Event Notification Report for November 20, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/19/2023 - 11/20/2023
Agreement State
Event Number: 56867
Rep Org: Texas Dept of State Health Services
Licensee: The Methodist Hospital
Region: 4
City: Houston State: TX
County:
License #: L00457
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Karen Cotton-Gross
Licensee: The Methodist Hospital
Region: 4
City: Houston State: TX
County:
License #: L00457
Agreement: Y
Docket:
NRC Notified By: Karen Blanchard
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 11/21/2023
Notification Time: 13:40 [ET]
Event Date: 11/20/2023
Event Time: 00:00 [CST]
Last Update Date: 11/21/2023
Notification Time: 13:40 [ET]
Event Date: 11/20/2023
Event Time: 00:00 [CST]
Last Update Date: 11/21/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Roldan-Otero, Lizette (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Roldan-Otero, Lizette (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - EQUIPMENT FAILURE
The following information was provided by the Texas Department of State Health Services (the Department) via email:
"On November 21, 2023, the licensee's radiation safety officer notified the Department that on November 20, 2023, during an intravascular brachytherapy (IVB) procedure, the strontium-90 source train did not reach the dwell position within 15 seconds. When they attempted to retract the source, it would not retract into the fully shielded position in the device, but it was outside the patient. Following established procedures, the delivery system (catheter, source train, etc.) was removed from the patient and placed in the device's emergency box. There were no overexposures to the patient or staff. The licensee used a second device and completed the IVB procedure on the patient. After a short time, the licensee was able to return the source train to the fully shielded position in the device. The manufacturer's representative will be coming onsite to perform an evaluation. The licensee did observe what appeared to be a possible kink in the catheter. More information will be provided as it is obtained in accordance with SA-300.
"Device Information: Best Vascular Novoste IVB model A1000
"Source Information: Source train of 16 strontium-90 sources, current total activity 35.9 millicuries."
Texas Incident Number: 10067
Texas NMED Number: TX230053
The following information was provided by the Texas Department of State Health Services (the Department) via email:
"On November 21, 2023, the licensee's radiation safety officer notified the Department that on November 20, 2023, during an intravascular brachytherapy (IVB) procedure, the strontium-90 source train did not reach the dwell position within 15 seconds. When they attempted to retract the source, it would not retract into the fully shielded position in the device, but it was outside the patient. Following established procedures, the delivery system (catheter, source train, etc.) was removed from the patient and placed in the device's emergency box. There were no overexposures to the patient or staff. The licensee used a second device and completed the IVB procedure on the patient. After a short time, the licensee was able to return the source train to the fully shielded position in the device. The manufacturer's representative will be coming onsite to perform an evaluation. The licensee did observe what appeared to be a possible kink in the catheter. More information will be provided as it is obtained in accordance with SA-300.
"Device Information: Best Vascular Novoste IVB model A1000
"Source Information: Source train of 16 strontium-90 sources, current total activity 35.9 millicuries."
Texas Incident Number: 10067
Texas NMED Number: TX230053
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 56866
Facility: Dresden
Region: 3 State: IL
Unit: [2] [] []
RX Type: [2] GE-3,[3] GE-3
NRC Notified By: Edward Burns
HQ OPS Officer: Ernest West
Region: 3 State: IL
Unit: [2] [] []
RX Type: [2] GE-3,[3] GE-3
NRC Notified By: Edward Burns
HQ OPS Officer: Ernest West
Notification Date: 11/20/2023
Notification Time: 17:53 [ET]
Event Date: 11/20/2023
Event Time: 09:56 [CST]
Last Update Date: 04/05/2024
Notification Time: 17:53 [ET]
Event Date: 11/20/2023
Event Time: 09:56 [CST]
Last Update Date: 04/05/2024
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):
Feliz-Adorno, Nestor (R3DO)
Feliz-Adorno, Nestor (R3DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
EN Revision Imported Date: 4/8/2024
EN Revision Text: HPCI DECLARED INOPERABLE
The following information was provided by the licensee via email:
"At 0956 [CST] on November 20, 2023, accumulated gas was identified in the Dresden Unit 2 high pressure coolant injection (HPCI) system discharge header. As a result, the HPCI system was declared inoperable. Since HPCI is a single-train system, this is a condition that could have prevented the fulfillment of a safety function; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D). The HPCI system was subsequently vented, and the accumulated gas has been removed, restoring the Dresden Unit 2 HPCI system to an operable status. All other emergency core cooling systems remained operable during this time period.
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The licensee administratively verified the isolation condenser was operable after declaring HPCI inoperable as required by technical specifications. The licensee stated there was no increase in plant risk. The cause of gas accumulating in the Dresden Unit 2 HPCI discharge header is under investigation, and this issue has been entered into the licensee's corrective action program.
* * * RETRACTION ON 4/5/2024 AT 1544 EDT FROM JON CHAPMAN TO IAN HOWARD * * *
"Further analysis demonstrated that the Unit 2 high pressure coolant injection (HPCI) system remained operable with the level of voiding found in the HPCI discharge line. This analysis also found that the additional loads that would be present if the HPCI system were actuated with this level of voiding are within design limits of the HPCI system piping and supports.
"Based on these results, this event is not reportable under 10 CFR 50.72(b)(3)(v)(D), `Any event or condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.' Therefore, EN 56866 submitted on November 20, 2023, is being retracted.
"The NRC Resident Inspector has been notified."
Notified R3DO (Havertape)
EN Revision Text: HPCI DECLARED INOPERABLE
The following information was provided by the licensee via email:
"At 0956 [CST] on November 20, 2023, accumulated gas was identified in the Dresden Unit 2 high pressure coolant injection (HPCI) system discharge header. As a result, the HPCI system was declared inoperable. Since HPCI is a single-train system, this is a condition that could have prevented the fulfillment of a safety function; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D). The HPCI system was subsequently vented, and the accumulated gas has been removed, restoring the Dresden Unit 2 HPCI system to an operable status. All other emergency core cooling systems remained operable during this time period.
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The licensee administratively verified the isolation condenser was operable after declaring HPCI inoperable as required by technical specifications. The licensee stated there was no increase in plant risk. The cause of gas accumulating in the Dresden Unit 2 HPCI discharge header is under investigation, and this issue has been entered into the licensee's corrective action program.
* * * RETRACTION ON 4/5/2024 AT 1544 EDT FROM JON CHAPMAN TO IAN HOWARD * * *
"Further analysis demonstrated that the Unit 2 high pressure coolant injection (HPCI) system remained operable with the level of voiding found in the HPCI discharge line. This analysis also found that the additional loads that would be present if the HPCI system were actuated with this level of voiding are within design limits of the HPCI system piping and supports.
"Based on these results, this event is not reportable under 10 CFR 50.72(b)(3)(v)(D), `Any event or condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.' Therefore, EN 56866 submitted on November 20, 2023, is being retracted.
"The NRC Resident Inspector has been notified."
Notified R3DO (Havertape)