Event Notification Report for May 10, 2001

AGREEMENT STATE REPORT - STOLEN GAUGE CONTAINING RADIOACTIVE ISOTOPES

A Troxler moisture density gauge (model #3440, serial #28940) was stolen from a truck parked at the Metric Engineering, Inc. office located at 13940 S.W. 136th Street, Suite 200, Miami, Florida 33186. The gauge contains 8 mCi Cs-137 and 40 mCi Am-241:Be. The gauge has been recovered.

"Licensee states their inspector, Dylan Grove, reported the gauge was stolen from the back of his truck at 11:10 AM on this date at the above location. The lock securing the gauge to the vehicle was cut. The name and phone number of the licensee was displayed on the gauge. The licensee reported the theft to this office at 2:05 PM. At approximately 3:00 PM, the licensee reported the gauge had been returned to their SR 436 field office by an anonymous gentleman. The gauge was reportedly undamaged. This incident has been transferred to the Radioactive Materials section for further action. An inspection of the work site by a state inspector is
scheduled for 11 May 01."

AGREEMENT STATE REPORT - STOLEN RADIOGRAPHY DEVICE

"On May 10, 2001, the Agency was notified by telephone that a truck containing a radiography device was missing and possibly stolen. SPEC 150, Camera #23, source serial number KB 0109, 40 curies iridium-192, cannot be located. The police found the truck, but the device was not inside.

"The Agency is investigating."

Incident 7754

10 CFR 21 REPORT - INTERIM REPORT ABOUT R-11 MONITOR PROBLEM

The following is taken from a faxed report:

Deviation being evaluated: An R-11 Monitor installed in Korea has been reported as having a rapid increase in displayed concentration and analog output values. Initial evaluation of the problem indicates the cause may be in one of the base 960 firmware modules, which are also installed in some US nuclear power plants. The significance of the problem is still under evaluation to determine if it could create a substantial safety hazard. The initial report was received on March 15, 2001.

Evaluation information to date: The problem is a rapid increase in displayed concentration and analog output values. The problem is not apparent at low levels of activity where low count rates and statistical variation mask the increase. When activity is near the upper range of the monitor, this spike in calculated activity has triggered radiation alarms and could place the channel into over range. The spiking in activity is believed to be due to the microprocessor being unable to read and clear a register within the allotted time. This results in a higher accumulated count value when the register is finally read. Since the problem is directly related to processor workload, the problem is most likely to occur in a complex channel configuration with multiple detectors (such as a PIG or Extended Range) and where the microprocessor is highly tasked with RMS computer or isolator communications.

For single range channels, the result of the spike would be a false radiation alarm and possibly an over range condition as well, although this has not been reported to the best of our knowledge. The other possibility is that this situation could occur on an Extended Range monitor thereby placing the channel in 'accident' or high range mode. If this occurs, the normal range is shut down and/or by-passed. If the accident range detector is brought online below its minimum operating range and the normal range detector is shut down, an unmonitored release might be possible.

A more detailed analysis of the firmware in specific channels is needed to determine if this last condition is possible.

The possible defect is believed at this time to only affect Model 960 firmware modules upgraded or purchased since 1992.

Evaluation completion date: July 10. 2001

* * * UPDATED AT 1215 EDT ON 7/11/2001 BY JANICE BROWNLEE TO FANGIE JONES * * *

Inovision faxed a follow-up to the interim report.

"Component containing defect: Firmware in Type IIA 960 Systems with a Real Time Clock (RTC) integrated circuit, programmed for use in pulse counting applications, and equipped with the following controller modules:
Model 960CD-220 (P/N 960CD-220-10)
Model 960CD-221 (P/N 960CD-221-10)
Model 960CD-223 (P/N 960CD-223-10)

"Monitors utilizing ionization chamber detectors are not affected

"The above controllers were equipped with Real Timer Clock and additional firmware to control the RTC.

"Affected facilities: The Pacific Gas and Electric's' Diablo Canyon Nuclear Power Plant is the only domestic, NRC licensed user affected by this defect. Their purchase orders ZS-7204A-AAO and ZS-7204B-AAO are affected and were shipped from 1991-1993. There were 20 potentially affected PROMs from those orders. Other potentially affected customers are located in Korea (KEPCO, KAREI) and in Belgium (SEMO, Electrabel). Notifications have been or will be sent to the affected facilities with further specific information.

"Corrective Action: Although there is a sporadic firmware program problem, we do not believe that problem represents a significant safety concern. It is our intention to notify the customers that are potentially affected by this anomaly and to identify for them the affected monitors/channels within their facility within 30 days The problem is only potentially present if the facility has the TARGET COUNT algorithm enabled. We will recommend that the facilities discontinue use of this algorithm. (Diablo Canyon does not use this function).

"As discussed earlier, a preliminary firmware fix has been identified. The decision to take further action will be addressed with each of the potentially affected facilities."

The R4DO (Chuck Cain) and NRR (Vern Hodge) have been notified

UNESCORTED ACCESS GRANTED INAPPROPRIATELY

The licensee discovered that a contract employee falsified a personal history questionnaire resulting in unescorted access to the Protected Area being granted inappropriately for a period of 25 days. Immediate compensatory actions were taken upon discovery. (Contact the NRC operations officer for additional details.)

The licensee submitted this notification in accordance with 10 CFR 73.71(b)(1); 10 CFR [Part] 73, Appendix G, paragraph I.b; and draft Regulatory Guide DG-5008 (RG 5.62), December 1997

The licensee notified the NRC resident inspector.

MEDICAL MISADMINISTRATION

On Tuesday, May 8, at 4:30 PM, at Franklin Square Hospital a patient was given a vaginal implant consisting of 10 ribbons each with 8 Ir-192 seeds. The activity per seed was about .495 mgRaEq, for a total implant of 39.6 mgRaEq (71.0 mCi). The intent was to deliver 60 cGy/hr to the periphery of the implanted treatment volume (4 cm diameter 8 cm long, for V= 100 cm3) for 50 hours for a total implant dose of 3000 cGy. This dose was to add to the already delivered external beam dose to that volume of 4500 cGy, for a total of 7500 cGy.

The patient was checked by the physician on Wednesday at 2:30 PM (after 22 hours) and all the needles were in place. The next check by the physician was at the time of removal, at 6:30 PM on Thursday. He found one needle with its ribbon of 8 seeds lying loosely on the folds of the bed sheet by the patient's hip, and 3 additional needles had also backed out by about 3 cm from their implanted positions. The patient was judged to be unable to describe the circumstances of the displacements.

Computer reconstruction showed that the reduction in the total tumor dose from the ribbon displacements was less than 10% and affected less than 15% of the implanted volume. And the corresponding increase in the position of the 50% isodose line at the other end of the implant was only about .5 cm. The physician has stated that he believes the patient had adequate brachytherapy treatment, and that no further interventions would be necessary. As for the dose to the patient from the dislodged ribbon, the physician has stated that there should not be significant dose to any viscera but to the skin and soft tissues. He does not think it has clinical significance for this patient.