Event Notification Report for February 26, 2013

UNUSUAL EVENT DECLARED DUE TO TOXIC GAS LEAK

"At 0900, the Brunswick Steam Electric Plant (BSEP) declared an Unusual Event due to a release of Freon from the 2A Turbine Building Chiller. The classification of the Unusual Event is based on Emergency Action Level (EAL) HU3.1, 'Toxic, corrosive, asphyxiant or flammable gases in amounts that have or could adversely affect normal plant operations.' Actions have been taken to secure the chiller and isolate the release of Freon; however, Freon continues to be released. The release is only affecting the area immediately surrounding the 2A Turbine Building Chiller. No other plant areas are being impacted.

"There is no impact on the health and safety of the public."

The licensee notified Brunswick Warning Point, Hanover Warning Point, State Warning Point and the NRC Resident Inspector.

Notified DHS, FEMA, DHS NICC and NuclearSSA (email).


* * * UPDATE AT 1555 EST ON 2/26/13 FROM ERIC WHITE TO S. SANDIN * * *

At 1545 EST on 2/26/13, Brunswick terminated their Unusual Event based on the fact that the entry conditions no longer existed. A temporary patch has been installed on the 2A Turbine Building Chiller and work is in progress to evacuate residual Freon from the chiller unit.

The licensee notified state and local agencies and the NRC Resident Inspector. Notified R2DO (Musser), IRD (Kozal) and NRR (Chernoff).

Notified DHS, FEMA, DHS NICC and NuclearSSA (email).

STATE AND LOCAL AGENCIES NOTIFIED OF INADVERTENT TRITIUM RELEASE DUE TO OVERFLOWING SUMP

"On February 25, 2013 at approximately 1030 CST, plant personnel discovered that a sump within a concrete berm area adjoining the condensate storage tank was overflowing. Water from the sump was entering an open excavation within the berm, and was soaking into the dirt underneath. At approximately 1400 [CST] that day, the sump level was pumped down to terminate the overflow. A portable tank has been staged in the area should any further pumping be required.

"Analysis of the water within the berm found tritium activity of 1.135 million picocuries per liter. Additionally, total gamma activity of 1.145 E-6 microcuries per milliliter was present in the sample. The estimated volume of water reaching the open excavation was approximately 380 gallons.

"Notification of this event has been made to local and state governmental agencies in accordance with NEI 07-07, Industry Ground Water Protection Initiative. The initial notifications were made at approximately 1430 CST today.

"This event is being reported in accordance with 10CFR50.72(b)(2)(xi) as a condition for which local and state governmental agencies have been notified. The station has also notified the NRC Resident Inspector, as well as NRC Region 4 personnel."

LOSS OF ASSESSMENT CAPABILITY DUE TO VITAL INVERTER MAINTENANCE

"At approximately 1630 PST on February 26, 2013, Pacific Gas & Electric (PG&E) will be performing repairs on a vital inverter. The clearance will remove power from various inputs to the Safety Parameter Display System (SPDS), Emergency Response Data System (ERDS), and Emergency Response Data and Recall Recorder Subsystem (ERFDS).

"PG&E expects to have the equipment repaired and returned to service within 12 hours. During this time, a dedicated licensed operator will be available to provide plant data to the NRC's Emergency Operations Center.

"DCPP is making this 8-hour, non-emergency notification under 10 CFR 50.72(b)(3)(xiii) as any event that results in a major loss of emergency assessment capability, offsite response capability, or offsite communications capability."

The licensee notified the NRC Resident Inspector.

RELAY BACKING PLATE FASTENERS DISCOVERED TO BE AT LESS THAN SPECIFIED TORQUE

"During a follow-up review of off-site testing of a sample of General Electric model HFA relays, it was discovered that some of these relays did not pass testing for full qualification in their as-found condition. Additional torquing of the relay backing plate mounting screws was required to fully meet the required qualification. Further investigation into the as-found condition of these relays installed in the plant continues at this time. The relays in question are installed in Engineered Safeguards Features, Auxiliary Feed Water, and 4160 volt systems and are used in protective and actuation functions. "

The licensee has notified the NRC Resident Inspector.

MANUAL REACTOR TRIP DUE TO EXCESSIVE REACTOR COOLANT PUMP SEAL LEAKOFF FLOW

"At 2302 EST, Vogtle Unit Two was manually tripped in response to excessive Reactor Coolant Pump #4, seal #1 leakoff flow. Seal leakoff flow exceeded the procedural limits for continued operation of the pump. Following the reactor trip, RCP #4 was shutdown per procedure guidance.

All systems operated correctly in response to the reactor trip. All control rods fully inserted. The Auxiliary Feed Water (AFW) system automatically actuated as expected. System responses allowed for an uncomplicated reactor trip response. The plant is stable in Mode 3 during cause investigation.

"The NRC Senior Resident was notified and is enroute to the plant for investigation."

AFW is supplying the steam generators and decay heat removal is to the condenser via steam dumps. No safety valves or relief valves lifted during the transient. The unit is in a normal post-trip electrical line-up. There was no impact on Unit One.

SEWAGE SPILL IN THE TURBINE BUILDING THAT DISCHARGED TO THE KEOWEE RIVER

"On 2/26/13 at 2030 hrs [EST], a four (4) inch sewage line in the Oconee Nuclear Station turbine building failed. This failure allowed sanitary wastewater to spill into the turbine building basement. An estimated 750 gallons entered into trench drains and traveled to the station sump which discharges into the conventional wastewater system. This conventional wastewater system is discharged to the Keowee River from NPDES (National Pollutant Discharge Elimination System) outfall 002. The discharge of outfall 002 is into the Keowee River below the Keowee Hydro Station. The normal discharge path for sanitary wastewater is to the City of Seneca, South Carolina (SC). South Carolina Department of Health and Environmental Control (SCDHEC) and the Oconee Joint Regional Sewer Authority (OJRSA) were notified of the spill on 2/27/13 at approximately 1358 hrs [EST].

"Note: SCDHEC requires the reporting of any overflow that reaches waters of the state, for overflows that exceed an estimated 500 gallons that don't reach water, and for any overflow that may cause a public health or environment concern.

"This event was determined to be reportable pursuant to 10CFR50.72(b)(2)(xi) due to notification of the SCDHEC and OJRSA.

"Initial Safety Significance: The sewage leak did not contain any plant produced radiological material and due to dilution, this event posed no safety risk with respect with respect to the health and safety of the public.

"Corrective Actions: The affected portions of the sanitary sewage system has been isolated and an investigation is underway to determine the cause. There was no impact on plant operations, and the cleanup has been completed. The event was entered into the correction action program.

"The licensee notified the NRC Resident Inspector."

POTENTIAL LOSS OF BRACHYTHERAPY SEEDS

On 2/25/2013, four Mick applicator kits with fifteen I-125 seeds in each applicator kit (60 seeds total) were shipped to the Dameron Hospital in Stockton, CA. Each seed contained 0.45 milliCuries. On 2/26/2013, 49 seeds were implanted with one seed jamming in the applicator. After the medical procedure, the radiologist stated that only 50 seeds were in the applicators i.e. ten missing. Surveys were performed but the missing seeds could not be found. The jammed seed is being returned to Biocompatibles.

* * * UPDATE AT 0748 EDT ON 3/20/13 FROM RICHARDSON TO HUFFMAN VIA FACSIMILE * * *

The following detailed event text was received from the licensee (Biocompatibles, Inc.) via fax:

"Biocompatibles, Inc. ('Biocompatibles') has investigated a report that ten (10) I-125 sources (0.450 mCi each Ref date 2/26/13) that Biocompatibles sent to Dameron Hospital in Stockton CA (the 'Hospital') are unaccounted for.

"On February 26, 2013, Biocompatibles received a report that at the end of an implant procedure for which Biocompatibles provided (60) sealed sources in four (4) Mick magazines of fifteen (15) sources each that:

* Forty-nine (49) sources were implanted in the patient
* One (1) source had jammed in the Mick Applicator and had been retained by the Hospital
* Ten (10) sources were unaccounted for at the end of the procedure

"A Biocompatibles sales representative was present during most of the procedure performed on February 26, 2013 and reported that there was no indication that there were not four (4) full magazines of (15) sources each at the start of the procedure. In addition, the Hospital has confirmed that the decision to implant forty-nine (49) sources was made by the operating physician at the time of the surgery.

"Several communications led Biocompatibles to believe that the sources were accounted for at the Hospital, but on March 13, 2013, a conversation with relevant personnel confirmed that the Hospital did not have the sources.

"Biocompatibles received the sources from its Supplier on February 19, 2013, and loaded all sources received into four (4) magazines on the same day. Biocompatibles' production records confirm that Biocompatibles received sixty (60) sources from its Supplier (OPSRAD SOP09-01), and subsequently confirmed with its Supplier that exactly sixty (60) sources were sent to Biocompatibles. Biocompatibles verified the source counts at magazine loading. Biocompatibles also performed Ludlum meter surveys for line clearance after both the assay (OPSRAD SOP09-02) and loading operations (OPSRAD SOP09-03) to ensure that no sources had been left behind. A final inspection (OPSRAD SOP09-04), performed by the Biocompatibles Quality Department, verified that the magazine plunger heights on the four (4) full magazines were identical, indicating fifteen (15) sources per magazine. After all of these quality control measures took place, all sixty (60) sources were sent to the Hospital.

"Biocompatibles delivered a sterile Applicator Kit (Case 75152), containing four (4) Mick magazines of fifteen (15) sources each, for a total of sixty (60) sources, to the Hospital on February 25, 2013. The lot number for the I-125 sealed sources was Lot 2013-24638.

"When first notified by the Hospital on February 26, 2013 of the possible issue, the Biocompatibles Radiation Lab performed additional meter surveys. Biocompatibles performs production station surveys at the completion of each production operation, and performs meter surveys of the entire facility at shift end. All surveys performed on February 26, 2013 through March 13, 2013 have not identified any misplaced seeds.

"The empty Supplier vial and pig used to deliver the sources to Biocompatibles was shipped to the Hospital with the case in question. Biocompatibles has requested all empty packing associated with the case to be returned to Biocompatibles for further investigation."

Notified R1DO (Trapp) and R4DO (Werner). ILTAB and FSME Events Resource notified via e-mail.


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

MEDICAL EVENT INVOLVING DELIVERED DOSE EXCEEDING PRESCRIBED DOSE >20%

During a review of post implant dosimetry for prostate cancer treatment at 0800 hours [MDT] on 4/02/13, it was discovered that a patient received 145 gray vice 110 gray prescribed as a "boost" treatment. The prescribing physician will inform the patient and consult with the urologist. The error occurred due to not taking into account that the prescribed dose was a "boost" to the previously delivered 45 gray on 2/14/13, and used the default value of 145 gray for initial treatment. The physician is evaluating any potential adverse consequences for the patient.

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.