Event Notification Report for July 10, 2012

METALLURGICAL SAMPLE PANS EXCEEDED VOLUME LIMIT

The following is a redacted summary of the event report provided by the licensee:

EVENT DESCRIPTION: Metallurgical samples at B&Ws NOG-L facility are contained in 'bread pans'. The bread pans are used to transport and store samples. Each bread pan has U235 quantity limits as well as spacing and volume limits for maintaining criticality controls. The volume of the bread pan is an Item Relied on For Safety (IROFS).

On July 10, 2012, at approximately 1230 EDT, a Nuclear Criticality Safety (NCS) engineer identified during a routine quarterly audit that the bread pans in use exceeded the volume liter limit. At the time of discovery, the mass controls for the bread pans were not exceeded. Neither was there excess moderation between storage locations.

EVALUATION OF THE EVENT: Although an IROFS was lost (the bread pan volume), other IROFS (operator control of mass, operator control of interspersed moderation) were available at the time of discovery of this condition to ensure the risk of a criticality remained highly unlikely. However, 10 CFR 70.61 (d) states in part: '...the risk of nuclear criticality accidents must be limited by assuring that under normal and credible abnormal conditions, all nuclear processes are subcritical, including use of an approved margin of subcriticality for safety.'

Further evaluation of the as-found condition of the bread pans indicated the licensed keff limit may have been exceeded. Therefore, the performance requirements of 10 CFR 70.61 were not maintained.

There was no immediate risk of a criticality or threat to the safety of workers or the public as a result of this event. However, the bread pan storage area is being shutdown.

NOTIFICATION REQUIREMENTS: B&W is making this 24 hour report in accordance with 10 CFR 70, Appendix A, (b)(1) Any event or condition that results in the facility being in a state that was not analyzed, was improperly analyzed, or is different from that analyzed in the Integrated Safety Analysis, and which results in failure to meet the performance requirements of 70.61.

STATUS OF CORRECTIVE ACTIONS: An investigation of the root causes of this event is ongoing. Corrective actions will be determined as a result of the investigation.

The licensee has notified the NRC Resident Inspector.

* * * RETRACTION AT 0845 EDT ON 8/6/2012 FROM TONY ENGLAND TO MARK ABRAMOVITZ * * *

The following is a redacted summary of the event report provided by the licensee:

The event was reported in 24 hours in accordance with 10 CFR 70. Appendix A. (b)(1): 'any event or condition that results in the facility being in a state that was not analyzed, was improperly analyzed, or is different from that analyzed in the Integrated Safety Analysis, and which results in failure to meet the performance requirements of 70.61'.

Upon further evaluation it was determined that keff limit in the NRC License was not exceeded. Therefore, the performance requirements of 10 CFR 70.61 were maintained. This is the basis for correcting Event Notification #48091 and withdrawing the report. A conservative approach was initially taken in evaluating the event in order to ensure compliance with the specified time periods established in the regulations. A reanalysis calculated keff less than the keff safety limit in NRC License SNM-42.

Although the facility was in a state that was not analyzed, was improperly analyzed, or is different from that analyzed in the Integrated Safety Analysis, the performance requirements of 10 CFR 70.61 were maintained. In accordance with 10 CFR 70.61 (b) and FCSS Interim Staff Guidance-12, although an IROFS was lost, the situation did not pose a safety concern that is significant enough to report to NRC. Other IROFS were available at the time of discovery of the condition to ensure the risk of a criticality remained highly unlikely. In addition, the calculated keff using an approved approach described in Section 5.2.2 of NRC License SNM-42 demonstrates compliance with 10 CFR 70.61 (d). The system remained subcritical, including use of an approved margin of subcriticality for safety, during a credible abnormal condition.

Therefore, in accordance with the guidance of FCSS ISG-12, Rev 0, '10 CFR Part 70, Appendix A - Reportable Safety Events,' B&W is correcting Event Notification #48091 in accordance with 10 CFR 70.74(a)(4) and withdrawing the 10 CFR 70, Appendix A, (b )(1) notification.

The licensee notified the NRC Resident Inspector. Notified the R2DO (Ernstes), NMSS (Stablein), and the Fuels Group OUO (via e-mail).

Contact the Headquarters Operations Officer for additional details on this event.

AGREEMENT STATE REPORT - UNDERDOSE DURING A YTTRIUM-90 THERASPHERE TREATMENT

The following information was provided by the Ohio Bureau of Radiation Protection via e-mail:

"A written directive was given for a patient to receive 115 mCi of Y-90 TheraSpheres microspheres.

"During the delivery of the microspheres, stasis occurred before the full quantity of the written directive delivered. The licensee did not expect to reach stasis, and will be sending the delivery system to the manufacturer after the remaining Y-90 decays to verify that there was not an equipment malfunction. The licensee calculates that the patient received 68.6 mCi, which is only 60% of the written directive (a 40% underdose). The written directive did not indicate include the phrase 'or until stasis'.

"The licensee has notified the attending physician. The licensee will be contacting the patient's physician prior to contacting the patient.

"The licensee states that there are no adverse effects to the patient. No corrective action is planned at this time.

"Event Discovered: July 11, 2012 at 11:00 am
Event Date: July 10, 2012 at 5:00 pm

"Reporting criteria - medical event
OAC 3701:1-58-101(a)(1)(a)
10 CFR 35.3045(a)(1)(i) "

Ohio Event Report #2012-017

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.

INVALID GROUP 5 ISOLATION DUE TO FAILED TEST SWITCH DURING SURVEILLANCE

"At 0236 CDT on Tuesday, July 10 2012, the Dresden Nuclear Power Station (DNPS) U3 Isolation Condenser System automatically isolated due to a inadvertent partial Group 5 Primary Containment Isolation System (PCIS) isolation, causing the inboard isolation valves to close. The PCIS isolation was caused during the performance of DIS 1300-07, 'U3 Isolation Condenser Steam/Condensate Line High Flow Calibration,' due to a failed test switch. The test switch failed to bypass the PCIS signal generated during the surveillance. All valves responded as expected due to this condition.

"The isolation condenser was declared inoperable and Technical Specification 3.5.3, Condition A was entered. HPCI was verified to be operable to satisfy the requirements of TS 3.5.3, Condition A.2. This condition is reportable under 10 CFR 50.72(b)(3)(v)(B) due to a condition occurring that could have prevented fulfillment of a safety function needed for residual heat removal."

The licensee notified the NRC Resident Inspector.

WRONG APPLICATOR USED IN PROCEDURE PREVENTING PATIENT FROM RECEIVING PROPER DOSE

"The RSO received a phone call from the physicist who explained she incorrectly connected the HDR unit during a patient treatment. She explained how she connected a transfer tube to the endobronch catheter, when she should have connected the endobronch catheter directly to the HDR unit. This would add about 1 meter of distance between the intended treatment site and the HDR unit source.

"It was determined that the source exited the HDR unit, but never made it to the patient. This was confirmed by a repeat test/reproduction with a dummy patient/setup in the exact format the patient treatment was performed. It was clear from observing this set up a mistaken addition of about 1 meter of transfer tube was added and that the source did not make it to the patient treatment site, or to the patient at all, and instead would be within the endobronch catheter potentially exposing a portion of patient skin (confirmed not to be in direct skin contact). We then placed a farmer chamber, a MOSfet and an Ion chamber in locations where we determined would be the highest possible patient skin dose measurements. We determined the highest potential skin dose to be 1.8cGy/1.8rem (significantly below the 50rem medical event definition) to the patient arm/shoulder area, however due to a folded blanket that was placed in that location it prevented direct skin contact.

"The hospital staff has changed policy as of today, to include a time out for the physicist to verbally voice the assurance to the in room nurse of proper connection to the HDR unit. They are planning an education process for their nursing staff so they may visually assist as a secondary visual confirmation. They are also reassessing additional support staff to be present during HDR treatment in a future meeting. The RSO believes the error happened due to human error, and a rushed procedure that occurred at the end of the day.

"The hospital staff is assessing the patient for potential skin burns both now and in the future (2wk, 5wks for reassessment). They do not expect to see skin burns, but will perform this patient skin burn assessment for assurance and to confirm our lower dose skin estimates. They intend on completing the patient treatment and therefore will complete this written directive dose which was scheduled for 500cGy, based upon the medical consult with the Radiation Oncologist. We are in process of follow-up with the patient, and referring physician."

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.

LOSS OF ERDS DUE TO COMMUNICATIONS NETWORK MODULE FAILURE

"A 'Communications Network Module' failed rendering the Emergency Response Display System (ERDS) incapable of transmitting data to the NRC. ERDS is out of service for both Unit 1 and Unit 2. Should an emergency be declared during this period, the Control Room will continue to have the capability to retrieve plant data inputs to assess plant conditions and perform core damage assessment. Control Room Emergency Response Organization personnel will use backup methods already captured in emergency response procedures to disseminate plant parameter data to the effected emergency response facilities and NRC during the plant data network outage. The module was removed from service and ERDS was restored at 2325 [EDT]."

The licensee will notify the NRC Resident Inspector.