Event Notification Report for November 17, 2011

UNANALYZED CONDITION ON STARTUP FOLLOWING MAINTENANCE OUTAGE

"On November 17, 2011, at 1345 Eastern Standard Time (EST), it was determined that an unanalyzed condition that significantly degraded plant safety existed on Unit 2 following a mid-cycle maintenance outage which required reactor vessel disassembly. Unit 2 had reached Mode 2 (i.e., Startup) during the power ascension, when elevated drywell leakage was identified and the plant was shutdown (see EN#47444). Unit 2 was subsequently operating in Mode 4 (i.e., Cold Shutdown) to allow for drywell entry. During leak investigation activities, it was determined that the reactor pressure vessel (RPV) head was not fully tensioned. This condition is being reported in accordance with 10 CFR 50.72(b)(3)(ii)(B) as a condition of the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety.

"The safety significance of this event was minimal. Unit 2 was in power ascension operating at a maximum of approximately 7% of rated thermal power. Control Room Operators took appropriate action to shutdown the Unit when elevated drywell leakage was identified.

"The NRC Senior Resident Inspector has been notified."

OFFSITE NOTIFICATION DUE TO DIESEL FUEL OIL SPILL

"A notification was made to the National Response Center and the Kansas Department of Health and Environment of a 7-10 gallon release of diesel fuel oil to the environment. The leak originated from a temporary diesel fueled heater in place for freeze protection for a temporary fire pump. The fuel oil was not released to surface water, and has been isolated."

The NRC Resident Inspector has been notified.

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO INOPERABLE FEEDWATER CHECK VALVE

"On Thursday, November 17, 2011, at 1515 hours, with the reactor at approximately 50% core thermal power, the station entered a 24 hour cold shutdown action statement due to the inability to provide a manual isolation for a main feedwater line check valve that had been declared inoperable due to a leak. As background, the reactor was at reduced power in order to perform a planned main condenser thermal backwash. While at reduced power an inspection of the main steam tunnel (a normally locked closed high radiation area) was performed as part of a scheduled system inspection. The inspection identified a leak on the feedwater line 'B' outboard check valve (6-CK-62B). The feedwater check valve was declared inoperable and the Limiting Condition for Operation (LCO) for Technical Specification (TS) 3.7.A.2.a.5 was entered. Because there is no ability to manually isolate the primary containment penetration the station is required to be in cold shutdown within 24 hours per TS 3.7.A.5.

"Currently, preparations are being completed to conduct the reactor shutdown and to initiate check valve repairs.

"This event had no impact on the health and safety of the public. The USNRC Senior Resident Inspector was onsite and has been notified."

The electrical lineup is normal and all safety related equipment required for shutdown and cooldown are operable.

AGREEMENT STATE REPORT - PATIENT RECEIVED GREATER THAN THE PRESCRIBED DOSE

A patient had a mass surgically removed from both sides of the nose and was undergoing a topical treatment for microscopic disease using a Nucletron HDR containing 8.52 curies of Ir-192 with a Valencia Model H3 skin applicator containing a platinum filter.

The planned administration was 7 fractions of 600 centigrays each on both the left and right side of the nose. During the initial planning for the treatment, an error was made in calculating the dwell time for each location and this incorrect data was entered into the HDR system. As a result of the error, the patient received 54% during each fraction (treatment) during two of the seven fractions on each side of the nose. Prior to the third fraction, the medical team is required per procedure to check calculations and caught the error before the third fraction (treatment) was performed.

The patient and prescribing physician have been informed, and there is no long range medical concern for disease as a result of this error. The total dose treatment has not been exceeded.

The state's licensee is revising procedures in order to prevent recurrence, and the state will be submitting an NMED report.

New Jersey Incident Number: #410674

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.

TEXAS AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING Y-90 MICROSPHERES

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

"On November 21, 2011, the Agency [Texas Department of State Health Services] was notified by one of its licensees that it had determined that a therapy event had occurred on November 17, 2011, during an administration of Yttrium-90 microspheres. The patient was prescribed a dose of 135 gray to the target tissue. Surveys of the administration equipment following the procedure indicated readings that were higher than expected if the full dose had injected into the patient. Initial estimates by the licensee are that a dose of 95.8 gray was administered to the target tissue, approximately a 29% variation from the prescribed dose. The licensee will confirm the dose administered and investigate to determine the cause of the event. Information on this event will be updated as it becomes available."

Texas Incident #: I-8904

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.