Event Notification Report for March 22, 2012

AGREEMENT STATE REPORT - PATIENT RECEIVED LESS THAN INTENDED DOSE

The following information was received via facsimile:

"On March 23, 2012 the Southeast Regional Office [of the Pennsylvania Department of Environmental Protection - Bureau of Radiation Protection (Department)] received notice from the hospital of a medical event involving yittrium-90 TheraSpheres.

"The patient was being treated for disease of the liver and received 76% of the intended dose in the first delivery and 56% of the intended dose in the second delivery.

"The cause of the event is currently under investigation. More information will be provided when received.

"No harm to the patient is expected. The oncologist was satisfied with the treatment and no additional delivery is anticipated. The Department will conduct a reactive inspection."

Pennsylvania Event Report ID No: PA120010

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.

NOTICE OF UNUSUAL EVENT - POTENTIALLY HAZARDOUS ATMOSPHERE DUE TO FREON LEAK

At 1034 CDT on 3/22/12, Cooper Nuclear Station declared a Notice of Unusual Event due to a freon leak from a glycol compressor in the sub-basement of their Augmented Radwaste Building. This created a potentially unsafe localized atmosphere in that area per Emergency Action Level HU 3.1.

The licensee made a public address system announcement to avoid the area and sent personnel to guard the area to prevent entry.

The licensee is monitoring the area for any deterioration. Oxygen levels are currently normal. Cooper Nuclear Station personnel plan to isolate the freon leak and ventilate the area to ensure a habitable atmosphere.

There are no safety related systems or components in the affected area. Plant operation is unaffected. As of 1045 CDT, the licensee has notified appropriate state and local governmental agencies.

The licensee notified the NRC Resident Inspector. Notified DHS SWO, DHS NICC, FEMA and Nuclear SSA via email.

* * * UPDATE AT 1320 EDT ON 3/22/12 FROM ROBERT LECHNER TO PETE SNYDER * * *

Cooper Nuclear Station personnel monitored the atmosphere in the affected area for safe entry then entered and isolated the freon leak. They did further extensive monitoring for any pockets of trapped freon gas and further ventilated the area to restore the area to a habitable condition. At 1142 CDT Cooper Nuclear Station exited their Unusual Event condition.

Offisite notifications were made per 10 CFR 50.72 (b)(2)(xi). A press release is planned to inform the public of this onsite event.

Notified DHS SWO, DHS NICC, FEMA and Nuclear SSA via email

AGREEMENT STATE REPORT - EQUIPMENT MALFUNCTION DURING TREATMENT

The State of Wisconsin provided the following information via e-mail:

"On March 22, 2012 at 2:30pm the Wisconsin Radiation Protection Section received a telephone notification that a fire had occurred at the licensee's location while performing a lung perfusion study at 11:45am, utilizing a 60 mCi dose of Tc-99m DTPA. The lung perfusion kit being used was a Biodex Medical Systems model Aerotech 1, lot #: 07811324. Per a discussion with the RSO, a patient was receiving a lung perfusion study when the perfusion kit 'burst into flames.' The Nuclear Medicine Technician (NMT) removed the face mask from the patient and the patient's hair caught on fire and the NMT put the fire out with their hands. The patient was immediately taken to the Emergency Room and the first degree burns on their face and neck have been treated.

"The area has been secured and surveys are in progress. The licensee will not be conducting any nuclear medicine procedures until the Radiation Protection Section has completed our investigation."

WI Event Report ID: WI120002.

POTENTIAL FIRE INDUCED SPURIOUS OPERATION OF STEAM GENERATOR BLOCK VALVES

"On February 28, 2005, Duke Energy notified the NRC of McGuire Nuclear Station's (MNS) intent to adopt NFPA 805 in accordance with 10 CFR 50.48(c). On April 18, 2006, Duke Energy notified the NRC that MNS had begun the process of transitioning to NFPA 805. For licensees transitioning to NFPA 805, assuming specific criteria are met, the NRC will exercise enforcement discretion for Appendix R non-compliances identified during the transition process and for existing Appendix R non-compliances that could reasonably be corrected under 10 CFR 50.48(c). As per NRC guidance and policy, enforcement discretion does not relieve the licensee of the requirement to make a required report to the NRC.

"As part of the NFPA 805 transition process, MNS has identified Appendix R related noncompliances which are being evaluated for appropriate dispositioning under NFPA 805. The evaluation of the non-compliances has recently identified a condition which could result in fire induced spurious operation of the block valves for the Unit 2 Steam Generator (SG) Power Operated Relief Valves (PORVs). This spurious operation could potentially damage these valves and render them inoperable. Since these valves are unisolable, they could not be repaired to allow the Unit 2 SGs to be used for Unit cool down if needed.

"This potential condition could adversely affect the ability of the plant to achieve and maintain a cold shutdown of Unit 2. This represents a condition reportable as per the requirements of 10 CFR 50.72(b)(3)(ii)(B). This potential condition is mitigated by existing compensatory measures (i.e. fire watches) which have been in place as part of the NFPA 805 transition.

"The NRC Resident Inspector has been notified."

FITNESS FOR DUTY [FFD] REPORT INVOLVING PROGRAMMATIC VULNERABILITY

"On March 9, 2012, Shaw's Vogtle 3&4 Construction Contractor FFD program manager notified SNC [Southern Nuclear Operating Company] FFD program manager of his discovery of anomalies in their random pool while preparing to perform the weekly random pool generation. At that time, approximately 20 people were identified as not being in the pool that had active badges. Corrective actions were implemented to update the pool and provide additional verification of any changes made to the pool. Subsequently discussions with licensing resulted in the conclusion that there was not an indication that there was a programmatic issue and thus was reportable under a 30 day report to the NRC. The NRC was informed of this decision and has been at Vogtle collecting data regarding this event.

"Since that time, Shaw has been checking past months to determine the extent of condition. On March 22, at 21:01, Shaw notified SNC that the October - December results of personnel who had active badges but was not in the pool was significantly higher than the January through March results, developed earlier. On the basis of this information, SNC has determined that this now rises to the level of a programmatic vulnerability and is subject to a 24-hour report to the NRC.

"SNC is providing this notification under the provisions of 10 CFR 26.719(b)(4) and 26.417(b)(1) as a discovered vulnerability of the FFD program."

The licensee informed the NRC Resident Inspectors.

* * * UPDATE FROM MAHAN TO HUFFMAN AT 1700 EDT ON 3/26/12 * * *

The licensee noted that this event is also being reported under 10 CFR 26.417(b)(1).

R2DO (Haag) has been notified.

SIX TRITIUM EXIT SIGNS UNACCOUNTED FOR AFTER SHIPPING TO MANUFACTURER

On 1/16/12, the licensee replaced the tritium exit signs in their facility. These exit signs were installed in the late 60's. They put the signs back into the original packaging to return them to the manufacturer. Gexpro [exit sign distributors] picked up the signs with the understanding that they would be shipped to SRB Technologies Inc. (the sign manufacturer). SRB technologies did not receive the signs. A search of the Gexpro warehouse did not locate the signs. Additionally, SRB Technologies had no record of receiving the signs.

A total of 6 tritium exit signs are unaccounted for. The serial numbers of the signs are 600275, 600276, 600277, 600278, and 600279. The remaining exit sign did not have a serial number attached any longer.

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

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 is it being categorized as a less than Category 3 source