Event Notification Report for September 29, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/28/2023 - 09/29/2023
Agreement State
Event Number: 56754
Rep Org: Florida Bureau of Radiation Control
Licensee: Cleveland Clinic
Region: 1
City: Weston State: FL
County:
License #: 4818-2
Agreement: Y
Docket:
NRC Notified By: Monroe Cooper
HQ OPS Officer: Lawrence Criscione
Notification Date: 09/22/2023
Notification Time: 16:16 [ET]
Event Date: 09/20/2023
Event Time: 00:00 [EDT]
Last Update Date: 09/22/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Dentel, Glenn (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Event Text
AGREEMENT STATE REPORT - MISSING I-125 SEED
The following was reported by the Florida Bureau of Radiation Control (BRC) via email:
"At 1537 EDT on 9/22/23, BRC received a call from Cleveland Clinic stating an I-125 source was lost after removal from a patient. The patient was suspected to have breast cancer, and two I-125 sources were implanted in the breast tissue. The patient returned home 9/18/23 with the implanted seeds, and returned to the clinic 9/20/23 to receive a Tc-99m injection prior to tissue removal. The licensee states they confirmed both seeds were no longer in the patient after surgery, however, when the samples were taken by pathology, only one seed was located in the removed tissue. Cleveland Clinic has completed surveys of the operating room and pathology."
Florida incident number: FL23-149
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: 56759
Facility: Monticello
Region: 3 State: MN
Unit: [1] [] []
RX Type: [1] GE-3
NRC Notified By: Brendon Eagle
HQ OPS Officer: John Russell
Notification Date: 09/27/2023
Notification Time: 15:28 [ET]
Event Date: 09/27/2023
Event Time: 10:41 [CDT]
Last Update Date: 09/28/2023
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(iv)(A) - Valid Specif Sys Actuation
50.72(b)(2)(iv)(B) - RPS Actuation - Critical
Person (Organization):
Orlikowski, Robert (R3DO)
Power Reactor Unit Info
| Unit |
SCRAM Code |
RX Crit |
Initial PWR |
Initial RX Mode |
Current PWR |
Current RX Mode |
| 1 |
A/R |
Y |
75 |
Power Operation |
0 |
Hot Shutdown |
Event Text
EN Revision Imported Date: 9/28/2023
EN Revision Text: ACTUATION OF REACTOR PROTECTION AND CONTAINMENT ISOLATION SYSTEMS
The following information was provided by the licensee via fax:
"[On 09/27/2023] at 1041 CDT, with the plant at 75 percent power and main turbine control valve testing in progress, a reactor pressure transient resulted in a reactor steam dome high pressure scram and subsequent group 1 primary containment isolation of the main steam lines (MSL). All main steam isolation valves closed as a result of the group 1 isolation signal. Additionally, a group 2 containment isolation signal was received due to reactor pressure vessel (RPV) level less than plus 9 inches during the transient. Operations personnel responded and stabilized the plant. The high-pressure coolant injection (HPCI) system was placed in service to control RPV pressure. HPCI did not inject into the RPV and was not needed to control RPV water level. The cause of the initial pressure transient is under investigation."
The NRC Resident Inspector has been notified.
***UPDATE ON 9/27/2023 AT 2350 EDT FROM NATHAN PIEPER TO LAWRENCE CRISCIONE***
The utility notified the State of Minnesota and Wright and Sherburne counties.
Notified R3DO (Orlikowski)