Event Notification Report for March 17, 2020
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/16/2020 - 03/17/2020
Power Reactor
Event Number: 54587
Facility: SOUTH TEXAS
Region: 4 State: TX
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: PAUL BURTON
HQ OPS Officer: ANDREW WAUGH
Region: 4 State: TX
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: PAUL BURTON
HQ OPS Officer: ANDREW WAUGH
Notification Date: 03/17/2020
Notification Time: 19:38 [ET]
Event Date: 03/17/2020
Event Time: 15:58 [CDT]
Last Update Date: 03/17/2020
Notification Time: 19:38 [ET]
Event Date: 03/17/2020
Event Time: 15:58 [CDT]
Last Update Date: 03/17/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
NEIL O'KEEFE (R4DO)
NEIL O'KEEFE (R4DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Cold Shutdown | 0 | Cold Shutdown |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
NOTIFICATION TO OTHER GOVERNMENT AGENCY
"At 1532 CDT, on 3/17/2020, it was reported to the Unit 1 Control Room that less than one gallon of hydraulic oil was spilled into the Colorado River during dredging activities. Cleanup using oil booms was completed at 1747 CDT. The cause of the hydraulic oil spill is under investigation.
"The Texas General Land Office was notified at 1558 CDT.
"The NRC Resident Inspector has been notified."
"At 1532 CDT, on 3/17/2020, it was reported to the Unit 1 Control Room that less than one gallon of hydraulic oil was spilled into the Colorado River during dredging activities. Cleanup using oil booms was completed at 1747 CDT. The cause of the hydraulic oil spill is under investigation.
"The Texas General Land Office was notified at 1558 CDT.
"The NRC Resident Inspector has been notified."
Agreement State
Event Number: 55655
Rep Org: Minnesota Department of Health
Licensee: Mayo Clinic
Region: 3
City: Rochester State: MN
County:
License #: 1047
Agreement: Y
Docket:
NRC Notified By: Sherrie Flaherty
HQ OPS Officer: Mike Stafford
Licensee: Mayo Clinic
Region: 3
City: Rochester State: MN
County:
License #: 1047
Agreement: Y
Docket:
NRC Notified By: Sherrie Flaherty
HQ OPS Officer: Mike Stafford
Notification Date: 12/16/2021
Notification Time: 14:17 [ET]
Event Date: 03/17/2020
Event Time: 00:00 [CST]
Last Update Date: 12/16/2021
Notification Time: 14:17 [ET]
Event Date: 03/17/2020
Event Time: 00:00 [CST]
Last Update Date: 12/16/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Skokowski, Richard (R3)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
CNSC (Canada), - (FAX)
Skokowski, Richard (R3)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
CNSC (Canada), - (FAX)
EN Revision Imported Date: 1/14/2022
EN Revision Text: AGREEMENT STATE REPORT - LOST BRACHYTHERAPY SEED
The following information was received from the state of Minnesota via email:
"It has come to our attention during our IMPEP review that we have some events that were not directly reported to the HOO as required. They were reported to NMED, but we are now reporting them directly to the HOO.
"Mayo Clinic reported the loss of an I-125 localization seed (Best Medical model 2301, lot #49827) that contained an activity of 9.03 MBq (244 microCi). A lesion and the seed were removed from a patient on 3/17/2020. After the lesion was removed from the patient, the surgeon confirmed that the seed was within the specimen with a survey meter. However, the surgeon did not perform a radiograph of the specimen, nor did he inform pathology per procedure that there was a seed to be removed. The seed was noted to be missing by a nuclear medicine technologist on 3/19/2020, which prompted an investigation. All of the remaining lesion tissue was recovered and surveyed, along with the entire pathology laboratory, on 3/20/2020. Mayo Clinic was unable to locate the seed following investigation and determined it was lost. They assumed that the seed was either washed down the sink in the pathology laboratory or incinerated as medical waste. The cause of the incident was concluded to be inadequate training. Corrective actions included developing a new process for selecting a surgeon and radiologist to ensure that qualified personnel are following procedures."
Minnesota event number: 200003
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
EN Revision Text: AGREEMENT STATE REPORT - LOST BRACHYTHERAPY SEED
The following information was received from the state of Minnesota via email:
"It has come to our attention during our IMPEP review that we have some events that were not directly reported to the HOO as required. They were reported to NMED, but we are now reporting them directly to the HOO.
"Mayo Clinic reported the loss of an I-125 localization seed (Best Medical model 2301, lot #49827) that contained an activity of 9.03 MBq (244 microCi). A lesion and the seed were removed from a patient on 3/17/2020. After the lesion was removed from the patient, the surgeon confirmed that the seed was within the specimen with a survey meter. However, the surgeon did not perform a radiograph of the specimen, nor did he inform pathology per procedure that there was a seed to be removed. The seed was noted to be missing by a nuclear medicine technologist on 3/19/2020, which prompted an investigation. All of the remaining lesion tissue was recovered and surveyed, along with the entire pathology laboratory, on 3/20/2020. Mayo Clinic was unable to locate the seed following investigation and determined it was lost. They assumed that the seed was either washed down the sink in the pathology laboratory or incinerated as medical waste. The cause of the incident was concluded to be inadequate training. Corrective actions included developing a new process for selecting a surgeon and radiologist to ensure that qualified personnel are following procedures."
Minnesota event number: 200003
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf