Event Notification Report for August 02, 2012

DISCOVERY OF AFTER-THE-FACT EMERGENCY CONDITION (UNUSUAL EVENT)

"This is a one-hour report for the discovery of a condition which met the Emergency Plan criteria for an emergency action level (EAL) declaration of an Unusual Event (UE). At 0320 hours on August 2, 2012, a flame was observed coming from a hydrogen vent pipe on the Turbine Building roof. At 0519 hours the hydrogen supply from the hydrogen storage facility was secured and the flame was extinguished. At 1109 hours, a detailed review of the event determined that the emergency plan criteria for declaration of an Unusual Event existed due to a flame greater than 15 minutes in the Protected Area. This report is being provided within one hour of the discovery of the undeclared event. As discussed in NUREG 1022, Revision 2, an actual declaration of an Unusual Event is not necessary. The basis for the emergency classification no longer existed at the time of discovery.

"The safety significance of this event is minimal. There was no known damage to plant equipment and no adverse effect to any plant safety systems. This event had no impact on the health and safety of the public."

The NRC Senior Resident Inspector has been notified, as well as the State and local governments.

AGREEMENT STATE REPORT - POTENTIALLY STOLEN MOISTURE DENSITY GAUGE

The following information was obtained from the State of Colorado via email:

"On Thursday August 2, at approximately 0840 MDT (Mountain Daylight Time) a portable gauge licensee (AG Wassenaar, Inc. License 212-01 Amendment 21) based in Denver, Colorado notified the Colorado Department of Public Health and Environment (CDPHE) Radioactive Materials Unit on-call duty officer that a gauge was missing and possibly stolen. The gauge had last been seen on Monday July 30 at 4:00 pm at the temporary work site. Upon returning to the office, the gauge user unlocked the box but became distracted and did not check-in the gauge. The gauge user then returned to his residence and parked his truck. The employee did not return to work until the morning of Thursday August 2nd, when he realized that the gauge was not in its case in the truck. The employee believes it may have been stolen from his residence on Tuesday night, however the licensee's employees are currently searching the residence, surrounding neighborhood, and last job site.

"The gauge involved was a Troxler model 3430 (gauge serial number 26071), containing 8 mCi of Cs-137 (serial #75-9099) and 40 mCi of Am-241:Be (serial #47-22450).

"The licensee was instructed to conduct a thorough search for the gauge in all known locations where it could be, and to also notify the local police should it not be found within the hour.

"Additional information and an incident report from the licensee is pending."

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

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

POTENTIALLY CONTAMINATED INDIVIDUAL TRANSPORTED OFFSITE

"A plant worker was overcome with heat and became unconscious while working in a non-contaminated area inside the Radiological Control Area. Onsite medical personnel determined the individual should be transported to an offsite medical facility for treatment. Radiation protection personnel were unable to fully verify the individual was not contaminated prior to transport to the offsite medical facility. Radiation protection personnel accompanied the individual to the medical facility, and while en route, completed the required surveys. No contamination was found.

"This report is being made in accordance with 10CFR50.72 (b)(3)(xii) for an event requiring the transport of a potentially radioactively contaminated individual to an off-site medical facility for treatment."

The licensee has notified the NRC Resident Inspector.

NON-WORK RELATED ONSITE FATALITY

"This is a non-emergency 4 hour informational notification to the NRC in accordance with the reporting requirements of 10CFR50.72(b)(2)(xi).

"At approximately 0900 on 8/02/12, a contract employee suffered a non-work related personal medical event and was transported offsite. The contract employee was pronounced deceased at a local hospital. A courtesy notification was made to OSHA at 1304."

The NRC Resident Inspector has been notified.

PATIENT RECEIVES UNDER DOSE

The following report was received via fax.

"Received report from the RSO on 2 Aug 2012 at approximately 1430 [EDT] hrs of a medical event that occurred on 1 Aug 2012. Two patients with similar procedures (mammosite) were being treated with an HDR [High Dose Rate]. First patient correctly treated, second patient treated with the same plan as the first. Second patient only under dosed by 0.5%. Their treatment plans were allegedly the same.

"Orlando office investigated licensee and found violation to be caused by operator error. Corrective action consists of a 'Time Out' to verify patient's name, plan, and treatment settings. Further action referred to the Office of Licensing and Materials, this office will take no further action on this incident."

The device is a Nucletron Microselection HDR; S/N 31591.

Florida Incident: FL12-061.

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.