Event Notification Report for October 14, 2009

AGREEMENT STATE REPORT INVOLVING A RADIOGRAPHY CAMERA SOURCE DISCONNECT

Received a call from State of Texas concerning an incident that occurred 10/14/09 at a temporary jobsite in Texas (location unknown). The company (not identified in the call) is located in Pasadena, TX. The State of Texas representative said that the Radiographer failed to follow procedures and connect the guide tube before cranking out the source. The source subsequently struck the wall and disconnected. The company RSO who is qualified for source retrieval recovered and secured the source. His extremity dosimetry indicated 57 mrem with a whole body dose of about 90 mrem. Details of the incident including licensee name and license number will be provided by update.

* * * UPDATE FROM ART TUCKER TO VINCE KLCO AT 1049 ON 10/16/2009 * * *

The following information was received by e-mail:

"On October 15, 2009, the Agency [State] was notified by the licensee that on October 14, 2009, they experienced a source disconnect while using an Amersham model 660 radiography camera containing a 45.3 curie Iridium (Ir) 192 source. The Radiation Safety Officer (RSO) stated that two radiographers were setting up for their first shot of the day. The guide tube they had was too short, so one of the radiographers connected an additional guide tube to the end of the existing guide tube, while the other radiographer prepared to perform the shot. Neither of the radiographers attached the guide tube to the camera. They then cranked the source out of the camera to perform their first shot. This caused the source to be pushed out of the camera, onto the floor of the shooting bay, and against the wall of a shooting bay. The camera operator felt that he had cranked the source out farther than it should have traveled for the shot and stopped cranking the source. He then tried to return the source to the camera. When the radiographer retracted the drive cable, the source was left loose on the shooting bay floor. The radiographer approached the shooting area with his dose rate meter and found the dose rates were elevated. The radiographer then secured the area and notified the RSO, who is specifically authorized on the license for source retrieval. The RSO developed a strategy to reconnect the source, and then successfully cranked the source back into the camera. No one involved with this event received an exposure exceeding any regulatory limit.

"The RSO stated that their investigation into the event determined that the root cause for the event was the failure of the two radiographers to follow procedure. He also noted a failure of the two radiographers to communicate adequately. The RSO stated that they will retrain all of their radiographers regarding their procedures for the proper connecting and disconnecting of equipment to their exposure devices. He also stated that this training would be repeated in their annual training in 2010."

Texas Incident: I-8678

Notified R4DO(Cain) and FSME (McIntosh).

PATIENT RECEIVED APPROXIMATELY 76% OF THE PRESCRIBED DOSE

A three year old boy was undergoing a palliative treatment for a cancer related illness with I-131. The boy was prescribed 180.5 milliCuries of I-131 by his physician. During the treatment, a technician noticed that there were air bubbles in the intravenous tubing leading to the boy and stopped the treatment. Upon subsequent investigation, it was revealed that the patient only received 138 milliCuries of the prescribed 180.5 milliCuries of I-131, which is approximately 76% of the prescribed dose. The patient's physician has been notified, and is making a decision whether to inform the boy's parents. The licensee is investigating the cause of the incident.

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.

FITNESS FOR DUTY REPORT INVOLVING A NON-LICENSED CONTRACT SUPERVISOR

A non-licensed contract employee supervisor failed to disclose derogatory information as required by the fitness-for-duty program. The employee's access to the plant has been terminated. Contact the Headquarters Operations Officer for additional details.

The licensee will inform the NRC Resident Inspector.

SAFETY SYSTEM FUNCTIONAL FAILURE - ALTERNATE SAFE SHUTDOWN SOURCE RANGE NEUTRON MONITOR INOPERABLE

"At 1500 hours on October 14, 2009, the power supply for neutron source range detector N-38 was determined to be unable to provide reliable power to detector N-38 and the detector was declared inoperable. Technical Specification (TS) 3.3.4 (Remote Shutdown) Basis Table 3.3.4-1, Function 1.a requires one channel. Technical Requirements Manual (TRM) 3.3.D (Appendix R Alternate Safe Shutdown Instrumentation) requires entry into the condition referenced in TRM Table 3.3.0-1 and entry into the applicable related TS referenced in TRM Table 3.3.D-1 when one or more required functions with one or more required instruments in Table 3.3.D-1 [are] inoperable. TRM Table 3.3.D-1, TRO 3.3.D1, neutron flux (source range only) lists and specifies detector N-38 only and references TS 3.3.4 Basis Table 3.3.4-1, Item 1a. Although there is an operable redundant source range neutron detector N-39, the only source range detector which has indication remote from the control room is N-38. Therefore, the safety function for safe shutdown remote from the control room for reactivity control in accordance with TS Basis Table 3.3.4-1, Function 1a can not be met with N-38 inoperable. The inability to meet the TS condition is a safety system functional failure. Actions are in progress to provide a reliable power supply for N-38. Unit 2 is at 100% and is not affected by the condition."

The licensee notified the NRC Resident Inspector.