Event Notification Report for December 16, 2013

AGREEMENT STATE REPORT - POSSIBLE MEDICAL MISADMINISTRATION

The following report was received via email:

"Description of Event: [The Georgia Department of Natural Resources] Received a call from the RSO [Radiation Safety Officer] of RCG [Radiotherapy Clinics of Georgia] on December 17, 2013 at 0930 EST, informing the Department of a possible misadministration that occurred at the Snellville location.

"The wrong [High Dose Rate] HDR treatment plan was selected and used on a patient resulting in some possible injury to the patient. An investigation is currently being initiated to determine the cause and effects of the error. The licensee will provide an official report to the Department within 15 days."

Georgia Incident Number 121613.

* * * UPDATE RECEIVED FROM DAVID CROWLEY TO JOHN SHOEMAKER AT 2034 EST ON 12/18/13 * * *

"[The Georgia State Investigator] received the initial call on 12/17/2013 at 0930 EST. The incident regarded an Ir-192 HDR afterloader and had occurred on 12/16/2013.
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"[The initial report stated:] It was determined that the wrong treatment plan was given and a misadministration had occurred. The correct site and applicator were used; however, a gynecological treatment plan ran in place of the intended skin treatment plan. No symptoms were evident at this time, but the patient was alerted to look for a reddening of the skin.

"The RSO did not communicate much information and left many details open until they could submit the final report. [The Georgia State Investigator] forwarded this information to the [NRC] upon documenting it.

"[A Georgia State Investigator] performed a reactive site [follow-up] inspection on 12/18/2013 to discern more information about the incident. One of the contributing causes appears to be similar last names on the two patient plans. No other verification of the treatment plans seemed to be conducted other than selecting the name; which the physicist inadvertently clicked on the wrong patient name in this selection process.

"113 seconds passed before the error was caught and the physicist pressed for manual interrupt of the treatment. The treatment was intended for the skin on the temporal region of the patient's head. This used a skin plaque type applicator. Instead, a gynecological plan ran in the system but with the skin plaque applicator in place on the correct location of the patient.

"The error caused the Ir-192 source to hit a dead end at the first channel due to it having a shorter channel length than the other plan anticipated. From what the physicist could determine it was stuck in that position for nearly the entire time.

"The prescribed procedure was for 40 (4000 rem) Gy to be delivered in a fractionated schedule. An actual delivered dose is yet to be calculated and will determine whether a corrective fractionation schedule will be prescribed to correct for this since most of the dose was deposited in the vicinity of the treatment site. This determination will be included in the final report. At this time, the only expected acute effects to the patient may
be reddening of the skin in the immediate location of the source.

"The source had an 8.0 Ci Ir-192 source from Alpha Omega Services, Inc. (Serial#: 24-01-2470-001-110113-12043-45). This was in a mobile HDR unit made by Varian (Model: Gamma Med(+)iX / Serial#: H640510-GM).

"Corrective actions are still being discussed and will be clearly identified in the final report to prevent future occurrences."

Notified the R1DO (Dimitriadis), FSME Events Resource and FSME (McIntosh) via email only.

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 - LICENSED OPERATOR TESTED POSITIVE FOR ALCOHOL

A licensed operator had a confirmed positive for alcohol during a random fitness for duty test. The employee's access to the plant has been restricted. The licensee has notified the NRC Resident Inspector.

LOSS OF CONTAINMENT SMOKE DETECTION CAPABILITY

"At 1454 CST on December 16, 2013, the Unit 1 pyro panel (smoke detection panel) was declared non-functional due to an unexpected failure. Viable compensatory measures have been established for all affected areas except the Unit 1 Containment Building. Since a fire in Containment is an entry condition for the site's Emergency Plan, this is considered a loss of emergency assessment capability and is being reported per 10CFR50.72(b)(3)(xiii). Containment temperatures are being monitored while the pyro panel is out of service, however, this is not considered a satisfactory compensatory measure for maintaining effective assessment capability."

The NRC Resident Inspector has been notified.

* * * UPDATE AT 2046 EST ON 12/17/13 FROM DARRIN GARD TO DANIEL MILLS * * *

The Unit 1 pyro panel has been returned to service as of 1554 CST on 12/17/13, which restores Unit 1 containment fire detection capability.

The NRC Resident Inspector has been notified.

Notified R2DO (Freeman).

UNANALYZED CONDITION DUE TO UNFUSED DIRECT CURRENT AMMETER CIRCUITS

"At 1627 CST on December 16, 2013 Farley Nuclear Plant determined that the following was an unanalyzed condition:

"As a result of recent industry operating experience (OE 305419, EN 49411, EN 49419) regarding the impact of un-fused Direct Current (DC) ammeter circuits in the Control Room, Farley performed a review of ammeter circuitry for similar issues. The review determined the described condition to be applicable to Farley resulting in an unanalyzed condition with respect to 10 CFR 50 Appendix R analysis requirements. The wiring design for the ammeters contains a shunt in the current flow from each DC battery and battery charger, but the ammeter wiring attached to the shunt does not contain fuses.

"It is postulated that a fire could cause one of the ammeter wires to short to ground. Concurrently, the fire causes another DC wire from the opposite polarity on the same battery to also short to ground. This would cause a ground loop through the un-fused ammeter cable. The potential exists that the cable could heat up, causing a secondary fire in the ammeter raceway. The secondary fire could adversely affect safe shutdown equipment and potentially cause the loss of the ability to safely shutdown per 10 CFR 50 Appendix R.

"This condition is reportable in accordance with 10 CFR 50.72(b)(3)(ii)(B) as an unanalyzed condition. Compensatory measures have been implemented for affected areas of the plant.

"The NRC Resident Inspector has been notified."

POTENTIAL FOR SPURIOUS START OF VARIOUS PUMPS DURING POSTULATED FIRE EVENTS

"A circuit analysis review for Appendix R Operator Manual Action deficiency extent of condition identified that fire damage to cable ES194-I is not isolated by the local control power transfer switch utilized in the Safe Shut-down Instruction. Fire damage to the non-isolated cable ES194-I in Fire Areas 01-03, 02-01, and 02-03 could cause the RHR Pump 2C to spuriously start (or restart after the Operator local trip action) when 4kV Shutdown Board B is credited for these Fire Areas. An undesired spurious start of RHR Pump 2C could overload the credited Diesel Generator or take away the necessary load capacity to allow operation of other Appendix R fire safe shutdown credited loads.

"The fire damage postulated would require a short to ES194-I from a separate cable conductor energized with the positive potential of the battery supplying 4kV Shutdown Board B (i.e., normally Shutdown Battery B). It is postulated for a fire-event that the necessary short to ES194-I could come from a cable-to-cable short or from a short to ground as the fire event may cause a separate conductor energized with the positive potential of the associated battery to short to ground.

"Similar conditions also exist for: RHR Pumps 1A, 1B, 1D, 2A, 2B, 3A, and 3C due to fire damage to cables in one or more Fire Areas.

"Compensatory actions in the form of an Operator Work Around [OWA] to remove the affected RHR Pump breaker close circuit control power fuses during the affected Safe Shut-down Instructions, a caution order on the appropriate transfer switches referencing the OWA, and fire watches in the affected Fire Areas to mitigate this condition are in place in accordance with the BFNP [Browns Ferry Nuclear Plant] Fire Protection Report.

"This condition is being reported pursuant to 10CFR50.72(b)(3)(ii)(B) and 10CFR50.72(b)(3)(v).

"The NRC Resident Inspector has been notified."

The licensee is also reporting under 10CFR50.72(b)(3)(v)(D) Accident Mitigation.

LEAD ANALYZER STOLEN FROM CAR

A lead analyzer was stolen from the trunk of a car belonging to an employee of the New Haven Health Department. The device was a RMD XRF Lead Analyzer, Model LPA-1, serial #3520, and contained a Co-57, 10-12 mCi source.

The missing device was reported to the New Haven, CT police department.

* * * UPDATE FROM ANDREW ZWICK TO VINCE KLCO ON 12/30/13 AT 0830 EST * * *

Notified by the State of Connecticut that the lead analyzer has been recovered and is in the possession of local law enforcement.

Notified the R1DO (Dwyer), and FSME Resources and ILTAB via email.

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

MARYLAND AGREEMENT STATE REPORT - UNABLE TO RETRACT RADIOGRAPHY SOURCE

The following information was obtained from the State of Maryland via email:

"At 12:17 PM on December 16, 2013, the Radiation Safety Officer of Maryland Q.C. Laboratories, called [the State of Maryland] to report an incident that occurred today in their radiography vault. She reported that they were performing industrial radiography using a 34.7 Ci Ir-192 source, QSA model A424-9 in a model 880 D camera, when a steel pipe fell on the guide tube preventing the source from retracting into the shielded position. She stated that attempts to retract the source were not successful. She further stated that QSA Global will arrive at the licensed facility tomorrow to recover the source. The source is in a tungsten collimator inside the vault. The assistant radiographer reported 10 mRem on his SRD. For security, Maryland Q.C. locked the door to the vault and will post a 2-man crew at the facility until QSA arrives. Maryland Health Physicist Bob Nelson is on site at this time conducting an investigation. He reports that the dose rates outside the vault are less than 1.0 mRem per hour."

* * * UPDATE FROM ALAN JACOBSON TO CHARLES TEAL AT 0937 EST ON 12/17/13 * * *

"The Maryland Health Physicists conducting the investigation at Maryland QC Laboratories reported on 12/17/2013 at 0930 hours that the source has been safely retrieved and stored in the camera."

Notified R1DO (Dimitriadis) and FSME Events Resource via email.

AGREEMENT STATE REPORT - LOST VIAL OF THALLIUM-201

"The Radiation Safety Officer at GE Healthcare (Mediphysics) [IL-01109-01] Arlington Heights, IL called the Agency [IL Emergency Management Agency] on December 18, 2013 to report an incident concerning an over pack shipment intended for their pharmacy in Atlanta, Georgia. On Sunday December 15, a package containing 12 shielded vials of TL-201, 31 milliCi each, was transferred to Delta Airlines Freight services at Chicago's O'Hare international airport for shipping to Atlanta. The package arrived at Atlanta's Hartsfield International Airport the next day and was unloaded. However during the trip from the air plane cargo hold to the freight hub, the package tumbled off the conveyance and was broken open. This occurred on Sunday night, December 16. That night and the next morning a 3rd party contractor hired by the airlines/airport collected the vials and its packaging and placed the material into an over pack and secured the drum until it could be claimed by GE Healthcare. Based on the description and measurements performed by the company which were provided to GE Healthcare, it appeared none of the glass vials within their shielded containers were broken. As such it was determined that the vials were to be repackaged and forwarded to the pharmacy for evaluation. When repackaging at the freight hub was attempted by the GE Atlanta pharmacist on Tuesday, December 17, it was confirmed that no contamination was present on the packaging or the interior containers, however, it became clear that only 11 of the 12 vials were present in the salvage drum, contrary to the contractor's initial assertions. GE Healthcare contacted the Georgia agreement state program regarding the matter. The contractor is conducting additional visual and radiological surveys of the tarmac and freight hub. As of today (12/18/13), calculations show that a single vial contains approximately 16 milliCi of TL-201. If intact and still shielded as the other vials which were found, GE Healthcare estimates that the vial would have a dose rate of approximately 350 microR/hr at one foot.

"A report on the matter from GE Healthcare is anticipated. They have indicated that they would keep us appraised of developments as this matter moves forward. The Agency has been in touch with a representative of the Georgia program regarding potential additional actions to recover the vial. Given the 72 hour half life of the material, there will be no TL-201 present within the next 30 days. Also given that no contamination was detected on the packaging and the other 11 containers of Tl-201 were found intact, there is reason to assume the missing container was still intact at the time of the accident and the search is being conducted accordingly."

Illinois Event Number: IL13036

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf