Event Notification Report for November 06, 2020

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.

AGREEMENT STATE REPORT - GAUGE SHUTTER FAILURE

The following information was received via E-mail from the Kentucky Department for Public Health & Safety, Radiation Health Branch (KY RHB):

"Big River Electric Corporation reported a shutter failure.
KY RHB was notified via email on October 28, 2020at 1511 EDT) by a
representative from a specifically licensed facility, Big Rivers Electric Corporation, indicating that one fixed gauging device (Kay Ray Model 7062P, Serial Number 8555), containing a 10 mCi Cs-137 source located in the Reid/Green/HMP&L Station II had a shutter malfunction. The source was found to have a broken shutter arm. The gauge has been left in place and a contractor will be scheduled to service the gauge. The Radiation Safety Officer (RSO) has notified the production manager and production leaders to ensure they are aware of the issue. Reporting criteria in 10 CFR 30.50(b)(2)."

Kentucky Event Report ID Number: KY200005

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.

AUTOMATIC REACTOR SCRAM DUE TO TURBINE/GENERATOR TRIP

"On November 6, 2020, at 0239 CST, Grand Gulf Nuclear Station (GGNS) experienced an Automatic Reactor Scram from 84 percent Reactor Power after a Main Turbine and Generator Trip.

"All control rods fully inserted and there were no complications. All systems responded as designed.

"Reactor pressure is being maintained with Main Turbine Bypass Valves. Reactor water level is being maintained in normal band with the condensate system.

"No radiological releases have occurred due to this event from the unit.

"The NRC Resident has been notified."