Event Notification Report for March 12, 2012

AGREEMENT STATE REPORT - ABORTED FRACTIONAL DOSE TREATMENT

The following information was received from the State of New Jersey:

"A patient was treated with a Nucletron microSelectron 106.990(v3) HDR unit on March 12, 2012. The prescription dose was 600 cGy per fraction for 5 fractions. The fractional treatment planned was for a total of 14 dwell positions in two different catheters: six dwell positions in the ring to be treated on HDR Channel 1 and eight dwell positions in the tandem to be treated on HDR Channel 3. After all appropriate QA, the patient treatment was started with Channel 1 being the first set of dwell positions treated. At the completion of the Channel 1 treatment, the HDR unit gave an error stating that there was a 'Possible incomplete source retraction in Channel 2.' Even though all radiation indicators did not detect the presence of radiation, and even though the licensee was not using Channel 2, immediate emergency procedures were implemented. The emergency stop was activated and the room was entered with a survey meter to verify that there was no elevated radiation present. All indications were that the source was retracted properly and that there was no danger to the patient or the staff.

"The error displayed on the treatment screen indicated that it was possible that dust was on the optocoupler, thus causing the fault. However, the error could not be cleared by using the reset button. Nucletron was immediately contacted. Nucletron support personnel attempted to walk the licensee through some steps that may have cleared the error, but they were unsuccessful. Therefore, the remaining part of the patient's treatment was aborted. Nucletron scheduled one of their service engineers to respond to the licensee's facility to repair the unit.

"The authorized user informed the patient that the complete treatment was not delivered due to the machine malfunction and that the authorized user would determine what action to take on the future fractions. The patient and the treatment room were surveyed prior to release. No elevated readings were observed. The patient received 120 cGy (versus the prescribed dose of 600 cGy). The deviation from the written directive was documented in the patient's chart."

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.

OFFSITE NOTIFICATION - NON-WORK RELATED ON-SITE FATALITY

"At 0742 PDT on March 12, 2012, a non-work related on-site fatality occurred at the Diablo Canyon Power Plant. The fatality was not related to the health and safety of the public or on-site personnel. Specifically, a contractor for Pacific Gas and Electric (PG&E) was found in the Engineering Offices before work hours with no pulse or life signs. The individual was promptly attended to by Diablo Canyon Industrial Fire Officers and a transfer to a local hospital by ambulance was completed. The individual was pronounced dead at the hospital.

"The individual was outside of the Radiological Controlled Area and no radioactive material or contamination was involved . The work location was outside of the Protected Area.

"PG&E has not observed any heightened public, media, or government concern as a result of the fatality. Because the fatality is unrelated to Diablo Canyon Power Plant industrial or radiological health and safety, no news release is planned.

"Because the fatality was not work-related, nor the result of an accident, no notification to other government agencies was made at the time. However, PG&E may make a notification to the California Occupational Safety and Health Administration due to a cardiac arrest on-site. Thus this ENS notification is in response to a notification to another government agency in accordance with 10CFR50.72(b)(2)(xi).

"The deceased person worked for Enercon Services.

"The licensee notified the NRC Resident Inspector."

PLANNED MAINTENANCE WINDOW ON TECHNICAL SUPPORT CENTER VENTILATION

"Planned preventive maintenance activities are being performed on the Hatch Nuclear Plant's Technical Support Center (TSC) Emergency Ventilation System on Monday, March 12, 2012. These maintenance activities include the performance of absorber charcoal replacement and DOP testing per 42SV-X75-001-1, 'Testing of TSC Filter Train.' These work activities are planned to be completed within the (12) hour day shift on 03/12/2012.

"During the time these activities are being performed, the TSC Emergency Ventilation System will be inoperable. As such, the TSC HVAC will be rendered non-functional during the performance of these work orders. If an emergency is declared requiring activation of the TSC during the time these work activities are being performed, then the contingency plans call for utilization of the TSC as long as habitability and radiological conditions allow. Procedure 73EP-EIP-063-0, 'Technical Support Center Activation,' provides instructions to direct TSC management to the Control Room and TSC support personnel to the Simulator Building to continue TSC activities if it is necessary to relocate from the primary TSC so that TSC functions can be continued.

"This event is reportable per 10CFR50.72 (b)(3)(xiii) as described in NUREG-1022, Rev. 1 since this work activity affects an emergency response facility for the duration of the evolution."

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM CHRIS BURKE TO JOHN KNOKE AT 1644 EDT ON 3/13/12 * * *

"During post Preventive Maintenance [PM] activity testing, the TSC emergency filter train bypass valve 1X75F005 damper failed to meet leakage criteria (CR 422749). PM activities were halted and a corrective maintenance Work Order SNC377526 initiated at approximately 2030 EDT to investigate, repair and retest the bypass valve damper. Repair work to the TSC emergency filter train bypass valve was completed. The retest and verification was performed and the TSC HVAC system returned to service at 1550 EDT on 3/13/12."

The licensee has notified the NRC Resident Inspector. Notified the R2DO (Eugene Guthrie)

AGREEMENT STATE REPORT - SURFACE CONTAMINATION IDENTIFIED ON LAB FLOOR

The following information was received from the State of Tennessee via e-mail:

"During the routine lab cleanup/surveys, the RSO found 50-70 spots of contamination throughout the lab on the floor. It was determined that the contamination had occurred when a pharmacist working with I-131 capsules under the hood, had removed his glove within the hood. Subsequently, the glove had fallen to the floor depositing an unknown quantity of I-131. The pharmacist then walked through the lab and spread the contamination throughout. The pharmacist failed to survey the area or himself upon exiting the lab. The RSO found no contamination outside the restricted area. The RSO proceeded to cover the floor with cardboard, covering all areas of contamination. Areas were surveyed and the dose rates were very low even at 1 ft. from the I-131 contamination. There were no dose readings at 1 meter. All staff bioassays were below detectable limits."

TN Report ID: TN-10-082

INTERIM REPORT CONCERNING BATTERY CELLS WITH POTENTIALLY REDUCED DISCHARGE CAPACITY

"This letter will serve as the interim report to the Commission as pursuant to 10CFR21.21 (a) (2). The notification is in regards to a 2GN-23 battery manufactured by EnerSys and installed as part of Station Battery 2-2 at the Dominion Virginia Power, North Anna Station. Battery verification testing performed at North Anna indicated that although the battery was able to meet North Anna's 2 hour discharge requirements, cell #59 appeared to show reduced capacity. As a result, Dominion returned cells #59 and #60 to EnerSys. The cells were received at the EnerSys Corporate Laboratory under Return for Analysis (RFA) ENS-11204.

"During our analysis, which consisted of float charging, discharge testing at the 3 hour rate and an internal inspection it was determined that the cell was unable to meet the defined technical requirements for discharge capacity. Following the determination a series of analytical tests were ordered to perform more in depth analyses of the internal components. Testing on the component samples is currently underway. At this time we have not yet been able to determine if a "defect" as defined in Part 21 exists and therefore this interim report has been prepared. It is expected that the current tests will be completed by May 11, 2012. However, it should be noted that further analysis including the return of additional cells may be required to determine the cause and the reportability under Part 21 reporting."

"Throughout the return and analysis processes EnerSys has been in contact with representatives of the North Anna Station. They have been made aware of the electrical test results and recently of the internal inspection results. They are also aware that there has been no cause determination at this time. Station personnel have also been notified that this interim report has been issued."

* * * RETRACTION FROM WILLIAM ROSS TO HOWIE CROUCH AT 0953 EDT ON 5/11/12 * * *

The following information was received from EnerSys via fax:

"Subsequent to the March 12th letter, analytical testing on the components of the returned cells was completed. The results indicated there were no material composition discrepancies or assembly process anomalies. The only issue seen in cell #59 was that a portion of the positive active material physically separated from the positive grid structure. Additionally, data recorded during the manufacturing process was reviewed with no issues or nonconformities noted.

"A visit to the North Anna site was undertaken by EnerSys Engineering to review information from both Station 1 and Station 2. Battery verification testing at both stations showed all station batteries to have acceptable performance. A comparison of the testing performed by North Anna and the testing performed by EnerSys indicated that there was no further capacity degradation in cell #59. It is expected that the cells in the two station batteries will perform similarly.

"Based upon our further investigation we have concluded that no deviation per 10CFR21.21 exists. The positive active material separation was determined to be to a unique inconsistency in that plate curing lot."

Notified R2DO (Freeman) and NRR Part 21 Group via email.