Event Notification Report for October 25, 2013

AGREEMENT STATE REPORT - MOISTURE DENSITY GAUGE DAMAGED BY EXCAVATOR

The following Agreement State Report was received via email:

"On October 25, 2013, at approximately 1430 [PDT], Fazel Barmaki, RSO [Radiation Safety Officer] of Fazel Barmaki, RML 7923-37, contacted [California Radiologic Health Branch] RHB Brea concerning their moisture/density gauge, CPN model MC-3, S/N M321106780 (with 10 mCi Cs-137 and 50 mCi Am-241/Be sources) that had been run over by an excavator and damaged while performing measurements at a construction site at 1186 N Ridgeline Rd., Orange, CA. A [California State] ICE RAM-South inspector arrived at the scene to assess the situation and to verify the integrity of the sources. The inspector observed the scene and was able to determine that the Cs-137 source was in the shielded position and the Am-241/Be source was still in the shielded housing. Wipe tests taken at the scene were surveyed and were found to be at background, indicating that the sources were not leaking. The rest of the gauge was inspected and it was observed that the hand and guide tube had broken off from the housing and the electronics were smashed and broken off of the gauge. Despite the damage to the non-radioactive parts, the shielding appeared to be undamaged, and the housing was placed in the transport case. A survey was performed on the transport case while using a Victoreen CHP-450. The highest dose rate on contact with the transport case was 1.8 mR/hr and 0.3 mR/hr at one foot, with a background of 0.01 mR/hr. These dose rates are consistent with a CPN MC-3 moisture density gauge.

"The RSO was interviewed by the [California State] inspector who stated that, between taking readings, he was observing the excavator as it was moving while standing near the gauge, making sure to maintain position between the excavator and gauge. While observing the excavator, the excavator made a sudden move toward him and he had to jump out of the way to prevent being run-over and the gauge was run over, causing the damage to the gauge. After checking on the damage, the RSO then immediately contacted RHB to report the incident.

"Since the radiation surveys indicated the dose rates were consistent with an intact and operational CPN MC-3 gauge and no leakage was indicated by an inspection of the integrity of the shielding and wipe tests at the scene of the incident, the RSO was allowed to return the gauge to their storage location at [in Escondido, CA.], for storage until the gauge can be sent to a service provider or CPN for repair or replacement. The [State's] investigation will be ongoing to determine if licensee will be cited. This is being reported to the NRC Operations Center as a 24 hour report under 10 CFR 30.5(b)(2) since the gauge cannot be locked in the shielded position (due to the source rod being sheared off from the gauge) despite the fact that the Cs-137 source is in the shielded position since it was in the shielded position at the time of the incident."

California Report Number: 102513

ADMINISTRATION OF LESS THAN THE PRESCRIBED DOSE TO A PATIENT

The following report was received via e-mail:

"10-25-2013 (Friday)
HDR [High Dose Rate] treatment to right breast with SAVI 9 Channel HDR unit: 1st channel treated appropriately but only fractional treatments to channel 2-8 of less than 50% of prescribed dose were delivered. Problems with the applicator's curvature caused source delivery problems. The manufacturer (Varian) was contacted but was unable to arrive before the next Monday.

"10-28-2013 (Monday)
Licensee made another attempt, but again only fractional treatments to channel 2-8 of less than 50% of prescribed dose was delivered.

"10-29-2013 (Tuesday)
The patient was taken to another Mount Carmel facility (MC West), parameters were recalculated and patient treatment was successfully concluded. The licensee stated they expect that no harm was done to the patient. The licensee stated that they didn't understand that this event was reportable until they were advised by Varian it was an equipment failure so it was a 24 hr. reportable event."

Event ID No: OH130015

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.

PART21 - DIODE CR7 WIRING REVERSED ON AUTOMATIC VOLTAGE REGULATOR PANELS

The following is a summary of information received via facsimile:

"Engine Systems Inc. (ESI) began a 10CFR21 evaluation on 10/25/2013 after receiving notification from APS-Palo Verde Nuclear Generating Station that diode CR7 on their automatic voltage regulator (AVR) panels had the wiring connections reversed. During installation of the AVR panels, generator output voltage buildup was observed to be longer than expected during fast start testing. The slow voltage buildup was determined to be caused by a lack of generator field flashing. Troubleshooting revealed that the field flash diode CR7 wiring was reversed.

"The evaluation was concluded on 11/11/2013, and it was determined that this issue is a reportable defect as defined by 10CFR21. The incorrect wiring of diode CR7 prevents field flashing of the generator. Lack of generator field flashing can result in failure of generator voltage buildup, or excessive voltage buildup time, during starting of the emergency diesel generator (EDG). This condition could therefore have impacted operability of the EDG and prevented it from performing its safety related function.

"APS-Palo Verde is the only affected customer. This reversed CR7 wiring condition only applies to the five (5) AVR panels (P/N 072-12200-100-PVNGS) shipped to Palo Verde on ESI sales order 8001720 (4 panels shipped in May 2013 and 1 panel shipped in June 2013)."