Event Notification Report for November 22, 2013

AGREEMENT STATE REPORT - RADIOGRAPHY TRUCK INVOLVED IN ACCIDENT

"On November 22, 2013, the Agency [Texas Department of State Health Services] received information from the Odessa, Texas, Emergency Management that an accident involving an industrial radiography truck carrying two radiography cameras had occurred near Andrews, Texas. The Agency contacted the licensee and they reported that the driver had hit a patch of ice on the road, lost control, and the truck turned over. Both of the cameras remained secured inside the transportation box in the truck's darkroom. Another of the licensee's radiographers was following the truck and maintained control of the cameras until the licensee's staff came from Midland to pick them up. There were no exposures to any individual as a result of this event.

"On November 25, 2013, an Agency investigator learned from the licensee that the driver had been taken by ambulance to a local hospital's emergency department following the accident. The driver was examined and released after approximately 5 hours. More information will be provided as it obtained in accordance with SA-300."

Texas Incident Number: I-9138

* * * UPDATE FROM ARTHUR TUCKER TO JOHN SHOEMAKER ON 12/27/13 AT 0815 CST * * *

The following Agreement State Report update was received via email;

"The following information was provided to the Agency [Texas Department of State Health Services] by the licensee. It provides additional information regarding the event and stated the cameras did not remain in the transport container throughout the event as previously reported.

"On, November 22, 2013, the licensee was transporting two radiography exposure devices from Midland, Texas to La Porte, Texas. The devices were stored in a transport container in one vehicle and a second vehicle was following the transport vehicle. Near Andrews, Texas the transport vehicle hit a patch of ice on the road causing the driver to lose control of the vehicle. The vehicle rolled five times before stopping in the upright position. The darkroom stayed attached to the truck until the last rollover, it then became free from the truck and the exposure devices were dislodged from the transport box. The driver of the second vehicle provided aid to the driver of the transport vehicle until the state police arrived. The driver of the second vehicle then performed an area survey and monitored the exposure devices. He stated dose rates were normal and he did not observe any damage to either exposure device. The exposure devices did not create an exposure risk to any individual. The driver of the transport vehicle was transported to the hospital by ambulance where he was released later that evening. The licensee's Radiation Safety Officer (RSO) contacted the licensee's Midland office and had them send a crew to take possession of the exposure devices. The devices were leak tested and the results were below the limit. The exposure devices were stored at the licensee's Midland location over the Thanksgiving Holiday and later transported to the manufacturer for further inspection. The manufacturer leak tested the devices and the sources and no contamination was detected. The manufacturer performed a thorough inspection of the devices and did not identify any damage to either device. The manufacturer returned the devices to the licensee for continued use. Additional information will be provided as it is received in accordance with SA-300."

Notified R4DO (Whitten) and FSME Events Resource via email.

CONTROL ROOM HVAC INOPERABLE

"This report is being made pursuant to 10CFR50.72(b)(3)(v)(D), Event or Condition that could have prevented fulfillment of a Safety Function needed to Mitigate the Consequences of an Accident. While the 'A' Train of Control Room HVAC was inoperable and out of service for emergent repairs due to a Freon leak, the 'B' Train of Auxiliary Electric Room HVAC became inoperable due to a failure of the Cooler Condenser Fan. The Main Control Room Envelope consists of the Main Control Room and the Auxiliary Electric Equipment Room. Both the Control Room HVAC and the Auxiliary Electric Equipment Room HVAC Systems are required to be Operable in the current Mode.

"This is a loss of safety function for a system that is intended to mitigate the consequences of an accident and is discussed in Chapter 6 of the UFSAR and is Tech Spec required and is Safety Related. Also, the system, structure, or component (SSC) is inoperable in a required mode in the Tech Spec Applicability and there is no redundant equipment in the same system that is operable.

"The Required actions of Tech Spec 3.7.5 were entered on 11/22/2013 at 1920 CST when the 'B' train became inoperable. Online Risk remains Green. The station is currently pursuing repairs to both trains."

The NRC Resident Inspector has been notified by the licensee.

PENNSYLVANIA AGREEMENT STATE REPORT - LOST THEN FOUND BRACHYTHERAPY SEEDS

The following information was obtained from the Commonwealth of Pennsylvania via facsimile:

"Notifications: On November 22, 2013, the DEP [Pennsylvania Department of Environmental Protection] Southwest Regional Office was notified that some palladium-103 (Pd-103) brachytherapy seeds were inadvertently disposed but then recovered by the licensee. On January 22, 2014, the Department was provided the actual activity amount and made the determination that this event qualifies as a reportable event under 10 CFR 20.2201(a)(1)(i).

"Event Description: On November 20, 2013, a box containing Pd-103 brachytherapy seeds was delivered to the Nuclear Medicine Department. On November 22, 2013, the Medical Physicist, prior to the implant procedure, noticed that all the seeds were not present. It was later acknowledged that all 90 seeds equaling 170 mCi of Pd-103 were inadvertently disposed.

"Cause of the Event: Human error. The seeds were not removed from the shipping box prior to the box being disposed of.

"Actions: On November 22, 2013, the Medical Physicist retrieved the missing box containing all the seeds. No exposure to anyone is expected while the seeds were missing. The regional office will further determine, with the licensee, the root cause of this event and the corrective actions to prevent this from reoccurring.

"Media attention: None at this time."

Event Report ID No: PA140001