Event Notification Report for August 22, 2013

VIOLATION OF THE FITNESS FOR DUTY PROGRAM

A licensed employee had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.

The licensee informed the NRC Resident Inspector and will inform stakeholders at their scheduled meeting.

OFFSITE NOTIFICATION OF A FATALITY AT MILLSTONE UNIT 3

"On August 22, 2013, a contract worker was discovered unresponsive at Millstone Power Station in the plant's condensate polishing facility. The worker was transported offsite to a local hospital. At 1450 [EDT], the Millstone Power Station Unit 3 Shift Manager was informed the individual had been pronounced dead at the hospital.

"The cause of the fatality is under investigation. The injury does not appear to be related to industrial work activities. The person was not contaminated. Local law enforcement and other government agencies have been notified.

"OSHA is being notified of the event under the requirements of 29 CFR 1904.

"No press release is planned. This event is reportable pursuant to 10 CFR50.72(b)(2)(xi).

"The NRC Resident Inspector has been notified."

The woman was found at the bottom of a staircase at 1258 EDT.

UNIT 1 COMMENCED A TS REQUIRED SHUTDOWN DUE TO UNIDENTIFIED RCS LEAKAGE > 1 GPM

"Salem Unit 1 has initiated a unit shutdown in accordance with TS (Technical Specification) Action Statement 3.4.6.2(b) for unidentified leakage greater than 1 gpm [gallon per minute] (Entered on 8/22/13 at 1029 EDT). TS 3.4.6.2 Action Statement (b) requires a reduction of leakage rate to within limits within 4 hrs. or be in at least Hot Standby within the following 6 hours. Initial investigation has indicated that the leakage source is from packing on Pressurizer Spray Valve 1PS1 located in the RCS [Reactor Coolant System] Pressurizer shroud area inside Containment. Unidentified leakage is currently indicating 4 gpm. NRC Resident [Inspector] has been notified. Manual isolation is in progress.

"Additionally, TS Action Statement 3.6.1.4 Primary Containment Internal Pressure was entered at 1510 [EDT] for exceeding 0.3 psig. Action requires restoration of containment pressure to within specification in 1 hour or be in hot standby within the next 6 hours. Containment pressure was restored to less than 0.3 psig at 1647 [EDT] and TS 3.6.1.4 was exited. Peak containment pressure reached [was] 0.33 psig.

"Location of leak: Unit 1 RCS (containment), Pressurizer, 1PS1 Pressurizer Spray Valve Packing
"Time & date leak started: 1019 [EDT] on 08/22/2013
"Leak rate: 4 gpm, T/S leak limits: 1 gpm
"Last known coolant activity: Primary (DEI [Dose Equivalent Iodine]-microCuries/cc) 5.973E-5 microCuries/cc
"Secondary (gbg [Gross Beta Gamma]-microcuries/cc) < LLD [Lower Limit of Detectability]
"Was this leak a sudden or long-term development? Sudden"

The licensee is reducing power at 30%/hour and anticipates entering Mode 3 in approximately 3 hours. The 1PS1 Pressurizer Spray Valve was replaced and the air operator rebuilt during the last refueling outage in April/May of 2013.

The licensee informed the State of New Jersey and will 9inform the Lower Alloways Creek [LAC] Township.

REACTOR PROTECTION ACTUATION (SCRAM)

"On Thursday, August 22, 2013 at 0755 hours [EDT], with the reactor critical at approximately 98% core thermal power, and the mode switch in RUN, a manual reactor scram was inserted due to lowering reactor water level. The cause of the lowering reactor water level was due to the trip of all three Feedwater Pumps. The cause of the Feedwater Pump trip event is currently under investigation.

"Following the reactor scram, all control rods were verified to be fully inserted. All 4kV busses transferred to the Startup Transformer as designed. Following the scram the reactor water level lowered to +12 inches initiating the Primary Containment Isolation System (Group II, Reactor Building Isolation System (RBIS); and Group VI - Reactor Water Cleanup System) automatically as per design.

"Reactor water level lowered to -46 inches initiating Primary Containment Isolation System Group I - Main Steam Isolation Valves (MSIVs); Emergency Core Cooling Systems (ECCS) actuated which included automatic start and injection of the High Pressure Coolant Injection (HPCI) System and the Reactor Core Isolation Cooling (RCIC) System and an automatic start of the Emergency Diesel Generators as designed. Reactor water level was promptly restored to normal level.

"Currently a cooldown is in progress with reactor pressure is being maintained by the HPCI System operating in the pressure control mode and reactor water level is being maintained by the RCIC System. Reactor Water Clean-up System and normal reactor building ventilation have been restored. Off-site power is being supplied to the station by the Start-up Transformer (normal power supply for shutdown operations).

"This event had no impact on the health and/or safety of the public. The USNRC Senior Resident Inspector has been notified. This 4-hour notification is being made in accordance with 10 CFR 50.72 (b)(2)(iv)(A) and (B)."

The plant is transferring from decay heat removal to the torus to decay heat removal to the main condenser. Reactor pressure is 371 psig.

Initial indications are that a main feedwater power supply breaker tripped.

ALCOHOL FOUND IN THE RESTRICTED AREA

"The following significant FFD policy violations and programmatic failures must be reported to the NRC Ops Center within 24 hours by telephone after the licensee or other entity discover the violation.

"(1) The use, sale, distribution possession or presence of illegal drugs, or the consumption or presence of alcohol within a protected area.

"Ours [licensee] is a conservative decision to notify due to the fact that the contraband was found in the restricted area and NOT in the protected area.

"On 8/22/13 at approximately 1300 hours, an employee conducting demolition work on the 542 level of the Auxiliary Building discovered an old dust covered pint glass bottle of Jim Beam Bourbon Whiskey containing approximately 1 inch of brown liquid which, when opened, smelled of alcohol. The bottle was located in bus trays 12 to 15 feet above the floor. The employees retrieved the bottle and handed it to an individual on the ground. Radiation Protection [RP] personnel bagged the bottled due to it being in a contaminated area. The bottle was surveyed by RP and released to Security. The bottle was removed to the FFD Office and the liquid was disposed of in the toilet. The glass bottle was then disposed of offsite."

The licensee will notify the NRC Resident Inspector.

AGREEMENT STATE REPORT - THERAPY DOSE APPLIED TO WRONG LOCATION

The following report was received via e-mail from the Louisiana Department of Environmental Quality:

"On 08/27/2013, the RSO for Tulane University Hospital called to notify the Department that their facility had a Medical Event involving [exposure to unintended tissue greater than] 50 Rem. The event was discovered on 08/27/2013 when an application was not able to be applied to the intended tissue. The HDR source had 'dog legged' into the bowel area when it was intended to apply the radiation dose to the cervical area. The films were pulled for the application on 08/22/2013 and revealed that the application had 'dog legged' also. The cervical tissue did not receive the initial intended dose.

"The HDR [High Dose Rate Brachytherapy Afterloader] unit was a Nucletron Micro-Selectron, loaded with [an] Ir-192 [source]. The therapy dose was 8.4 Gray [840 rads] given in fractions. The patient is to receive the entire corrected therapy dose prescribed.

"This is believed to be (under investigation) a positioning problem and not an equipment malfunction.

"The patient's physician has been notified. However, the patient was heavily sedated and has not been notified.

"Updates will be made when additional information is available."

Louisiana Report ID: LA-130001

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 REPORT - MISSING BRACHYTHERAPY SEED

The following was received by the Commonwealth of Massachusetts via fax:

"On 8/22/2013, Brigham and Women's Hospital (BWH) was involved in a discrepancy in the contents of a shipment of I-125 brachytherapy seeds. The shipment was labeled to contain 71 seeds (as ordered), plus 4 seeds to be used for QC purposes. Upon opening, in preparation for administration, a count of the sources revealed only 70 of the 71 expected therapy seeds.

"Immediate recount and subsequent survey & investigation of the area, packaging and container showed no indication of the presence of the 71st seed. There was also no evidence of contamination detected.

"BWH does not believe the 71st seed was delivered.

"Meanwhile, the supplier, Bard Brachytherapy, Inc.'s (BBI) investigation indicates that the 71st seed was shipped to BWH.

"The expected 71st seed was a Bard Brachytherapy, Inc., model 125I containing 0.561 mCi (with an apparent activity of 0.330 mCi), with a reference date of 8/17/2013."

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