Event Notification Report for May 01, 2012

AGREEMENT STATE REPORT - RADIOACTIVE SPILL DURING MEDICAL TREATMENT

"The SC Department of Health and Environmental Control was notified on Wednesday, May 2, 2012, at 1400 hrs, that a nurse's aide was attempting to empty a Foley bag containing I-131 at 1500 hrs on May 1, 2012, when she inadvertently spilled 200-300 cc of the contents of the bag on the floor, her shoe and sock. The patient had received 203 mCi of I-131 for in-patient treatment. The Supervisor, Nuclear Med, was notified and the nurse's aide's foot was decontaminated. Surveys after the decontamination did not indicate the presence of any radioactive material on her skin. The nurse's aide had a bioassay on May 2, 2012, and no uptake was indicated. Absorbent paper had been placed on the floor prior to the in-patient procedure and most of the spill was contained on the absorbent paper. A 12 x 100 inch area of the floor under the patient bed may have contamination and the area will be cleaned and surveyed once the patient has been released.

"[The Nuclear Med Supervisor] was advised by [South Carolina] to submit a written report detailing this event to the [South Carolina] Department within 30 days. The event is open and pending the licensee's investigation and report to the [South Carolina] Department. Updates will be made through the national NMED system."

FLOOR DRAIN BLOCKAGE ADVERSELY AFFECTS ASUMPTIONS OF PIPE BREAK ANALYSIS FOR ELECTRICAL SWITGHEAR ROOMS

"At 1300 on May 1, 2012, as a result of fire water flushing operations, it was observed that the floor drains in the 'A' and 'B' ESF (Engineered Safety Features) 4160 VAC switchgear rooms were draining extremely slow. Engineering was consulted and it was identified that the floor drains in these rooms are credited with preventing any water accumulation in these rooms as a result of internal flooding due to a pipe break. It is expected that the floor drains in the 'A' ESF switchgear room can drain approximately 134 gallons per minute (gpm) and the floor drains in the 'B' ESF switchgear room can drain approximately 208 gpm. With the floor drains partially blocked, a break in the 'A' Essential Service Water pipe in the 'B' ESF Switchgear Room would result in flood levels in the 'B' ESF Switchgear Room to exceed the maximum levels calculated in the current flooding analysis. The higher flood level may result in the inoperability of 'B' train Electrical Switchgear. The 'A' train Essential Service Water supplied equipment would be adversely affected due to the reduced flow. Consequently the pipe break would result in both ESF trains being adversely affected.

"Compensatory measures have been taken to restore system operability.

"The NRC Resident Inspector has been notified."

* * * RETRACTION FROM KEITH DUNCAN TO JOHN KNOKE AT 1534 ON 05/31/12 * * *

"On May 1, 2012, Callaway Plant made an ENS notification in accordance with 10 CFR 50.72(b)(3)(ii)(B) to report the discovery of partially blocked floor drains in the safety-related 4160 V switchgear rooms. At the time of the initial notification, preliminary information indicated that the partially blocked floor drains could have caused a postulated flooding event to adversely affect independent trains of safety-related equipment inside these rooms.

"Upon further analysis, Callaway Plant staff determined that the pipe break assumed in the flooding calculation of these rooms was overly conservative. Specifically, based on seismic qualifications, the guillotine break of Essential Service Water piping that was originally assumed is not required to be postulated. Instead, a much smaller, through-wall crack of fire protection system piping is the most severe break that must be postulated in the safety-related 4160 V switchgear rooms.

"An analysis of a postulated flood hazard in these rooms was performed based on the correct water source. Even if considering a complete blockage of the floor drains in these rooms, this analysis demonstrates that a postulated fire protection system piping crack would not have adversely affected safety-related equipment.

"Based on the results of this analysis, the partially-blocked floor drain condition described in EN 47885 did not meet the criteria for reportability as an unanalyzed condition that significantly degrades plant safety. Event Notification 47885 is hereby retracted."

The licensee has notified the NRC Resident Inspector. Notified the R4DO (Greg Pick)

FAA NOTIFIED OF REMOVAL OF STACK AVAITION OBSTRUCTION LIGHTS

"On May 1, 2012 at 12:10 EDT, Indian Point Unit 2 notified the Federal Aviation Administration that the Unit 1 Ventilation Stack Aviation Obstruction Lights were removed from service at 12:05 EDT on May 1, 2012. This is a planned evolution as Indian Point no longer requires the Unit 1 ventilation stack and plans to dismantle the stack to an approximate elevation of 167 feet which will remove the obstruction to air navigation and its associated aviation obstruction lights.

"The NRC Resident Inspector has been notified."

The licensee estimates that the job will be completed September 6, 2012.

RADIOPHARMACEUTICAL THERAPY RECORD TRANSPOSITION ERROR

A doctor prescribed a patient 0.4 mCi/Kg Zevalin (a prescription medication containing Yttrium-90). The calculated dose based on the patient's weight was 44 mCi; however, the package insert for the drug says the maximum dose to be used is 32 mCi. So 32 mCi of Y-90 was to be given to the patient.

A radiopharmaceutical therapy record was prepared as required at the hospital but the dose on the radiopharmaceutical therapy record was improperly copied as 23 mCi.

The dose prepared at the radiopharmacy and delivered to the patient was 31.8 mCi. The dose differed from that specified on the radiopharmaceutical therapy record by more than 20%.

The prescribing physician is aware and there is no significant impact to 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.

MEDICAL EVENT - ACTUAL DOSE DIFFERED FROM PRESCRIBED DOSE

An NRC Region I Inspector (Abogundi) performed an inspection at the licensee facility and determined that a medical event occurred and should have been reported.

In May, 2011, a patient received prostate LDR (Low-Dose Rate brachytherapy) treatment using 86 Pd-103 seeds for a prescribed dose of 125 Gy. During post-treatment evaluation, it was determined that the patient received between 72% and 75% of prescribed dose. The prescribing physician was notified and will not be notifying the patient due to treatment success.

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.

* * * RETRACTION FROM SARAH BULL TO HOWIE CROUCH AT 1130 EST ON 2/4/13 * * *

After reviewing their reporting procedures and in consultation with their Regional NRC Inspector (Abogundi), the licensee determined that this event did not meet their activity-based (versus dose-based) reporting criteria. Based on this information, the licensee has retracted this event notification.

Notified R1DO (Powell) and FSME Resource via email.