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Event Notification Report for July 8, 2016

U.S. Nuclear Regulatory Commission
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Event Reports For
07/07/2016 - 07/08/2016

** EVENT NUMBERS **


52014 52050 52052 52070 52072

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Agreement State Event Number: 52014
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: UNIVERSITY OF CALIFORNIA LOS ANGELES
Region: 4
City: LOS ANGELES State: CA
County:
License #: 1335-19
Agreement: Y
Docket:
NRC Notified By: DONELLE KRAJEWSKI
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/17/2016
Notification Time: 12:06 [ET]
Event Date: 06/16/2016
Event Time: [PDT]
Last Update Date: 07/07/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - DOSE ADMINISTERED TO WRONG PATIENT

The following information was received from the State of California via email:

"On June 16, 2016, [the] Radiation Safety Officer of the University of California, Los Angeles (UCLA), contacted the Brea office of the Radiologic Health Branch to report a medical event. The event resulted in a dose to the wrong patient that exceeded 20 percent of the prescribed dose (the dose that was likely to be given to another patient scheduled to be treated on June 17, 2016). The patient was given an activity of 4.02 GBq of Yttrium 90 (Nordion TheraSphere), resulting in a dose to the liver of 226.3 Gray. This dose exceeded the prescribed dose of 120 Gray. This activity was later discovered to be the activity that was most likely to have been ordered for a patient that was to be treated on June 17, 2016. The patient that was treated on June 16, 2016 has been notified. The investigation is ongoing to determine the cause of the event."

5010 Number: 061616

* * * UPDATE AT 1740 EDT ON 06/21/16 FROM ANDREW TAYLOR TO S. SANDIN VIA EMAIL * * *

"This is a revision/update of EN #52014.

"On June 16, 2016, [the] Radiation Safety Officer of the University of California, Los Angeles (UCLA), contacted the Brea office of the Radiologic Health Branch to report a medical event.

"Two patients were scheduled to be treated with Nordion TheraSpheres containing yttrium 90, one on June 16 and the other on June 17. The first treatment occurred on June 16; however, the treatment dosage of 4.02 GBq (108.6 mCi) was approximately 1.9 times the prescribed dosage, apparently because the dosage for the second patient was given to the first patient. As a result, the first patient received a liver dose of 226.3 gray (22,630 rad) instead of the prescribed dose of 120 gray (12,000 rad).

"The patient has been notified, and the licensee is investigating to determine the cause of the event."

Notified R4DO (Rollins) and NMSS Events Notification via email.

* * * UPDATE AT 0611 EDT ON 07/07/16 FROM ROBERT GREGER TO S. SANDIN VIA EMAIL * * *

"This is a revision/update of EN #52014.

"On 7/1/16 UCLA submitted a written report of this medical event. That report noted that in addition to the incorrect treatment dosage, the incorrect liver lobe was treated. As a result, the dose to the incorrect liver lobe was calculated as 328 Gy (32,800 rad). This differs from the previously reported liver dose of 226.3 Gy (22,630 rad) due to the difference in the sizes of the liver lobes."

Notified R4DO (Drake) and NMSS Events Notification via email.

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: 52050
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: UNIVERSITY OF LOUISVILLE
Region: 1
City: LOUISVILLE State: KY
County:
License #: 202-029-22
Agreement: Y
Docket:
NRC Notified By: MARISSA VEGA VELEZ
HQ OPS Officer: JEFF HERRERA
Notification Date: 06/29/2016
Notification Time: 10:15 [ET]
Event Date: 05/18/2016
Event Time: [CDT]
Last Update Date: 06/29/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HAROLD GRAY (R1DO)
NMSS_EVENTS_NOTIFIC (EMAI)

Event Text

AGREEMENT STATE REPORT - PATIENT OVERDOSE OF IODINE-125 DURING MEDICAL TREATMENT

The following report was received from the Kentucky Department of Public Health and Safety, Radiation Health Branch via email:

"The KY Radiation Health Branch [RHB] was notified on 6/28/16 by the RSO at the University of Louisville that a patient received 297.7 cGy (rad), instead of the prescribed 31 cGy (rad). The patient was implanted with a 7.4 MBq (200 uCi) I-125 localization seed for treatment of non-palpable breast cancer on 3/18/16. The seed was to be removed within five days after implant. However, shortly after induction of anesthesia on the day of removal the patient became unstable, surgery was cancelled, the patient was placed in ICU, and the seed wasn't removed until 5/18/16. The dose was calculated by the radiation oncologist with a reference point of 1 cm around the seed. KY RHB has been in contact with the licensee and expects additional information to be provided by the licensee."

KY Event Report ID No.: KY160006

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: 52052
Rep Org: COLORADO DEPT OF HEALTH
Licensee: EXTENDED STAY AMERICA
Region: 4
City: AURORA State: CO
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: LINDA BARTISH
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/29/2016
Notification Time: 13:01 [ET]
Event Date: 06/29/2016
Event Time: [MDT]
Last Update Date: 06/29/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG WERNER (R4DO)
NMSS_EVENTS_NOTIFIC (EMAI)

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

Event Text

AGREEMENT STATE REPORT - MISSING TRITIUM EXIT SIGNS

The following information was received from the State of Colorado via email:

"Details: The corporate office of Extended Stay America responded to the 2016 General License Annual reports. In their letter, it is stated, after a full investigation of the property, the exit signs were not found. There were 17, B100 Series, SN 625444 to 625460, with 9.2 Ci and 9 BXU10WS, SN 631179 to 631186, with 9.2 Ci not located. The total lost exit signs being reported are 26. Due to employee turnover from date reported shipped 4-23-1998 and 7-20-1998 to 2016 no records were maintained as the company had no knowledge of the status of Tritium Exit Signs associated with the site.

"Event Description: The Company will be conducting a special project to determine if Tritium Exit Signs exist at any of their facilities in Colorado when fire inspections are completed. Should they locate any Tritium Exit Signs the signs will be properly disposed. The company will notify the Radioactive Materials Unit [State of Colorado] that the signs were removed and properly disposed."

CO Event Report ID No.: CO16-I16-10

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: 52070
Facility: COOPER
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: CURTIS MARTIN
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/07/2016
Notification Time: 09:48 [ET]
Event Date: 07/07/2016
Event Time: 06:10 [CDT]
Last Update Date: 07/07/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JAMES DRAKE (R4DO)

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

Event Text

LOSS OF TONE ALERT RADIO SYSTEM TOWER

"At 0610 CDT on 7/7/2016, Cooper Nuclear Station confirmed 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 were notified of the condition and the effect on the tone alert radios and will utilize the 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 unknown.

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

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Power Reactor Event Number: 52072
Facility: HARRIS
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: CHUCK YARLEY
HQ OPS Officer: BETHANY CECERE
Notification Date: 07/07/2016
Notification Time: 14:39 [ET]
Event Date: 07/07/2016
Event Time: 12:10 [EDT]
Last Update Date: 07/07/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
DEBORAH SEYMOUR (R2DO)

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

Event Text

ACCIDENT MITIGATION - MAIN STEAM SAFETY VALVES NOT ADEQUATELY PROTECTED FROM TORNADO MISSILES

"During an evaluation of protection for Technical Specification (TS) equipment from the damaging effects of tornados, Harris Nuclear Plant personnel identified conditions in the plant design such that specific TS equipment is considered not adequately protected from tornado missiles. A tornado could generate multiple missiles capable of striking exhaust piping on multiple main steam safety valves (MSSVs), resulting in crimping of the piping that could impact flow capacity and render the MSSVs inoperable. If the tornado caused a loss of offsite power, the MSSVs are credited to remove decay heat to achieve cold shutdown. Compensatory measures have been implemented to ensure safety in the event of a tornado.

"Enforcement discretion per Enforcement Guidance Memorandum EGM 15-002 and Interim Staff Guidance DSS-ISG-2016-01 has been implemented and required actions taken. Corrective actions will be documented in a follow-on licensee event report."

The licensee has notified the NRC Resident Inspector.

Page Last Reviewed/Updated Friday, July 08, 2016
Friday, July 08, 2016