Event Notification Report for June 14, 2013

UNUSUAL EVENT DECLARED DUE TO HIGH CO2 LEVELS IN THE TURBINE BUILDING

"Beaver Valley Unit 2 declared an Unusual Event (EAL HU.5, Toxic Gas Release) at 0835 EDT hours due to a CO2 (Toxic Gas) discharge in the turbine building. No report of fire and no injuries resulted from discharge. At 0851 EDT, the turbine building was clear of any detectible CO2. There was no operational impact from the CO2 discharge. The cause of the CO2 discharge is under investigation. The required states and counties were notified. The Resident NRC inspector was notified."

The inadvertent CO2 discharge was from the turbine fire protection system which now isolated while troubleshooting is in progress.

Notified DHS SWO, FEMA, DHS NICC, and Nuclear SSA via email.

* * * UPDATE FROM JAMES SCHWER TO CHARLES TEAL ON 6/14/13 AT 1006 EDT * * *

"Beaver Valley Unit 2 has terminated the Unusual Event at 0955 EDT * * *

Notified R1DO (Dentel), NRR EO (Chernoff), IRD (Grant), DHS SWO, FEMA, DHS NICC, and Nuclear SSA via email.

INVALID CONDITIONS DISCOVERED DUE TO EXCLUSION OF SMALL BORE PIPING FROM ANALYSIS

"While revising calculations for the station analyses for potential high-energy line breaks outside of containment, the station determined that the conditions required to validate the exclusion from analyzing for a break in some small-bore (1- to 4-inch diameter) piping could not be validated. The piping is contained within the station's auxiliary building. In the unlikely event of a break of one of these lines during power operations, the plant may not have been able to respond as expected. The plant is currently in cold shutdown, with the fuel removed from the core."

The licensee notified the NRC Resident Inspector.

INVALID PRIMARY CONTAINMENT ISOLATION SYSTEM ACTUATION DUE TO A RADIATION MONITOR SPIKE

"This notification is being made in accordance with 10CFR50.73(a)(2)(iv)(A) to provide information pertaining to an invalid Primary Containment Isolation System (PCIS) Group 3 actuation signal that affected containment valves in more than one system.

"On 6/14/2013, and again on 7/11/2013, with the reactor at 100% power, an invalid PCIS Group 3 actuation occurred from a momentary spike of the 'A' Refuel Floor radiation monitor which reached the instrument's high radiation trip setpoint. A radiation protection technician was dispatched to the refuel floor and dose rates in the vicinity of the 'A' radiation monitor detector were verified to be normal and below the alarm setpoints. The radiation monitor was verified to be indicating normal expected radiation levels. Subsequent visual inspection and functional checks of the radiation monitors were completed satisfactory and the instrument channel was returned to service. The cause of the spurious spikes is attributed to an unknown source of electrical noise. The issue with spurious spiking has been entered into the station's corrective action program.

"Both trains of Standby Gas Treatment System started as designed and Reactor Building ventilation isolated. The train actuation was complete.

"The PCIS functioned successfully providing a complete Group 3 isolation. The PCIS Group 3 isolation involves the following systems.

"Drywell and Suppression Chamber air and vent: V16-19-6A, 6B, 7, 7A, 7B, 8, 9, 10, 23
"Containment Makeup: V-16-20-20, 22A, 22B
"Containment Air Sampling: VG-23, 26, V109-76A, 76B
"Containment Air compressor suction: V72-38A, 38B
"Containment Air Dilution: VG-9A, 9B, 22A, 22B, NG-11A, 11B, 12A, 12B, 13A, 13B

"In accordance with 10CFR50.73(a)(1) a telephone notification is being made instead of submitting a written Licensee Event Report."

The licensee has notified the NRC Resident Inspector and will notify the State and local agencies.

AGREEMENT STATE REPORT - BRACHYTHERAPY TONGUE LOW DOSE RATE IMPLANT RESULTED IN OVERDOSE TO SKIN

The following report was received from the Kentucky Department of Health via facsimile:

"Brachytherapy LDR [low dose rate] tongue implant was loaded with thirty 1.12 mCi lr-192 sources on 6/13/13 by attending radiation oncologist. On 6/14/13 at [0730] [CDT] another physician rounded on the patient and all catheters and sources were in the proper position. At [1000] nursing on 6 East changed bedding of patient. At [1230] attending radiation oncologist rounded on patient and discovered one of the strands of sources (5 sources total) was no longer in the catheter. Physician removed nursing personnel and himself from the room and notified Physics. A Geiger counter was used to survey the room and a hot area was found in the linen basket. The linens were surveyed individually and the source was found. At [1245] the sources were reinserted into the proper catheter. Dosimetry was done to compare the plans and the deviation was well below the 20% reportable levels and almost indiscernible on the DVH [Dose Volume Histogram].

"During an inspection of the medical broad scope license, RHB [Kentucky Radiation Health Branch] reviewed the above procedure and inquired as to the dose potentially received by healthy tissues, namely the skin, assuming worst the case scenario. Specifically, the lr-192 strand displaced from the catheter actually lay against the patient's skin in one location for the whole 2 hours and 15 minutes between the time the physician last saw the strand in place and the time the patient's bed linen were changed. Based on this unrecognized worst case scenario, the RSO performed a dose calculation to the patient's skin and determined the patient may have potentially received a dose of 51.75 rem to the skin at a location which was not anticipated to receive any appreciable dose had the strands remained in place. A dose of 51.75 rem exceeds the limit requiring the report and notification of the Medical Event. A dose to the skin or an organ or tissue other than the treatment site that exceeds by five-tenths (0.5) Sv (fifty (50) rem) to an organ or tissue and fifty (50) percent or more of the dose expected from the administration defined in the written directive. The RSO at U of L [University of Louisville] e-mailed RHB a copy of the Medical Event report on July 6, 2015 at [1446]. Upon receipt of an email to the Radiation office the required 24 hour notification is made to the NRC Headquarters Operations Officer.

"The physician was notified of this potential medical event at the time of the inspection. The patient had follow up visits during and after the course of 6/14/13 treatment and was not found to be necessary to notify them of this potential event since no effects to the patient were noted."

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.