Event Notification Report for May 15, 2011

PORTION OF HIGH PRESSURE FIRE WATER SYSTEM DECLARED INOPERABLE

"At 1254 CDT, on 05/15/2011, the Plant Shift Superintendent was notified that the C-333 High Pressure Fire Water (HPFW) Sprinkler System C-14 had been inspected by Fire Services and eleven sprinkler heads had visible corrosion on them. The system configuration was evaluated using EN-C-822-99-047, 'Effects of Impaired Sprinkler Heads on System Operability' and determined that with these heads potentially impaired, a portion of the building would not have sufficient sprinkler coverage. The HPFW system is required to be operable according to TSR LCO 2.4.4.5. HPFW system C-14 was declared inoperable and TSR LCO 2.4.4.5 Required Action B was implemented for the area without sprinkler coverage. Based on past testing results, there is a possibility that the heads would have been able to perform their specified safety function. Once the heads are removed from the system, testing will be performed to determine the actual affect on operability.

"This event is reportable under 10 CFR 76.120(c)(2) as an event in which equipment required by the TSR is disabled or fails to function as designed.

"The NRC Senior Resident Inspector has been notified of this event.

"PGDP [Paducah Gaseous Diffusion Plant] Assessment and Tracking Report No. ATR-11-1192; PGDP Event Report No. PAD-2011-08; Responsible Division: Operations

"An hourly fire patrol is being conducted in the affected area. [Licensee] estimated correction date: 5/20/2011."

* * * RETRACTION FROM BILLY WALLACE TO JOE O'HARA AT 1145 EDT ON 5/20/11 * * *

"Subsequent to the event, the corroded sprinkler heads were replaced with new heads and the removed heads were tested in the laboratory. Testing by the laboratory has shown that six of the 10 removed sprinkler heads would have performed their safety function, five of the heads would not have performed their safety function, but these heads would not affect the system operability. The conclusion of the tests is that the C-333 sprinkler system C-14 would have performed its intended safety function if called upon.

"The NRC Senior Resident Inspector has been notified of this retraction."

Notified R2DO(Shaeffer) and NMSS EO(Damon)

AGREEMENT STATE REPORT - MEDICAL EVENTS INVOLVING USE OF SAVI BRACHYTHERAPY APPLICATORS

The following information was provided by the State via facsimile:

"On June 10, 2011, the licensee's Radiation Safety Officer reported the identification of two medical events involving a HDR [High Dose Rate] Partial Breast Treatment using SAVI applicators. For both patients, treatment was delivered twice a day for five consecutive days in May 2011. It was determined later that the distance as determine by use of a Varian VariSource check ruler was incorrect. The check wire was blocked approximately 4.5 cm from the end of the lumen. The preliminary results from re-planning indicates that in both cases the most distal half of the applicator was under dosed at least 20 percent and the proximal half received approximately 200 percent more dose than what was prescribed. The patients will be notified by the referring physician. The licensee has suspended SAVI treatments until the root cause can be identified. Further updates will be made through NMED.

"The State of Wisconsin Department of Health Services will conduct a special inspection at the licensee's location."

Wisconsin Report No: WI 110006

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.