Home NRC Library Document Collections Events, Reports Associated with Event Notification Reports 2019

Event Notification Report for October 31, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/30/2019 - 10/31/2019

** EVENT NUMBERS **

Agreement State	Event Number: 54343
Rep Org: CALIFORNIA RADIATION CONTROL PRGM Licensee: BAY AREA GEOTECHNICAL GROUP Region: 4 City: SAN JOSE State: CA County: License #: 1625-43 Agreement: Y Docket: NRC Notified By: K. ARUNIKA HEWADIKARAM HQ OPS Officer: OSSY FONT	Notification Date: 10/22/2019 Notification Time: 15:41 [ET] Event Date: 10/21/2019 Event Time: 02:30 [PDT] Last Update Date: 10/22/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): CALE YOUNG (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL) - CNSNS (MEXICO) (EMAIL)

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

Event Text

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following was received from the California Department of Public Health Radiologic Health Branch (RHB) via email:

"On 10/21/19, the RSO [radiation safety officer] contacted RHB to report a stolen moisture density gauge. The gauge is a CPN Model MC1Elite, S/N 30492, containing 50 mCi of Cs-137 and 50 mCi of Am-241. It was stolen on 10/21/19 around 0230 [PDT] from the back of a truck parked at the gauge user's residence. The gauge was being used at a temporary job site near the user's residence and it was stolen by cutting the locks securing the gauge. The licensee provided video footage of the crime taking place from a video camera at the user's residence. The licensee had contacted the Salinas Police Department to notify them of the incident (Case #19-101002). A flyer has been posted with a reward for the safe return of the gauge. RHB will be following up on this investigation."

CA 5010 No.: 102119

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

!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State	Event Number: 54344
Rep Org: OZARK MEDICAL CENTER Licensee: OZARK MEDICAL CENTER Region: 3 City: WEST PLAINS State: MO County: License #: 24-18733-01 Agreement: N Docket: NRC Notified By: JOHN MCKENZIE HQ OPS Officer: OSSY FONT	Notification Date: 10/22/2019 Notification Time: 16:24 [ET] Event Date: 10/22/2019 Event Time: 13:30 [CDT] Last Update Date: 10/29/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 35.3045(a)(2) - DOSE > SPECIFIED EFF LIMITS	Person (Organization): KARLA STOEDTER (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

ADMINISTRATION OF DOSE TO WRONG INDIVIDUAL

The following is a synopsis of information received via phone:

On 10/22/19, at approximately 1330 CDT, 22.0 mCi of Tc-99m-white blood cells was administered to the wrong patient. The patient was confused and not able to correctly confirm that they were the patient receiving the dose. This patient was informed of event, but has a power of attorney who will also be notified. This patient's condition means the dose, carried by the white blood cells, will possibly end up in their bowel. Extra monitoring is being performed.

The correct patient will be rescheduled.

* * * RETRACTION ON 10/29/2019 AT 1257 EDT FROM JOHN MCKENZIE TO ANDREW WAUGH * * *

After discussion with R3 (Gattone), Ozark Medical Center is retracting this event because the delivered dose does not exceed the reportable limits described in 10 CFR 35.3045.

Notified R3DO (Riemer) and NMSS Events Notification (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.

Power Reactor	Event Number: 54362
Facility: SAINT LUCIE Region: 2 State: FL Unit: [1] [] [] RX Type: [1] CE,[2] CE NRC Notified By: CHARLES PIKE HQ OPS Officer: DONALD NORWOOD	Notification Date: 10/30/2019 Notification Time: 01:20 [ET] Event Date: 10/30/2019 Event Time: 00:26 [EDT] Last Update Date: 10/30/2019
Emergency Class: UNUSUAL EVENT 10 CFR Section: 50.72(a) (1) (i) - EMERGENCY DECLARED 50.72(b)(2)(xi) - OFFSITE NOTIFICATION	Person (Organization): GERALD MCCOY (R2DO) LAURA DUDES (R2A) HO NIEH (NRR) JEFFERY GRANT (IRD) CHRIS MILLER (NRR EO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

Defueled

Event Text

UNUSUAL EVENT DUE TO RELEASE OF FLAMMABLE GAS

"On 10/30/19 at 0026 EDT, an Unusual Event (HU3) was declared due to a release of flammable gas to the Unit 1 Pipe Penetration area (Reactor Auxiliary Building). The hydrogen supply valve to the area has been isolated. The area is being ventilated and follow-up air sampling will be performed.

"The NRC Resident Inspector has been notified."

Notified DHS SWO, FEMA Ops Center, DHS NICC, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

* * * UPDATE FROM FRED POLLAK TO DONALD NORWOOD AT 0521 EDT ON 10/30/2019 * * *

"The Notice of Unusual Event was terminated at 0454 EDT on 10/30/19. The area has been purged and normal access restored."

The licensee notified the NRC Resident Inspector.

Notified R2DO (McCoy), NRR EO (Miller), and IRD (Grant). Notified DHS SWO, FEMA Ops Center, DHS NICC, FEMA NWC (email), DHS Nuclear SSA (email), and FEMA NRCC SASC (email).

Page Last Reviewed/Updated Wednesday, March 24, 2021