Event Notification Report for July 19, 2012

AGREEMENT STATE REPORT - 15 PROSTATE BRACHYTHERAPY MEDICAL EVENTS

The following information was received via facsimile:

"On July 19, 2012, the licensee reported the identification of 15 medical events that were discovered on July 18, 2012, involving permanent implants of iodine-125 for prostate brachytherapy where the total dose delivered differs from the prescribed dose by 20% or more. During a recent inspection, DHS [Department of Health Services] inspectors determined that the licensee was not reviewing prostate brachytherapy cases against the medical event criteria. The licensee established dose based criteria used by post-operation CT, prostate D90 values <80% or >130% for classifying medical events. The licensee has evaluated all prostate implants performed since 2001.

"--Overdose to the prostate (medical event criteria used -D90>130%):
08/20/2009: 137.3%

"--Underdose to the prostate (medical event criteria used -D90<80%):
07/15/2005: 79.27%
03/13/2006: 79.17%
03/15/2006: 67.10%
07/26/2006: 72.35%
07/26/2006: 57.06%
02/13/2006: 78.37%
05/14/2009: 78.67%

"--Overdose to the rectum (medical event criteria used -V100>2cc):
12/13/2006: 2.42cc
12/19/2007: 2.23cc
03/03/2009: 2.54cc
07/08/2009: 3.32cc
11/19/2009: 2.89cc
05/05/2010: 2.41cc
05/20/2010: 3.92cc

"DHS inspectors conducted an investigation of these medical events and are awaiting completion of the licensee's review."

Wisconsin Event Report ID No.: WI120008

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.

TECH SPEC REQUIRED SHUTDOWN DUE TO INABILITY TO RESTORE MAIN STEAM ISOLATION AUTOMATIC ACTUATION LOGIC AND ACTUATION RELAYS WITHIN THE REQUIRED TIME

"At 1530 on July 19, 2012, operators commenced shutdown of DC Cook Unit 1 to comply with LCO 3.3.2, Condition I when the 6 hour time limit to complete Condition C Required Action could not be completed.

"At 0734 on July 19, 2012, operators identified that power had been lost to two of four Steam Generator Stop Valve Dump Valves (Dump Valves) on one of the two trains. DC Cook entered LCO 3.3.2 Condition B for Function 4a, manual initiation: 'restore required channel or train to operable within 48 hours.' DC Cook also entered LCO 3.3.2 Condition C for Function 4b, automatic actuation logic and actuation relays: 'restore required channel or train to operable within 6 hours.' Power was restored to one Dump Valve which was then declared operable at 1030. Efforts continue to restore power to the remaining Dump Valve.

"Enforcement Discretion was verbally granted by the Nuclear Regulatory Commission at 1736 on July 19, 2012 to begin at 1934 and end at 1934 on July 20, 2012. Upon receiving the Enforcement Discretion, the power reduction was stopped at 1738 at 50% power.

"This event is reportable under 10CFR50.72(b)(2)(i), 'The initiation of any nuclear plant shutdown required by the plant's Technical Specifications,' as a four (4) hour report. The DC Cook Sr. Resident NRC Inspector has been notified."

REACTOR PROTECTION SIGNAL ACTUATION DUE TO CHANGING MODE SWITCH POSITION DURING SURVEILLANCE TESTING

"During surveillance testing, the reactor mode switch was moved from the locked shutdown position and placed in the refuel position without the minimum required operable source range monitors per Limerick Generating Station Technical Specifications.

"Upon discovery of the issue, the reactor mode switch was returned to the locked shutdown position causing an expected but valid RPS actuation.

"No control rod motion occurred because all control rods were already inserted at the time of the event."

The licensee has notified the NRC Resident Inspector.