Event Notification Report for August 19, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/18/2021 - 08/19/2021
Agreement State
Event Number: 55654
Rep Org: Minnesota Department of Health
Licensee: Fairview Southdale Hospital
Region: 3
City: Edina State: MN
County:
License #: 1039
Agreement: Y
Docket:
NRC Notified By: Sherrie Flaherty
HQ OPS Officer: Mike Stafford
Licensee: Fairview Southdale Hospital
Region: 3
City: Edina State: MN
County:
License #: 1039
Agreement: Y
Docket:
NRC Notified By: Sherrie Flaherty
HQ OPS Officer: Mike Stafford
Notification Date: 12/16/2021
Notification Time: 14:17 [ET]
Event Date: 08/19/2021
Event Time: 00:00 [CST]
Last Update Date: 12/16/2021
Notification Time: 14:17 [ET]
Event Date: 08/19/2021
Event Time: 00:00 [CST]
Last Update Date: 12/16/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Skokowski, Richard (R3)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
CNSC (Canada), - (FAX)
Skokowski, Richard (R3)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
CNSC (Canada), - (FAX)
EN Revision Imported Date: 1/14/2022
EN Revision Text: AGREEMENT STATE REPORT - LOST BRACHYTHERAPY SEED
The following information was received from the state of Minnesota via email:
"It has come to our attention during our IMPEP review that we have some events that were not directly reported to the HOO as required. They were reported to NMED, but we are now reporting them directly to the HOO.
"Fairview Southdale Hospital (FSH) reported a missing 8.36 MBq (226 microCi) I-125 localization seed (IsoAid model IAI-125A). The seed was discovered missing on 8/19/2021. Two I-125 seeds were placed in a patient for localization of non-palpable lesions. Both seeds were removed in the operating room, which was confirmed by imaging. The tissue was sealed in a container in the operating room and taken to Pathology. During processing of the tissue, Pathology could only locate one of the seeds. FSH surveyed the operating room and Pathology. The seed was not located. The operating room had been cleaned prior to the survey. It is not known if the seed went missing in the operating room or Pathology. FSH planned to modify their procedure to place the specimen in a Zip-Lock bag before being imaged in the operating room and kept in the bag when transported to Pathology. Also, Pathology will analyze the specimen in a timely fashion so if a seed does go missing, it will have less time to be moved around."
Minnesota event number: 210006
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 - LOST BRACHYTHERAPY SEED
The following information was received from the state of Minnesota via email:
"It has come to our attention during our IMPEP review that we have some events that were not directly reported to the HOO as required. They were reported to NMED, but we are now reporting them directly to the HOO.
"Fairview Southdale Hospital (FSH) reported a missing 8.36 MBq (226 microCi) I-125 localization seed (IsoAid model IAI-125A). The seed was discovered missing on 8/19/2021. Two I-125 seeds were placed in a patient for localization of non-palpable lesions. Both seeds were removed in the operating room, which was confirmed by imaging. The tissue was sealed in a container in the operating room and taken to Pathology. During processing of the tissue, Pathology could only locate one of the seeds. FSH surveyed the operating room and Pathology. The seed was not located. The operating room had been cleaned prior to the survey. It is not known if the seed went missing in the operating room or Pathology. FSH planned to modify their procedure to place the specimen in a Zip-Lock bag before being imaged in the operating room and kept in the bag when transported to Pathology. Also, Pathology will analyze the specimen in a timely fashion so if a seed does go missing, it will have less time to be moved around."
Minnesota event number: 210006
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
Power Reactor
Event Number: 55418
Facility: Point Beach
Region: 3 State: WI
Unit: [1] [2] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: Travis Nettekoven
HQ OPS Officer: Kerby Scales
Region: 3 State: WI
Unit: [1] [2] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: Travis Nettekoven
HQ OPS Officer: Kerby Scales
Notification Date: 08/19/2021
Notification Time: 18:14 [ET]
Event Date: 08/19/2021
Event Time: 08:42 [CDT]
Last Update Date: 08/19/2021
Notification Time: 18:14 [ET]
Event Date: 08/19/2021
Event Time: 08:42 [CDT]
Last Update Date: 08/19/2021
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
PETERSON, HIRONORI (R3)
FFD GROUP, (EMAIL)
PETERSON, HIRONORI (R3)
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: 9/17/2021
EN Revision Text: PERSONNEL VIOLATED FFD POLICY
A covered employee had a confirmed positive during a for-cause fitness-for-duty test. The employee's access to the plant has been terminated.
The NRC Resident Inspector has been notified.
EN Revision Text: PERSONNEL VIOLATED FFD POLICY
A covered employee had a confirmed positive during a for-cause fitness-for-duty test. The employee's access to the plant has been terminated.
The NRC Resident Inspector has been notified.