Event Notification Report for June 10, 2010

TECHNICAL SUPPORT CENTER VENTILATION MAINTENANCE

"On June 10, 2010, at 0830 hours CDT, Byron Station removed part of the Technical Support Center (TSC) ventilation (I.e., OVV25C) filtration system from service to facilitate necessary maintenance on the makeup fan. This work is expected to last approximately 10 hours. This maintenance affects the ability of the TSC ventilation to maintain adequate radiological habitability in the event of an emergency with an airborne radiological release. If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using existing emergency planning procedures. If the TSC becomes uninhabitable, then the Station Emergency Director will relocate the TSC staff to an alternate TSC location in accordance with applicable site procedures.

"This notification is being made in accordance with 10 CFR 50.72 (b)(3)(xiii) due to the potential loss of an emergency response facility because of the unavailability of the emergency filtration mode of the ventilation system. An update will be provided once the TSC ventilation has been restored to normal operation. The NRC Resident Inspector has been notified."

* * * UPDATE FROM MIKE LINDEMANN TO PETE SNYDER AT 1542 EDT ON 6/10/10 * * *

Maintenance has been completed and the TSC ventilation system was returned to service as of 1430 CDT. The licensee notified the NRC Resident Inspector.

Notified R3DO (Phillips).

AGREEMENT STATE REPORT - BRACHYTHERAPY DOSE RECEIVED WAS GREATER THAN 20% OF PRESCRIBED DOSE

The following was received from the State via fax:

"On June 9, 2010, the Radiation Safety Officer (RSO) reported that earlier that day a patient undergoing an intravascular brachytherapy procedure was administered a dose to the coronary artery exceeding the prescribed dose by more than 20%. This is a medical event as described in DHS 157.72(1)(a)1. The prescribed dose was 18.4 Gy; the dose delivered was 23 Gy. The treatment device is a Novoste Beta-Cath intravascular brachytherapy device containing Sr-90. The overdose was identified during the post-planning for the procedure. The treatment time for this procedure is based on the measured diameter of the coronary artery. Depending on the diameter, one or three treatment times is selected; in this case the wrong treatment time was selected. The RSO stated that this treatment time is supposed to be independently reviewed and approved on the written directive, which is to be signed by the authorized user. The written directive was not signed by the authorized user prior to administration. [Wisconsin] DHS inspectors will investigate this medical event on June 11, 2010."

Event Report No.: WI100008

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.

AGREEMENT STATE REPORT - PROCESS GAUGE MALFUNCTIONS

"On June 11, 2010 at 1100 Central Daylight Time, the Agency, [Texas Department of Health,] was notified by the licensee that the shutters on six gauges failed in the open position. Three of the gauges were manufactured by Berthold [Model 7400D] and each contained 30 millicuries of Cesium (Cs) - 137 (S/N's: 2423, 2425, 2426). The other three gauges were manufactured by Ohmart/VEGA [Model SHD] and each contained 150 millicuries of Cs-137 (S/N's: 74452, 74453, 73491). The licensee stated that dose rates taken in the area were normal, since the shutters failed in their normal operating positions. The licensee has contacted the manufacturer to schedule a repair of the gauges. The Agency reminded the licensee to request an exemption to continue to use the gauges while their shutters are awaiting repair so that that the licensee would not violate a condition of their license."

A contractor is making arrangements for the gauges to be repaired by their manufacturers.

Texas Incident No: I-8753

MISSING SEAMAN MOISTURE DENSITY GAUGE

Carro & Carro Enterprises Inc. reported that a Seaman Model C-300 Moisture Density Gauge containing a 4.5 mCi Radium-226 source was discovered missing from a temporary job location in San Juan, Puerto Rico on Thursday, June 10th. A search was conducted on Friday with negative results. A police report was filed on Monday, June 14th, and a reward offered in two local newspapers.


* * * UPDATE FROM DANIEL IRIZARRY TO DONALD NORWOOD AT 1135 EDT ON 06/28/2010 * * *

Missing gauge was returned to Carro & Carro Enterprises, Inc. this morning at about 0730 local time. The individuals returning the gauge were not identifiable because they were wearing masks at the time. Carro and Carro had a radiation safety consultant check the gauge. No damage to the gauge was noted, however it had been returned without its storage case. A new case will be ordered.

Notified R1DO (Dwyer) and FSME DEO (McIntosh). Notified ILTAB via e-mail.

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