Event Notification Report for November 05, 2020

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
11/04/2020 - 11/05/2020

EVENT NUMBERS
54969 54983
Non-Agreement State
Event Number: 54969
Rep Org: Spectrum Health
Licensee: Spectrum Health
Region: 3
City: Grand Rapids   State: MI
County:
License #: 210024306
Agreement: N
Docket:
NRC Notified By: Evan Boote
HQ OPS Officer: Ossy Font
Notification Date: 10/28/2020
Notification Time: 16:50 [ET]
Event Date: 10/28/2020
Event Time: 12:00 [EDT]
Last Update Date: 10/28/2020
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
Person (Organization):
HIRONORI PETERSON (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
IODINE-125 SEED INADVERTENTLY LEFT IN PATIENT

The following is a summary of a call with the licensee:

On October 28, 2020, during a routine mammogram, the radiologist found an I-125 seed in the left axilla that was believed to have been previously removed. The 250 microCi seed was implanted on July 5, 2019 as part of a 10 CFR 35.1000 lesion location procedure. It was supposed to have been removed the same day during removal of the lesion.

On the follow-up x-ray of the lesion, the seed was not identified. The radiologist called the operating room, which stated and documented that they had recovered the seed. The licensee noted that there was a second seed implanted in the left breast that was recovered. Both seeds are documented on the same paperwork.

An investigation is in progress, but the licensee believes that the dose to the patient is more than 50 rem to the tissue and total dose delivered differs from the prescribed dose by 20 percent or more.

The patient was informed and no effects are expected.

The licensee will notify the NRC Region 3 Office.

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: 54983
Facility: Browns Ferry
Region: 2     State: AL
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: Michael Millsap
HQ OPS Officer: Bethany Cecere
Notification Date: 11/05/2020
Notification Time: 06:32 [ET]
Event Date: 11/04/2020
Event Time: 21:50 [CDT]
Last Update Date: 11/05/2020
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
MARK MILLER (R2DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 17 Power Operation 16 Power Operation
Event Text
HIGH PRESSURE COOLANT INJECTION INOPERABLE

"At 2150 CST on 11/04/2020, it was discovered that Unit 1 High Pressure Coolant Injection System (HPCI) was INOPERABLE; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v), as an event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.

"During performance of 1-SR-3.5.1.7, HPCI Main and Booster Pump Set Developed Head and Flow Rate Test at Rated Reactor Pressure, Unit 1 HPCI was manually tripped by the control room operator due to local report of excessive shaking of the cooling water supply from the booster pump line.

"There was no impact to the safety of the public or plant personnel. The NRC Resident Inspector has been notified.

"CR 1650042 documents this condition in the Corrective Action Program."

The Unit is in a 14-day LCO 3.5.1(c). The RCIC System is operable.

Page Last Reviewed/Updated Thursday, November 05, 2020