Event Notification Report for September 13, 2011

24-HOUR REPORT INVOLVING POTENTIAL FAILURE TO MAINTAIN DOUBLE CONTINGENCY CRITERIA

"As part of the ongoing GNF-A Fuel Manufacturing Operation (FMO) Integrated Safety Analysis (ISA) project, reviews of documentation for scrap accumulation hoods were performed that identified procedural actions that were different than described in the criticality safety analysis. It was determined at approximately 2:45 PM on September 13, 2011 that uranium mixed with small amounts of moderator were not prevented from movement into these hoods. This resulted in a condition where the moderation criticality control documented as being necessary to meet double contingency may not have been maintained. The other criticality control on geometry was maintained at all times.

"At no time was an unsafe condition present, however the accumulation hoods were shut down until necessary controls were available. Additional corrective actions and extent of condition are being evaluated.

"This event is being conservatively reported pursuant to GNF-A internal procedure reporting requirements within 24 hours of discovery."

The licensee will inform state and local agencies and the NRC Region II Office of this incident.

LOSS OF TECHNICAL SUPPORT CENTER VENTILATION

"VA-106, TSC HVAC Unit VA-107 Rooftop Condensing Unit, tripped off and attempts to restart were unsuccessful. The cause of VA-106 tripping is unknown at this time. Troubleshooting is in progress.

"This condition renders the Technical Support Center unavailable for Emergency Planning Responses. Approved compensatory actions are to relocate personnel to alternate facilities if required. This condition is being reported pursuant to 10 CFR 50.72(b)(3)(xiii) for Loss of Emergency Preparedness Capabilities."

The licensee informed the NRC Resident Inspector.


* * * UPDATE FROM ERICK MATZKE TO DONALD NORWOOD AT 1245 EDT ON 9/16/2011 * * *

"TSC ventilation troubleshooting has been completed and the system was determined to be functional today, September 16, 2011 at 1115 CDT."

The licensee notified the NRC Resident Inspector.

Notified R4DO (Pick).

FITNESS FOR DUTY REPORT INVOLVING A NON-LICENSED SUPERVISOR EMPLOYEE

A non-licensed employee supervisor had a confirmed positive drug test during random testing. The employee's access to the plant has been terminated. Contact the Headquarters Operations Officer for additional details.

The licensee informed the NRC Resident Inspector.

AGREEMENT STATE REPORT INVOLVING A TRACTOR-TRAILER INCIDENT WHILE TRANSPORTING NUCLEAR GAUGES

The following report was received from the State of Georgia via fax:

"Location of Event: I-20 EB near Six Flags Road (near exit 46)

"A tandem tractor trailer carrying 8 Troxler moisture-density gauges overturned at [about 2330 EDT] on 9/12/2011 after hitting the guardrail. Gauges were en route from Alexandria, LA to Cleveland, TN to be calibrated.

"County HAZMAT arrived on the scene, assisted by GA Environmental Radiation Program personnel (paged by GEMA at [0047 EDT], 9/13/2011). All 8 shipping containers sustained damage. Seven (7) gauges were intact in the shipping containers. One (1) gauge sustained damage: electronic components were separated from the gauge body, survey and wipe smear indicated shielding was still intact, no release of radioactive material.

"At [about 0445 EDT], 9/13/2011, a local Environmental Cleanup Company took temporary possession of the gauges and secured them at their facility. A representative from the calibration lab in Cleveland, TN will bring replacement shipping containers and repackage the gauges on 9/14/2011.

"Isotope: Cs-137; Am-241
"Amount of Activity: 8 mCi; 40 mCi (per gauge)

"Date of Event: 9/12-13/2011 (overnight)
"Date of Report to RCP (Radioactive Control Program: 9/13/2011, [0047 EDT]
"Describe clean-up actions taken by RCP: Performed area surveys and took wipes to confirm integrity of the gauges (no release of radioactive material)

"List radiation measurements taken by RCP:
"Background: 10 uR/hr
"Highest reading, outside trailer: 120 uR/hr
"Damaged gauge, contact: 50 mR/hr
"Damaged gauge, @1m: 50 uR/hr"

GA Incident No.: GA-2011-46i

National Response Center Incident No.: 989403

MEDICAL EVENT INVOLVING THE ADMINISTRATION OF THE WRONG RADIOPHARMACEUTICAL

At approximately 1000 HST a patient scheduled to receive an administration of 5 mCi In-111 for an imaging scan (Octreotide) received instead a 1.55 mCi Sr-89 injection. The Sr-89 dose, originally 4mCi, was expired (89 days) and administered unintentionally due to personnel error. The RSO calculates that the red bone marrow will receive a dose of 63 rem.

The patient was informed and is being monitored for changes in blood chemistry. The attending and prescribing physician will be informed.

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 - MEDICAL EVENT INVOLVING THE MISADMINISTRATION OF I-125 SEEDS IN A PROSTATE CANCER TREATMENT

The following was received from the state via e-mail:

"On Thursday, September 15, the Radiation Safety Officer (RSO) for the licensee called [the state] to make a preliminary advisement that a medical event involving a prostate cancer treatment had occurred at their facility. The treatment called for the placement of seventy one I-125 seeds in the prostate. As advised by the RSO, post implant imaging revealed only 3 seeds located in the target, indicating a dose under 20 percent of the prescribed amount in the written directive was likely. Post operatively, seven seeds were discovered to be in the bladder and were immediately removed. Additional post operative imaging indicated that a number of seeds were placed in bowel wall, bladder wall, and the lumen of the bowel.

"Subsequent to that initial notification, the licensee conducted additional imaging and reviews of the case in order to assess the dosimetry associated with the implant. The written directive called for 145 Gray to the target and allowed for up to 100% of the reference dose to the prostatic urethra and 150% of the dose to the rectum. Preliminary estimates are that the D90 to the prostate was 2.2 Gy. The dose to the prostatic urethra was 15.3 Gy and the dose to the rectum was 63.9 Gy. Due to the misplaced application of the seeds, doses to the large bowel (10 cc), small bowel (10 cc) and bladder are also believed likely to have occurred. Those doses are 49.19 Gy, 20.7 Gy and 23.8 Gy, respectively. All estimates provided were preliminary and subject to change.

"The patient and referring physician were advised of the event on the day following surgery. The patient was cautioned that due to seed placement, the sources may be passed in the patient's stool and/or urine. Imaging on September 15 suggested the patient in fact passed 8 seeds since the initial implant on September 13. (Additional passages would affect dose estimates.) The patient intends to attempt a second placement procedure at the licensee's facility in order to treat the cancer. Additional corrective measures and risks were also discussed with the patient.

"The licensee notes that two procedural items that have been consistent with other successful treatments at their facility were not in place during this event. Fluoroscopy was not used during needle placement and the benefit of the physical presence of a medical physicist was not used. The Agency [state] intends to conduct an on-site investigation to gather additional information related to the cause of this event and review the licensee's proposed corrective action as well as review additional cases conducted at the facility. The licensee was advised of the 15 day written reporting requirement. Pending submission of that report and the Agency's investigation, this item remains open."

Illinois Item Number: IL11126

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.

EARLY SITE PERMIT POSTULATED SEISMIC ACCELERATION IS LESS THAN PROJECTED BASED ON NEW INFORMATION

"On August 23, 2011, an earthquake occurred with an epicenter 11 miles from the North Anna Unit 3 site. Instruments recorded earthquake data at the North Anna Unit 1 containment structure base mat. Certified data regarding the earthquake was received on September 13, 2011 and a Condition Report was initiated. This best available earthquake data exceeded at low frequencies the Safe-Shutdown Earthquake (SSE) response spectra established in the North Anna Early Site Permit (ESP-003). The event data also exceeded the site 250 foot elevation Ground Motion Response Spectra (GMRS) and the hard rock SSE developed for the North Anna Unit 3 Combined Operating License Application (COLA) based on the ESP SSE spectra.

"The US-APWR standard plant (i.e., Reactor Building Complex and Power Source Building) Certified Seismic Design Response Spectra (CSDRS) envelops the actual seismic response recorded on August 23, 2011. However, the site-specific Seismic Category I Ultimate Heat Sink Related Structures, Essential Service Water Pipe Tunnel and Power Source Fuel Storage Vault use design inputs presented in the ESP. The recorded seismic response on August 23, 2011 exceeded the seismic design spectra presented in the ESP and COLA.

"As defined in 10 CFR 21, this condition represents a 'deviation' in the seismic design information contained in the ESP and a 'defect' in that it involves a 'basic component' that could result in a major design deficiency that has safety implications, if it were to remain uncorrected. Therefore, NRC notification of this condition is required pursuant to 10 CFR 21.21(d)(1). The basis for this conclusion is discussed in the following paragraph.

"In August 2007, the NRC amended the regulations applicable to the licensing and approval processes for nuclear power plants (e.g., ESP, COLA) to clarify various requirements, and made conforming amendments to other related regulations, including 10 CFR21. The discussion of changes to 10 CFR 21 (Federal Register / Vol. 72, No. 166, Page 49424) states that: 'services that are required to support an early site permit application (e.g., geologic or seismic analyses, etc.) that are safety-related and could be relied upon in the siting, design, and construction of a nuclear power plant, are to be treated as basic components as defined in part 21.' The discussion also states: 'if the ESP holder becomes aware of a significant safety concern with respect to its site (e.g., that the specified site characteristics for seismic acceleration is less than the projected acceleration due to new information), the concern should be reported to the NRC so that it may be considered in the review of any future application referencing the ESP.' Based on these statements of consideration, the analyses supporting the seismic design information in the ESP would be considered a 'basic component' and the recorded response data from the August 23, 2011 seismic event represents new information that impacts the seismic analyses.

"This defect resulted from new data, not an error in the performance of the seismic analyses for the ESP. While there was no error in the performance of the seismic analyses, Dominion is assessing whether any changes should be made to the North Anna Unit 3 COLA."

The licensee will be notifying the NRC Resident Inspector.