Event Notification Report for July 20, 2005

AGREEMENT STATE REPORT INVOLVING POTENTIALLY ABANDONED SOURCES

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

"Description of Incident: Received notification 7-20-05 from Mississippi Emergency Management Agency (MEMA) that another State Agency (DEQ) had discovered the abandonment of a AEA Model 680 Cobalt-60 exposure device and a SPEC Model 150 exposure device containing Iridium-192. Division of Rad Health (DRH) personnel responded to location and determined that no devices were missing from the licensed storage facility. It had been assumed from other emergency responders that a overpack (Model 680-OP) for the Cobalt device may have contained radioactive material and was missing from the container. The event generated television and newspaper media attention. DRH personnel explained that the overpack was only used when the device was transported on public roads. All radioactive material was accounted for and secured in the storage area. Also, DRH and DEQ personnel went to Struthers Industries location at the 34th Street facility located in Gulfport, MS, where all radioactive material ( a Model 680 Cobalt 60 exposure device and a Model 660 Iridium 192 device) was accounted for and still secured in the locked storage vault. There was security concerns due to the companies being in bankruptcy and the new owners not knowing about the radioactive devices. DRH had investigated the security of the sources on 6-28-05 and found the sources safe, but met with the president of company who assured DRH he would properly dispose of the devices. On 7-21-05 AEA Technology was contacted to remove the sources. The sources were put in approved overpacks. Leak tests had been performed on the sources and determined that the sources were not leaking. AEA personnel also removed all radiation signs and associated equipment at the 2 locations. DRH personnel did closeout surveys along with AEA personnel to ensure no radioactive sources were left behind. All radioactive material that was licensed by the 2 licenses (MS-750-01 and MS-259-01) were accounted for and removed by AEA personnel. It has not been determined by DRH personnel if devices were abandoned and the investigation is ongoing by DRH personnel.

"Isotope(s)/Activity: Cobalt 60 (2 devices/sources) @ 23 curies in each device, Iridium 192 (2 devices/sources) @ 5 curies in each device

"Date of Incident: 7-20-05
"Date Reported To DRH: 7-20-05

"Describe clean-up actions taken by DRH: After determining all radioactive devices were accounted for, DRH contacted AEA Technology about the removal of the devices. DRH personnel stayed at location until all sources and devices were removed and caution signs and associated radiography equipment was removed.

"List radiation measurements taken by DRH: Highest readings were @ 30 mR/hr at surface of the Co-60 exposure devices. The readings on the Iridium-192 devices were less than 5 mR/hr.

"List any other actions required of DRH: Event is under investigation by DRH, EPA, MS DEQ, and FBI.

"List any actions taken to notify NRC, other Agreement States: NRC Ops Center notified by E-mail 7-22-05; NMED notified 7-22-05 by E-mail. Event was reported to EPA due to other hazardous materials that were discovered at the site. Also investigated by FBI and inquiries made from Homeland Security.

"Enforcement action taken: Investigation ongoing as to if devices were abandoned or if the owner was still in process of disposing of the devices."

EMERGENCY SIRENS FAILED FOR ONE HOUR

"At 2017 CDST on July 20, 2005, it was determined that greater than 25% of Braidwood Station Emergency Sirens, which are maintained by others, had been failed for one hour. The initial failure occurred at 1917 CDST on July 20, 2005, and was apparently caused by storm activity in the area. At 2041 CDST on July 20, 2005, Braidwood Station was notified by the Corporate Emergency Planning organization that the number of failed Emergency sirens was less than 25% of the total number of sirens, and that sirens were in the process of being restored at that time.

"This notification is required by 10CFR 50.72(b)(3)(xiii)"

The licensee notified the NRC Resident Inspector.

MINIMUM RECIRCULATION VALVES WILL NOT AUTOMATICALLY OPEN IN LOCAL OPERATING MODE

"While performing a test start of P-38A Motor Driven Auxiliary Feedwater Pump utilizing the local control station, it was discovered that AF-4007, the mini-recirculation valve for P-38A would not automatically open in the local mode of operation. The mini-recirculation valve provides a minimum flow path for pump operation to prevent pump damage. After this condition was discovered, a review of procedures associated with initiating safe shutdown via local operation disclosed that the procedure did not address manually opening the mini-recirculation valve prior to local pump start. As a result, pump damage could occur due to no flow though the pump prior to aligning a flow path into a steam generator. This condition is also applicable to AF-4014, the mini-recirculation valve for P-38B Motor Driven Auxiliary Feedwater Pump.

"P-38A and P-38B Motor Driven Auxiliary Feedwater pumps would only be used in a safe shutdown local control condition if steam generator level could not be maintained using the normal means of 1P-29 and 2P-29 Turbine Driven Auxiliary Feedwater Pumps.

"The station has taken compensatory actions to brief the operators about the condition. Additionally, temporary procedure changes are in progress to direct the operator to manually open each Motor Driven Auxiliary Feedwater Pump's associated mini-recirculation valve prior to a local start of the P-38A or P-38B Motor Driven Auxiliary Feedwater Pump.

"The associated mini-recirculation valve will operate when P-38A or P-38B Motor Driven Auxiliary Feedwater Pump is started from the control room. Follow up testing has verified P-38A Auxiliary Feedwater Pump operability."

The licensee notified the NRC Resident Inspector.

MEDICAL EVENT - DELIVERED DOSAGE EXCEEDED PRESCRIBED DOSAGE

"On Wednesday July 20, 2005 it was discovered, during a routine audit of the Nuclear Medicine records, that two patients were administered I-131 in amounts exceeding 30 microcuries without a written directive. Furthermore, the doses fell more than 20% outside the prescribed dose range as set by the Authorized User (AU) physician. Below I will discuss the particulars of each administration.

"1. Patient #1: 25 year old female was administered 31 µCi of I-131 Sodium Iodide (Nal) on 18 July 2005 without a written directive prepared or signed by the AU previous to administration. The purpose of the study was to ascertain the thyroid uptake fraction and image the thyroid tissue. The prescribed does range, as set by the AU, was 8 to18 microcuries. This dose was 72% higher than the maximum dose allowed by the AU for this diagnostic procedure. (The patient's actual 24-hour thyroid uptake fraction was 27.5%).

"2. Patient #2: 61 year old female was administered 42 µCi of I-131 Nal on 14 July, 2005 without a written directive prepared or signed by the AU previous to administration. The purpose of the study was to ascertain the thyroid uptake fraction and image the thyroid tissue. This dose was 133% higher than the maximum dose allowed by the AU for this diagnostic procedure. (The patient's actual 24-hour uptake fraction was 14%).

"Dose Estimates From These Procedures

"1. Patient #1: Using data found in NUREG CR-6435 "Radiation Dose Estimated from Radiopharmaceuticals" we estimate the following doses for the (a) Whole Body: 1.209 rem, and (b) Thyroid (target organ) 40.3 rad

"2. Patient #2: Using data from NUREG CR-6345 and from other sources we estimate the following dose for the (a) Whole Body: 1.638 rem, and (b) Thyroid: 17.6 rad."