Event Notification Report for March 08, 2012

NOTIFICATION OF THE MINNESOTA POLLUTION CONTROL AGENCY FOR RELEASE OF AMERTAP BALLS

"At 0954 on 3/8/12 Xcel Energy notified the Minnesota Pollution Control Agency of an Amertap ball release exceeding 1.5 barrels per agreement. Three barrels of Amertap balls are unaccounted for. Plant operational personnel are inspecting the site water system for unaccounted Amertap balls. A survey of the river performed by personnel only produced 4 of the missing balls."

The licensee notified the NRC Resident Inspector.

REPORT OF A SINGLE EMERGENCY SIREN ACTUATION

"Limerick Generating Station was informed by Montgomery County 911 dispatch center that Limerick Emergency Preparedness Zone (EPZ) siren # 128, at the corner of Vaughn and Springer town roads in Montgomery County was sounding.

"Notification time was 2218 EST. The siren was silenced at 2227 EST.

"The siren maintenance contractor was contacted for repairs.

"No actual plant emergency exists. The siren activation was caused by an equipment malfunction.

"The remaining 164 of 165 Limerick EPZ sirens remain functional. No other reportability thresholds have been met or exceeded.

"An 'Event of Potential Public Interest' will be issued to the state and local agencies."

The licensee has notified the NRC Resident Inspector. The licensee will also notify state and local authorities.

AGREEMENT STATE REPORT - UNDERDOSE DURING HEPATIC TREATMENT USING YTTRIUM-90 THERASPHERES

The following information was received via e-mail from the State of North Carolina Radiation Protection Section:

"The agency [NC Radiation Protection Section] was notified of a medical event at UNC - Chapel Hill by the RSO. The event occurred yesterday. The patient was administered a Y-90 therasphere dose. Three flushes were done and proper surveys were made to ensure none of the dose was left in the IV lines. As per protocol, dose delivered is calculated via measurement of the administration vial and the waste collection vial. At this point it was noted that the patient only received 78% of the prescribed dose. The surveys indicate that the dose was left in the administration vial.

"Exact prescription dose was not provided at this time. No cause has been determined yet. There was no spilling, but the physician did note that it was harder to push the plunger for the flush to go through than he usually experiences. A second dose was delivered to a different patient using the same lot today, and the administration was successful (95% delivered).

"The patient who received the underdose has not yet been notified due to other health complications not caused by the underdosage. The patient's physician is aware and waiting for an appropriate opportunity to inform the patient. It has been determined that a second dose will not be administered since the physician has deemed the dose received adequate."

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.

INOPERABLE STEAM GENERATOR NARROW RANGE LEVEL TRANSMITTERS DUE TO PART 21 CONCERN

"Pacific Gas and Electric (PG&E) is supplying this information as a voluntary report. On March 8, 2012, at 1850 PST, Diablo Canyon Power Plant (DCPP), Unit 1, declared the steam generator (SG) 1-1 narrow-range, low-low, water level channels for level transmitters LT-517 and LT-519 inoperable. This resulted from DCPP determining that the low-low setpoints were non-conservative as a result of its evaluation of the Rosemount Nuclear's 10 CFR Part 21 notification titled 'Notification Under 10 CFR Part 21 on Certain Rosemount Model 1154 Series H Pressure Transmitters,' dated March 2, 2012.

"PG&E determined that the following SG narrow-range level transmitters having reactor protection and emergency safeguards actuation functions are affected:

Unit 1:

- two channels on SG 1-1
- one channel each on SGs 1-2 and 1-4

Unit 2:

- one channel each on SGs 2-1, 2-2, 2-3 and 2-4

"The Part 21 notification identified that the high temperature/pressure accuracy specification changed for certain transmitters which have higher impedance resistors installed in their temperature compensation circuitry. PG&E's evaluation concluded that narrow range SG low-low level setpoint uncertainty increased by as much as 2 percent of span due to the revised specification. Under the most limiting conditions, this deficiency could result in a short delay in relay actuation.

"At 1953 PST, DCPP personnel declared the LT-517 and LT-519 water level low-low channels for SG 1-1 to be operable after adjusting the low-low setpoints from 15 percent to 17 percent on SG 1-1. DCPP also changed the low-low setpoints on SG 1-2 and SG 1-4 on March 8, 2012, and is changing this setpoint on all four of the Unit 2 SGs.

"PG&E plans to submit a Licensee Event Report on this issue.

"Plant personnel notified the NRC Resident Inspector."

AGREEMENT STATE REPORT - GAMMA KNIFE MEDICAL OVEREXPOSURE

The following information was received from the State of Florida via email:

"Licensee reported a possible medical event on 8 March which was confirmed in a written report received on 22 March. Patient was being treated by Gamma Knife with 8 shots at four sites when the fifth shot was interrupted for a bathroom break. While in the bathroom the patient fell and dislodged the stereotactic frame. The frame was reapplied and treatment plan recalculated. However, the computer did not start the treatment at the correct site resulting in an increase in dose of 22.2% at site 2, 14.8% at site 3 & 15, and 7% at site 4. The doses are well within clinical practice. A conservative dose prescription had been elevated to a moderate prescription. The referring physician and patient have been notified. No medical consequences are expected. The cause is human error. Any further investigation referred to Licensing and Materials. No further action will be taken on this incident by this office."

Device: Leksell Perfexion
Serial Number: 6130

Florida Incident: FL-12-034

"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.