Event Notification Report for November 18, 2005

LOST POWER TO CIRCULATING WATER DILUTION PUMP ELEVATING DISCHARGE TEMPERATURES TO BAY

At 2235 the licensee notified the New Jersey Environmental Protection (NJEP) Agency that their circulating water discharge temperature to Barnegat Bay was elevated. This is due to the fact that the licensee lost power to their non-safety related circulating water dilution pump. The licensee is currently working to restore power to the dilution pump and reducing reactor power to minimize the temperature difference between the discharge water and Bay water.

The licensee notified the NRC Resident Inspector.

AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE OF A RADIOGRAPHER

At 2000 on 11/18/05 during a radiography job at P2S in Sand Springs, OK, a radiographer received a 23 Rem calculated dose. He went out to change the camera film when he thought his assistant had fully retracted the source. The radiographer was in front of the camera for approximately 3 minutes. The licensee stated that the cause of the overexposure was miscommunication.

When the radiographer was on his way to the camera he set down his radiation detection instrument and answered a cell phone call. At the same time the assistant who was responsible for retracting the source was sending a text message on his cell phone. The radiographer's alarming rate meter was turned off. The camera was a SPEC Model 150 with a 66 Curie Iridium-192 source. The camera was tested after the event and found to be in good operating condition.

Both the radiographer and the assistant have been suspended pending further investigation. The dosimeters of the individuals have been sent to be read and readings should be available on 11/21/05. The licensees radiation safety officer made the report to the state after taking both individuals to the hospital for blood tests as a precautionary measure. On 11/21/05 the state will investigate this incident further at the jobsite.

* * * UPDATE FROM STATE (M. BRODERICK) TO M. RIPLEY 1515 ET 02/16/06 * * *

The results of a chromosome analysis performed on a blood sample indicated that the best estimate of the radiographer's exposure as a result of the event was 4 Rem (with a 95% confidence interval of 0 - 17 Rem). The licensee states that the blood analysis results are in agreement with the radiographer's dosimetry, and the radiographers dose for the year is calculated to be 6.9 Rem.

Notified R4 DO (D. Graves) and NMSS EO (G. Morell)

PROBLEM WITH A VARIAN HIGH DOSE RATE (HDR) AFTERLOADER

The licensee provided the following information via facsimile:

"On December 1, 2005, [an NRC Region 1 inspector] conducted an inspection of our facility. During the inspection [the inspector was told] about a problem [the hospital was] having with [its] HDR unit [Varian Model VS-200] . On November 18, 2005, during a patient treatment the unit reported a fault during source retraction which reported as a source path constriction. However, the source retracted fully and the error was cleared. The patient received the treatment as prescribed; there was no unintended radiation exposure to the patient. During the following treatment, on November 21, 2005, the error recurred and Varian was contacted to service the unit. The source again retracted fully; the patient received the treatment as prescribed. Varian arrived on November 26, 2005. The engineer repaired that fault, but after the repair, a new problem arose. During post-repair testing by Varian, the inactive wire failed to move from the shielded safe position. [The NRC inspector] requested [..] a report of the findings of the manufacturer after the repair was completed.

"Varian subsequently sent a new loaner HDR to [the] West Penn [hospital], and [the] HDR unit was returned to the [Varian] factory in England for repair. [The hospital] immediately forwarded the Varian Troubleshooting Report to [the NRC inspector] upon receipt on January 31, 2006. The report from the factory indicated that the cause of the wire not moving was a signal wire that had been improperly stripped at the time of assembly. Over time, this connection oxidized causing a loss of contact for that signal, which was for the drive mechanism. This caused the inactive source wire not to drive out of the safe.

"Although [the West Penn Hospital is] reporting this as requested, [it] respectfully disagree[s] with the NRC interpretation of the 10 CFR 30.50(b)(2) reporting requirement. 10 CFR 30.50(b)(2) states that a 24 hour report is required when 'An event in which equipment is disabled or fails to function as designed when: (i) The equipment is required by regulation or license condition to prevent releases exceeding regulatory limits, to prevent exposures to radiation and radioactive materials exceeding regulatory limits, or to mitigate the consequences of an accident; (ii) The equipment is required to be available and operable when it is disabled or fails to function; and (iii) No redundant equipment is available and operable to perform the required safety function.' [The West Penn Hospital] believe[s] the safety systems of the HDR unit functioned appropriately by reporting the fault. [The hospital] notified the vendor and requested repair when the fault repeated and discontinued using the HDR unit until it was repaired and tested. No regulatory limits were exceeded; the source did not stick; the safety systems did not fail. [The hospital] also do[es] not believe this to be a manufacturing defect requiring reporting under 10 CFR 21.21 but defer[s] to the manufacturer and the NRC interpretation."