Event Notification Report for November 01, 2012

FITNESS FOR DUTY - CONTRACT SUPERVISOR FOUND IN POSSESSION OF PROHIBITED SUBSTANCE

A non-licensed contract supervisor was found to have in his possession a prohibited substance prior to entry into the plant protected area. The contractor's access to the plant has been terminated. This event has been re-posted after additional discussions with the licensee. Contact the Headquarters Operations Officer for additional details.

The licensee has notified the NRC Resident Inspector.

AGREEMENT STATE - DOSAGE ADMINISTERED LESS THAN PRESCRIBED

The following was received from the State of California via email:

"Patient was prescribed to receive 30.24 mCi of Y90 in Microsphere form (MDS Nordion, Model TheraSphere) through a catheter. The catheter became plugged during the procedure not allowing approximately 47% of the prescribed spheres to reach the treatment location. Patient received 16.2 mCi of the prescribed 30.24 mCi (53%)

"The dosage to the patient was not available at the time of report, therefore RHB (Radiation Health Branch) was unable to determine whether this met all requirements to be classified as a 'Medical Event.'

"The reporting requirements will be reviewed once the licensee provides RHB with the dose information.

"A formal, written report will be compiled by the licensee and submitted to RHB Brea and Sacramento."

California 5010 #: 110112

* * * UPDATE FROM DONALD OESTERLE TO CHARLES TEAL ON 11/5/12 AT 1428 EDT * * *

"On 11/2/2012, the dosage to the patient was not available at the time of the report, therefore RHB was unable to determine whether this met all requirements to be classified as a Medical Event. The reporting requirements will be reviewed once the licensee provides RHB with the dose information. A formal, written report will be compiled by the licensee and submitted to RHB Brea and Sacramento.

"At 11:00 am, 11/5/2012 RHB received additional information: The physician's written directive prescribed 130 Gy (13,000 rem) to the liver. The patient received 68.9 Gy (6,890 rem) to the intended organ. The remaining activity was contained by the microsphere delivery system.

"The NRC Operation Center was updated on 11/5/2012; 11:25AM confirming this report as meeting the necessary conditions of classifying this as a Medical Event. "

Notified R4DO (Farnholtz) and FSME Event Resource via email.

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.

OFFSITE NOTIFICATION - OIL SPILL INTO NAVIGABLE WATERS

"At approximately, 1215 EDT, November 1, 2012, Fermi 2 experienced an oil spill to navigable waters, requiring notification of National Response Center, Michigan Department of Environmental Quality (MDEQ) Pollution Emergency Alert System (PEAS), and Primary Public Safety Answering Point (911). The spill has not left site. A fuel oil and water mixture overflowed from a tank onto the ground during the performance of station fire header flushing. It is estimated that the volume of the overflow was less than ten gallons. A portion of the overflow entered the site storm drains. The source of the spill has been terminated.

"The NRC Resident Inspector has been notified."

AGREEMENT STATE REPORT - DAMAGED MOISTURE/DENSITY GAUGE

The following information was provided by the State of Texas via email:

"On November 1, 2012, the licensee notified the Agency that one of its Campbell-Pacific Model MC-3 moisture/density gauges had been run over by a pickup truck at a temporary work site in Houston, Texas. The gauge contained one 10 millicurie cesium-137 source and one 50 millicurie americium-241/beryllium source. The sources were in the safe position when it was run over. The source rod was broken off at the top of the housing. The gauge was taken to a gauge service company where it was checked. There was no leakage of radiation. A determination will be made by the licensee as to whether they will have the gauge repaired or replaced. There was no exposure to any individual as a result of this incident.

"Gauge Information:
Mfg: Campbell-Pacific
Model: MC-3
SN: M38118595

"Source Information:
cesium-137 -- 10 millicuries -- SN: C8595
americium-241/beryllium -- 50 millicuries -- A8595"

Texas Incident Number: I-9005

INTEGRATED PLANT COMPUTER SYSTEM OUT-OF-SERVICE OUTSIDE THE CONTROL ROOM FOR PLANNED MAINTENANCE

"Beginning November 01, 2012, at approximately 1000 [EDT], the Fermi 2 Integrated Plant Computer System (IPCS) will be removed from service outside of the Control Room to support installation of a Cyber Security Modification. The Safety Parameters Display System (SPDS) and Emergency Response Data System (ERDS) reside on the IPCS platform and will be out of service when the IPCS is removed from Emergency Response Facilities (ERFs). These systems will be unavailable to all Emergency Response Facilities (ERFs) for approximately 196 hours.

"By 1600 [EDT] on November 9, 2012 it is planned to restore IPCS, including SPDS and ERDS, to the Operational Support Center, the Technical Support Center, and alternate facilities. During this time dose assessment (Raddose) capability will only be available in the manual data input mode. The SPDS indications and Raddose remain available to the plant staff in the Control Room, and will be used for emergency response, if needed. Information will be communicated to the NRC using other available communication systems as needed. A follow-up notification will be submitted when the IPCS is completely restored.

"This 8-hour non-emergency notification is being made per the requirements of 10 CFR 50.72(b)(3)(xiii), as an event that results in a major loss of emergency assessment capability. ERDS previously reported out of service under event number EN 48451 ."

The licensee informed the NRC Resident Inspector.

* * * UPDATE ON 11/9/12 AT 2056 EST FROM BRETT JEBBIA TO DONG PARK * * *

"This is a follow up to EN #48468 & EN #48451.

"On October 29, 2012, Fermi experienced a failure of a data server within the process computer system which feeds data to Emergency Response Data System (ERDS), and EN #48451 was made to the NRC.

"On November 1, 2012, planned maintenance for Cyber Security Modification began which removed ERDS, SPDS, and IPCS from service, and EN #48468 was made to the NRC.

"On November 9, 2012, planned maintenance on ERDS, SPDS, and IPCS is complete, restoring full emergency assessment capabilities to all onsite emergency response facilities (EN #48468). The maintenance also repaired the data server within the process computer system which feeds data to ERDS (EN #48451)."

The licensee has notified the NRC Resident Inspector. Notified R3DO (Lipa).

AGREEMENT STATE REPORT - STUCK SHUTTER ON PROCESS GAUGE

The following information was received from the Louisiana Department of Environment Quality via facsimile:

"On 11/01/2012, the RSO for Rock Tenn called to report a stuck shutter on a [density] gauge utilized on a process [line] in the paper mill refinery. There was no possible exposure to the mill workers because the gauge is installed on a process [line in a remote location] and, [consequently,] the shutter remaining [open] is not a problem. The gauge is a Berthold, Model LB 7400 Series, loaded with a 50 mCi Cs-137 [source]. The gauge has been in the elements for a prolonged period of time and the shutter malfunctioned due to corrosion in the mechanism of the source holder. All of the sources were evaluated and inspected and only one needed repair. The manufacturer stated that it appeared to be from being in the elements. The manufacturer stated that they were looking into finding a modification to shield the shutter mechanism from the elements. The Louisiana Department of Environmental Quality considers this item closed."

Louisiana Incident Number: T144358