Event Notification Report for April 20, 2010

AGREEMENT STATE - STUCK SHUTTER

"On April 21, 2010, the agency [Texas Department of Health] was notified by the licensee that while performing a scheduled shutter operation check, the shutter on a Ronan model SA1 nuclear gauge failed to close. The gauge contains five millicuries of Cesium (Cs) 137, and was installed in 1995. The gauge is in its normal operating position and a radiation survey conducted by the licensee indicated that radiation levels are normal. The gauge was leak tested and the test sent for analysis. The licensee stated that there is no risk of additional exposure to their workers. The licensee is working with the manufacturer to schedule the repair of the gauge during a shutdown starting on May 3, 2010."

Texas Incident #: I-8733

AGREEMENT STATE REPORT - POSSIBLE OVEREXPOSURE TO A MEMBER OF THE PUBLIC

"Ohio Department of Health (ODH), Bureau of Radiation Protection (BPR) was notified of a possible overexposures to a member of the general public which occurred on 4/20/10 at the Ohio State University located in Columbus, Ohio.

"A patient received a temporary implant of Cs-137 and Ir-192 seeds on April 16-18, 2010. The patient's visitor (her fiancÚ) was instructed by the licensee that he could stay no longer than 2 hours with the patient in a twenty four hour period, and must stay behind the bedside shield during these visitations. On Tuesday, April 20, 2010, the licensee was informed by the Assistant Nurse Manager that the fiancÚ spent the night in the patient's room on two consecutive nights. In addition, the initial investigation by the licensee indicates that the visitor told the Assistant Nurse Manager that he slept in the same bed with the patient both nights. Nursing Management personnel are in the process of interviewing staff members that were involved directly with the care of the implant patient to verify that the fiancÚ was in the room overnight with the patient.

"A preliminary and conservative worst case dose estimate for the visitor is 6 Rad (6 cGy) whole body exposure, based on a 16-hour stay time (8 hours each night for two nights). ODH BRP will continue to collect information of this event and conduct an investigation. The licensee has initiated an internal investigation."

Ohio Report OH100005

* * * UPDATE FROM STEPHEN JAMES TO CHARLES TEAL ON 7/8/10 AT 1128 EDT * * *

"After investigation by the licensee and ODH the revised calculations indicate a dose estimate to the visitor to be 1.25 Rem. The licensee has instituted major procedural changes and conducted training for medical staff involved with brachytherapy treatments."

ANTICIPATED LOSS OF RADIOACTIVE MATERIAL

The licensee reported that two cementing densometers were aboard the Deep Water Horizon Oil Rig when the oil rig caught fire on the evening of April 20, 2010. The oil rig is located in Federal waters in the Gulf of Mexico (Mississippi Canyon Block 252). At the time of the report, the oil rig was sinking in 4000 feet of water.

The two gauges on the oil rig were as follows:
1. Device 10SD, Device S/N: V32785, Source S/N: DA071, Isotope Products Model No. A-3906, Isotope: Cs-137, Current Activity: 8.3 mCi
2. Device 10SD, Device S/N: W25980, Source S/N: XA923, Gammatron Model No. GTGHP, Isotope: Cs-137, Current Activity: 8.2 mCi

When brought onto the oil rig, both devices were high integrity sources inside a tungsten cavity, and further contained in steel. The licensee had no information whether or not the sources were compromised as a result of oil rig fire and sinking.

Based on the depth of the water where the oil rig is sinking, the licensee does not anticipate that the devices will be recoverable.

The licensee notified the Region IV office of the incident.

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore, it is being categorized as a less than Category 3 source

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

FIVE POTENTIAL ISSUES DISCOVERED DURING POST-FIRE SAFE SHUTDOWN REVIEW

"While performing a post-fire safe shutdown (PFSSD) review per Enforcement Guidance Memorandum (EGM) 09-002, 'Enforcement Discretion for Fire Induced Circuit Faults', and Regulatory Guide (RG) 1.189, Revision 2, five issues were identified that could be potentially reportable. EGM 09-002 provides enforcement discretion for non-compliances related to fire-induced multiple spurious operations (MSOs). The enforcement discretion period allows 6 months from the date of issuance of RG 1.189, Rev. 2 to perform the following:

- Identify noncompliances related to multiple fire induced circuit failures
- Implement compensatory measures for the noncompliances, and
- Place the noncompliances in the licensees' corrective action program

"The five fire-induced issues that were identified are:

- Three issues which could potentially prevent operation of the Residual Heat Removal Pump(s),
- An issue where all four Reactor Coolant Pumps may not stop from the Control Room, and
- An issue where a Centrifugal Charging Pump could spuriously start and fill the pressurizer solid.

"RG 1.189 was issued on November 2, 2009. Therefore, the 6-month identification period ends on May 2, 2010. For issues identified during the 6-month identification period, enforcement discretion continues for an additional 30 months to resolve identified issues.

"The 10 CFR 50, Appendix R Fire is not a Design Basis Accident. While Appendix R fires are postulated to cause a Technical Specification (TS) inoperability of a [System, Structure or Component] SSC, the failure to previously identify these issues does not constitute an actual TS inoperability. Rather, the issues identified during this MSO are noncompliances with the Current Licensing Basis (CLB). Therefore, the affected systems are considered operable but degraded or non-conforming as defined in Regulatory Issue Summary (RIS) 2005-20."

The licensee has notified the NRC Resident Inspector.

OFFSITE NOTIFICATION - SODIUM HYDROXIDE RELEASED INTO BERM

"At about 0755 (PDT) on April 20, 2010, approximately 200 gallons of sodium hydroxide (caustic) was released into the SONGS Caustic Skid Berm. The release was fully contained within the bermed area and there was no release to the environment. The release is believed to have occurred from a Unit 2 caustic pump pressure safety valve (PSV) during the performance of condensate polishing demineralizer regeneration. The release has been secured and SONGS personnel have pumped the caustic to poly drums.

"Between 1103 and 1125 (PDT) SONGS notified the San Diego Department of Environmental Health (DEH), the State of California Emergency Management Agency (CalEMA), and the National Response Center of the contained non-radioactive caustic spill within the protected area of the facility. Therefore, Southern California Edison is reporting this occurrence to the Nuclear Regulatory Commission in accordance with 10 CFR 50.72(b)(2)(xi).

"SONGS Unit 2 is in Mode 1 at approximately 98% power and Unit 3 is in Mode 1 at approximately 50% power. The NRC Resident Inspector will be notified of this occurrence and will be provided a copy of this report.

"Additional information regarding this event will be provided to one of the Resident Inspectors at the site."