United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for October 25, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/24/2012 - 10/25/2012

** EVENT NUMBERS **


48261 48298 48409 48411 48412 48417 48436 48437 48439 48440

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Agreement State Event Number: 48261
Rep Org: NV DIV OF RAD HEALTH
Licensee: UNIVERSITY OF NEVADA
Region: 4
City: LAS VEGAS State: NV
County:
License #: 03-13-0305-01
Agreement: Y
Docket:
NRC Notified By: SNEHA RAVIKUMAR
HQ OPS Officer: STEVE SANDIN
Notification Date: 08/31/2012
Notification Time: 15:48 [ET]
Event Date: 10/01/2011
Event Time: [PDT]
Last Update Date: 10/24/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - STUDENT RECEIVED POTENTIAL INHALATION OVEREXPOSURE

The following information was received from the State of Nevada via email:

"A graduate student inhaled a mixture of U-233 and U-238 while working in the lab grinding a compound of Uranium Octoxide. [The graduate student] used a glove box instead of the hood with the HEPA filter, contrary to UNLV [University of Nevada Las Vegas] approved procedure.

"This happened twice and could have been between October 1, 2011 and April 1, 2012.

"The first bioassay, based on an inhalation date of October 1, 2011, showed 17.72 rem total. When the inhalation date was assumed to be April 1, 2012, the result was 5.52 rem.

"[U-233]*1.6 = [U-238] contribution.

"The student will be getting a third bioassay on September 5, 2012 at the Lawrence Livermore National Lab (LLNL). This will involve a low-energy chest count to detect Th-234 and an organ count, looking at the kidneys for Uranium.

"The student has been restricted from all lab work since April.

"The bioassay was done at Test America."

* * * UPDATE AT 1553 EDT ON 10/24/12 FROM SNEHA RAVIKUMAR TO S. SANDIN * * *

The following update was received from the State of Nevada via email:

"NMED Item No.: NV120022

"Preliminary results:

"1. September 5, 2012:

Low-energy lung count, kidney count and hand count were performed at LLNL.
The lung count was less than MDA for U-233, Th-234, U-234 & U-2235.
The detect/non-detect kidney & hand counts were both non-detect.

"2. September 12, 2012:

Third Bioassay results received.
U-238 - 0.66 dpm/sample
U-235 - less than CRDL
U-233/234 - 1.25 dpm/sample"

Notified R4DO (Hagar) and FSME Events Resource via email.

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Agreement State Event Number: 48298
Rep Org: RI DEPT OF RADIOLOGICAL HEALTH
Licensee: ROGER WILLIAMS MEDICAL CENTER
Region: 1
City: PROVIDENCE State: RI
County:
License #: 7D-026-01
Agreement: Y
Docket:
NRC Notified By: CHARMA WARING
HQ OPS Officer: STEVE SANDIN
Notification Date: 09/11/2012
Notification Time: 13:07 [ET]
Event Date: 08/28/2012
Event Time: [EDT]
Last Update Date: 10/24/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER NEWPORT (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - PATIENT RECEIVED TWO UNDERDOSES OF Y-90 TO DIFFERENT TREATMENT SITES

The following information was received from the State of Rhode Island via fax:

"Event Type: Medical event involving the administration of Yttrium-90 microspheres.

"Notification(s): On August 30, 2012, the RI Department of Health Office of Facilities Regulation, Radiation Control Program received a phone call from the facility's Radiation Safety Officer, with a follow-up e-mail the same day.

"Event Description: On 08/28/2012, two incorrect doses were prepared for a Y-90 microsphere treatment. Both doses were for the same patient (i.e., two different treatment sites). One dose was drawn at 28.7% less than prescribed and the other dose was drawn at 22.9% less than prescribed. The final administered doses were less than 40.3% and 27.2% prescribed, respectively.

"Cause of the event: Under investigation and unknown at this time.

"Actions: Adverse effects to the patient are not expected; a follow-up reactive inspection is planned.

"[Rhode Island] Event Report ID: 2012-001"

* * * UPDATE FROM CHANDRA WARING TO PETE SNYDER AT 1503 EDT ON 10/24/12 * * *

The State of Rhode Island provided the following information via fax:

"Cause of the event: For both doses, after withdrawing the microspheres from the shipping container, the licensee nuclear medicine technologist added sterile water to the syringe prior to transferring them into the v-vial. The policy is that the Y-90 is transferred into the v-vial prior to adding sterile water. The technologist then added additional sterile water to the v-vials in accordance with procedure.

"For both doses, after placing the v-vial into the dose calibrator, the technologist noticed that the dose was less than the 10% prescribed by the physician. The technologist was confused about the correction factor of 0.82 required for the v-vial when placed into the dose calibrator. The technologist did not understand why the original dose drawn from the shipping vial was within +/- 10%, but the v-vial dose was not. The technologist ultimately concluded that the shipping v-vial should have also been corrected by 0.82 and sent the dose to Interventional Radiology (IR) where it was administered.

"Although the dose withdrawn from the shipping container was originally within +/- 10%, some of the microspheres were most likely lost during transfer to the v-vial. The most likely cause was due to adding sterile water, prior to transfer. The doses drawn by the Nuclear Medicine Technologist were 9.84 mCi for the right lobe (Vial 1) and 10.41 mCi for segment VII, neither of which are within the +/- 10% established by policy.

"After administration of both doses, the v-vials were sent back to Nuclear Medicine per procedure and assayed in the dose calibrator for residual activity. The dose to the right lobe (Vial 1) and the dose to segment VII (Vial 2) had 1.6 mCi and 0.57 mCi remaining, respectively. Therefore, not all of the microspheres were administered. As a result, the final administered dose to the right lobe was 8.24 mCi and the dose to Segment VII was 9.84 mCi. This resulted in an under administered dose of 40.3% to the right lobe and an under administered dose of 27.2% to segment VII.

"Licensee Actions: As a result of this event, the RSO performed an in-service training [that] was held on 9/21/12. The licensee also does an additional 'timeout' when the dose is brought to the IR suite to verify prescribed versus drawn dose. The Nuclear Medicine staff alternate drawing the Y-90 doses to maintain familiarity with the procedure.

"RI RCP [Rhode Island Radiation Control Program] Actions: The corrective actions outlined by the licensee have been complete therefore, no further action is required at this time."

Notified R1DO (Caruso) and FSME Events Resource (email).

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.

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Agreement State Event Number: 48409
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: WATCH CITY MUSEUM
Region: 1
City: WALTHAM State: MA
County:
License #: GENERAL
Agreement: Y
Docket:
NRC Notified By: JOHN SUMARES
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/16/2012
Notification Time: 11:31 [ET]
Event Date: 09/11/2012
Event Time: [EDT]
Last Update Date: 10/16/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAKE WELLING (R1DO)
FSME EVENTS RESOURCE (E-MA)

Event Text

AGREEMENT STATE- DAMAGED WATCH WITH REMOVABLE RADIUM CONTAMINATION

The following report was received from the Commonwealth of Massachusetts via facsimile:

"During a decommissioning survey of the Watch City Museum, the museum's consultant 'Babcock Services, Inc.' (BSI), discovered an antique radium watch with potential damage. The subject watch, marked '8-Day Watch' was missing the glass face. BSI obtained the following radiological survey results:

- Maximum radiation reading on contact [was] 0.38 mR/hr and
- Alpha plus beta removable contamination smear of 52,767 dpm/100 cm2.
- The estimated Ra-226 activity is less than 1 microCuries

"The 8-Day Watch was removed from the museum, securely wrapped, and placed in a secure container.

"The owner of the 8-Day Watch, 'Charles River Museum of Industry and Innovation', was notified about the condition of the 8-Day Watch. The timepiece owner and the Watch City Museum agreed that the damaged timepiece should be properly disposed as radioactive waste. The 'Watch City Museum' arranged for the disposal of the timepiece with their decommissioning consultant, BSI. The Agency agreed with the disposition of the damaged timepiece.

"The Agency conducted a confirmatory radiological survey of the timepiece display case and the adjacent museum floor. The survey included the display case glass cover (outside and inside surfaces), the display case base, the adjacent floor within 2 feet of the display case, the secured container of the 8-Day Watch, [and] the viewing surface where the timepiece was displayed. [The] inspector observed no readings above background of 10 cpm using an alpha probe. Maximum radiation level at the surface of the time piece container was 0.2 mR/hr using a gamma probe.

"The Agency considers this event to be closed."

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Agreement State Event Number: 48411
Rep Org: NV DIV OF RAD HEALTH
Licensee: 21ST CENTURY ONCOLOGY
Region: 4
City: LAS VEGAS State: NV
County:
License #:
Agreement: Y
Docket:
NRC Notified By: SNEHA RAVIKUMAR
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/16/2012
Notification Time: 17:23 [ET]
Event Date: 10/15/2012
Event Time: [PDT]
Last Update Date: 10/16/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
FSME EVENTS RESOURCE (E-MA)

Event Text

AGREEMENT STATE REPORT - DOSE DIFFERENT FROM PRESCRIBED

The following report was received from the Nevada Radiation Control Program via e-mail:

"We would just like to inform you of a medical event.

"Preliminary info: Yesterday (10-15-2012) we received a call from the RSO of 21st Century Oncology, regarding an incident that occurred with their HDR. Due to a faulty ruler, a parameter was entered incorrectly in the HDR control panel, resulting in a dose to the skin of the patient of around 160 centiGray. The skin area was one cubic cm. The intended dose was 160-170 cGy [to a different treatment site].

"The intended target was an almost spherical volume located in the right breast. The skin that was exposed is located in the right breast, at the entrance of the device (multi lumen mammosite) catheter.

"The closest organ is the right lung.

"The patient is fine and was informed of this.

"The sealed source remained inside the tube.

"[The event is] being reported under 10 CFR 35.3045 (a)(3): A dose to the skin or an organ or tissue other than the treatment site that exceeds by 0.5 Sv (50 rem) to an organ or tissue and 50 percent or more of the dose expected from the administration defined in the written directive (excluding, for permanent implants, seeds that were implanted in the correct site but migrated outside the treatment site)."

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.

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Non-Agreement State Event Number: 48412
Rep Org: HEMLOCK SEMICONDUCTOR CORPORATION
Licensee: HEMLOCK SEMICONDUCTOR CORPORATION
Region: 3
City: HEMLOCK State: MI
County:
License #: 21-32682-01
Agreement: N
Docket:
NRC Notified By: WALLACE MILLETT
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/16/2012
Notification Time: 17:32 [ET]
Event Date: 10/16/2012
Event Time: [EDT]
Last Update Date: 10/16/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
STEVE ORTH (R3DO)
FSME EVENTS RESOURCE (E-MA)

Event Text

PROCESS GAUGE SHUTTER STUCK OPEN

The RSO reported a shutter problem on a fixed mounted process gauge manufactured by Vega Americas (Model SHF-2B) containing an 800 mCi Cs -137 source. The shutter problem was discovered during a semi-annual shutter check when it was determined that the shutter would not close. The shutter is normally always open to support the manufacturing process and the failure to close does not pose any personnel exposure risk. The RSO is following up with a vendor to repair the shutter onsite.

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Agreement State Event Number: 48417
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: TEAM INDUSTRIAL SERVICES
Region: 4
City: ALVIN State: TX
County:
License #: 00087
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/17/2012
Notification Time: 15:55 [ET]
Event Date: 10/16/2012
Event Time: [CDT]
Last Update Date: 10/17/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4DO)
FSME EVENTS RESOURCE (E-MA)

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA SOURCE DISCONNECT

The following report was received from the State of Texas Radiation Branch via facsimile:

"On October 17, 2012, the Agency [Texas Radiation Branch] was notified by the licensee that on October 16, 2012, a radiography source had disconnected from the drive cable during radiography at a field location. The radiographers were using a SPEC 150 exposure device [redacted]. The radiographers had completed an exposure and as they were surveying the exposure device, the radiographer noted that the dose rates at the front of the device were higher than expected. The radiographers contacted their Radiation Safety Officer. A source recovery team was sent to the location and the source was recovered without incident. The licensee read the Instadose dosimeters for the individuals involved in the event and no over exposures occurred. No additional exposure to a member of the general public occurred due to this event. The licensee was not able to determine the cause for the disconnect. The exposure device and the crank-out device the radiographers were using are being sent to the manufacturer for inspection."

Texas Incident #: I-8994

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Power Reactor Event Number: 48436
Facility: NORTH ANNA
Region: 2 State: VA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP,[3] M-4-LP
NRC Notified By: JONATHAN ALLEN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/24/2012
Notification Time: 02:40 [ET]
Event Date: 10/24/2012
Event Time: 01:47 [EDT]
Last Update Date: 10/24/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
RANDY MUSSER (R2DO)
MICHELE EVANS (NRR)
JANE MARSHALL (IRD)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 99 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP ON LOW STEAM GENERATOR WATER LEVEL

"On 10/24/12 at 0147, North Anna Unit 2 reactor tripped automatically. The reactor first out is the 'C' steam generator lo-lo level. The turbine first out is reactor tripped, turbine trip. The event was apparently initiated by a loss of load on the secondary side. The cause of the loss of load is still being investigated. All systems responded as expected. This event is reportable per 10 CFR 50.72(b)(2)(iv)(B) due to actuation of the Reactor Protection System.

"The Auxiliary Feedwater pumps received an automatic start signal due to low-low level in all steam generators at the time of the trip, Steam generator levels have been restored to normal operating level. The Auxiliary Feedwater System operated as designed with no abnormalities noted. This event is reportable per 10 CFR 50.72(b)(3)(iv)(A) due to actuation of an ESF system.

"All control rods inserted into the core at the time of the trip and decay heat is being removed via the main condenser steam dumps. Several secondary [feedwater] relief valves lifted and reseated during the event. North Anna Unit 2 is currently stable at no load temperature and pressure in mode 3.

"At 0147 EDT, the Unit 2 Pressurizer Power Operated Relief Valve (PORV) , 2-RC-PCV-2455C, opened during an automatic reactor trip of Unit 2. The valve indicated open for less than 1 second. During this time, the identified leakage threshold for EAL SU6.1 [25 gpm] was exceeded."

The cause of the loss of secondary load, which is believed to have caused the low steam generator water level and the lifting of the pressurizer PORV, is still under investigation. The licensee is focusing on the high pressure to low pressure turbine intercept valves or reheat valves going shut for reasons unknown at this time. The licensee's data shows that a pressurizer PORV opened momentarily. The instantaneous leak rate exceeded the unusual event threshold leak rate of 25 gpm. The PORV reseated and no ongoing leakage occurred during the transient. The rest of the transient was characterized as uncomplicated. The unit is in a normal post-trip electrical configuration. All systems functioned as required. There was no impact on Unit 1.

The licensee has notified the NRC Resident Inspector.

* * * UPDATE AT 1346 EDT ON 10/24/12 FROM PAGE KEMP TO S. SANDIN * * *

The licensee is updating their report to RETRACT the portion related to the after-the-fact entry into EAL SU6.

"At 0147 hours EDT on 10-24-12, a Unit 2 Pressurizer Power Operated Relief Valve, 2-RC-PCV-2455C, opened during automatic reactor trip. The valve indicated open for less than 1 second. 2-RC-PCV-2455C opened as designed in response to the plant trip and allowed a small amount of water to transfer to the Pressurizer Relief Tank, as designed. The Pressurizer Power Operated Relief Valve subsequently re-closed and remains available for automatic operation, if needed. Initially, this issue was reported to the NRC at 0240 hours on 10-24-12 as an After-The-Fact Unusual Event for EAL SU6.1. Subsequent review has determined that the Pressurizer Power Operated Relief Valve functioned as designed and the small amount of inventory was transferred to the Pressurizer Relief Tank as designed and therefore does not meet the criteria for an Unusual Event and this notification is being retracted.

"NEI 99-01, Rev. 5 provides additional guidance that relief valve normal operation should be excluded from this Initiating Condition. However, a relief valve that operates and fails to close per design should be considered applicable to this Initiating Condition if the relief valve cannot be isolated. In this case, the Pressurizer Power Operated Relief Valve operated as designed and returned to automatic operation."

The licensee informed state and local agencies and the NRC Resident Inspector. Notified R2DO (Musser).

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Power Reactor Event Number: 48437
Facility: LASALLE
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] GE-5,[2] GE-5
NRC Notified By: CHRISTOPHER SMITH
HQ OPS Officer: BILL HUFFMAN
Notification Date: 10/24/2012
Notification Time: 09:31 [ET]
Event Date: 10/24/2012
Event Time: 08:25 [CDT]
Last Update Date: 10/24/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
PATTY PELKE (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

TECHNICAL SUPPORT CENTER VENTILATION REMOVED FROM SERVICE FOR PLANNED MAINTENANCE

"On October 24, 2012, at approximately 08:25 hrs [CDT], the Exelon LaSalle Station Technical Support Center (TSC) Ventilation system was removed from service for planned TSC ventilation system maintenance.

"The removal of the ventilation system potentially affects the TSC habitability during a declared emergency requiring activation. The Emergency Response Organization (ERO) team has been notified of the maintenance and the possible need to relocate during an emergency. If an emergency is declared and the TSC ERO activation is required, the TSC will be staffed and activated unless the TSC becomes uninhabitable due to ambient temperatures, radiological, or other conditions. If relocation of the TSC staff becomes necessary, the Station Emergency Director will relocate the staff to an alternate TSC location in accordance with applicable site procedures.

"The ventilation system is expected to be out of service for approximately 21 hours.

"This telephone notification is provided in accordance with Exelon Reportability Manual SAF 1.10, 'Major Loss of Emergency Preparedness Capabilities', and 10CFR50.72(b)(3)(xiii)."

The licensee has notified the Senior Resident Inspector of the issue.

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Power Reactor Event Number: 48439
Facility: PILGRIM
Region: 1 State: MA
Unit: [1] [ ] [ ]
RX Type: [1] GE-3
NRC Notified By: DAVID NOYES
HQ OPS Officer: PETE SNYDER
Notification Date: 10/24/2012
Notification Time: 19:23 [ET]
Event Date: 10/24/2012
Event Time: 19:20 [EDT]
Last Update Date: 10/24/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
JOHN CARUSO (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

PRESS RELEASE REGARDING STATUS OF ONGOING LABOR NEGOTIATIONS

"On October 24, 2012, at 1920 EDT hours with the reactor at 100% core thermal power the following press release is being issued by Entergy Nuclear regarding the status of the ongoing labor negotiations.

"ENTERGY NUCLEAR STATEMENT - ENTERGY AND UWUA LOCAL 369 AGREE TO TENTATIVE CONTRACT

"October 24, 2012

"Plymouth, Mass. - Entergy Nuclear and the Utility Workers Union of America (UWUA) reached a tentative agreement today on a new four-year labor contract for Local 369 technical employees at Pilgrim Station, pending a ratification vote by Union membership.

"Additionally, the parties have agreed to a 21-day extension that will expire at midnight on Nov. 14. The previous contract for the approximately 67 workers affected by this union contract will remain in effect during the extension. The original contract was set to expire at midnight Oct. 24.

"Pilgrim's Site Vice President Robert Smith said, 'We appreciate the hard work of both parties to come to a successful outcome to this negotiation process. We believe the new proposal represents fair and equitable terms both for our employees and the Company.'

"END

"The Resident Inspector staff has been informed of this press release and notification.

"This notification is being made in accordance with 10 CFR 50.72(b)(2)(xi)."

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Power Reactor Event Number: 48440
Facility: HARRIS
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: RYAN MacNAIL
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/24/2012
Notification Time: 20:09 [ET]
Event Date: 10/24/2012
Event Time: 15:30 [EDT]
Last Update Date: 10/24/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RANDY MUSSER (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

TECHNICAL SUPPORT CENTER VENTILATION SUPPORT SYSTEM NON-FUNCTIONAL

"At 3:30 PM EDT on October 24, 2012, Harris Operations discovered that the Technical Support Center (TSC) outside differential pressure controller (PDC-4011) was not working. This pressure controller makes the TSC non-functional due to the ventilation system not being capable of maintaining a positive pressure with respect to outside. Procedural guidance exists for the Radiation Protection staff to perform continuous air monitoring of the TSC atmosphere to determine habitability conditions. Actions are being taken to expeditiously restore the system.

"This event is reportable per 10 CFR 50.72(b)(3)(xiii) due to the Technical Support Center ventilation support system being non-functional. The on call Site Emergency Coordinator and Emergency Response Manager have been notified.

"The NRC Senior Resident Inspector has been informed."

Page Last Reviewed/Updated Thursday, October 25, 2012
Thursday, October 25, 2012