Event Notification Report for July 08, 2014

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following information was received via fax:

"On July 9, the licensee's radiation safety officer called to report a potential medical event had occurred the previous afternoon. The Agency was advised that an interstitial treatment could not be completed involving a High Dose Rate afterloader (HDR) at the University of Illinois at Chicago. As a result of safety features built into the HDR's programming, the first fraction of a four fraction treatment of 300 rad was automatically terminated and the source returned to the safe/stored position after only 6 rad had been delivered when unexpected resistance was detected in the source wire as it moved to the second dwell position. Subsequent attempts to clear the path and reinitiate the treatment were unsuccessful. As a result, an underdose of 98% of the fraction occurred. The HDR unit was subsequently re-run through its quality assurance tests for positioning accuracy with no anomalies noted. The patient was notified of the event immediately.

"A week before, the patient had 3 catheters surgically placed near the pelvis and their location relative to the treatment site verified by CT scan with an additional scan just before treatment was initiated. After reviewing the scan the written directive was modified to call for 18 dwell positions in three channels for a duration of 101 seconds. Four fractions were going to be completed on successive days. The scan suggested the possibility of the catheters being moved as a result of distention of some internal organs. Although the 'dummy' wire successfully traversed the initial path, and the active wire reached the first treatment position, after the initial 2 seconds of programmed dwell time, the HDR unit detected an unexpected delay in the wire moving to the second dwell position, presumably due to constriction of the pathway, and automatically retracted the active wire to the safe store position. With the assistance of the manufacturer's off site technical advisor, the error code was cleared and attempts were made to reinitiate the treatment however, the 'dummy' wire could not traverse the path and the treatment abandoned.

"In this instance the device performed as designed and subsequent quality assurance tests confirmed the device was operating as expected. Although no effect on the patient is expected from the event, physicians are determining what course of treatment options are available at this time. The licensee was advised of the requirement to submit a written report of the event in accordance with the regulations. Pending additional developments and submission of the report, this matter remains open for now."

The HDR Afterloader has a 5 Ci Ir-192 source and was being used to treat a cancer in the pelvic area.

Illinois Report Number: IL14011

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.

UNIT 2 SPRAY ADDITION DECLARED INOPERABLE DUE TO TANK INDICATION GREATER THAN 67%

"At 0024 CDT on 7/8/2014, Unit 2 Spray Addition was declared inoperable and LCO 3.6.7 (Spray Additive System) not being met, which resulted in a condition reportable pursuant to 10CFR50.72(b)(3)(v)(D). The inoperability was caused by Unit 2 Sodium Hydroxide Tank level indication greater than 67%, at 67.5%. This exceeds a current Prompt Operability Determination compensatory action requirement stating 'level shall be maintained no higher than 67%.'

"At 0104 CDT on 7/8/2014, Unit 2 Sodium Hydroxide Tank level was restored to an acceptable level, less than 67%. TSAC 3.6.7B was exited and LCO 3.6.7 met."

The licensee informed the NRC Resident Inspector.

* * * RETRACTION PROVIDED BY BRADLEY DERINGTON TO JEFF ROTTON AT 1710 EDT ON 09/05/2014 * * *

"Point Beach is retracting EN# 50262 made on July 8, 2014 at 0628 CDT. The Operability Determination for this condition has been revised based upon engineering analysis. The event notification is being retracted based upon the subsequent Operability Determination revision that shows the NaOH Injection System was capable of performing its safety function at an observed Spray Additive Tank level of no higher than 77.2 percent."

The licensee has notified the NRC Resident Inspector.

Notified R3DO (Lipa).

UNUSUAL EVENT DUE TO SMOKE ALARM INSIDE CONTAINMENT

"Unusual Event declared at 0935 EDT on July 8, 2014 due to a single fire alarm in containment. ELA HU4. No abnormal condition or plant impact at this time. The plant remains stable at 100% power."

A single smoke detector inside containment alarmed at 0925 EDT. There are no other indications of smoke or fire at this time. Adjacent smoke detectors are not in alarm. A containment entry team is being assembled to verify that there is no fire inside containment. The smoke detector alarm cleared at 1006 EDT.

The licensee notified the NRC Resident Inspector. The licensee will make appropriate notifications to state and local government agencies.

Notified DHS, FEMA, and NICC via email and phone. Notified FEMA NWC and Nuclear SSA via email.

* * * UPDATE FROM CHARLIE STEENBERGEN TO VINCE KLCO ON 7/8/14 AT 1419 EDT * * *

"The Unusual Event was terminated at 1328 EDT on 7/8/14. A containment entry was performed and no indications of a fire existed. The fire alarm was spurious and the detector has been disabled. There was no notification of other government agencies and there is no media /press release planned."

The plant maintained stable operations at 100% power.

The licensee notified the NRC Resident Inspector, the state of Ohio and local officials.

Notified R3DO (Hills) NRR EO (McGinty), IRC MOC (Grant). Notified DHS, FEMA, and NICC via email and phone. Notified FEMA NWC and Nuclear SSA via email.

OFFSITE NOTIFICATION DUE TO DIESEL FUEL OIL LEAK

"At 1148 EDT, Fermi-2 Environmental Engineering identified that approximately 2500 gallons of Diesel Fuel Oil was noted to be in a secondary containment collection basin. The Control Room Staff was subsequently notified. Michigan Pollution Control (MPC) has been contacted for cleanup.

"DTE Energy notified Michigan Department of Environmental Quality (MDEQ) of the condition.

"Fermi-2 is making this 4-hour report to the NRC in accordance with 10CFR50.72(b)(2)(xi) and NUREG-1022 (rev 3) Section 3.2.12.

"Investigation regarding the cause is currently in progress. No fuel oil was released to the ground or navigable waters.

"The NRC Resident Inspector has been notified."