Event Notification Report for December 02, 2014

AGREEMENT STATE REPORT - LEAKING NI-63 SEALED SOURCES

The following information was provided by the Commonwealth of Massachusetts via email:

"Morpho Detection is in the process of moving its facility, and as part of this process wipe-tests were conducted on older Ni-63 sealed sources (approx. 8 - 10 millicuries per source), that were in storage prior to transfer to a contractor for disposal. The leak tests showed that four groups of sealed sources had results that were above the threshold limit of 5 nanocuries. Thus one or more of the sealed sources within each group showed signs of leakage or contamination. Licensee reports that additional wipe tests were not conducted to determine the specific sources that were leaking.

"The Ni-63 sealed sources were identified by the licensee as Model Number NER-004 and GE Homeland Protection detector heads containing those sources.

"Overall, the leak tests revealed that Ni-63 contamination ranged from 0.030 to 0.98 microcuries for the four groups of sealed sources that were analyzed.

"Wipes were taken by the licensee by swabbing the exterior of a group of sealed sources of similar type (R&D dual-source detector heads were differentiated from R&D single source detector heads, etc.), thus the multiple sources within a group were swabbed with a single swab which was ultimately analyzed by a licensed contractor (Radiation Safety Control Services, Stratham NH).

"Subsequent to finding contamination, the sources were placed in containers, sealed, and wipe-tests (using swabs) were carried out on the exterior of the storage containers along with the interior and exterior of the cabinet in which they were being stored The wipe tests of the containers and cabinet showed no levels that indicated Ni-63 contamination.

"The licensee disposed of the sealed sources by contracting the services of Viola Environmental Services (12/09/14).

"The Agency [Commonwealth of Massachusetts] considers this event open.

"Equipment problems:
R&D Dual-source detector heads (9 dual sources), 1 swab, resulted in a finding of 0.98 microcuries
EntryScan detector heads (6 sources), 1 swab, resulted in a finding of 0.069 microcuries
R&D Single-source detector heads (9 single sources), 1 swab, resulted in a finding of 0.155 microcuries
Ni-63 bare sources (9 sources), 1 swab, resulted in a finding of 0.0301 microcuries"

AGREEMENT STATE - MEDICAL EVENT INVOLVING OVERDOSAGE DURING HDR BRACHYTHERAPY TREATMENT

The following information was received via email:

"The licensee reported a medical event at 0958 PST involving a patient treated for vaginal cancer. The treatment involved an Ir-192 high dose rate afterloader (HDR) source at 5.369 Curies activity (December 2nd) delivered to the vaginal vault via a 3 cm single-channel cylinder for a prescribed dose fraction of 400 cGy (rad). Instead, a 5 cm single-channel cylinder was used that delivered a 700 cGy dose (rad), or 75 percent (300 cGy) above the prescribed dose. The licensee stated that an afternoon patient's treatment plan was being reviewed on the console while the morning patient was being prepped for treatment and the patient subsequently treated with the other patient's plan. The licensee failed to verify the patient's identification before starting the treatment. The cause is therefore determined to be human error. The licensee stated that the patient was scheduled for three fractionated doses at 400 cGy (rad) each for a total dose of 1200 cGy (rad). This was the 2nd fraction so the total dose delivered to the patient is currently 1100 cGy (rad). The licensee performed a biological effective dose (BED) calculation and that the final effective dose is within 4 percent and 10 percent of the intended dose in terms of short/long term effects and the final fraction dose will most likely not be administered. The licensee notified the patient's physician who will notify the patient of the error. The licensee will submit a formal report to Oregon RPS including corrective actions to prevent recurrence."

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.

MANUAL REACTOR TRIP DUE TO FAILURE OF CONDENSATE PUMP

"Initiated a manual Unit 1 reactor trip due to imminent failure of 1P-25B Condensate Pump. Unit 1 had commenced a rapid down power due to the degradation of the pump. The event is reportable under 10CFR50.72(b)(2)(iv)(B) for a manual actuation of the reactor protection system when the reactor is critical and 10CFR50.72(b)(3)(iv)(A) for an actuation of specified system (6) PWR auxiliary feedwater system. Auxiliary feedwater system actuation was due to low steam generator water levels in both 'A' and 'B' Steam Generators, an expected system response during a reactor trip. Decay heat removal is by forced circulation and is being controlled by auxiliary feedwater system and condenser steam dumps.

"After the trip, both main steam generator feedwater pumps were secured due to feed pump suction pressure remaining low post trip.

"All other plant systems functioned as required. All control rods fully inserted in the core due to the manual trip. There was no ECCS actuation. Off-site power has been maintained throughout the event."

No primary or secondary safety relief valves lifted during the reactor trip. Unit 1 is in a normal shutdown electrical lineup. There was no effect on Unit 2.

The licensee notified the NRC Resident Inspector.