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Event Notification Report for May 10, 2016

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/09/2016 - 05/10/2016

** EVENT NUMBERS **


51893 51894 51898 51912 51913

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Agreement State Event Number: 51893
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: MAYO CLINIC ARIZONA
Region: 4
City: PHOENIX State: AZ
County:
License #: AZ 07-448
Agreement: Y
Docket:
NRC Notified By: BRIAN GORETZKI
HQ OPS Officer: DANIEL MILLS
Notification Date: 04/30/2016
Notification Time: 13:53 [ET]
Event Date: 04/27/2016
Event Time: [MST]
Last Update Date: 04/30/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEREMY GROOM (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

This material event contains a "Less than Cat 3 " level of radioactive material.

Event Text

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.

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Agreement State Event Number: 51894
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: TUCSON MEDICAL CENTER
Region: 4
City: TUCSON State: AZ
County:
License #: AZ 10-010
Agreement: Y
Docket:
NRC Notified By: BRIAN GORETZKI
HQ OPS Officer: DANIEL MILLS
Notification Date: 04/30/2016
Notification Time: 14:31 [ET]
Event Date: 04/29/2016
Event Time: [MST]
Last Update Date: 04/30/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEREMY GROOM (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

The following was received from Arizona via email:

"On April 29th, the licensee [Tucson Medical Center] discovered that a patient had received 37 percent more than the prescribed dose of Xofigo (Radium-223). The licensee had received two doses of Ra-223 for two patients the day prior. The technologist usually asks a patient their weight in order to re-calculate the dose, but forgot and accidently grabbed another Xofigo patient's dose on April 28th. The technologist realized the mistake when she went to inject the second patient on the 29th and the name on the patient's dose did not match the current patient's name. The prescribed dose was 86.7 microcuries and the actual administered dose was 119.3 microcuries.

"The investigation into this event is ongoing.

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

Arizona Incident # 16-008

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.

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Agreement State Event Number: 51898
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: ARIAS & ASSOCIATES INC
Region: 4
City: SAN ANTONIO State: TX
County:
License #: 04964
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/02/2016
Notification Time: 17:07 [ET]
Event Date: 05/02/2016
Event Time: 05:30 [CDT]
Last Update Date: 05/02/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN KRAMER (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
CNSNS (MEXICO) (FAX)

This material event contains a "Less than Cat 3 " level of radioactive material.

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following information was obtained from the State of Texas via email:

"On May 2, 2016, the licensee notified the Agency [State of Texas] that one of its technicians had discovered at approximately 0530 CDT, that a Troxler Model 3430 moisture/density gauge had been stolen out of the back of the licensee's pickup while it was parked at the technician's residence. The licensee's radiation safety officer (RSO) reported the technician had checked out the gauge on Saturday, April 30, 2016, to do a job in another town. After traveling to the job site, the job was cancelled. The technician failed to follow the licensee's procedures and went home instead of returning the gauge to the facility. The gauge was left chained inside the back of the company pickup. The technician told the RSO that the trigger lock was on the device. The technician told the RSO he heard noise outside his house at approximately 0300-0400 CDT this morning and suspects that was when it was being stolen. He found the chains had been cut and the transport case and gauge were gone along with another concrete testing device. Local law enforcement was notified and the technician drove around searching the area. The RSO contacted multiple pawn shops in the area.

"Device: Troxler Model 3430 moisture/density gauge Serial #: 31528
Sources: Cesium-137 - 8 millicuries; Americium-241 - 40 millicuries

"More information will be provided as it is obtained in accordance with SA-300."

Texas Incident No.: I-9395


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

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Power Reactor Event Number: 51912
Facility: BRAIDWOOD
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: KEVIN MORES
HQ OPS Officer: DONALD NORWOOD
Notification Date: 05/09/2016
Notification Time: 17:18 [ET]
Event Date: 05/07/2016
Event Time: 23:50 [CDT]
Last Update Date: 05/09/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
ERIC DUNCAN (R3DO)

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

OFFSITE NOTIFICATION - REPORTING THAT SITE WAS NOTIFIED OF SIREN SOUNDING

"At approximately 1420 CDT on 5/9/2016, the Braidwood Station Main Control Room was notified by Exelon Corporate Emergency Preparedness of the inadvertent actuation of all 27 Full Sounding Sirens in Will County, Illinois. Exelon Emergency Preparedness was notified at 1309 CDT on 5/9/2016. The inadvertent actuation occurred on 5/7/16 at 2350 CDT during a training activity performed by Wescom (Western Will County Communications Center).

"This event is reportable per 10 CFR 50.72(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."

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Power Reactor Event Number: 51913
Facility: DRESDEN
Region: 3 State: IL
Unit: [ ] [2] [3]
RX Type: [1] GE-1,[2] GE-3,[3] GE-3
NRC Notified By: JOSH PICKETT
HQ OPS Officer: STEVE SANDIN
Notification Date: 05/09/2016
Notification Time: 17:34 [ET]
Event Date: 05/07/2016
Event Time: 23:50 [CDT]
Last Update Date: 05/09/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
ERIC DUNCAN (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation
3 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION - REPORTING THAT SITE WAS NOTIFIED OF SIREN SOUNDING

"At approximately 1430 CDT on 5/9/2016, the Dresden Station Main Control Room was notified by Exelon Corporate Emergency Preparedness of the inadvertent actuation of all 27 Full Sounding Sirens in Will County, Illinois. Exelon Emergency Preparedness was notified at 1309 CDT on 5/9/2016. The inadvertent actuation occurred on 5/7/16 at 2350 CDT during a training activity performed by Wescom (Western Will County Communications Center).

"This event is reportable per 10 CFR 50.72(b)(2)(xi), News Release or Notification of Other Government Agencies. This is a 4-hour reporting requirement.

"The Dresden NRC Resident has been notified."

Page Last Reviewed/Updated Tuesday, May 10, 2016
Tuesday, May 10, 2016