Event Notification Report for September 20, 2012

LOSS OF EMERGENCY ASSESSMENT CAPABILITY DUE TO INOPERABLE SEISMIC MONITORING INSTRUMENTATION

"At 1240 CDT on 9/20/2012, Operations personnel determined that Browns Ferry Nuclear Plant had experienced a loss of assessment capability. The loss of assessment capability identified was due to not having functional seismic monitoring instrumentation during performance of a modification. The loss of seismic monitoring capability was determined to have existed from 8/17/2012 until 9/15/2012.

"The ability to declare an Unusual Event per Emergency Action Level 7.1-U or an Alert per Emergency Action Level 7.1-A could potentially be hampered by the unavailability of the seismic monitoring instrumentation, because the declarations would be based on personnel feeling an earthquake. In addition, the unavailability of the seismic monitoring instrumentation could potentially hamper the operators in determining the magnitude of an earthquake in order to determine if it reached Operating Basis Earthquake levels or Safe Shutdown Earthquake levels. Therefore, this event is being considered reportable as it results in a loss of emergency assessment capability. Compensatory measures were established on 9/15/2012 which restored assessment capability.

"This condition is reportable per 10CFR50.72(b)(3)(xiii). The NRC Resident Inspector has been notified."

TECHNICAL SUPPORT CENTER VENTILATION INOPERABLE

"At 2035 CDT on 9/20/2012 power was removed from the Technical Support Center ventilation for planned maintenance on the supply breaker and the supply breaker cubicle. At 2109 CDTduring restoration, it was discovered that the breaker for the Technical Support Center ventilation could not be closed.

"The cause for not being able to close the supply breaker is unknown. Troubleshooting is currently in progress and the Technical Support Center ventilation is expected to be returned to service on 09/21/2012.

"This event is reportable under 10 CFR 50.72(b)(3)(xiii) as described in NUREG-1022, Rev.2 since this work activity affects an emergency response facility."

The licensee has notified the NRC Resident Inspector.

AGREEMENT STATE REPORT - MISSING OHMART BETA GAUGE

The following information was provided by the State of Arkansas via email:

"While conducting an investigation of a citizen's allegation on September 20, 2012, the Department [Arkansas Department of Health] recovered a generally licensed device in a scrap yard in Dermott, Arkansas. The device is:

"Ohmart Beta Gauge: Model BAL
Gauge Serial Number: 3780BC
Isotope: SR-90
Activity: 25 millicuries

"This device was retrieved and transported to the Department's [Arkansas Department of Health] storage location in Little Rock at approximately 1800 CDT on September 20, 2012.

"Ohmart provided information concerning the shipment date (12/1994) and the location. The device was shipped to Burlington House Mill in Monticello, Arkansas. Ohmart also informed the Department [Arkansas Department of Health] that a second device had also been shipped with this source. The source holder serial number for this device is 3779BC.

"Health Physicists visited the old Burlington site after finding the device in the scrap yard in Dermott, Arkansas.

"Health Physicists returned on September 21, 2012 to the Monticello and Dermott areas to search in locations where the second device may have been disposed. At the time of this notification, the Department [Arkansas Department of Health] considers the second device to be missing.

"The Department [Arkansas Department of Health] has notified the Mississippi Department of Health.

"The Department [Arkansas Department of Health] is still investigating and searching for the missing device. An investigation is on-going to identify the possible owner of the devices.

"The Department [Arkansas Department of Health] considers this event open at this time pending the completion of the investigation."

Arkansas Incident Number AR-2012-009.

* * * UPDATE AT 1014 EDT ON 10/02/12 FROM ROBERT PEMBERTON TO S. SANDIN * * *

The following update was received from the State of Arkansas via email:

"On October 1, 2012, while conducting a follow-up investigation of allegation ARK-2012-009, the Department recovered the second generally licensed device originally shipped to the Burlington House Mill in Monticello, Arkansas. The device is described as follows:

Manufacturer: Ohmart
S.O. : AR940603068A
Source Holder: BAL
Source Serial Number: 3779BC
Isotope: Sr-90
Activity: 25 mCi
Date 12/94

"The device was retrieved from property on East Calhoun Street, Monticello, Arkansas and transported to the Department's storage vault in Little Rock.

"The device housing was not damaged and preliminary wipes of the device showed no removable contamination.

"An investigation is on-going to identify the possible owner of the devices.

"The Department considers this event open at this time pending the completion of the investigation."

Notified R4DO (Powers), FSME RESOURCE and ILTAB via email.

* * * UPDATE FROM THE ARKANSAS DEPT. OF HEALTH VIA FAX ON 11/9/12 AT 1530 EST * * *

"On November 9, 2012, both recovered sources were picked up for disposal from the Department's storage vault in Little Rock Arkansas. Neither source has been found to be leaking.

"The Department has completed its investigation and considers this event closed."

Notified R4DO (Farnholtz) and FSME Resources email.


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

CREMATORY CONTAMINATED DUE TO MEDICAL IMPLANT

The following information was provided via facsimile transmission:

"The Wisconsin Department of Health Services (DHS) received a phone call from the Radiation Safety Officer (RSO) at the University of Wisconsin-Madison informing them that the university had received a phone call from a funeral home that had just cremated remains of a person who had received an I-125 lung mesh implant. The implant was put in the patient on September 13, 2012 at the University of Wisconsin-Madison hospital. The patient was implanted with a lung mesh with 40 seeds totaling 23 mCi. The funeral home received a phone call during the cremation, from a family member notifying them that the person had received a radiation treatment a few weeks prior to the cremation. The cremation took place on September 20, 2012. After the cremation was completed, the crematory remained closed until DHS inspectors arrived. DHS conducted an investigation on September 21, 2012. Radiation readings inside the crematorium were 0.75 mR/hr with a Victoreen, Model 451 (#199588, calibrated on 1/20/2012). The cremains read 3.8 mR/hr on contact with a plastic bag. They have placed the cremains in a concrete container and radiation levels were at background on the outside of the container. No other areas of the facility were contaminated. The facility has agreed to suspend the operations until clean-up."

* * * UPDATE FROM KUHLMAN TO KLCO ON 10/8/2012 AT 1012 EDT* * *

The following corrected information was received by email:

The State of Wisconsin made the clarification that the funeral home received notification from an authorized medical physicist from the University of Wisconsin-Madison.

Notified the R3DO(Valos) and FSME via email.

Wisconsin Event Report ID No.: WI120013

AUTOMATIC SCRAM AND HIGH PRESSURE COOLANT INJECTION SYSTEM INITIATION

"On September 20, 2012 at 0923 EDT, Nine Mile Point Unit 1 experienced an automatic reactor scram due to a turbine trip at power. The cause of the turbine trip is currently under investigation. All control rods fully inserted and all plant systems responded per design following the scram.

"Following the automatic scram, the High Pressure Coolant Injection (HPCI) System automatically initiated as expected. At Nine Mile Point Unit 1, a HPCI System actuation signal on low Reactor Pressure Vessel (RPV) level is normally received following a reactor scram, due to level shrink. HPCI is a flow control mode of the normal feedwater systems, and is not an Emergency Core Cooling System. At 0924 EDT, RPV level was restored above the HPCI System low level actuation set point and the HPCI System initiation signal was reset. Pressure control was established on the Turbine Bypass Valves, the preferred system. No Electromatic Relief Valves actuated due to this scram.

"Nine Mile Point Unit 1 is currently in Hot Shutdown, with reactor water level and pressure maintained within normal bands. Decay heat is being removed via steam to the main condenser using the bypass valves. The offsite grid is stable with no grid restrictions or warnings in effect. One 115kv off site power source (Line 4) is unavailable for planned maintenance at the James A Fitzpatrick Nuclear Power Plant. Both Reserve Station Transformers are in service and being supplied by the other 115kv offsite power source (Line 1). Both Emergency Diesel Generators are operable and in standby. The unit is currently implementing post scram recovery procedures."

The licensee has notified the NRC Resident Inspector. Licensee has notified the state.

AUTOMATIC REACTOR TRIP DUE TO REACTOR PROTECTION SYSTEM ACTUATION

"On September 20th at 1416 EDT, Three Mile Island automatically tripped due to a flux to flow imbalance as a result of a trip of the 'C' reactor coolant pump. The cause of the trip of the 'C' reactor coolant pump is still under investigation.

"The electrical grid is stable and unit 1 is being supplied by offsite power. All control rods have fully inserted. Decay heat is being removed by main feedwater flow to both steam generators that are exhausting via the normal main condenser cooling loop under manual control. Preliminary evaluation indicates that all plant systems functioned normally following the reactor trip, except for automatic operation of turbine bypass valve control due to failure of the automatic control function to control precisely at setpoint. Three Mile Island remains stable in hot shutdown mode while conducting the post trip review. No radioactive releases were experienced as a result of this event.

"This event is reportable under 10 CFR 50.72(b)(2)(iv)(B), Reactor Protection System (RPS) actuation, and under 10 CFR 50.72 (b)(2)(xi) due to an information release to local officials. Both are four hour reports.

"The licensee notified the NRC Resident Inspector."

The licensee has notified the state and local governments, and will be making a media release.

AGREEMENT STATE REPORT- PATIENT UNDEREXPOSURE USING YTTRIUM-90 THERASPHERES TREATMENT

New York City was notified by the licensee Radiation Safety Officer of a patient receiving an underdose of Yttrium-90 TheraSpheres for liver treatment. The prescribed dose was 120 gray, but only 11.4 gray was delivered to the patient. A review of the licensee's patient delivery system indicates that about 90% of the prescribed dosage remained in the catheter.

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.

AGREEMENT STATE - PATIENT BEING TREATED WITH Y-90 THERASPHERES RECEIVED ONLY 9.5% OF A TOTAL DOSE

The following report was received from New York City via email.

"Summary: Patient being treated with Y-90 Theraspheres received only 9.5% of a total dose of Y-90. The rest remained in the tubing.

"Details of the incident: A patient [at the NYC Mount Sinai Medical Center] was being treated with Y-90 Theraspheres. The target organ was the liver. Due to the need to access the liver via the radial artery in the arm, the angiocatheter was too short to connect to the delivery apparatus directly, thus requiring an extension tubing. The entire contents of the dose vial was emptied and flushed 4 times. It was discovered by the radiochemist [after the patient's treatment] that only 9.5% of the total dose was delivered. The rest remained in the extension tubing. [The prescribed dose was 120 Gy and the delivered dose was 11.4 Gy].

"Corrective action taken by the facility: More time will be taken to reposition the patient proximal to the delivery system. Also, the use of extension tubing will be avoided if possible. Policy and procedures will be updated to include when the use of extension tubing is allowed.

"Causes/Contributing Factors: Inadequate policy and procedures.

"RSO's review summarization: The failure to administer the correct dose to the patient was due to the addition of extension tubing. Because of the additional 40cm of IV tubing, which was used to bridge the distance between the Y-90 delivery system and the radial catheter, the intended dose remained lodged inside the extension. The additional flush used was not enough to push the dose through to the target."

The dose deviation was greater than 50%, and no additional patient testing or extended hospital stay was required. The patient and referring physician have been notified.

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.