Event Notification Report for April 09, 2014

AGREEMENT STATE REPORT - CABLE DISCONNECT ON RADIOGRAPHY CAMERA

The following report was received from the State of Texas via email:

"The licensee called [Texas Department of Health] to report that a disconnect occurred due to a broken drive cable. The SPEC-150 radiography device contained a 28 curie iridium-192 source. The cable broke near the ball stop on the crank out connector. The source remained in the source guide tube. The radiography crew called the incident in and waited for an authorized person to retrieve the source. The source was retrieved with minimal exposure. Incident doses were based on pocket dosimeter readings. The radiographer received 15 mrem and the trainee received 2 mrem. The radiographer retrieving the source received 25 mrem and his assistant received 9 mrem.

"It is believed that the cable failed due to metal fatigue. The individual providing the report did not know when the cable was last tested."

Texas Incident #: I-9180

AGREEMENT STATE REPORT - RADIOGRAPHER OVEREXPOSURE

The following information was received from the Ohio Bureau of Radiation Protection via email:

"The corporate RSO for Acuren Inspection made an immediate telephone notification under OAC [Ohio Administrative Code] 3701:1-38-21(B)(1) [same as 10 CFR 20.2202(a)(1)] to the Ohio Department of Health Bureau of Radiation Protection at 1320 [EDT on] April 9, 2014, to report a radiographer overexposure at a temporary job site in Marietta, OH. The event happened about 1100-1130 [EDT] this morning. The initial estimates regarding the male radiographer is that he may have received a 15 Rem whole body exposure and an estimated 3000-5000 Rem to the hand. The radiographer's whole body dosimeter is being sent off for immediate processing.

"The radiographer has been sent for medical attention. REAC/TS [Radiation Emergency Assistance Center/Training Site] was contacted by the licensee who gave REAC/TS the contact information for the attending physician of the radiographer.

"The radiographer was working with an 88 Ci Ir-192 source at the time. The radiographer supposedly had all his dosimetry and a survey meter at the time of the incident.

"The corporate RSO and a local [RSO] are both enroute to the temporary job site.

"Sequence of events:
The radiographer had sat down and was chatting while waiting for an exposure to complete. At the end of the shot time, he had assumed that the other radiographer had retracted the source and proceeded to set up for the next shot. When he noticed that the other radiographer was not present he went back and checked to find that the source had not been cranked back.

"The [State of Ohio] Department will have an inspector on scene in the morning to investigate the incident and also to observe and review the incident reenactments.

"Ohio event report number 2014-007."

* * * UPDATE FROM KARL VON AHN TO CHARLES TEAL ON 4/10/14 AT 1530 EDT * * *

"On April 10, 2014, the [State of Ohio] Department performed an onsite inspection and observed the licensee perform a reenactment of the incident scenario.

"It was determined that the radiographer did not handle the end of the source tube with the source in it and did not receive the initially assumed hand dose. The whole body deep dose is still expected to be about 15 Rem. The hand dose is expected to be on the order of the whole body dose, about 15 Rem.

"During the reactive inspection, the [State of Ohio] Department found that the radiographer's alarming rate meter had a dead battery, and the survey meter was not functional and had not been checked that day.

"The Assistant Radiographer was trailing the radiographer approximately one and a half minutes in entering the shielded bunker, and it was the assistant radiographer's alarming rate meter and survey instrument that identified the presence of the exposed source. The source collimator was not being used in the bunker, and so the 89 Ci Ir-192 source was not shielded."

Notified R3DO (Pelke), FSME Duty Officer (McIntosh), and FSME Event Resource.

* * * UPDATE FROM KARL VON AHN TO CHARLES TEAL ON 4/11/14 AT 1234 EDT * * *

"The Acuren Inspection Services RSO has provided the Department [State of Ohio] with the following updates:

"(1) The radiographer's whole body dosimeter reading was 836 mRem.

"(2) Based on the dose estimates from the scene reenactments, Acuren will assign the radiographer a whole body dose of 13 Rem, and an extremity dose of 6.5 Rem. [The radiographer's chest was much closer to the source than his dosimeter was.]

"(3) The radiographer will be under continued medical surveillance and REAC/TS will remain involved."

Notified R3DO (Pelke), FSME Duty Officer (McIntosh), and FSME Event Resource.

PART 21 - POTENTIAL DEFECT IN GENERAL ELECTRIC TYPE CR120AD CONTROL RELAYS

The following information was received via fax:

"This letter is being issued by QualTech NP, Huntsville, AL, to provide an initial notification to the Nuclear Regulatory Commission and Nebraska Public Power District [NPPD] Cooper Nuclear Station concerning a potential defect in General Electric Type CR120AD control relays. A failure analysis revealed that the most likely initiator of the failure was a flaw or defect in the start wrap of the magnet wire. The flaw created an arc that involved windings directly beneath the start wrap which resulted in an open circuit on the coil windings. This failure is classified as infant mortality, which is similar to the failure mode identified in the 10 CFR part 21 30 day report (accession number 9706190261) dated June 12, 1997 submitted by GPU Nuclear.

"Investigation of documents dating back to 1997 revealed that the manufacturer issued an informal recommendation to detect infant mortality in these relays by performing burn-in testing and mechanical cycle aging of the relay. QualTech NP, in conjunction with NPPD, determined that the risk of infant mortality can be mitigated by subjecting these relays to a 100 hour burn-in and performance of 100 mechanical cycles prior to installation.

"It has been confirmed that only two orders, with two units each, for this particular relay are affected. Both orders have been shipped to Nebraska Public Power District as requested by purchase orders 4500149953 and 4500142705. All subject relays shall be subjected to a 100 hour bum-in and exposed to 100 mechanical cycles or returned to QualTech NP for replacement.

"Additional details will be provided in the formal written report. Please contact Matthew Thelen at 256-924-7441 (office) or mthelen@curtisswright.com for additional information.

"Matthew Thelen
Project Manager
QualTech NP Huntsville Operations
a business unit of Curtiss-Wright Flow Control Company
http://qualtechnp.cwfc.com"

* * * UPDATE AT 1707 EDT ON 05/09/14 FROM MATTHEW THELEN TO S. SANDIN VIA FAX * * *

"(File No.: QTHuntsville 10CFR21-2014-01)

"To whom it may concern:

"This letter is being issued by QuaiTech NP, Huntsville Operations to provide a final notification to the Nuclear Regulatory Commission and Nebraska Public Power District (NPPD) Cooper Nuclear Station concerning a potential defect in General Electric Type CR120AD control relays.

"Replacement relays have been provided to NPPD. All required dedication procedures at QualTech NP have been revised to include a 100 hour burn-in and 100 mechanical cycles in an effort to detect infant mortality. No further actions are required at this time.

"This 10CFR part 21 file is closed."

Notified R2DO (Bonser), R4DO (Whitten) and NRR Part 21 Group via email.

AGREEMENT STATE REPORT - IODINE-125 SEED FOUND IN WELL CHAMBER

The following was received from the State of Nebraska via fax:

"On April 9, 2014, the State of Wisconsin Radiation Protection Section called to inform the State of Nebraska Radioactive Materials Program that a State of Wisconsin licensee (University of Wisconsin) had found an Iodine-125 seed (measured at 0.255 millicuries) in a well chamber that had been sent to the University of Wisconsin from Regional West Medical Center (Nebraska Radioactive Material License # 21-01-03) for calibration. The I-125 seed has been secured by the University of Wisconsin and is awaiting disposition."

"The State of Nebraska Radioactive Materials Program called Regional West to confirm that there was no misadministration to the patient since one seed was left in the counting chamber. Regional West confirmed that the proper dose was administered to the patient."

Nebraska Report #: NE140002