Event Notification Report for January 20, 2009

VARIAN HDR SOURCE STUCK OUT IN AN UNSHIELDED POSITION

The Varian equipment representative (R. Piccolo) provided notification of the following event that occurred at the McLaren Regional Medical Center (License #21-04171 04) in Flint, Michigan.

A technician was warming up a GammaMedPlus, HDR Unit, Model GM325 in preparation for a patient treatment when the Ir-192 source became stuck in the unshielded position. The Ir-192 source has an activity level of 8.3 Curies. After consulting with Varian Medical Systems, the technician unsuccessfully attempted to retract the source with the hand crank. The area is secured, and Varian Medical Systems is on-site troubleshooting the problem. The licensee will forward dosimetry for evaluation.

AGREEMENT STATE REPORT - STUCK SOURCE

The following report was received via fax:

"The field service engineer was conducting the quarterly source exchange at the facility. While unloading the source into the transport container, the engineer received an error code indicating there were issues with the source side drive mechanism. The problem with the drive mechanism prohibited the source from fully deploying into the transport container or retracting back into the safe. The emergency motor was not able to retract the source. Following emergency procedures, the engineer tried to manually retract the source, however, the cable drum was locked-up and would not wind the source cable, He removed the unload transfer tube from the indexer, cut the exposed source cable and manually inserted the source in to the emergency container. The engineer disassembled the drive mechanism and collected the damaged parts. The unit was then cleaned and the cable drum and gear wheel were replaced. The system was tested repeatedly and found to be functioning properly.

"Initial calculations of 241 mR whole body dose were 'worst case scenario'. The dosimeter badge report indicated a whole body dose of 40 mR which does not exceed the regulatory limit for occupational exposure.

"The Root Cause Investigation was completed on 06-15-2009 by Nucletron B.V. in the Netherlands.

"For the investigation and analysis of the incident, the collected damaged parts were sent to Nucletron B.V. in the Netherlands where they were photographed and inspected. Additionally, the engineer was asked for his findings and the system logbook was scrutinized.

"According to the damage on the source cable drum, the drum had made at least 2.2 rotations before it got stuck (293 mm to move out of the indexer; 242 mm from where the source cable was cut off; source cable drum diameter is 80 mm). After examining the damaged parts, there was no visible cause as to why the drum became damaged. An obstruction at this position during the source exchange into the transport container is not expected since at this point it is a single straight tube; however, this cannot be ruled out as a possibility.

"The message logbook of the system was investigated and showed that during the source exchange, the engineer received seven error code 3's at 176 mm all within a six minute time frame. Error code 3 is a source obstruction which can happen when the bushing between the rigid and flexible part of the source cable cannot pass through the indexer clamp of the unload tube due to a misalignment of the clamping mechanism or damage to the source cable. The transfer tube was removed and a normal 'treatment' was performed without problem. The transfer tube was then reattached to exchange the source and four more error code 3's were received within two minutes at the same distance, thus indicating it was purely a container problem.

"There were no errors in the logbook that indicated the source remained outside the system. After the multiple tries with the error code 3, the system was switched off. Upon restart an hour later, two more attempts were made. However, the engineer now received error code 2 indicating the source would no longer come out of the safe. The system was turned back off again. Upon restart thirty minutes later, the unit had a dummy source in it; the source had apparently been unloaded by hand and replaced with a dummy. Later, the source exchange procedure was performed and a dummy source loaded properly; after which, the system worked normally again.

"According to the engineer, the system did not show any error or radiation/out-of-safe message when it was switched off following the problem with the container. When he entered the treatment room, he unexpectedly found the source to be outside the system, at which point he followed the emergency procedures in order to secure the source. Once the source was secure, the engineer forcibly pulled the remaining cable from the cable drum. He then proceeded to clean the system and assess the damaged parts.

"There is no logical explanation as to how the source got stuck outside the system. The logbook does not have any indication to this fact. The damage to the drum and cable may have occurred during the emergency procedure that was carried out to secure the source. Since operator error by the service engineer cannot be ruled out, a retraining on source exchange and handling is required. In addition, the transport container has been returned to Nucletron B.V. in the Netherlands for further investigation."

The source exchange was being conducted on a MicroSelectron HDR-V2, S/N 31526, TCS software version 1.50C, located at the Grant/Riverside Methodist Hospital in Columbus Ohio.

The field problem report number is FPR 252753.

AGREEMENT STATE REPORT - SOURCE SHUTTER STUCK OPEN

The following report was received from the state via e-mail:

"Nucor Steel Company informed the [Arkansas] Department [of Health] that they had a stuck shutter on one of their caster sources. The licensee utilized a lifting mechanism that allowed the technicians to lift and move the source without being near the source. The source and source holder were placed in an appropriate container and surveys were performed. The highest reading on the storage container with the shutter open at contact was 120 MicroR/hour.

"The storage container was relocated to a remote area on the casting deck and surveys were performed. A source service provider was contacted and arrived on site the next day to evaluate the problem.

"Source: Berthold Model LB 300 MLT, Serial number 730-4-97, 36 mCi of Co-60 used for mold level control.

"On 02/12/2009, at 10:01 AM the licensee provided the Department with a more detailed description of the steps taken by the technicians during the event, storage of the source, exposure reading at the source, and security of the source at this time. The licensee is currently awaiting feedback from the gauge service provider.

"The Department will leave this report open pending receipt of a final written report from the licensee, due in 30 days."

Arkansas Report: 09-02-01

* * * UPDATE FROM ROBERT PEMBERTON (VIA EMAIL) TO HOWIE CROUCH ON 4/17/09 @ 1119 EDT * * *

"The following are the findings of Arkansas Department of Health [ADH], Radioactive Materials Program, concerning event Number 44847 at NUCOR Steel in Armorel, AR. From information provided by NUCOR Steel and JENDCO Corporation, the Department [ADH] has determined this event was caused by a small metal chip that interfered with the rotation of the shutter. The Department has concluded that the root cause of this incident is mechanical failure. The Department considers this incident to be closed."

Notified FSME (Flannery) and R4DO (Whitten).

INVALID ACTUATION OF SECONDARY CONTAINMENT

"Monticello Nuclear Generating Plant is making a telephone Report in Accordance with 10 CFR 50.73(a)(2)(iv)(A) Invalid Actuation of the Standby Gas Treatment and Secondary Containment Isolation Systems due to high resistance resulting from inadequate contact wipe of a relay. This report is being made in lieu of a written Licensee Event Report.

"SPECIFIC TRAINS AND SYSTEMS THAT WERE ACTUATED

"The 'A' Standby Gas Treatment system actuated and Secondary Containment isolated.

"DESCRIPTION OF WHETHER EACH TRAIN ACTUATION WAS COMPLETE OR PARTIAL

"On January 20, 2009, during performance of Step 29 of Procedure 0003, Drywell High Pressure Scram and Groups 2, 3, & Secondary Containment Isolation Test and Calibration, the Standby Gas System automatically initiated and Secondary Containment isolated due to high contact resistance on a Drywell High Pressure HFA relay. This resulted in increased steam chase temperatures, entry into Action Statement TS 3.3.6.2.A for Secondary Containment Isolation Instrumentation, entry into Action Statement TS 3.6.4.1.A for Secondary Containment, entry into Action Statement TS 3.6.4.3.A for Standby Gas Treatment, and 10CFR50.73 reportability.

"DESCRIPTION OF WHETHER OR NOT THE SYSTEM STARTED AND FUNCTIONED SUCCESSFULLY

"All systems started and functioned successfully.

"The cause of the initiation of SBGT and isolation of Secondary Containment during performance of Step 29 of Procedure 0003 was the presence of high resistance at relay 16A-K60A, contacts 5-6. The cause of high resistance at relay 16A-K60A, contacts 5-6, was inadequate contact wipe. The cause of the inadequate contact wipe was inadequate contact wipe adjustment after replacement of HFA coils with the new Century series coil.

"The NRC Resident Inspector was notified of this event report."