Event Notification Report for December 11, 2007

MASSACHUSETTS AGREEMENT STATE REPORT - LOST SHIPMENT OF IRIDIUM-192 SOURCES

"The RSO for QSA Global called to report a missing shipment. The shipment was dispatched from QSA on 12/5/07 via Roadway. Roadway has a signed receipt (dated 12/11/07) from LAN Cargo in Miami, FL. LAN Cargo cannot locate the shipment in Miami. The initial notification was made to QSA on Tuesday morning, 12/18/07, and there was some initial confusion as Roadway said that it was delivered [LAN Cargo], and LAN Cargo said they did not know where it was. Official notification of the missing shipment was not made to QSA until yesterday, 12/20/07. As of today, the shipment is still missing and QSA notified MA RCP.

"The shipment contains 4 sources containing a total of just under 800 curies of Ir-192. The investigation is on-going and more details will follow as they are received."

The following additional information was obtained from QSA Global's RSO:

Date Shipped: Dispatched from QSA on 12/5/07 via Roadway, PRO #100-971702-4, for LAN Cargo in Miami. Roadway has a signed receipt for the shipment from LAN Cargo, but LAN Cargo cannot locate the shipment in Miami.

Customer: Caefe NDT, Rioja 4855, 2000 Rosairo (SF) Argentina

RAM: Seven (7) IR-192 sources in four containers on a skid: 4066.3 GBq, 8572.9 GBq, 8025.3 GBq, and 8162.3 GBq.

Status:

The initial notification was made to QSA Tuesday morning and there was some initial confusion as Roadway said that it was delivered, and LAN said they didn't know where it was. It is a skid that weighs over 400 lbs, so it is not something that can be easily moved. Because of the initial confusion over the actual status, official notification of the missing shipment wasn't made to QSA until yesterday morning. As of today, it is still missing and therefore, QSA is making the formal notification to MRCP per 105 CMR 120.281. A second shipment bound for Lima, Peru was consigned to LAN Cargo on the same day and we are investigating whether the missing shipment went to Lima instead of Argentina.


The licensee has also contacted the State of Florida. ILTAB (Sandler) and R2DO (Shaeffer) notified.

* * * UPDATE PROVIDED BY STATE OF MASSACHUSETTS (BOB WALKER) TO JEFF ROTTON AT 1542 ON 12/23/07 * * *

The shipment has been located at the Miami Roadway Express Terminal Dock.

Notified R1DO (Henderson), FSME (Mohseni, Pangburn), IRD (Cruz), R2DO (Shaeffer), ILTAB (Sandler).
Notified DHS (Steve York), DOE(Sal Morrone), FEMA (Erwin Casto), USDA (Amanda Jimenez), HHS (Jamie Whitt).

THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL

Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy.

LOSS OF 11 ALERT AND NOTIFICATION SIRENS DUE TO SEVERE ICE STORM

"Due to a severe winter ice storm in the area surrounding Cooper Nuclear Station, 11 of 24 Alert and Notification System Sirens were discovered to be out of service as of 1019 hours on 12/11/07. This event impacts the ability to readily notify a portion of the 10 Mile Emergency Planning Zone (EPZ) Population for Cooper Nuclear Station. This event also meets NRC 8 hour reporting criterion 10 CFR 50.72(b)(3)(xiii), major loss of the off-site emergency notification system.

"Eight of the failed sirens are located in Atchison County, MO (Seven have failed directly due to loss of AC power and one has partially failed due to other aspects of the storm). One of the failed sirens is located in Richardson County, NE (due to direct loss of AC Power). The other two sirens are located in Nemaha County, NE (One has failed directly due to loss of AC power and one has partially failed due to other aspects of the storm).

"Atchison, Richardson, and Nemaha County Authorities have been notified and compensatory emergency route alerting has been discussed as an alternate means of public notification. NOAA/EAS Tone Alert Radios issued for notification of rural residents within the 10-mile emergency planning zone are available and the local NOAA radio transmitter is operable. Contact of the local power utilities has been initiated so that power restoration efforts can be monitored. The licensee also notified the NRC Resident Inspector, FEMA Region 7, Missouri State Emergency Management Agency, and the Nebraska Emergency Management Agency."

** UPDATE FROM BRAD BARE TO J. KNOKE AT 2207 ON 12/12/07 **

"As of 1702 on 12/12/07, the number of inoperable Alert and Notification System (ANS) sirens fell below 25% of the total number of sirens (24) which was the basis for reporting the major loss of the off-site emergency notification system. Currently there are 4 sirens still inoperable in Atchison County, MO. Power restoration activities by local power companies are still in progress in Atchison County. All ANS Sirens located in the Nebraska side of Cooper Nuclear Station 10-Mile EPZ have been returned to service. The licensee has notified the NRC Resident Inspector, and authorities in Atchison County and State of Missouri."

Notified R4DO (Bywater)

LOSS OF RHR ROOM COOLER

"At 08:55 on 12/11/07 the division 1 RHR room cooler, V-AC-5 would not start. At approximately 10:00, troubleshooting determined that the cause of the failure was a blown line fuse on the B phase of the 480 VAC supply breaker. In accordance with plant procedures, a loss of this room cooler requires that the associated division 1 core spray pump and both division 1 LPCI pumps be declared inoperable. The result is entry into Technical Specification 3.5.1 Condition M due to having two or more ECCS injection/spray subsystems inoperable. This requires entry into LCO 3.0.3. At 10:53 on 12/11/07 the blown line fuse was replaced, the unit was tested and operability was restored. LCO 3.0.3 was exited at this time.

"The Technical Specification bases for Technical Specification 3.5.1 Condition M states that when multiple ECCS subsystems are inoperable, as stated in Condition M, the Plant is in a condition outside of the accident analyses. As described in this bases section the plant is in an unanalyzed condition and pursuant to 10 CFR 50.72(b)(3)(ii) an 8 hour report is being made.

"At this time, the station believes there was no loss of safety function. Further review of the event is in progress at the station.

"The station has informed the NRC resident inspector of this event."

* * * UPDATE AT 1710 EST ON 02/08/08 FROM RANDY SAND TO S. SANDIN * * *

After further review, the licensee is retracting this report based on the following:

"The notification was initiated due a TS Bases that stated the plant was outside of its accident analyses with multiple ECCS subsystems are inoperable. This was considered an unanalyzed condition.

"Further evaluation by plant staff has determined that for the conditions present at the time of the event the station was bounded by the accident analysis and therefore the event was not an unanalyzed condition. A review of Section 14 of the Updated Safety Analysis Report (USAR) determined that with one low-pressure ECCS division inoperable, the plant was not outside the ECCS accident analysis as described in the SAFER GESTR ECCS licensing topical report for Monticello and reflected in Chapter 14 of the USAR."

The licensee informed the NRC Resident Inspector. Notified R3DO (Tom Kozak).

MAJOR LOSS OF COMMUNICATIONS CAPABILITY

"On Tuesday, December 11, 2007, at approximately 1105 PST, the San Onofre Nuclear Generating Station Control Room Red Phone and commercial telephone systems became inoperable for approximately 10 minutes. Control Room Red Phone operability was confirmed by a successful call to NRC Headquarters Operation Office about 1115 PST.

"Southern California Edison is reporting this event in accordance with 10CFR50.72(b)(3)(xiii) for a condition that resulted in a major loss of offsite communications capability (Emergency Notification System and offsite notification system).

"As part of the problem solving efforts, the Red Phone may become inoperable for brief periods of time.

"At the time of this report, Unit 2 is in Mode 6 in a refueling outage and Unit 3 is in Mode 1 at 100 percent power. The NRC Senior Resident Inspector has been notified of this event and provided a copy of this report."

The licensee still had satellite phone communications capability.

FLORIDA AGREEMENT STATE REPORT

"A misadministration occurred on 11-Dec-2007 this office notified at 1520 hours. The prostate was to receive 140 Gy, but received only 100 Gy. This incident referred to Radioactive Materials for Investigation. This office will take no further action on this incident."

Isotope: I-125

Activity: 92 seeds at 0.295 millicuries per seed

Material Form: Interstitial Brachytherapy Seeds

Incident Number: FL07-193


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.


* * *UPDATE BY FSME (FLANNERY) TO MACKINNON AT 1105 ON 12/13/07* * *

"This event (EN43838) has been reviewed and determined to be a reportable medical event."

60-DAY NOTIFICATION OF AN INVALID ACTUATION OF UNITS 2 AND 3 PRIMARY CONTAINMENT ISOLATION SYSTEMS

"This 60-day report, as allowed by 10 CFR 50.73(a)(1), is being made under the reporting requirement in 10CFR50.73(a)(2)(iv)(A) to describe an unplanned, invalid actuation of specified systems, specifically the Units 2 and 3 Primary Containment Isolation Systems (PCIS).

"On 12/11/07, at approximately 1645 hours, the 13 Kv non-safety related AS4 feeder breaker tripped as a result of an electrical fault downstream of the breaker. The electrical fault resulted in a momentary voltage dip on the offsite power source (3SU). The momentary voltage dip resulted in PCIS Group II and III isolations on Units 2 and 3. Unit 2 experienced inboard PCIS isolations, while Unit 3 experienced outboard PCIS isolations. The isolations involved various process lines including Reactor Water Cleanup (RWCU), Containment Atmospheric Control (CAC) / Containment Atmospheric Dilution (CAD), Drywell Sumps, and Containment Instrument Nitrogen. The Units 2 and 3 PCIS isolations were reset by approximately 1715 hours in accordance with procedures. All required isolation valves operated as designed.

"The AS4 breaker trip has been preliminarily determined to be an electrical fault of a fuse clip associated with a non-safety related transformer (00X029). This transformer provides power to equipment at the discharge canal control structure. This issue has been entered into the site Corrective Action Program (CRs 710316, 711652, 710769) for evaluation and implementation of further corrective actions.

"The NRC resident has been informed of this notification."

AGREEMENT STATE REPORT - MISSISSIPPI - MISADMINISTRATION INVOLVING AN HDR TREATMENT

The State provided the following information via email:

"On 3-26-08, licensee's RSO notified DRH [Mississippi Division of Radiation Health] of a Iridium-192 HDR treatment misadministration. The reportable event involves the administration of 3 separate fractions for one (1) patient over a six (6) day period. The misadministration was caused by not measuring the catheters. Measurements taken on 3-25-08 of the tandem and ovoid applicators connected to the Varion Varisource HDR indicated that the length of the source wire entered in the treatment planning system should be 128 cm instead of 120 cm. Further inspection of the catheters revealed that the ovoid catheters were correct but the tandem catheter should have been used with a different applicator. The error resulted in the dose being delivered approximately 86 mm inferior to the desired location. The prescribed treatment was for 5 fractional treatments for 600 cGy each (3000 cGy total); however, due to the error only 470 cGy was administered in 3 treatments (26% of the prescribed dose). It was noted during the investigation by DRH that for other problems not associated with the HDR treatments, the patient did not return for the final 2 fractional doses. The dose to the vaginal region inferior to the treatment area received a 1300 cGy overexposure as a result of the error. The Radiation Oncologist does not foresee this patient experiencing adverse health effects as a result of this misadministration. The referring physician and the patient have been notified. "

MS Report No. MS-08004

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.