Event Notification Report for September 30, 2014

PART 21 REPORT - SERIES 20 MODULE MAY ALLOW THE SIDE COVER TO TOUCH THE WIRE INSULATION

The following information was excerpted from report received via email:

"The orientation (90 degrees) of the placement (soldering) of the internal wire on the resistor terminal used in the above referenced Series 20 modules may allow the side cover screw to touch the wire insulation. The engineering drawing nor manufacturing assembly instructions did not clearly describe the correct orientation.

"On the basis of our evaluation, it was determined on September 30, 2014, that Electroswitch does not have the capability to perform the evaluation to determine if a defect, which could create a substantial safety hazard, exists.

"Purchasers are being advised to perform testing to verify operation or return the product to Electroswitch.

"The following personnel may be contacted regarding this notification:

Larry Friedman
Quality Assurance Manager
781-607-3309

Ed Reszenski
Engineering Manager
781-607-3341"

AGREEMENT STATE REPORT - PRELIMINARY REPORT ON A CONTAMINATED EMPLOYEE

The following was received from the State of Tennessee via email:

"Not much information is known at present, but on September 30th, an employee at Siemens was involved in some type of exposure that resulted in a skin dose contamination. No other spread of contamination has been noted. REACT/s was notified via Siemens and is being used for additional consultation. Awaiting more information from the licensee on [the type of] isotopes involved, a full detailed report of the incident, and their plan of action for the employee. Will update accordingly."

TN ID NO.: TN-14-186

* * * UPDATE ON 10/6/14 AT 1539 EDT FROM SABRINA ROBERTSON TO DONG PARK * * *

The following report from the licensee was received from the State of Tennessee via email:

"Description of the Event

"On 9/30/2014 at approximately 2:35pm, [an employee] was drawing activity to manufacture line sources out of a stock vial of Ge-68. She drew up the required activity into a syringe and when she removed the syringe from the rubber septum of the Ge-68 DTPA stock solution vial, the vial evidently became pressurized and sprayed liquid on to her nasal facial area. Another employee in the area immediately notified the Radiation Safety Officer (RSO).

"Mitigation

"The Radiation Safety Department responded and assisted with decontamination of the affected areas. Decontamination was started approximately 15 minutes after notification of the incident. A water lavage of the facial area was performed and washing of the affected area with hand soap and shaving cream. Wet nasal swabs were used to remove contamination from the nasal passage. After decontamination it was determined that the contamination was confined to the area around her nose and mouth, including inside her nasal passage. Since that
time she has collected all nasal excretions and any sputum, as well as wipes of her skin in the affected area. Radiation surveys are done several times per day to ascertain activity reduction. We are continuing to perform surveys, nasal swabs and urine bioassays until all contamination is removed. To date all urine bioassay samples have been within the range of background. REAC/TS was contacted on October 2, 2014 to determine if they had any further ideas for contamination removal. They recommended the use of make-up removal pads on the face, but did not have any further ideas for removal of contamination from the nasal passage.

"Dose Estimation

"Using the surveys and an initial estimated activity for the contamination event of 76 microCuries in the highest affected area, VARSKIN was used to calculate dose to the skin. Initial calculations estimated the dose to remain below regulatory limits. On October 2, 2014 the Health Physicist running the VARSKIN program noticed that it was not calculating the dose from both Ge-68 and its daughter Ga-68. The calculations were revised and the results exceeded the regulatory limits. The RSO notified the State of Tennessee Division of Radiological Health on October 3, 2014. As of October 3, the calculations showed that skin dose is approximately 132 rem, which exceeds the regulatory limit of 50 rem. [The employee] has been notified of her estimated dose levels and has been involved with decontamination procedures. We will continue to adjust the total dose daily as
surveys are performed. We will submit the final dose number when all contamination is removed and calculations are completed. Our current estimated dose at 10 days from today with no further removal of contamination is 240 rem to the skin."

Notified R1DO (Bower) and FSME Events Resource via email.

* * * UPDATE FROM SABRINA ROBERTSON TO HOWIE CROUCH (VIA EMAIL) AT 0825 EDT ON 10/8/14 * * *

The following update was received from the State of Tennessee via email:

"Summary of the long-term plan for monitoring the employee We will continue to monitor the employee's nasal facial area daily, collect and count wipe samples from skin in the affected area and nasal secretions, collect and count urine bioassay samples for at least the next week (October 14, 2014) unless all measurements are within the range of background before that date. We will assess the value of continued measurements at that time.

"Contamination and projected 10-day calculated skin dose for Monday, October 6 and Tuesday, October 7, 2014. The two areas from which skin dose is being estimated are the bridge of the nose (#1) and the tip of the nose (#2). Measurements are taken using a pancake GM detector (Ludlum 44-9). Skin dose is calculated using VARSKIN.

"October 6 - contamination readings: #1 = 840 cpm; #2 = 4940; calculated skin dose @10 days = 229, 934 mrad
"October 7 - contamination readings: #1 = 740 cpm; #2 = 6040 cpm; calculated skin dose @ 10 days = 239, 070 mrad

"[Licensee staff] are trying to determine a more realistic efficiency for the Ludlum 44-9 GM detector, as we believe it is closer to that of P-32 than to F-18. The use of a higher efficiency will substantially reduce the calculated dose. As you suggested, we have contacted REAC/TS about conduct an independent verification of our skin dose calculation. They informed us they are not able to conduct independent verification. However, they did provide us with consultants who are able to provide this service.

"Finally, as we discussed [with the State of Tennessee], Siemens will provide you with a daily update of the contamination readings and 10-day projected skin dose."

Notified R1DO (Bower) and FSME Events Resource email.

AGREEMENT STATE REPORT - UNABLE TO RETRACT RADIOGRAPHY CAMERA SOURCE

The following information was obtained from the State of Texas via email:

"On October 1, 2014, the Agency [Texas Department of State Health Services] received notice that on September 30, 2014, a radiography source disconnect had occurred at a temporary field site in east Houston. The camera was a Sentinel 880D (s/n D6746) with 68.3 curies of selenium-75 (s/n SE3877). The port cover had not been opened and the source had not been connected to the drive cable. Upon crank-out, the source was stopped at the port cover and could not be retracted. Retrieval was done by pushing the source back in via another drive cable from the other side. The person doing the retrieval received 38 mR to the body and 98 mR to the hand according to pocket dosimeters.

"Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I-9240