Event Notification Report for July 21, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/20/2023 - 07/21/2023
Power Reactor
Event Number: 56632
Facility: Vogtle 3/4
Region: 2 State: GA
Unit: [3] [] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: Jason Hayes
HQ OPS Officer: Karen Cotton-Gross
Region: 2 State: GA
Unit: [3] [] []
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: Jason Hayes
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 07/21/2023
Notification Time: 15:06 [ET]
Event Date: 07/21/2023
Event Time: 11:48 [EDT]
Last Update Date: 07/21/2023
Notification Time: 15:06 [ET]
Event Date: 07/21/2023
Event Time: 11:48 [EDT]
Last Update Date: 07/21/2023
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical
Person (Organization):
Miller, Mark (R2DO)
Miller, Mark (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | A/R | Y | 32 | Power Operation | 0 | Hot Standby |
AUTOMATIC REACTOR TRIP
The following information was provided by the licensee via email:
"At 1148 EDT on 07/21/2023, with Unit 3 in Mode 1 at 32 percent power, the reactor automatically tripped on low reactor coolant pump (RCP) speed due to decaying RCP motor voltage during power ascension testing. The trip was not complex, with all safety-related systems responding normally post-trip.
"Operations responded and stabilized the plant. Decay heat is being removed by discharging steam via steam generator power operated relief valves to the atmosphere, and startup feedwater is supplying the steam generators. Units 1, 2, and 4 are not affected.
"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).
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
The following information was provided by the licensee via email:
"At 1148 EDT on 07/21/2023, with Unit 3 in Mode 1 at 32 percent power, the reactor automatically tripped on low reactor coolant pump (RCP) speed due to decaying RCP motor voltage during power ascension testing. The trip was not complex, with all safety-related systems responding normally post-trip.
"Operations responded and stabilized the plant. Decay heat is being removed by discharging steam via steam generator power operated relief valves to the atmosphere, and startup feedwater is supplying the steam generators. Units 1, 2, and 4 are not affected.
"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).
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
Agreement State
Event Number: 56634
Rep Org: PA Bureau of Radiation Protection
Licensee: Albert Einstein Medical Center
Region: 1
City: Philadelphia State: PA
County:
License #: PA-0135
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Karen Cotton-Gross
Licensee: Albert Einstein Medical Center
Region: 1
City: Philadelphia State: PA
County:
License #: PA-0135
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 07/23/2023
Notification Time: 13:04 [ET]
Event Date: 07/21/2023
Event Time: 00:00 [EDT]
Last Update Date: 07/23/2023
Notification Time: 13:04 [ET]
Event Date: 07/21/2023
Event Time: 00:00 [EDT]
Last Update Date: 07/23/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Carfang, Erin (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Carfang, Erin (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL EVENT (UNDERDOSE)
The following information was provided by the PA Bureau of Radiation Protection (the Department) via email:
"On July 21, 2023, the licensee informed the Department of an underdose incident involving yttrium-90 (Y-90) TheraSpheres. It is reportable as per 10 CFR 35.3045(a)(1). It was determined that 76 percent of the prescribed dose to the target tissue was delivered for the above treatment.
"This is believed to have happened for possibly the following reasons: The spheres were attached to the bottom / interior portion of the septum and remained there even through 4 flushes of the system; There was clumping of spheres in the microcatheter connector, which did not clog the lines, that remained in the microcatheter connector.
"Possible reasons for these theories or reasons for the above theories are, there was no contamination in the room, or interior / exterior of box. The required alarming Rados personal dosimeter on the back of the box read zero as expected after the original 3 flushes. The authorized user (AU) had no indication from pushing the line that anything was wrong with the flow and in total 4 flushes went into the patient with no problem. All procedures and policies were followed, and this was directly observed by the Radiation Safety Officer (RSO) and the Boston Scientific Corporation, Incorporated (BSCI) company rep who was in the room.
"It was observed on the optional, additional, personal dosimeter that was used on the steel arm coming from the box, that the dose rate did not decrease as expected after the original first 3 flushes. The patient and referring physician have been informed. The Department is currently in contact with the licensee and will update this event as soon as more information is provided.
"The cause of the event is unknown at this time. The Department will perform a reactive inspection. More information will be provided as received."
* * * UPDATE FROM JOHN CHIPPO TO DONALD NORWOOD 1007 EDT ON 7/25/2023 * * *
The source was 1.09 GBq of Yttrium 90 TheraSpheres (Lot # 2399334, vial # 8). The patient was prescribed 120 Gy, but it is calculated they received 91.4 Gy. The material was collected in the standard waste container. No one other that the patient received any dose.
Notified R1DO (Biickett) and NMSS Events Notification email group.
Pennsylvania Event Report ID Number: PA230019
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 PA Bureau of Radiation Protection (the Department) via email:
"On July 21, 2023, the licensee informed the Department of an underdose incident involving yttrium-90 (Y-90) TheraSpheres. It is reportable as per 10 CFR 35.3045(a)(1). It was determined that 76 percent of the prescribed dose to the target tissue was delivered for the above treatment.
"This is believed to have happened for possibly the following reasons: The spheres were attached to the bottom / interior portion of the septum and remained there even through 4 flushes of the system; There was clumping of spheres in the microcatheter connector, which did not clog the lines, that remained in the microcatheter connector.
"Possible reasons for these theories or reasons for the above theories are, there was no contamination in the room, or interior / exterior of box. The required alarming Rados personal dosimeter on the back of the box read zero as expected after the original 3 flushes. The authorized user (AU) had no indication from pushing the line that anything was wrong with the flow and in total 4 flushes went into the patient with no problem. All procedures and policies were followed, and this was directly observed by the Radiation Safety Officer (RSO) and the Boston Scientific Corporation, Incorporated (BSCI) company rep who was in the room.
"It was observed on the optional, additional, personal dosimeter that was used on the steel arm coming from the box, that the dose rate did not decrease as expected after the original first 3 flushes. The patient and referring physician have been informed. The Department is currently in contact with the licensee and will update this event as soon as more information is provided.
"The cause of the event is unknown at this time. The Department will perform a reactive inspection. More information will be provided as received."
* * * UPDATE FROM JOHN CHIPPO TO DONALD NORWOOD 1007 EDT ON 7/25/2023 * * *
The source was 1.09 GBq of Yttrium 90 TheraSpheres (Lot # 2399334, vial # 8). The patient was prescribed 120 Gy, but it is calculated they received 91.4 Gy. The material was collected in the standard waste container. No one other that the patient received any dose.
Notified R1DO (Biickett) and NMSS Events Notification email group.
Pennsylvania Event Report ID Number: PA230019
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.