Event Notification Report for July 20, 2013

AGREEMENT STATE REPORT - UNABLE TO RETRACT SOURCE INTO RADIOGRAPHY CAMERA

The following information was obtained from the State of Texas via E-mail:

"On July 23, 2013, the Agency [Texas Department of State Health Services] was notified by the licensee that on July 20, 2013, a radiography crew was unable to retract an Iridium - 192 source into a QSDA 880 D exposure device. The failure was caused by a spool that had fallen on the guide tube, crimping the tube so that the source could not pass through the tube at the crimp. The radiographers isolated the area, placed bags of concrete over the source to reduce area dose rates, and contacted their Radiation Safety Officer (RSO). The RSO drove to the location and reach the site about six hour later. The RSO was able to remove the crimp enough to allow the source to pass through the crimp and lock back in the exposure device. The camera was returned to the licensee's facility for further inspection. No one involved in the event received an exposure that exceeded any regulatory limit. No member of the general public was exposed to any radiation due to this event. Additional information will
be provided as it is received in accordance with SA-300."

Texas Incident #: I-9099

HPCI SYSTEM DECLARED INOPERABLE

"During performance of 1-SR-3.3.5.1.3(D), 'High Pressure Coolant Injection System Condensate Header Low Level Switch Calibration and Functional Test,' the High Pressure Coolant Injection (HPCI) system was declared inoperable due to exceeding the allotted 1 hour time frame for instrument inoperability of 1-LS-073-0056A and 1-LS-073-0056B [low condensate storage tank (CST) level HPCI suction transfer switches]. The HPCI system was declared inoperable in accordance with technical specification (TS) 3.3.5.1 Condition D.1. Condition D of TS 3.3.5.1 is required to be entered during performance of this surveillance. The surveillance disables the automatic CST to Torus suction path transfer function of the HPCI system by booting relay contacts in order to perform a functional test of referenced switches. The 1 hour completion time of TS 3.3.5.1 required by action D.1 was exceeded due to issues with associated test equipment. This constitutes an unplanned HPCI system inoperability and requires an 8 hour NRC notification per 10CFR50.72(b)(3)(v)(D). HPCI remained available for automatic and manual injection during this time period.

"The HPCI system was declared inoperable at 0438 CDT on 7/20/13 and operability (CST to Torus suction transfer function) was restored at 0454 CDT on 7/20/13.

"The NRC resident inspector has been notified."

The level switches (suction transfer switches) had been taken out-of-service for calibration and testing at 0338 CDT on 7/20/13.

CALIFORNIA AGREEMENT STATE REPORT - HISTORICAL MEDICAL EVENTS DISCOVERED DURING STATE INVESTIGATION

The following information was provided by the State of California via email:

"RHB [ California Radiation Heath Branch] personnel noted irregularities in the way brachytherapy was being performed by an authorized user and investigated all facilities where he is authorized to perform brachytherapy.

"On August 3, 2015, after reviewing files and consulting with the RSO of the facility, it was determined that there had been two medical events that had gone unreported. Both events were prostate Pd-103 implants performed in 2013 and 2014. One treatment resulted in a dose of only 37.6 percent of the target dose to the prostate (139.5 mCi Pd-103) and the second resulted in a dose of 66.9 percent of the target dose to the prostate (189.1 mCi Pd-103). The licensee will submit a follow up report within 15 days."

CA 5010 (Date Notified): 072015

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.