Event Notification Report for February 06, 2008

PART 21 - REINFORCING BARS BELOW ACI STANDARDS

"The purpose of this letter is to inform the NRC Operations Center that Shaw AREVA MOX Services, LLC (MOX Services) has identified a deviation associated with reinforcing bar supplied by Energy and Process Corporation (E&P).

"The condition involves reinforcing bars (rebar) supplied by E&P that have a bend radius below the minimum specified by ACI Standard 315-99 and ACI Standard 349-97. The condition was initially observed on 06 February 2008. The extent of condition determination found that a significant portion of bent rebar in all sizes failed to meet the minimum bend radius specified by ACI Standard 315-99 and ACI Standard 349-97. Based on this finding, it was concluded that a similar nonconforming population could be present embedded in those areas of the plant where concrete had already been poured.

"MOX Services has determined that the IROFS [Item Relied On For Safety] function of the BMF structure was not diminished by the rebar installed in concrete poured to date and that a substantial safety hazard would not result in the MFFF [Mixed Oxide Fuel Fabrication Facility] if the deviation had not been discovered. For industry awareness, we have conservatively chosen to report this deviation under the provisions of 10 CFR 21.21(d)(3)(i)."

FLOOD WATCH DUE TO SNOW MELT AND HEAVY RAIN

"On February 6, 2008 at 1119 hours, Clinton Lake level reached 694 feet 0 inches (mean sea level). Normal lake level is 690 feet 0 inches. Per Clinton Power Station (CPS) procedure 4303.02, 'Abnormal Lake Level,' the CPS Main Dam - Emergency Action Plan requires that a 'Flood Watch' be declared. This resulted in a notification to the DeWitt County Sheriff's Department that occurred at 1133 hours. Lake level continues to slowly rise due to the melting snow and heavy rains received in the area for the past several days. Expected peak is approximately 694 feet 6 inches. Mitigating measures are currently being instituted as a precautionary measure in the screen house, per CPS procedures.

"The NRC Resident has been notified."

High lake level only affects the plant intake structure.

* * * UPDATE AT 1248 EST ON 02/09/08 FROM DALE SHELTON TO S. SANDIN * * *

"On February 8, 2008 at 1655 hours, Clinton Lake level reached 693 ft-0 inches (mean sea level). Clinton Power Station (CPS) Procedure 4303.02, 'Abnormal Lake Level', and the CPS Main Dam - Emergency Action Plan allow termination of the 'Flood Watch.' This resulted in a notification to the DeWitt County Sheriff's Department that occurred on February 8, 2008 at 2043 hours when the Offnormal procedure was exited. Maximum lake level observed was 694 ft-4 inches (mean sea level). Lake level is currently 692 ft-6 inches (mean sea level) and lowering. Inspections have identified no damage due to the heavy rainfall or associated elevated lake level."

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

AGREEMENT STATE REPORT - EXTREMITY OVEREXPOSURE TO TWO INDIVIDUALS

"Anazao Health contacted [the Florida Bureau of Radiation Control] Licensing and Materials Office by fax concerning an over exposure to two individuals on 28 January 2008. Initial determination was on 27 December 2008. During routine facility audit on 6 February 2008 inspector found documentation concerning over exposure. No verbal communication was sent by Anazao Health to state officials. One individual received 105.3 [REM] to right extremity TLD finger ring, and 82.3 [REM] to his left extremity TLD finger ring. Both are shallow dose equivalent for calendar year 2007. Second individual received 53.186 [REM] to right extremity TLD finger ring, and 80.066 [REM] to his left extremity TLD finger ring. Florida is investigating."

Florida Incident number FL08-018

* * * UPDATE AT 1423 EST ON 02/07/08 FROM STEVE FURNACE TO S. SANDIN * * *

The following information was received as an update via email:

"Anazao Health compounds radiopharmaceutical drugs. The company makes capsules of concentrated doses normally one quarter the size of standard capsules. The company primarily accomplishes these tasks by hand.

"Both employees worked with I-131 liquid in the preparation of nuclear medicine capsules. The I-131 stock contained up to 3 Curies and the individuals removed stock liquid into other vials for diagnostic or therapy capsule production. Operations were conducted within a fume hood. A buffer solution was added to vials in order to dilute the I-131 to required activity levels. The individuals removed liquid from these vials to make capsules.

"The individuals stood outside the flume hood behind lead shielding, while the forearms and hands were placed inside the fume hood in order to manually work with I-131 liquid vials and to prepare capsules of required activity. Employees wore double latex gloves, plastic sleeves and a disposable lab coat.

"Manually working with significant amounts of I-131 in the preparation of diagnostic and therapy capsules from liquid inside a fume hood caused both employees extremity finger rings to exceed State of Florida limits. Syringe shields were not used by the individual when extracting liquid I-131 from vials. There are no written procedures for this operation for the individual to follow. No remote tools were used during the preparation process.

"Florida is investigation this incident."

Notified R1DO (Cahill) and FSME (Burgess).

AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE GREATER THAN 25 REM

The 4Q07 dosimetry badge reading results indicated an exposure of 261,067 mrem shallow dose, beta, probably from P-32. It is believed that this reading may be a result of leaving a contaminated glove in a lab coat pocket following work, and then placing the badge in the same pocket, and the two remaining together for a period of over a month. The worker has been withdrawn from all radiation work. An investigation is in progress.

"02/06/08 - Radiation Safety Officer [REDACTED] of OHSU (License #OR-90731) notified [OREGON PUBLIC HEALTH] at the Agency that while reviewing dosimetry reports from Global Dosimetry Co., he discovered one user who had a 261,067 mrem shallow dose. [OREGON PUBLIC HEALTH] contacted [RSO] regarding the high dose and found that the dose was reported on a whole body badge for 4Q07. Further, it was found through this discussion that the isotope was P-32 and the user told [RSO] that he placed a contaminated glove in the pocket of his lab jacket and later placed his whole-body badge in the pocket with the glove. This was done approximately after 1 month into 4Q07 and the dosimetry and jacket were not used for 2 months. Unknown dose to the user during the first month from the glove. The glove was checked when found in the pocket and found to have 1100cpm (3400dpm) at that time. The user has been suspended from using radioactive material until an investigation (both OHSU and State Radiation Protection Services) can be performed and results determined. [RSO] is writing a preliminary report to be sent to [OREGON PUBLIC HEALTH] and [OREGON PUBLIC HEALTH] this afternoon or tomorrow.

"02/06/08: SA-300 consulted, potential dose exceeds 250 rem shallow dose level. Notified NRC Operations Center by phone per significant reportable event requirements at 1458 EST (11:58 PST) and received Event number 43966. Relayed preliminary information as acquired so far, will follow with fax of this information as well. Licensee to issue preliminary investigative report sometime this afternoon or early tomorrow."

TRAIN "A" 250 VDC CABLE PASSES THROUGH TRAIN "B" SWITCHGEAR ROOM

"On February 6, 2008 at 1920 hours, Cook Nuclear Plant Engineering personnel identified an unanalyzed condition that has the potential to degrade plant safety. Specifically, a cable routing error in the original design for safety related Train 'A' 250 VDC was discovered. A short section of Train 'A' 250 VDC was found to pass through the Train 'B' 4kV switchgear room. This routing was discovered to exist in both units. The routing of the cabling presents the possibility that a fire could disable the remote control to both 4kV switchgear trains.

"Local inspection identified no additional or supplementary fire barrier such as fire retardant wrapping.

"Compensatory measures (fire watch) have been established.

"In accordance with 10 CFR 50.72(b)(3)(ii) this condition is reportable as a condition that resulted in the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety."

The licensee notified the NRC Resident Inspector.

AGREEMENT STATE REPORT - LOUISIANA - LEAKING CHECK SOURCE

The State provided the following information via facsimile:

"On February 8, 2008, Waste Management reported a leaking source. On February 7, 2008, an e-mail from Suntrac was opened. This e-mail contained information on two leak tests that were performed on two sealed radioactive check sources. One of the sealed sources had removable activity that was above 0.005 uCi. A 5 mCi source of Cs-137 had a removable activity of 0.0084 uCi. This source has been taken out of service. Waste Management will contact Suntrac for disposal of the source. The source was identified as 'Orange #2' and a serial number was not known."

LA Report ID LA080003

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE DURING PROSTATE BRACHYTHERAPY

The following report was received via e-mail:

The following report details "three Ohio Event Reports for two unreported medical events in 2008 (OH100022 and OH100023) and one unreported medical event in 2009 (OH100024). These events were discovered as a result of a special inspection conducted by ODH on 9/10/2010."

Ohio Report Number OH100022: "An unreported medical event occurred at Clinton Memorial Hospital in Wilmington, Ohio on 2/6/08. On that date the licensee performed a prostate seed implant with I-125 seeds prescribed to deliver a dose of 144 Gray to the prostate. Post implant dosimetry showed that the received dose was >20 % below the prescribed dose." [The actual dose delivered was 97.5 Gray]

Ohio Report Number OH100023: "An unreported medical event occurred at Clinton Memorial Hospital in Wilmington, Ohio on 3/21/08. On that date the licensee performed a prostate seed implant with I-125 seeds prescribed to deliver a dose of 145 Gray to the prostate. Post implant dosimetry showed that the received dose was >20 % below the prescribed dose." [The actual dose delivered was 102.5 Gray]

Ohio Report Number OH100024: "An unreported medical event occurred at Clinton Memorial Hospital in Wilmington, Ohio on 5/20/09. On that date the licensee performed a prostate seed implant with I-125 seeds prescribed to deliver a dose of 144 Gray to the prostate. Post implant dosimetry showed that the received dose was >20 % below the prescribed dose." [The actual dose delivered was 107.5 Gray]

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.