Event Notification Report for August 05, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/04/2021 - 08/05/2021
Agreement State
Event Number: 55381
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: MC Squared, Inc.
Region: 1
City: Kennesaw State: GA
County:
License #: GA 1569-1
Agreement: Y
Docket:
NRC Notified By: Leslines Leveque
HQ OPS Officer: Jeffrey Whited
Licensee: MC Squared, Inc.
Region: 1
City: Kennesaw State: GA
County:
License #: GA 1569-1
Agreement: Y
Docket:
NRC Notified By: Leslines Leveque
HQ OPS Officer: Jeffrey Whited
Notification Date: 07/28/2021
Notification Time: 11:19 [ET]
Event Date: 07/27/2021
Event Time: 00:00 [EDT]
Last Update Date: 07/28/2021
Notification Time: 11:19 [ET]
Event Date: 07/27/2021
Event Time: 00:00 [EDT]
Last Update Date: 07/28/2021
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: 8/5/2021
EN Revision Text: AGREEMENT STATE REPORT - DAMAGED GAUGE
The following was received via email from the Georgia Radioactive Materials Program:
"A gauge was reported hit by a bulldozer [while on site] on 7/27/21. The rod was not exposed and there is no contamination leaking."
Incident #: 43
EN Revision Text: AGREEMENT STATE REPORT - DAMAGED GAUGE
The following was received via email from the Georgia Radioactive Materials Program:
"A gauge was reported hit by a bulldozer [while on site] on 7/27/21. The rod was not exposed and there is no contamination leaking."
Incident #: 43
Agreement State
Event Number: 55382
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: COLQUITT REGIONAL MEDICAL CENTER
Region: 1
City: Moultrie State: GA
County:
License #: GA 509-1
Agreement: Y
Docket:
NRC Notified By: Stacy Allman
HQ OPS Officer: Thomas Herrity
Licensee: COLQUITT REGIONAL MEDICAL CENTER
Region: 1
City: Moultrie State: GA
County:
License #: GA 509-1
Agreement: Y
Docket:
NRC Notified By: Stacy Allman
HQ OPS Officer: Thomas Herrity
Notification Date: 07/28/2021
Notification Time: 13:36 [ET]
Event Date: 07/19/2021
Event Time: 00:00 [EDT]
Last Update Date: 07/28/2021
Notification Time: 13:36 [ET]
Event Date: 07/19/2021
Event Time: 00:00 [EDT]
Last Update Date: 07/28/2021
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: 8/5/2021
EN Revision Text: AGREEMENT STATE REPORT - DAMAGED SEALED SOURCE
The following was received via email from the Georgia Radioactive Materials Program:
"During a routine 6 month leak test, a sealed source Cs-137 vial [0.035 milli-Curie] failed the leak test. [Leak Test Results: less than 0.005 micro-Curie.] Damage was detected on the vial and the source was immediately placed back into its shielded container and sealed with tape. All potentially contaminated items such as gloves were triple bagged, sealed, and labeled and placed in a shielded storage container in the hot lab. Area surveys and wipe tests were conducted and no contamination was found. The licensee is obtaining quotes for disposal and will follow up when the source has been disposed of."
Georgia Incident Number: 44
EN Revision Text: AGREEMENT STATE REPORT - DAMAGED SEALED SOURCE
The following was received via email from the Georgia Radioactive Materials Program:
"During a routine 6 month leak test, a sealed source Cs-137 vial [0.035 milli-Curie] failed the leak test. [Leak Test Results: less than 0.005 micro-Curie.] Damage was detected on the vial and the source was immediately placed back into its shielded container and sealed with tape. All potentially contaminated items such as gloves were triple bagged, sealed, and labeled and placed in a shielded storage container in the hot lab. Area surveys and wipe tests were conducted and no contamination was found. The licensee is obtaining quotes for disposal and will follow up when the source has been disposed of."
Georgia Incident Number: 44
Agreement State
Event Number: 55383
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: Northwest Community Hospital
Region: 3
City: Arlington Heights State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Thomas Herrity
Licensee: Northwest Community Hospital
Region: 3
City: Arlington Heights State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Thomas Herrity
Notification Date: 07/28/2021
Notification Time: 14:30 [ET]
Event Date: 07/28/2021
Event Time: 00:00 [CDT]
Last Update Date: 07/28/2021
Notification Time: 14:30 [ET]
Event Date: 07/28/2021
Event Time: 00:00 [CDT]
Last Update Date: 07/28/2021
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: 8/5/2021
EN Revision Text: AGREEMENT STATE REPORT - CONTAMINATION OF MEDICAL WORKER
The following was received from the Illinois Emergency Management Agency (the Agency) via email:
"The Agency was contacted at approximately 1230CDT on July 28, 2021 by GE Healthcare to advise that one of their employees required unplanned medical treatment due to a laceration and radioactive contamination. A glass vial containing approximately 4 milliCurie of Indium-111 oxyquinoline was being manipulated by a technician at the licensee's Arlington Heights facility when the neck of the vial broke. The broken glass cut the employee's finger and resulted in contamination of the wound with the radiopharmaceutical. The employee has since been treated, released and is estimated to have approximately 0.2 micro-Curie of non-removable contamination remaining within the wound. The amount of radioactive material involved will not result in occupational exposures exceeding the applicable limits. No permanent injury or deleterious effects are expected from the radioactive material. No other reportable exposures to medical staff occurred as a result of this incident."
Illinois Item Number: IL 210021
EN Revision Text: AGREEMENT STATE REPORT - CONTAMINATION OF MEDICAL WORKER
The following was received from the Illinois Emergency Management Agency (the Agency) via email:
"The Agency was contacted at approximately 1230CDT on July 28, 2021 by GE Healthcare to advise that one of their employees required unplanned medical treatment due to a laceration and radioactive contamination. A glass vial containing approximately 4 milliCurie of Indium-111 oxyquinoline was being manipulated by a technician at the licensee's Arlington Heights facility when the neck of the vial broke. The broken glass cut the employee's finger and resulted in contamination of the wound with the radiopharmaceutical. The employee has since been treated, released and is estimated to have approximately 0.2 micro-Curie of non-removable contamination remaining within the wound. The amount of radioactive material involved will not result in occupational exposures exceeding the applicable limits. No permanent injury or deleterious effects are expected from the radioactive material. No other reportable exposures to medical staff occurred as a result of this incident."
Illinois Item Number: IL 210021
Power Reactor
Event Number: 55394
Facility: Hatch
Region: 2 State: GA
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Nick Hightower
HQ OPS Officer: Thomas Kendzia
Region: 2 State: GA
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Nick Hightower
HQ OPS Officer: Thomas Kendzia
Notification Date: 08/03/2021
Notification Time: 13:18 [ET]
Event Date: 08/03/2021
Event Time: 10:26 [EDT]
Last Update Date: 08/03/2021
Notification Time: 13:18 [ET]
Event Date: 08/03/2021
Event Time: 10:26 [EDT]
Last Update Date: 08/03/2021
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical 50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS Actuation - Critical 50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
Person (Organization):
MILLER, MARK (R2)
MILLER, MARK (R2)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | A/R | Y | 100 | Power Operation | 0 | Hot Standby |
EN Revision Imported Date: 8/5/2021
EN Revision Text: AUTOMATIC REACTOR TRIP
"At 1026 EDT on 8/3/21, with Unit 1 in MODE 1 at 100 percent power, the reactor automatically tripped due to low reactor water level. The low reactor water level condition was due to a loss of both reactor feed pumps. The cause of the loss of feed pumps is under investigation. Additionally, the low reactor water level resulted in the automatic actuation of High Pressure Coolant Injection (HPCI) and Reactor Core Isolation Cooling (RCIC) systems, and Containment Isolation Valves (CIVs) in multiple systems. All safety systems responded normally.
"Operations responded and stabilized the plant. Reactor water level is being maintained via RCIC system. Decay heat is being removed by discharging steam to the main condenser using the turbine bypass valves. Unit 2 is not affected.
"Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). It is also reportable under 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the HPCI and RCIC systems and CIVs. There was no impact on the health and safety of the public or plant."
The Licensee notified the NRC Resident Inspector. The Unit will proceed to Mode 4 while the cause of the loss of feed pumps is under investigation.
EN Revision Text: AUTOMATIC REACTOR TRIP
"At 1026 EDT on 8/3/21, with Unit 1 in MODE 1 at 100 percent power, the reactor automatically tripped due to low reactor water level. The low reactor water level condition was due to a loss of both reactor feed pumps. The cause of the loss of feed pumps is under investigation. Additionally, the low reactor water level resulted in the automatic actuation of High Pressure Coolant Injection (HPCI) and Reactor Core Isolation Cooling (RCIC) systems, and Containment Isolation Valves (CIVs) in multiple systems. All safety systems responded normally.
"Operations responded and stabilized the plant. Reactor water level is being maintained via RCIC system. Decay heat is being removed by discharging steam to the main condenser using the turbine bypass valves. Unit 2 is not affected.
"Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). It is also reportable under 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the HPCI and RCIC systems and CIVs. There was no impact on the health and safety of the public or plant."
The Licensee notified the NRC Resident Inspector. The Unit will proceed to Mode 4 while the cause of the loss of feed pumps is under investigation.
Power Reactor
Event Number: 55395
Facility: Braidwood
Region: 3 State: IL
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Zachary Myers
HQ OPS Officer: Kerby Scales
Region: 3 State: IL
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Zachary Myers
HQ OPS Officer: Kerby Scales
Notification Date: 08/03/2021
Notification Time: 19:35 [ET]
Event Date: 08/03/2021
Event Time: 15:39 [CDT]
Last Update Date: 08/03/2021
Notification Time: 19:35 [ET]
Event Date: 08/03/2021
Event Time: 15:39 [CDT]
Last Update Date: 08/03/2021
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):
KOZAK, LAURA (R3)
KOZAK, LAURA (R3)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
EN Revision Imported Date: 8/5/2021
EN Revision Text: OFFSITE NOTIFICATION - INADVERTENT SIREN ACTUATION
"At approximately 1539 CDT on 8/3/2021, the Braidwood Station Main Control Room was notified of the inadvertent actuation of 17 Full Sounding sirens affecting Braidwood Station in Will County Illinois while testing other sirens. Will County EMA inadvertently actuated the sirens on 08/03/2021 at 1440 CDT.
"This event is reportable per 10CFR50.72(b)(2)(xi), News release or Notification of Other Government Agencies. This is a 4 Hour Reporting requirement.
"The Braidwood NRC Resident has been notified."
See related Event Notification #55396.
EN Revision Text: OFFSITE NOTIFICATION - INADVERTENT SIREN ACTUATION
"At approximately 1539 CDT on 8/3/2021, the Braidwood Station Main Control Room was notified of the inadvertent actuation of 17 Full Sounding sirens affecting Braidwood Station in Will County Illinois while testing other sirens. Will County EMA inadvertently actuated the sirens on 08/03/2021 at 1440 CDT.
"This event is reportable per 10CFR50.72(b)(2)(xi), News release or Notification of Other Government Agencies. This is a 4 Hour Reporting requirement.
"The Braidwood NRC Resident has been notified."
See related Event Notification #55396.
Agreement State
Event Number: 55386
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: Piedmont Fayette Hospital
Region: 1
City: Fayetteville State: GA
County:
License #: GA 1340-1
Agreement: Y
Docket:
NRC Notified By: John Hays
HQ OPS Officer: Howie Crouch
Licensee: Piedmont Fayette Hospital
Region: 1
City: Fayetteville State: GA
County:
License #: GA 1340-1
Agreement: Y
Docket:
NRC Notified By: John Hays
HQ OPS Officer: Howie Crouch
Notification Date: 07/30/2021
Notification Time: 13:47 [ET]
Event Date: 07/14/2021
Event Time: 00:00 [EDT]
Last Update Date: 07/30/2021
Notification Time: 13:47 [ET]
Event Date: 07/14/2021
Event Time: 00:00 [EDT]
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: 8/6/2021
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION
The following information was received from NMED for the Georgia Radioactive Materials Program:
"This incident occurred on July 14 at Piedmont Fayette Hospital (GA 1340-1). The unnecessary study was an administration of 25.6 mCi of Tc-99m exametazime-labeled white blood cells (Ceretec WBC), for which the TEDE was about 9 mSv. The individual who received the unnecessary study only came to the hospital for the study and was not an inpatient or there for any other reason."
Georgia Incident Number: 45
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 MISADMINISTRATION
The following information was received from NMED for the Georgia Radioactive Materials Program:
"This incident occurred on July 14 at Piedmont Fayette Hospital (GA 1340-1). The unnecessary study was an administration of 25.6 mCi of Tc-99m exametazime-labeled white blood cells (Ceretec WBC), for which the TEDE was about 9 mSv. The individual who received the unnecessary study only came to the hospital for the study and was not an inpatient or there for any other reason."
Georgia Incident Number: 45
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
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: 8/6/2021
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.
Non-Agreement State
Event Number: 55388
Rep Org: Rodriguez Sun Group
Licensee: Rodriguez Sun Group
Region: 1
City: Hormigueros State: PR
County:
License #: 52-35550-01
Agreement: N
Docket:
NRC Notified By: Alfonso Hernandez Bosquel
HQ OPS Officer: Howie Crouch
Licensee: Rodriguez Sun Group
Region: 1
City: Hormigueros State: PR
County:
License #: 52-35550-01
Agreement: N
Docket:
NRC Notified By: Alfonso Hernandez Bosquel
HQ OPS Officer: Howie Crouch
Notification Date: 07/30/2021
Notification Time: 15:43 [ET]
Event Date: 07/30/2021
Event Time: 13:05 [EDT]
Last Update Date: 08/03/2021
Notification Time: 15:43 [ET]
Event Date: 07/30/2021
Event Time: 13:05 [EDT]
Last Update Date: 08/03/2021
Emergency Class: Non Emergency
10 CFR Section:
30.50(b)(2) - Safety Equipment Failure
10 CFR Section:
30.50(b)(2) - Safety Equipment Failure
Person (Organization):
CAHILL, CHRISTOPHER (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
CAHILL, CHRISTOPHER (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 8/6/2021
EN Revision Text: DAMAGED INSTROTEK MOISTURE DENSITY GAUGE
The following is a summary of a phone call with the licensee:
On 7/30/2021 while at the jobsite in Moca, Puerto Rico, the licensee's InstroTek MC-3 Elite gauge was run over by a paving roller while in the safety drum. The gauge plastic casing was damaged and the source rod was broken. The sources were in the shielded position at the time of the incident. The InstroTek gauge serial number is 31331 and contains nominally 10 mCi of Cs-137 and 50 mCi of AmBe.
The damaged gauge was placed in its storage container and returned to the licensee's Cabo Rojo facility for a swipe test. After the incident, the gauge read 0.2 to 0.3 mR/hr at 1 meter with a survey meter.
No overexposures were reported.
* * * RETRACTION ON 8/3/21 AT 1320 EDT FROM ALFONSO BOSQUE TO KERBY SCALES * * *
The following retraction is a summary of a phone call with the licensee:
The Radiation Safety Officer inspected the gauge and verified that the gauge maintained its safety function. The source was secured and a leak test verified no leakage.
Notified R1DO (Eve) and NMSS Event Notification via email.
EN Revision Text: DAMAGED INSTROTEK MOISTURE DENSITY GAUGE
The following is a summary of a phone call with the licensee:
On 7/30/2021 while at the jobsite in Moca, Puerto Rico, the licensee's InstroTek MC-3 Elite gauge was run over by a paving roller while in the safety drum. The gauge plastic casing was damaged and the source rod was broken. The sources were in the shielded position at the time of the incident. The InstroTek gauge serial number is 31331 and contains nominally 10 mCi of Cs-137 and 50 mCi of AmBe.
The damaged gauge was placed in its storage container and returned to the licensee's Cabo Rojo facility for a swipe test. After the incident, the gauge read 0.2 to 0.3 mR/hr at 1 meter with a survey meter.
No overexposures were reported.
* * * RETRACTION ON 8/3/21 AT 1320 EDT FROM ALFONSO BOSQUE TO KERBY SCALES * * *
The following retraction is a summary of a phone call with the licensee:
The Radiation Safety Officer inspected the gauge and verified that the gauge maintained its safety function. The source was secured and a leak test verified no leakage.
Notified R1DO (Eve) and NMSS Event Notification via email.
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: 8/6/2021
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: 55398
Facility: South Texas
Region: 4 State: TX
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Michael Samuels
HQ OPS Officer: Thomas Kendzia
Region: 4 State: TX
Unit: [1] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Michael Samuels
HQ OPS Officer: Thomas Kendzia
Notification Date: 08/05/2021
Notification Time: 17:30 [ET]
Event Date: 08/05/2021
Event Time: 17:42 [CDT]
Last Update Date: 08/05/2021
Notification Time: 17:30 [ET]
Event Date: 08/05/2021
Event Time: 17:42 [CDT]
Last Update Date: 08/05/2021
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
GEPFORD, HEATHER (R4)
FFD GROUP, (EMAIL)
GEPFORD, HEATHER (R4)
FFD GROUP, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
EN Revision Imported Date: 8/6/2021
EN Revision Text: NON-LICENSED SUPERVISORY PERSONNEL VIOLATED FFD POLICY
A non-licensed supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.
The NRC Resident Inspector has been notified.
EN Revision Text: NON-LICENSED SUPERVISORY PERSONNEL VIOLATED FFD POLICY
A non-licensed supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.
The NRC Resident Inspector has been notified.