Event Notification Report for December 04, 2024
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/03/2024 - 12/04/2024
Agreement State
Event Number: 57458
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: St. Francis Medical Center
Region: 3
City: Peoria State: IL
County:
License #: IL-01361-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Jon Lilliendahl
Licensee: St. Francis Medical Center
Region: 3
City: Peoria State: IL
County:
License #: IL-01361-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Jon Lilliendahl
Notification Date: 12/06/2024
Notification Time: 15:51 [ET]
Event Date: 12/04/2024
Event Time: 00:00 [CST]
Last Update Date: 12/16/2024
Notification Time: 15:51 [ET]
Event Date: 12/04/2024
Event Time: 00:00 [CST]
Last Update Date: 12/16/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Learn, Matthew (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Allen, Logan (NMSS)
Learn, Matthew (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Allen, Logan (NMSS)
EN Revision Imported Date: 12/17/2024
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was provided by the Illinois Emergency Management Agency (the Agency) via phone and email:
"On December 4, 2024, while administering Y-90 microspheres to a patient for radioembolization of the liver, a portion was shunted to the gastrointestinal tract. The shunting was not identified in the licensee's pre-administration macroaggregated albumin (MAA) mapping. The shunting is estimated to have resulted in approximately 100 cGy (rem) to the patient's stomach. The patient and physician have been notified. The licensee has not been reachable for additional details and a site visit is being coordinated."
* * * RETRACTION ON 12/16/2024 AT 1448 FROM GARY FORSEE TO IAN HOWARD * * *
"The Agency conducted a reactive inspection on 12/11/24. Inspectors spoke with the authorized user (AU) to determine if shunting to non-treatment sites had been assessed in advance of the administration in accordance with the manufacturer's instructions. Proper shunting calculations had been performed for the lung and no additional non-treatment sites were identified. The licensee had performed an angiogram to evaluate GI flow on the day of procedure with nothing unique noted. Specifically, no GI flow was observed. The AU continued with administration to segment 4 of the liver using a Progreat 2.4Fr by 130 cm microcatheter, lot numbers: 240701 (exp. 6/30/26) and 240619 (exp. 5/31/26). No pressure, blockage or other abnormalities were encountered during administration. Nothing new or unique about the target or delivery was reported or identified. However, upon performing post-administration PET scans, uptake to the stomach was observed. The Agency has seen an increased number of licensees performing post administration PET scans and as a result, licensees are now able to visualize shunting to other organs. For example, in this case, without the post administration scan, the uptake to the stomach would not be known.
"The inspector's reactive inspection memorandum is pending and this report will be updated with additional details. However, at this point, both the physician and the inspectors believe the shunting to the stomach was due to the vasculature of the patient and not improper catheter placement. As a result, this medical event is being requested for retraction. This report is being kept open pending addition of the inspector's detailed findings."
Notified R3DO (Stoedter), NMSS (Allen), and NMSS Events Notification (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 - MEDICAL EVENT
The following information was provided by the Illinois Emergency Management Agency (the Agency) via phone and email:
"On December 4, 2024, while administering Y-90 microspheres to a patient for radioembolization of the liver, a portion was shunted to the gastrointestinal tract. The shunting was not identified in the licensee's pre-administration macroaggregated albumin (MAA) mapping. The shunting is estimated to have resulted in approximately 100 cGy (rem) to the patient's stomach. The patient and physician have been notified. The licensee has not been reachable for additional details and a site visit is being coordinated."
* * * RETRACTION ON 12/16/2024 AT 1448 FROM GARY FORSEE TO IAN HOWARD * * *
"The Agency conducted a reactive inspection on 12/11/24. Inspectors spoke with the authorized user (AU) to determine if shunting to non-treatment sites had been assessed in advance of the administration in accordance with the manufacturer's instructions. Proper shunting calculations had been performed for the lung and no additional non-treatment sites were identified. The licensee had performed an angiogram to evaluate GI flow on the day of procedure with nothing unique noted. Specifically, no GI flow was observed. The AU continued with administration to segment 4 of the liver using a Progreat 2.4Fr by 130 cm microcatheter, lot numbers: 240701 (exp. 6/30/26) and 240619 (exp. 5/31/26). No pressure, blockage or other abnormalities were encountered during administration. Nothing new or unique about the target or delivery was reported or identified. However, upon performing post-administration PET scans, uptake to the stomach was observed. The Agency has seen an increased number of licensees performing post administration PET scans and as a result, licensees are now able to visualize shunting to other organs. For example, in this case, without the post administration scan, the uptake to the stomach would not be known.
"The inspector's reactive inspection memorandum is pending and this report will be updated with additional details. However, at this point, both the physician and the inspectors believe the shunting to the stomach was due to the vasculature of the patient and not improper catheter placement. As a result, this medical event is being requested for retraction. This report is being kept open pending addition of the inspector's detailed findings."
Notified R3DO (Stoedter), NMSS (Allen), and NMSS Events Notification (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.
Power Reactor
Event Number: 57453
Facility: Turkey Point
Region: 2 State: FL
Unit: [3] [] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: Arturo Alvarez
HQ OPS Officer: Jon Lilliendahl
Region: 2 State: FL
Unit: [3] [] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: Arturo Alvarez
HQ OPS Officer: Jon Lilliendahl
Notification Date: 12/04/2024
Notification Time: 13:24 [ET]
Event Date: 12/04/2024
Event Time: 10:33 [EST]
Last Update Date: 12/04/2024
Notification Time: 13:24 [ET]
Event Date: 12/04/2024
Event Time: 10:33 [EST]
Last Update Date: 12/04/2024
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):
Suber, Gregory (R2DO)
Suber, Gregory (R2DO)
| 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 |
AUTOMATIC REACTOR TRIP
The following information was provided by the licensee via phone or email:
"At 1033 EST on December 4, 2024, with Unit 3 in mode 1 at 100% power, the reactor automatically tripped in response to a reactor protection system channel failure while planned maintenance was in progress on a redundant channel. The plant is currently in mode 3. Decay heat is being removed by steam dumps to atmosphere. Unit 4 is unaffected. An actuation of the auxiliary feedwater system occurred and started as designed. An actuation of the emergency core cooling system (ECCS) occurred and started as designed. This event is being reported pursuant to 10 CFR 50.72(b)(2)(iv)(B), and 10 CFR 50.72(b)(3)(iv)(A).
"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 ECCS actuation included safety injection, residual heat removal, and emergency containment cooling. The cause of the trip and the ECCS actuation are under investigation. There are no indications of primary to secondary leakage.
The following information was provided by the licensee via phone or email:
"At 1033 EST on December 4, 2024, with Unit 3 in mode 1 at 100% power, the reactor automatically tripped in response to a reactor protection system channel failure while planned maintenance was in progress on a redundant channel. The plant is currently in mode 3. Decay heat is being removed by steam dumps to atmosphere. Unit 4 is unaffected. An actuation of the auxiliary feedwater system occurred and started as designed. An actuation of the emergency core cooling system (ECCS) occurred and started as designed. This event is being reported pursuant to 10 CFR 50.72(b)(2)(iv)(B), and 10 CFR 50.72(b)(3)(iv)(A).
"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 ECCS actuation included safety injection, residual heat removal, and emergency containment cooling. The cause of the trip and the ECCS actuation are under investigation. There are no indications of primary to secondary leakage.
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 57454
Facility: Brunswick
Region: 2 State: NC
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Chris Denton
HQ OPS Officer: Jon Lilliendahl
Region: 2 State: NC
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Chris Denton
HQ OPS Officer: Jon Lilliendahl
Notification Date: 12/04/2024
Notification Time: 19:01 [ET]
Event Date: 12/04/2024
Event Time: 16:40 [EST]
Last Update Date: 01/23/2025
Notification Time: 19:01 [ET]
Event Date: 12/04/2024
Event Time: 16:40 [EST]
Last Update Date: 01/23/2025
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(C) - Pot Uncntrl Rad Rel
10 CFR Section:
50.72(b)(3)(v)(C) - Pot Uncntrl Rad Rel
Person (Organization):
Suber, Gregory (R2DO)
Suber, Gregory (R2DO)
| 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: 1/24/2025
EN Revision Text: SECONDARY CONTAINMENT INOPERABLE
The following information was provided by the licensee via phone and email:
"At 1640 EST, on December 4, 2024, secondary containment was declared inoperable. This condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(C), as an event or condition that could have prevented fulfillment of a safety function.
"Secondary containment was declared inoperable due to a small hole discovered in the service water piping within secondary containment. The effective safety function was restored at 1730 EST by installation of a temporary repair and secondary containment has been restored to operable.
"There was no impact on the health and safety of the public or plant personnel.
"The NRC Resident Inspector has been notified."
Notified R2DO (Suber)
* * * RETRACTION ON 01/23/2025 AT 1001 EST FROM QUINTIN HOLLEY TO JOSUE RAMIREZ * * *
The following information was provided by the licensee via phone and email:
"The purpose of this notification is to retract EN 57454 which was made on December 4, 2024, at 1901 EST.
"At 1640 on December 4, 2024, secondary containment was declared inoperable due to a small hole discovered in the service water piping within secondary containment. This condition was reported as a non-emergency notification per 10 CFR 50.72(b)(3)(v)(C).
"Subsequent to this, additional analysis of the hole size determined that secondary containment was operable. Secondary containment maintained adequate leak tightness thereby ensuring the technical specification required vacuum could be established and maintained, and releases to the environment following a postulated accident would be within regulatory limits.
"The operability determination for secondary containment has been updated indicating that secondary containment operability was never lost for this event. As a result, there was not a condition that could have prevented the system from fulfilling the safety function. Secondary containment was operable during this time.
"The NRC Resident Inspector has been notified."
Notified R2DO (Suggs)
EN Revision Text: SECONDARY CONTAINMENT INOPERABLE
The following information was provided by the licensee via phone and email:
"At 1640 EST, on December 4, 2024, secondary containment was declared inoperable. This condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(C), as an event or condition that could have prevented fulfillment of a safety function.
"Secondary containment was declared inoperable due to a small hole discovered in the service water piping within secondary containment. The effective safety function was restored at 1730 EST by installation of a temporary repair and secondary containment has been restored to operable.
"There was no impact on the health and safety of the public or plant personnel.
"The NRC Resident Inspector has been notified."
Notified R2DO (Suber)
* * * RETRACTION ON 01/23/2025 AT 1001 EST FROM QUINTIN HOLLEY TO JOSUE RAMIREZ * * *
The following information was provided by the licensee via phone and email:
"The purpose of this notification is to retract EN 57454 which was made on December 4, 2024, at 1901 EST.
"At 1640 on December 4, 2024, secondary containment was declared inoperable due to a small hole discovered in the service water piping within secondary containment. This condition was reported as a non-emergency notification per 10 CFR 50.72(b)(3)(v)(C).
"Subsequent to this, additional analysis of the hole size determined that secondary containment was operable. Secondary containment maintained adequate leak tightness thereby ensuring the technical specification required vacuum could be established and maintained, and releases to the environment following a postulated accident would be within regulatory limits.
"The operability determination for secondary containment has been updated indicating that secondary containment operability was never lost for this event. As a result, there was not a condition that could have prevented the system from fulfilling the safety function. Secondary containment was operable during this time.
"The NRC Resident Inspector has been notified."
Notified R2DO (Suggs)