Event Notification Report for July 29, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/28/2021 - 07/29/2021
Agreement State
Event Number: 55389
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: Jeffrey Whited
Licensee: Mayo Clinic
Region: 3
City: Rochester State: MN
County:
License #: 1047
Agreement: Y
Docket:
NRC Notified By: Sherrie Flaherty
HQ OPS Officer: Jeffrey Whited
Notification Date: 07/30/2021
Notification Time: 16:57 [ET]
Event Date: 07/29/2021
Event Time: 00:00 [CDT]
Last Update Date: 07/30/2021
Notification Time: 16:57 [ET]
Event Date: 07/29/2021
Event Time: 00:00 [CDT]
Last Update Date: 07/30/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
HANNA, JOHN (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
HANNA, JOHN (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 8/30/2021
EN Revision Text: AGEEMENT STATE REPORT - MEDICAL EVENT
The following was received from the Minnesota Department of Health via email:
"The Mayo Clinic Rochester, MN had a medical event in which the total dose differs from the prescribed dose by greater than 20 percent and the dose difference to the whole body exceeds 5 rem. Under clinical trials on 7/29/2021, a patient who was prescribed 11.2 mCi of I-131 as an infusion of IOMAB-B Therapy, only received 5.74 mCi. The licensee reports an issue with air in the tubing that prevented the entire administration of the treatment. They are continuing to investigate and will submit a final report within 15 days."
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: AGEEMENT STATE REPORT - MEDICAL EVENT
The following was received from the Minnesota Department of Health via email:
"The Mayo Clinic Rochester, MN had a medical event in which the total dose differs from the prescribed dose by greater than 20 percent and the dose difference to the whole body exceeds 5 rem. Under clinical trials on 7/29/2021, a patient who was prescribed 11.2 mCi of I-131 as an infusion of IOMAB-B Therapy, only received 5.74 mCi. The licensee reports an issue with air in the tubing that prevented the entire administration of the treatment. They are continuing to investigate and will submit a final report within 15 days."
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: 55385
Facility: Columbia Generating Station
Region: 4 State: WA
Unit: [2] [] []
RX Type: [2] GE-5
NRC Notified By: Tracy Howard
HQ OPS Officer: Bethany Cecere
Region: 4 State: WA
Unit: [2] [] []
RX Type: [2] GE-5
NRC Notified By: Tracy Howard
HQ OPS Officer: Bethany Cecere
Notification Date: 07/30/2021
Notification Time: 00:16 [ET]
Event Date: 07/29/2021
Event Time: 16:51 [PDT]
Last Update Date: 07/30/2021
Notification Time: 00:16 [ET]
Event Date: 07/29/2021
Event Time: 16:51 [PDT]
Last Update Date: 07/30/2021
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(v)(C) - Pot Uncntrl Rad Rel 50.72(b)(3)(v)(D) - Accident Mitigation
10 CFR Section:
50.72(b)(3)(v)(C) - Pot Uncntrl Rad Rel 50.72(b)(3)(v)(D) - Accident Mitigation
Person (Organization):
PICK, GREG (R4)
PICK, GREG (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | N | 100 | Power Operation | 100 | Power Operation |
EN Revision Imported Date: 8/27/2021
EN Revision Text: INOPERABLE SECONDARY CONTAINMENT
"At 0922 PDT, on 07/28/21, the reactor building roof hatch was opened to support maintenance activities on the roof. Secondary containment differential pressure lowered and was recovered by the operating crew. Secondary containment differential pressure was maintained negative during the transient and was verified to have met technical specification requirements the whole time, however it was not identified at the time that the secondary containment was inoperable due to the roof hatch exceeding the allowable containment breech size and as such a TS 3.6.4.1.A entry was warranted.
"This report is being made pursuant to 10 CFR 50.72(a)(1)(ii) when it was identified that the secondary containment was inoperable while the roof hatch was open and a report should have been made under 10 CFR 50.72(b)(3)(v)(C) and (D) for loss of safety function.
"There were no radiological releases, system actuations, or isolations associated with this event."
The licensee has notified the NRC Resident Inspector.
EN Revision Text: INOPERABLE SECONDARY CONTAINMENT
"At 0922 PDT, on 07/28/21, the reactor building roof hatch was opened to support maintenance activities on the roof. Secondary containment differential pressure lowered and was recovered by the operating crew. Secondary containment differential pressure was maintained negative during the transient and was verified to have met technical specification requirements the whole time, however it was not identified at the time that the secondary containment was inoperable due to the roof hatch exceeding the allowable containment breech size and as such a TS 3.6.4.1.A entry was warranted.
"This report is being made pursuant to 10 CFR 50.72(a)(1)(ii) when it was identified that the secondary containment was inoperable while the roof hatch was open and a report should have been made under 10 CFR 50.72(b)(3)(v)(C) and (D) for loss of safety function.
"There were no radiological releases, system actuations, or isolations associated with this event."
The licensee has notified the NRC Resident Inspector.
Agreement State
Event Number: 55387
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: St Elizabeth - Edgewood
Region: 1
City: Edgewood State: KY
County:
License #: 202-152-27
Agreement: Y
Docket:
NRC Notified By: Angela Wilbers
HQ OPS Officer: Jeffrey Whited
Licensee: St Elizabeth - Edgewood
Region: 1
City: Edgewood State: KY
County:
License #: 202-152-27
Agreement: Y
Docket:
NRC Notified By: Angela Wilbers
HQ OPS Officer: Jeffrey Whited
Notification Date: 07/30/2021
Notification Time: 15:10 [ET]
Event Date: 07/29/2021
Event Time: 00:00 [CDT]
Last Update Date: 07/30/2021
Notification Time: 15:10 [ET]
Event Date: 07/29/2021
Event Time: 00:00 [CDT]
Last Update Date: 07/30/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
CAHILL, CHRISTOPHER (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
CAHILL, CHRISTOPHER (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 8/30/2021
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT
The following was received from the Kentucky Department of Radiation Control, Radiation Health Branch (RHB) via email:
"At approximately 1230 CDT on 7/29/21 the Hospital [Radiation Safety Officer] RSO called RHB to report a failure of a Therasphere Y-90 administration kit. Authorized User (AU) indicated an almost immediate failure to administer the dose. There was no flow into the administration catheter. Saline observed exiting the administration set up into an overflow vial. After adjusting the pressure and a second attempt failed, a call was placed to the administration kit representative. Three more attempts failed. The AU decided to stop the process and remove the administration catheter. Patient procedure was stopped. Not rescheduled at this time. A survey of the vial and administration set up, and multiple patient surveys seem to indicate that no dose was administered to the patient.
"Y-90 set up and vials were packaged and stored into appropriate waste. No contamination, no release of material. No patient administration. Expected 4.15 GBq and received none. Licensee suspects an administration set up kit failure. Licensee will provide full reports to the RHB staff within 15 days."
KY Event Report ID: 210002
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 was received from the Kentucky Department of Radiation Control, Radiation Health Branch (RHB) via email:
"At approximately 1230 CDT on 7/29/21 the Hospital [Radiation Safety Officer] RSO called RHB to report a failure of a Therasphere Y-90 administration kit. Authorized User (AU) indicated an almost immediate failure to administer the dose. There was no flow into the administration catheter. Saline observed exiting the administration set up into an overflow vial. After adjusting the pressure and a second attempt failed, a call was placed to the administration kit representative. Three more attempts failed. The AU decided to stop the process and remove the administration catheter. Patient procedure was stopped. Not rescheduled at this time. A survey of the vial and administration set up, and multiple patient surveys seem to indicate that no dose was administered to the patient.
"Y-90 set up and vials were packaged and stored into appropriate waste. No contamination, no release of material. No patient administration. Expected 4.15 GBq and received none. Licensee suspects an administration set up kit failure. Licensee will provide full reports to the RHB staff within 15 days."
KY Event Report ID: 210002
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.