Event Notification Report for January 15, 2013

AGREEMENT STATE REPORT - ASSISTANT RADIOGRAPHER EXCEEDED ANNUAL EXPOSURE LIMIT

The following was received from the state of Oklahoma via email:

"On January 15 [the Oklahoma Department of Environmental Quality] was informed by the RSO for AIT [Advanced Inspection Technologies] that one of their radiographer assistants had exceeded the 5 R limit for exposure during calendar year 2012. This individual consistently had higher exposures than other employees at AIT and had failed to turn in his badge at the end of April, 2012, instead continuing to wear it through May. This resulted in a reading of 1075 mR on the April report, but this also included the month of May. His May badge was not used and showed a dose of only 19 mR when processed. This situation was discussed with the RSO during their routine inspection in June. At the end of October the assistant again failed to turn in his badge and wore it through November. At the beginning of October, his cumulative dose for the year was 4580 mR. The badge was sent in for processing at the end of November and Landauer contacted the licensee on January 15, 2013 to inform him that the exposure on the October badge was 1282 mR. This put his 2012 total at 5864 (the unused November badge showed 2 mR). The RSO submitted a written report of this incident to us [State of Oklahoma] on Jan. 22, 2013.

"On January 23, [the Oklahoma Department of Environmental Quality] spoke with the radiographer who the assistant radiographer worked with most often. The radiographer [was asked] if there had been any incidents which might have caused the high doses the assistant radiographer had received. The radiographer replied that there had been no 'major' incidents that he was aware of. [The radiographer was] then asked about any minor incidents and the radiographer replied that 'two or three times' they had retracted the source into the exposure device, however when they approached the device, their rate alarms went off (these are required to be set to alarm at a dose rate of 500 mR/hr). They then cranked the source out again and again tried to retract it, which was successful. The fact that they got close enough to the source to encounter a 500 mR/hr radiation field indicates that they were not performing the post-exposure surveys required by 10 CFR 34.49(b). The radiographer [was then asked] if he had reported these incidents to the RSO to which he replied that in all cases he had checked the direct-reading dosimeters of he and the assistant radiographer's and found that they indicated a dose of 10 mR or less. Therefore, he decided not to report them. He also stated that the need to keep up with the work load played a role in his decision. The radiographer could not remember specific dates or locations where this had occurred. On January 28, 2013, [the Oklahoma Department of Environmental Quality] spoke with the RSO again and informed him of the conversation with the radiographer. The RSO professed to have no knowledge of the 'incidents' described by the radiographer. The RSO [was requested] to perform another investigation into this incident, specifically focusing on whether this was an isolated incident or if this was representative of the overall culture at the facility, and that enforcement action [would be deferred] pending the results of his investigation. The RSO agreed to this stipulation. It should be noted that AIT is, in general, one of [the] better licensees when it comes to compliance with [the Oklahoma Department of Environmental Quality] regulations. Investigation into this incident is continuing. As the over-exposure did not occur within a period of 24 hours as stipulated by 10 CFR 20.2202(b)(1), [the Oklahoma Department of Environmental Quality] is treating this as a reportable event under 10 CFR 20.2203(a)(2)."

LOSS OF A 4160 VOLT BUS WHILE PERFORMING TESTING

"On January 15, 2013 at 2112 EST while performing testing associated with the remote shutdown system at the James A. FitzPatrick Nuclear Power Plant, an unexpected loss of the 10600 bus 'B' division AC vital power system occurred. This loss of power to the 10600 bus resulted in an automatic actuation of the 'B' and 'D' Emergency Diesel Generators. The diesel generators started as expected, but did not close in to energize the 10600 Bus due to the configuration at the time of the event. As a result of the loss of the 10600 bus, the 'B' Reactor Protection System (RPS) lost power resulting in a half scram signal and a Group II Primary Containment Isolation System (PCIS) actuation. This actuation resulted in closing containment isolation valves in multiple systems and isolating Reactor Water Clean-Up (RWCU). Based on these system actuations, the event is reportable under criterion 10 CFR 50.72(b)(3)(iv).

"Power to the 10600 Bus was restored January 16, 2013 at 0400 EST, and the half scram and isolation signals have been reset. Additional actions to restore systems to a normal operating line-up are on-going. Investigation into the cause of the unexpected power loss is on-going and will be addressed through the corrective action program.

"The NRC Resident Inspector has been notified."

AGREEMENT STATE REPORT - MISPLACEMENT OF BRACHYTHERAPY SOURCE DURING MEDICAL TREATMENT

The following information was provided by the State of Ohio:

"The Ohio Department of Health Bureau of Radiation Protection was notified by the licensee RSO of a potential medical event. A patient was planned for a vaginal cylinder (HDR) procedure. Approved plan prescribed 4 Gy to target organ (vaginal canal) and 4.61 Gy to rectum. On the first of three fractions, the cylinder was inserted by the Authorized User (AU) in the rectum instead of the vaginal canal. The AU reviewed the film and approved the position for treatment. The physicist determined that the rectum received approximately 6.1 Gy (132% of the prescribed dose). At the time of this report it appears that the intended treatment target received less than 2 Gy (less than 50% of prescribed dose)."

The device used is a remote afterloader HDR manufactured by Nucletron, Model Microselectron S/N 31472, containing a single sealed source of 4.15 Ci Ir-192. The cause is identified as human error.

Item Number: OH130001

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.