Event Notification Report for October 17, 2012

60-DAY TELEPHONE NOTIFICATION OF AN INVALID SYSTEM ACTUATION

"This 60-day telephone notification is being made in accordance with the reporting requirements specified by 10 CFR 50.73(a)(2)(iv)(A) and 10 CFR 50.73(a)(1) to describe an invalid actuation of a general containment isolation signal affecting more than one system.

"On October 17, 2012, at 2301 hours Central Daylight Time (CDT), the 3A Reactor Protection System (RPS) Motor Generator (MG) Set tripped, causing the loss of the 3A RPS Bus, resulting in a half scram. Loss of the 3A RPS Bus automatically isolated Primary Containment Isolation System (PCIS) groups 2, 3, 6, and 8 which initiated 'A' Train of Control Room Emergency Ventilation (CREV) and 'A', 'B', and 'C' Trains of Standby Gas Treatment (SGT) while isolating the Reactor Water Cleanup System (RWCU).

"Plant Conditions which initiate PCIS Group 2 actuations are Reactor Vessel Low Water Level, High Drywell Pressure, or Reactor Vessel High Pressure. The PCIS Group 3 actuations are initiated by Reactor Vessel Low Water Level or Reactor Water Cleanup Area High Temperature. The PCIS Group 6 actuations are initiated by Reactor Vessel Low Water Level, High Drywell Pressure, or Reactor Building Ventilation Exhaust High Radiation (Reactor Zone or Refuel Zone). The PCIS Group 8 actuations are initiated by Low Reactor Vessel Water Level or High Drywell Pressure. At the time of the event, these conditions did not exist; therefore, the actuation of the PCIS was invalid.

"The affected equipment responded as designed.

"This condition was caused by the 3A RPS MG-Set motor winding's insulation failing due to age related degradation. To correct this condition, the 3A RPS MG Set was removed, rewound, refurbished, and re-installed.

"There were no safety consequences or impact to the health and safety of the public as a result of this event.

"This event was entered into the Corrective Action Program as Problem Evaluation Report 625651.

"The NRC Resident Inspector has been notified of this event."

AGREEMENT STATE REPORT - POSSIBLE MEDICAL EVENT INVOLVING MISADMINISTRATION

"On 10/17/12, the licensee notified RHB (Radiation Health Branch) of an issue related to prostate brachytherapy and questioned if this falls into the category of Medical Event (ME). RHB is currently investigating this matter to evaluate if a ME had occurred.

"The RSO called RHB for guidance about three permanent prostate seed implants for which post-implant dosimetry showed less than ideal dose coverage of the gland. The RSO reiterated that none of these deviations were a surprise all were expected based on intra-operative experience. In one Iodine-125 case, poor coverage of the lateral base resulted from significant pubic arch interference. In the other two cases, both Palladium-103, poor coverage of the base occurred from vendor failure to disclose an additional unplanned spacer at the end of each seed strand.

"As stated, the D90 value (minimum dose to 90% of the CT-defined prostate one month following the implant) for the I-125 case was 77% and for the two Pd-103 cases was 68% and 53% of the dose prescribed as a minimum peripheral dose to the ultrasound-defined prostate +margin prior to the implant. The RSO requested RHB read this statement carefully, as it compares apples to oranges 'The RSO will make the case that the post-plan D90 is relevant as an assessment of plan and programmatic quality but is irrelevant for definition of a medical event'.

"The RSO indicated that the hospital's physicians do not prescribe by D90. What is prescribed is a minimum peripheral dose (MPD) to the ultrasound-defined prostate gland plus planning margin (PTV). A pre-plan is generated to deliver the intended MPD (145 Gy for I-125 monotherapy and 125 Gy for Pd-103 monotherapy) to the PTV. The resulting planned combination of radionuclide, source strength, and number of sources is what is approved, prescribed, ordered, and implanted.

"Very often, changes are made intra-operatively to account for implantation difficulties and clinical factors (deviation of urethra from predicted path, pubic arch interference, presence of more aggressive disease in a specific part of the gland, etc). In addition, extra seeds are ordered for each case, to be implanted at the discretion of the Authorized User (AU). Extra seeds may be implanted to boost areas of sparse coverage following implantation of planned seeds. Extra seeds may also be implanted to boost areas of known aggressive disease to a dose higher than the initial MPD. It is impossible to mentally arrive at a new dose that might correlate to a D90 on post-implant dosimetry under these conditions. The AU recognizes that this will result in an increase to the D90 on the post-plan but does not alter the dose on the written directive but only the number of sources (in part to of the written directive following implant but prior to release of the patient) to reflect the intra-operative changes. This is because the prescribed dose refers to a MPD for the pre-implant ultrasound prostate volume with margin (as our policy states). It was never meant to correlate with a D90 on a CT-defined prostate volume (which volume may be double the ultrasound-defined pre-implant volume) a month after the implant.

"As a result of the clinically discretional implantation of extra seeds, many of our D90 results in post-implant dosimetry actually exceed 100% of the prescribed dose. Several even exceed 120% of the 'prescribed' dose, and this is intentional. Nevertheless, the radionuclide, source strength, number of seeds, and duration of implant (permanent) indicated on part 2 of each written directive (the part completed following implantation but prior to release of the patient) correctly reflects what was done, as required by 10 CFR 35.41. The RSO called RHB about these three cases because the dose delivered to parts of these prostate glands was less than intended, an anticipated but initially unplanned result due to known but unplanned and uncontrollable outside factors.

"The Authorized Users for these cases are still reviewing the clinical data to determine what, if any, additional medical actions will be taken. Note that none of these cases meet the criteria for a medical event as recommended by the Nuclear Regulatory Commission's Advisory Committee on the Medical Use of Isotopes on October 18, 2011 (see attached). These criteria analyze the spatial distribution of seeds within octants of the gland as well as the overall D90 (threshold for which is lowered to 60% of prescription dose, and only in conjunction with failure of the spatial analysis). In each of these cases (and in contrast to what happened in the VA cases), very few seeds (only a few percent) were implanted outside the planning margin of the prostate CTV. Even by the older document the state reference, the May 18, 2011 Prostate Permanent Implant Brachytherapy and Associated Medical Event Questions and Answers from Clarification of Current Guidance for Prostate Permanent Implant Brachytherapy, the hospital assert (as in Case 2) that ' in accordance with NRC regulations, a ME has not occurred, since the delivered activity is equal to the prescribed activity for the treatment site (as defined by the AU). Even though the D90 values differ by more than 20 percent; the AU does not use D90 to prescribe dose, and is therefore, not required to use D90 to perform the regulatory evaluation of the prescribed dose'."

CA 5010 Number: 101712

AGREEMENT STATE REPORT- UNABLE TO RETRACT RADIOGRAPHY CAMERA SOURCE

The following information was received by email:

"On October 18, 2012, the Agency [Texas Radiation Branch] was notified by the licensee that on October 17, 2012, a radiographer was unable to retract a [source] into the QSA 880F exposure device. The guide tube for the device was damaged during radiography operation in the fixed facility when a part fell on it, crimping the guide tube to a point where the source could not pass through it. The licensee stated that they were able to repair the guide tube enough to retract the source and lock it in the exposure device. The licensee stated that no over exposure occurred from the event and no member of the general public received any exposure from the event. Additional information will be provided as it is received in accordance with SA 300.

Texas Incident: I-8998

EMERGENCY RESPONSE DATA SYSTEM (ERDS) OUT OF SERVICE

"At approximately 0800 hours EDT on October 17, 2012, computer engineering personnel will be taking the plant integrated computer system (ICS) out-of-service for planned maintenance. During the time ICS is out-of-service, the Safety Parameter Display System (SPDS) and the Emergency Response Data System (ERDS) will be unavailable. The computer outage is scheduled for twelve hours.

"In the event of an emergency, plant parameter data will be communicated to the facilities through the Status Board Ring Down circuit with back-up by the Private Branch Exchange, Off Premise Exchange, and various redundant intra-facility circuits throughout the emergency facilities. The dose assessment function will be maintained during the out-of-service time period by manual input of data into the Meteorological Information and Dose Assessment System (MIDAS). The ability to open and maintain an 'open line' using the Emergency Notification System will not be affected and will be the primary means of transferring plant data to the NRC as a contingency until the ERDS can be returned to service.

"This event is being reported in accordance with 10 CFR 50.72(b)(3)(xiii). A follow-up notification will be made when the maintenance activities are complete and the equipment is restored. The [NRC] Resident Inspector has been notified."

* * * UPDATE FROM THOMAS MORSE TO VINCE KLCO ON 10/17/12 AT 2146 EDT * * *

As of 2140 EDT on 10/17/12, the ERDS system was tested and restored to service. The licensee notified the NRC Resident Inspector.

Notified the R3DO (Orth).

OFFSITE NOTIFICATION OF WASTE WATER PIPE LEAK CONTAINING TRITIUM

"The Harris Nuclear Plant is following the guidance in NEI 07-07 and has initiated this event notification as a result of our voluntary communication to state agencies in accordance with the Groundwater Protection Initiative. The state was notified at 1138 EDT.

"On October 16, 2012 at 5:12 pm, plant personnel identified a leak from a pipe on plant property. The pipe carries secondary plant and water treatment building waste water for chemical processing. The water, containing a low level of tritium (10,760 picocuries per liter), leaked into the surrounding soil. The surrounding soil is being excavated and the leak is being repaired. The EPA Drinking Water Standard is 20,000 picocuries per liter.

"The health and safety of the public are not affected by this event, based on the location of the leak and the low tritium levels.

"The NRC Resident Inspector has been notified."

The licensee also plans to notify local authorities.

CONFIRMED POSITIVE FITNESS FOR DUTY TEST

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

The NRC Resident Inspector has been notified.

CONFIRMED POSITIVE FITNESS FOR DUTY TEST

A non-licensed contract supervisor had a confirmed positive for alcohol during a for-cause fitness-for-duty test. The contractor's access to the plant has been suspended. Contact the Headquarters Operations Officer for additional details.

The NRC Resident Inspector has been notified.