Event Notification Report for December 14, 2009

AGREEMENT STATE REPORT - IRRADIATOR SAFETY INTERLOCKS BYPASSED

While engaged in production, the irradiator source was brought down due to an electrical fault. To verify the source was in the shielded position, an operator was sent to the roof and verified that there was no slack in the cables and the position of the cables indicated the source as in the shielded position. The interlocks were bypassed and an operator entered the cell. A damaged wire was discovered and repaired. Operators did not receive any radiation dose from this event.

Previously, a flex conduit was discovered with damaged insulation that had caused a short (Ref: EN # 45486).

* * * UPDATE ON 12/16/09 AT 1724 FROM TRUDY HILL TO MARK ABRAMOVITZ * * *

The Nebraska item number for this event is NE090018.

Notified the R4DO (Whitten).

UNANALYZED CONDITION RELATED TO CERTAIN FIRE CONDITIONS

"During review of the safe shutdown strategies for NFPA 805 in Fire Area 32, it was identified that fire induced damage to cable 1C-333 could cause a spurious lockout of 1RY transformer. The Appendix R Safe Shutdown Compliance assessment for Fire Area 32 credited the 1RY transformer source to safeguards 4kv bus 16 for safe shutdown. Cable 1C-333 was not previously identified as a required cable for the 1RY source in the Appendix R circuit analysis.

"It was determined that D2 Emergency Diesel Generator could be credited as the safe shutdown power source to safeguards 4kv bus 16. Cabling required to support D2 Emergency Diesel Generator passed through Fire Area 32 but should be protected with a thermal shield as approved by the 5/4/1983 NRC Fire Protection Safety Evaluation Report. While inspecting these thermally shielded cables, it was identified that they are not wrapped after leaving the cable tray and prior to entering the bus room located above.

"A fire watch was established in Fire Area 32 as a compensatory measure. Actions to ensure a power source remains available to achieve safe shutdown have been initiated.

"The discovery of this non-compliance is being reported as an unanalyzed condition as defined by 10 CFR 50.72(b)(3)(ii)(B). An hourly fire watch has already been in place for Fire Area 32 as a compensatory measure for other issues identified in this fire area."

The licensee notified the NRC Resident Inspector of this event.

AGREEMENT STATE REPORT - FETAL EXPOSURE IN EXCESS OF 500 MILLIREM DURING A PET/CT SCAN

The following information was obtained from the State of Colorado via facsimile:

"The Department received notification on March 23, 2010, of a fetal exposure in excess of 500 milliRem from a PET/CT Scan. The licensee, PET Imaging of Northern Colorado, License No. 1105-0, is located in Fort Collins, Colorado. The licensee reported that on December 14, 2009, a female patient received 17.4 mCi of F-18 and underwent a PET/CT scan. The patient had indicated that she was not pregnant on her medical history questionnaire and told the technologist she was not pregnant prior to the scan. Later, the patient's physician notified the licensee that the patient was indeed pregnant at the time of the scan.

"A consulting medical physicist calculated the total dose to the fetus from the PET/CT scan as 2.6 Rem (26 mGy). However, the medical physicist did not report the individual dose from the F-18 component alone, and this information has been requested from the licensee.

"The licensee's authorized user physician reported that the risk of abnormality for the fetus is considered to be negligible per the guidance from the American College of Radiology Practice Guidelines.

"No other details are available at this time."

* * * RETRACTION FROM ED STROUD TO PETE SNYDER AT 1550 ON 4/6/10 * * *

The following information was obtained from the State of Colorado via facsimile:

"Following a full investigation of the incident, the fetal exposure was determined to be below the NRC's reporting requirement of 5 REM."

Notified R4DO (Proulx) and FSME EO (VonTill).