch. The licensee is pausing Therasphere administrations from the same lot number. We are still waiting on additional information from the hospital about the investigation."
Event Report ID No.: CO230014
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 provided by the Colorado Department of Health via email:
"On May 24, 2023, the Radiation Safety Officer of the University of Colorado Hospital (RAML [Radioactive Material License] 828-01) reported a medical event. The medical event occurred during the administration of Y-90 TheraSphere treatment that took place in the afternoon on Wednesday, May 24, 2023. During the administration, there appeared to be an obstruction in the catheter's line preventing the target from receiving the intended dose. The obstruction was noticed early in the procedure and it's estimated only 5 to10 percent of dose went to the target organ. After the obstruction was observed, the catheter was removed from the patient and the rest of the dose was not administered. This event is similar to an event at the same hospital on May 18, 2023 (CO230012) which occurred with a different AU [authorized user]. The TheraSpheres were from the same batch. The licensee is pausing Therasphere administrations from the same lot number. We are still waiting on additional information from the hospital about the investigation."
Event Report ID No.: CO230014
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.
Fuel Cycle Facility
Event Number: 56550
Facility: Louisiana Energy Services
Region: 2 State: NM
Unit: [] [] []
RX Type:
NRC Notified By: Dirk Lundgren
HQ OPS Officer: Brian P. Smith
Region: 2 State: NM
Unit: [] [] []
RX Type:
NRC Notified By: Dirk Lundgren
HQ OPS Officer: Brian P. Smith
Notification Date: 06/01/2023
Notification Time: 20:16 [ET]
Event Date: 06/01/2023
Event Time: 02:39 [MDT]
Last Update Date: 06/01/2023
Notification Time: 20:16 [ET]
Event Date: 06/01/2023
Event Time: 02:39 [MDT]
Last Update Date: 06/01/2023
Emergency Class: Non Emergency
10 CFR Section:
70.50(b)(2) - Safety Equipment Failure
10 CFR Section:
70.50(b)(2) - Safety Equipment Failure
Person (Organization):
Miller, Mark (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Miller, Mark (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
PARTIAL LOSS OF CRITICALITY ACCIDENT ALARM SYSTEM
The following information was provided by the licensee via email:
"On June 1, 2023, during inclement weather, a Phase 2 CAAS [Criticality Accident Alarm System] detector fault was received. Troubleshooting efforts indicated two CAAS nodes are impacted and SBM1005 [Process Services Corridor] was evacuated. The affected detectors are located in the north end of the SBM1005 Process Services Corridor. Compensatory measures are implemented in the affected area to support maintenance troubleshooting efforts.
"UUSA is reporting this event per 10 CFR 70.50(b)(2)."
The following information was provided by the licensee via email:
"On June 1, 2023, during inclement weather, a Phase 2 CAAS [Criticality Accident Alarm System] detector fault was received. Troubleshooting efforts indicated two CAAS nodes are impacted and SBM1005 [Process Services Corridor] was evacuated. The affected detectors are located in the north end of the SBM1005 Process Services Corridor. Compensatory measures are implemented in the affected area to support maintenance troubleshooting efforts.
"UUSA is reporting this event per 10 CFR 70.50(b)(2)."
Power Reactor
Event Number: 56551
Facility: Palo Verde
Region: 4 State: AZ
Unit: [2] [] []
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: Lukas Knight
HQ OPS Officer: Adam Koziol
Region: 4 State: AZ
Unit: [2] [] []
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: Lukas Knight
HQ OPS Officer: Adam Koziol
Notification Date: 06/02/2023
Notification Time: 10:44 [ET]
Event Date: 06/02/2023
Event Time: 04:05 [MST]
Last Update Date: 06/02/2023
Notification Time: 10:44 [ET]
Event Date: 06/02/2023
Event Time: 04:05 [MST]
Last Update Date: 06/02/2023
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):
Gepford, Heather (R4DO)
Gepford, Heather (R4DO)
| 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 TRIP
The following information was provided by the licensee via email:
"The following event description is based on information currently available. If through subsequent reviews of this event additional information is identified that is pertinent to this event or alters the information being provided at this time a follow-up notification will be made via the ENS [Emergency Notification System] or under the reporting requirements of 10 CFR 50.73.
"At 0405 MDT on June 2, 2023, the Unit 2 reactor automatically tripped on low steam generator water levels due to degraded flow from the A main feedwater pump. Steam generator water levels reached the automatic Auxiliary Feedwater Actuation System (AFAS) setpoint resulting in automatic AFAS-1 and AFAS-2 actuations and subsequent start of both class auxiliary feedwater pumps.
"Steam Generator water levels are being restored to normal band with the class 1E powered motor driven auxiliary feedwater pump.
"Following the reactor trip, all control element assemblies inserted fully into the core. No emergency plan classification was required per the Emergency Plan. Safety related buses remained powered from offsite power during the event and the offsite power grid is stable. Both emergency diesel generators automatically started on the AFAS-1 and AFAS-2 actuations as designed and are currently running unloaded. This event is being reported as a reactor protection system actuation in accordance with the reporting criteria of 10 CFR 50.72(b)(2)(iv)(B) and a specified system actuation in accordance with 10 CFR 50.72(b)(3)(iv)(A).
"The NRC Senior Resident Inspector has been informed. Unit 1 and 3 are in Mode 1 at 100 percent power."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
Decay heat is being removed to main condenser via automatic steam bypass and B auxiliary feedwater pump.
The following information was provided by the licensee via email:
"The following event description is based on information currently available. If through subsequent reviews of this event additional information is identified that is pertinent to this event or alters the information being provided at this time a follow-up notification will be made via the ENS [Emergency Notification System] or under the reporting requirements of 10 CFR 50.73.
"At 0405 MDT on June 2, 2023, the Unit 2 reactor automatically tripped on low steam generator water levels due to degraded flow from the A main feedwater pump. Steam generator water levels reached the automatic Auxiliary Feedwater Actuation System (AFAS) setpoint resulting in automatic AFAS-1 and AFAS-2 actuations and subsequent start of both class auxiliary feedwater pumps.
"Steam Generator water levels are being restored to normal band with the class 1E powered motor driven auxiliary feedwater pump.
"Following the reactor trip, all control element assemblies inserted fully into the core. No emergency plan classification was required per the Emergency Plan. Safety related buses remained powered from offsite power during the event and the offsite power grid is stable. Both emergency diesel generators automatically started on the AFAS-1 and AFAS-2 actuations as designed and are currently running unloaded. This event is being reported as a reactor protection system actuation in accordance with the reporting criteria of 10 CFR 50.72(b)(2)(iv)(B) and a specified system actuation in accordance with 10 CFR 50.72(b)(3)(iv)(A).
"The NRC Senior Resident Inspector has been informed. Unit 1 and 3 are in Mode 1 at 100 percent power."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
Decay heat is being removed to main condenser via automatic steam bypass and B auxiliary feedwater pump.
Non-Power Reactor
Event Number: 56553
Rep Org: North Carolina State University (NCSU)
Licensee: North Carolina State University
Region: 0
City: Raleigh State: NC
County: Wake
License #: R-120
Agreement: Y
Docket: 05000297
NRC Notified By: Gerald Wicks
HQ OPS Officer: Brian Lin
Licensee: North Carolina State University
Region: 0
City: Raleigh State: NC
County: Wake
License #: R-120
Agreement: Y
Docket: 05000297
NRC Notified By: Gerald Wicks
HQ OPS Officer: Brian Lin
Notification Date: 06/02/2023
Notification Time: 13:17 [ET]
Event Date: 06/02/2023
Event Time: 08:18 [EDT]
Last Update Date: 06/02/2023
Notification Time: 13:17 [ET]
Event Date: 06/02/2023
Event Time: 08:18 [EDT]
Last Update Date: 06/02/2023
Emergency Class: Non Emergency
10 CFR Section:
10 CFR Section:
Person (Organization):
Duane Hardesty (NRR)
Andy Waugh (NPR COOR)
Duane Hardesty (NRR)
Andy Waugh (NPR COOR)
UNSCHEDULED SHUTDOWN
The following information was provided by the licensee via fax or email:
"An unscheduled shutdown of the reactor occurred on 6/2/23 at 0818 EDT due to an abnormal response of the Safety Power Level channel during the approach to power of 1 MW at 150 kW. The Reactor Operator observed a discrepancy in power indications by the Linear Power Level and Safety Power Level channels and took immediate actions required by procedure NRP-OP-105, Response to SCRAMS, Alarms, and Abnormal Conditions. The reactor was shut down and secured immediately. The Designated Senior Reactor Operator was immediately notified.
"The Safety Power Level channel is required to be operable per Technical Specification 3.3.b Table 3.3-1 while the reactor is being operated. During the startup checklist, the channel performed satisfactorily. The Safety Power Level channel is part of the reactor safety system and has two automatic shutdowns (SCRAMs) associated with it. Reactor power was correctly monitored by all other operable power monitoring channels which have redundant SCRAM capabilities. No SCRAM occurred or was needed due to the power level of the reactor. Following the reactor shutdown, the reactor staff investigated and determined that the high voltage power supply in the Safety Power channel was faulty. The power supply was replaced and a channel calibration of the Safety Power channel will be performed using procedure PS 1-05-03A:S1 to verify the channel is operable. Maintenance Log #0888 has been opened. There was no safety issue with this event. Procedures were followed during reactor operation, shutdown, and the investigation.
"This unscheduled shutdown is a reportable event per TS 6.7.1 based on the circumstances and as defined in the facility Technical Specification (TS 1.2.24.d) for reportable events from operation in violation of Limiting Conditions for Operation (LCO) established in TS. TS 1.2.24.d, does not allow for an exception for taking prompt remedial action.
"A report to the NRC is required within one working day and will be made by 1700 EDT by phone on 6/2/23, as required by TS 6.7.1. Also as required by TS 6.7.1, a written report to the NRC is due in 14 days (6/16/23)."
The following information was provided by the licensee via fax or email:
"An unscheduled shutdown of the reactor occurred on 6/2/23 at 0818 EDT due to an abnormal response of the Safety Power Level channel during the approach to power of 1 MW at 150 kW. The Reactor Operator observed a discrepancy in power indications by the Linear Power Level and Safety Power Level channels and took immediate actions required by procedure NRP-OP-105, Response to SCRAMS, Alarms, and Abnormal Conditions. The reactor was shut down and secured immediately. The Designated Senior Reactor Operator was immediately notified.
"The Safety Power Level channel is required to be operable per Technical Specification 3.3.b Table 3.3-1 while the reactor is being operated. During the startup checklist, the channel performed satisfactorily. The Safety Power Level channel is part of the reactor safety system and has two automatic shutdowns (SCRAMs) associated with it. Reactor power was correctly monitored by all other operable power monitoring channels which have redundant SCRAM capabilities. No SCRAM occurred or was needed due to the power level of the reactor. Following the reactor shutdown, the reactor staff investigated and determined that the high voltage power supply in the Safety Power channel was faulty. The power supply was replaced and a channel calibration of the Safety Power channel will be performed using procedure PS 1-05-03A:S1 to verify the channel is operable. Maintenance Log #0888 has been opened. There was no safety issue with this event. Procedures were followed during reactor operation, shutdown, and the investigation.
"This unscheduled shutdown is a reportable event per TS 6.7.1 based on the circumstances and as defined in the facility Technical Specification (TS 1.2.24.d) for reportable events from operation in violation of Limiting Conditions for Operation (LCO) established in TS. TS 1.2.24.d, does not allow for an exception for taking prompt remedial action.
"A report to the NRC is required within one working day and will be made by 1700 EDT by phone on 6/2/23, as required by TS 6.7.1. Also as required by TS 6.7.1, a written report to the NRC is due in 14 days (6/16/23)."