Event Notification Report for March 09, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/08/2021 - 03/09/2021
Power Reactor
Event Number: 55128
Facility: Susquehanna
Region: 1 State: PA
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Darvin Duttry
HQ OPS Officer: Bethany Cecere
Region: 1 State: PA
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Darvin Duttry
HQ OPS Officer: Bethany Cecere
Notification Date: 03/09/2021
Notification Time: 08:08 [ET]
Event Date: 03/09/2021
Event Time: 03:13 [EST]
Last Update Date: 03/09/2021
Notification Time: 08:08 [ET]
Event Date: 03/09/2021
Event Time: 03:13 [EST]
Last Update Date: 03/09/2021
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):
GRAY, MEL (R1)
GRAY, MEL (R1)
| 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: 4/9/2021
EN Revision Text: HIGH PRESSURE COOLANT INJECTION INOPERABLE
"At 0313 EST on March 9th, 2021, during performance of Unit 1 High Pressure Coolant Injection (HPCI) valve exercising, the inboard vacuum breaker isolation valve did not stroke closed as expected, but remained mid-position. The affected penetration of primary containment was isolated by closing the outboard HPCI vacuum breaker isolation valve. This results in an unplanned inoperability of the Unit 1 HPCI system.
"This is being reported as a loss of an entire safety function condition in accordance with 10CFR50.72(b)(3)(v)(D).
The licensee notified the NRC Resident Inspector.
Unit 1 is in a 14-day LCO for Tech Spec 3.5.1(d), HPCI inoperability. Tech Spec 3.6.1.3(a), Containment Penetration Valve, was completed with closing the outboard HPCI vacuum breaker isolation valve. The Units are in a normal offsite power line-up.
EN Revision Text: HIGH PRESSURE COOLANT INJECTION INOPERABLE
"At 0313 EST on March 9th, 2021, during performance of Unit 1 High Pressure Coolant Injection (HPCI) valve exercising, the inboard vacuum breaker isolation valve did not stroke closed as expected, but remained mid-position. The affected penetration of primary containment was isolated by closing the outboard HPCI vacuum breaker isolation valve. This results in an unplanned inoperability of the Unit 1 HPCI system.
"This is being reported as a loss of an entire safety function condition in accordance with 10CFR50.72(b)(3)(v)(D).
The licensee notified the NRC Resident Inspector.
Unit 1 is in a 14-day LCO for Tech Spec 3.5.1(d), HPCI inoperability. Tech Spec 3.6.1.3(a), Containment Penetration Valve, was completed with closing the outboard HPCI vacuum breaker isolation valve. The Units are in a normal offsite power line-up.
Agreement State
Event Number: 55959
Rep Org: SC Dept of Health & Env Control
Licensee: McLeod Regional Medical Center
Region: 1
City: Florence State: SC
County:
License #: 139
Agreement: Y
Docket:
NRC Notified By: Leland Cave
HQ OPS Officer: Thomas Herrity
Licensee: McLeod Regional Medical Center
Region: 1
City: Florence State: SC
County:
License #: 139
Agreement: Y
Docket:
NRC Notified By: Leland Cave
HQ OPS Officer: Thomas Herrity
Notification Date: 06/24/2022
Notification Time: 10:39 [ET]
Event Date: 03/09/2021
Event Time: 12:00 [EDT]
Last Update Date: 06/24/2022
Notification Time: 10:39 [ET]
Event Date: 03/09/2021
Event Time: 12:00 [EDT]
Last Update Date: 06/24/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Gray, Mel (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
Gray, Mel (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
EN Revision Imported Date: 6/27/2022
EN Revision Text: AGREEMENT STATE REPORT - TREATMENT SEEDS RELEASED TO PUBLIC SEWER
The following was received from the State of South Carolina via email:
"On March 10, 2021, the inspector received a telephone message recorded at 7:30 a.m. [EST] from McLeod Regional Medical Center (Lic No. 139) to report an incident that occurred at their facility. The chief medical physicist at the hospital, called to report that at approximately 1:30 p.m., a member of the Day Hospital nursing staff flushed three implant seeds down the toilet into the sanitary sewer. The inspector called to get additional information about the incident.
"On March 9, 2021, at approximately noon, a patient had prostate seed implantation to act as a boost to the external beam treatment. Following the implantation, the patient passed three Theragenics Model 200 Pd-103 seeds with activity of 1.3 milli-Curie each (3.9 milli-Curie total).
"On March 12, 2021, the inspector travelled to McLeod Regional Medical Center to talk to the Chief Medical Physicist, Radiation Safety Officer, and other staff to find out additional information about the incident. During the review, the inspector was informed that a nurse did as she was instructed about straining the patient's urine but did not know the next steps once the implant seeds were filtered out. The nurse stated that she was told by another unnamed nurse that they could be flushed. This goes against the procedures that state that a member of health physics is to be informed, and will pick up the seeds once strained. Nursing is supposed to use the available seed recovery kits when a situation like this occurs. Because the toilets flow directly into the public sewer system, the seeds were irretrievable. Additionally, the licensee has procedures in place that state that a urologist will be present to perform a cystoscopy upon the conclusion of the implantation to ensure that there are no seeds in the bladder. This was not performed on the patient before his release to the Day Hospital staff.
"Both health physics and nursing explained that there has been a high turnover in nursing and that the training should be performed more frequently to ensure compliance from the staff. They are changing the policy to increase the training from annual to at least quarterly to address communication, training, and turnover issues. Day Surgery management stated that they plan to retrain monthly."
NMED #210164
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 - TREATMENT SEEDS RELEASED TO PUBLIC SEWER
The following was received from the State of South Carolina via email:
"On March 10, 2021, the inspector received a telephone message recorded at 7:30 a.m. [EST] from McLeod Regional Medical Center (Lic No. 139) to report an incident that occurred at their facility. The chief medical physicist at the hospital, called to report that at approximately 1:30 p.m., a member of the Day Hospital nursing staff flushed three implant seeds down the toilet into the sanitary sewer. The inspector called to get additional information about the incident.
"On March 9, 2021, at approximately noon, a patient had prostate seed implantation to act as a boost to the external beam treatment. Following the implantation, the patient passed three Theragenics Model 200 Pd-103 seeds with activity of 1.3 milli-Curie each (3.9 milli-Curie total).
"On March 12, 2021, the inspector travelled to McLeod Regional Medical Center to talk to the Chief Medical Physicist, Radiation Safety Officer, and other staff to find out additional information about the incident. During the review, the inspector was informed that a nurse did as she was instructed about straining the patient's urine but did not know the next steps once the implant seeds were filtered out. The nurse stated that she was told by another unnamed nurse that they could be flushed. This goes against the procedures that state that a member of health physics is to be informed, and will pick up the seeds once strained. Nursing is supposed to use the available seed recovery kits when a situation like this occurs. Because the toilets flow directly into the public sewer system, the seeds were irretrievable. Additionally, the licensee has procedures in place that state that a urologist will be present to perform a cystoscopy upon the conclusion of the implantation to ensure that there are no seeds in the bladder. This was not performed on the patient before his release to the Day Hospital staff.
"Both health physics and nursing explained that there has been a high turnover in nursing and that the training should be performed more frequently to ensure compliance from the staff. They are changing the policy to increase the training from annual to at least quarterly to address communication, training, and turnover issues. Day Surgery management stated that they plan to retrain monthly."
NMED #210164
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