Event Notification Report for April 27, 2016

AGREEMENT STATE REPORT - IMPLANTED IODINE 125 SEED NOT ACCOUNTED FOR

The following was received from Arizona via email:

"On April 27th, the licensee [Mayo Clinic Arizona] discovered that one (1) I-125 seed was missing with an approximate activity of 0.3 millicuries. The breast tissue from a patient was analyzed by the licensees' surgical staff on April 26th and one seed was removed and then brought down to the nuclear medicine department on the morning of the 27th. The nuclear medicine staff quickly realized that there should have been two seeds, since two seeds were initially implanted. The licensee's radiation safety staff surveyed both the hospital surgical path area as well as the pathology/histology area and no source was discovered.

"The investigation into this event is ongoing.

"The U.S. NRC and Arizona Governor's office are being notified of this event."

Arizona Incident # 16-007

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.

LOSS OF TONE ALERT RADIO SYSTEM TOWER

"At 0823 CDT on 4/27/2016, Cooper Nuclear Station was notified by the National Weather Service that the Shubert radio transmission tower was not functioning. This affects the tone alert radios used to notify the public in the event of an emergency condition. This is considered to be a major loss of the public prompt notification system capability and is reportable under 10CFR50.72(b)(3)(xiii).

"Nemaha, Richardson and Atchison county authorities within the 10 mile EPZ [Emergency Planning Zone] were notified of the condition and the effect on the tone alert radios and will utilize local route notification (backup notification method) making this condition reportable under 10CFR50.72(b)(2)(xi) for notification of other government agencies.

"Estimated return to service time is unknown. The cause of the failure is a loss of communication with the tower.

"The NRC Senior Resident Inspector has been notified of this condition."

MEDICAL EVENT - DOSE GIVEN TO INCORRECT SEGMENT OF THE LIVER

During a Y-90 TheraSphere treatment (hepatocellular carcinoma) to the right lobe of the liver segments 5, 6, 7, and 8 (estimated volume of 1290 ml), the catheter moved and the dose was actually given to medial segment 4 (estimated volume of 330 ml). The prescribed dose was 120 Gy (3.3 GBq) and the delivered dose was approximately 118.5 Gy as determined by bremmstrahlung imaging. Segment 4 was previously treated and there was some residual cancer at this location. This dose is not expected to have detrimental effects on the patient.

It is anticipated that segments 5,6,7,8 will be treated at some future time.

The patient has been notified and the prescribing physician will be notified.

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.

HIGH ENERGY LINE BREAK DOOR DISCOVERED OPEN

"On April 27, 2016 at 20:07 [EDT], a high energy line break (HELB) door between the turbine driven auxiliary feedwater pump and the motor driven auxiliary feedwater pump rooms was discovered open and unattended. In the event of a HELB, this condition could have rendered both trains of auxiliary feedwater inoperable. The boundary was not operable for approximately 1 hour. Upon discovery, the door was closed restoring the boundary.

"This event is being reported pursuant to 10 CFR 50.72(b)(3)(v) as any event or condition that alone could have prevented the fulfillment of the safety function of structures or systems that are needed to: (B) Remove residual heat; and (D) Mitigate the consequences of an accident.

"The NRC Senior Resident Inspector has been notified."

The Licensee notified the Connecticut DEEP and Waterford Dispatch.