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Home NRC Library Document Collections Events, Reports Associated with Event Notification Reports 2023

Event Notification Report for February 22, 2023

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
02/21/2023 - 02/22/2023

EVENT NUMBERS
56353 56374 56376
Agreement State
Event Number: 56353
Rep Org: Texas Dept of State Health Services
Licensee: The University of Texas Health Center at San Antonio
Region: 4
City: San Antonio   State: TX
County:
License #: L 01279
Agreement: Y
Docket:
NRC Notified By: Chris Moore
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 02/14/2023
Notification Time: 16:06 [ET]
Event Date: 02/13/2023
Event Time: 00:00 [CST]
Last Update Date: 02/15/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Williams, Kevin (NMSS)
Event Text
AGREEMENT STATE REPORT - DOSE DELIVERED TO THE WRONG TREATMENT SITE

The following information was provided by the Texas Department of State Health Services (the Agency) via email:

"On February 13, 2023, the Agency was notified that a patient was prescribed to receive 35.74 mCi (1.32 GBq) of Y-90 microspheres to the right lobe of the liver. The dose was given to the left lobe (wrong lobe) of a patient during treatment on February 13, 2023. The dose delivered (36.48 mCi (1.35 GBq)) to the left lobe was within 20 percent of the prescribed dose. The dose that was delivered to the left lobe is also within 20 percent of the dose that would have been prescribed for the left lobe in 2 weeks according to the physician. The treatment was clinically insignificant to the patient as both lobes were to be treated with a pending remapping of the second lobe to confirm the dosage but both have similar tumor volumes. More information will be provided as it is obtained in accordance with SA-300.

NMED National Number: TX230005

Texas Incident Number: 9889

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: 56374
Facility: North Anna
Region: 2     State: VA
Unit: [1] [2] []
RX Type: [1] W-3-LP,[2] W-3-LP,[3] M-4-LP
NRC Notified By: Ken Anderson
HQ OPS Officer: Adam Koziol
Notification Date: 02/20/2023
Notification Time: 17:07 [ET]
Event Date: 02/20/2023
Event Time: 16:18 [EST]
Last Update Date: 02/23/2023
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
Person (Organization):
Miller, Mark (R2DO)
Power Reactor Unit Info
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
Event Text
EN Revision Imported Date: 2/24/2023

EN Revision Text: OFFSITE NOTIFICATION TO STATE AGENCY

The following information was provided by the licensee via fax:

"At 1618 EST on February 20, 2023, North Anna Power Station notified the Virginia Department of Environmental Quality (DEQ) that water discharged into Lake Anna following hydrostatic testing of tanks associated with a new on-site sewage treatment plant had exceeded the project's general permit (VAG83) pH value.

"Hydrostatic test water discharge activities to Lake Anna began on February 20, 2023 at 0900 EST. A pH sample was collected at 0955 EST on February 20, 2023 and determined to have a pH of 9.1 which exceeded the maximum permit pH of 9.0. Discharge ceased after the reading was collected. Approximately 354 gallons were discharged to Lake Anna. A follow-up ambient pH sample result of 7.8 was collected on February 20, 2023 at 1401 EST from Lake Anna in the vicinity of the discharge pipe. No evidence of dead fish, foam, or other negative environmental impacts were observed.

"This event is reportable in accordance with 10 CFR 50.72(b)(2)(xi) for 'Any event or situation, related to the health and safety of the public or on-site personnel, or protection of the environment, for which a news release is planned or notification to other government agencies has been or will be made. Such an event may include an on-site fatality or inadvertent release of radioactively contaminated materials.'"

* * * UPDATE ON 02/23/2023 AT 1342 EST FROM BOB PAGE TO IAN HOWARD * * *

The following is a summary of information provided by the licensee via telephone:

The licensee called to correct the pH sample results from a pH of 9.1 to a pH of 9.93.

Notified R2DO (Miller) via phone


Power Reactor
Event Number: 56376
Facility: San Onofre
Region: 4     State: CA
Unit: [] [] []
RX Type: Unit 2
NRC Notified By: Guadalupe Robles
HQ OPS Officer: Ian Howard
Notification Date: 02/21/2023
Notification Time: 19:16 [ET]
Event Date: 02/21/2023
Event Time: 14:02 [PST]
Last Update Date: 02/22/2023
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(2)(xi) - Offsite Notification
Person (Organization):
Roldan-Otero, Lizette (R4DO)
NMSS_Events_Notification, (EMAIL)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
Event Text
EN Revision Imported Date: 2/23/2023

EN Revision Text: OFFSITE NOTIFICATION TO LOCAL AGENCY

The following information was provided by the licensee via email:

"On 2/21/2023 at 1402 [PST] SONGS [San Onofre Nuclear Generating Station] notified San Diego Regional Water Quality Control Board (SDRWQCB) regarding the results of a quarterly monitoring report. The report indicated the 24-effluent toxicity sample resulted in a 'Fail.' The results prompted a 24 hour notification to the SDRWQCB in accordance with the NPDES [National Pollutant Discharge Elimination System] permit. There was no significant effect on the health and safety of the public or the environment.

"Action Taken: SCE [Southern California Edison] Environmental notified the SDRWQCB via telephone voice mail at 1402 on 2/21/2023 followed by an e-mail describing the reason for the notification."

* * * UPDATE ON 02/22/2023 AT 1403 EST FROM GUADALUPE ROBLES Jr. TO IAN HOWARD * * *

The following is a summary of information provided by the licensee via email:

The licensee corrected the Unit from ISFSI to Unit 2 and the name of the quarterly test to note it was for the first quarter of 2023.

Notified R4DO (Roldan-Otero), and NMSS Events Notification via email.