Event Notification Report for March 05, 2014

AGREEMENT STATE REPORT - UNDER DOSE INVOLVING YTTRIUM 90 MICROSPHERES

The following information was received by email:

"On March 6, 2014, UMass Memorial Health Care (license number 60-0096) reported [to the Massachusetts Radiation Control Program] that on March 5, 2014 they had under dosed a patient by more than 20% using Y-90 microspheres. Further pertinent data is:

"Prescribed Activity: 26.4 mCi of Y-90 (in one fraction injection)
Delivered Activity: 20.4 mCi of Y-90 (more than 20% different from prescribed)

"Resulting in:
Prescribed Liver dose: = 32.6 Gy
Delivered Liver dose: = 25.2 Gy
Dose difference in organ: = 740 rads (i.e., greater than 50 rem and 20% difference)

"Note Also:
Effective dose (requested): 32.6 Gy * 0.04 = 1.3 Sv
Effective dose (delivered): 25.2 Gy * 0.04 = 1.0 Sv
Effective dose difference: 1.3-1.0=0.3 Sv = 30 rem (greater than 5 rem difference)"

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.

DISCOVERY OF INDIVIDUAL PATHWAYS THAT COULD BYPASS FLOOD BARRIERS

"During walk downs to ensure the availability of flood protection barriers, a condition was identified which had the potential to adversely impact the ability to address external flooding conditions. Several individual pathways between both unit's Turbine Building and Auxiliary Building were identified that could bypass flood barriers. In the aggregate however, the current equipment could become overwhelmed and the flooding in the Auxiliary Building could then potentially challenge equipment necessary to remove residual heat.

"The identified pathways were for the most part unscheduled partially filled conduits. There were no isolation features on these pathways and no barriers to flooding were in place between the Turbine Building and Auxiliary Building thus the potential existed to bypass the existing flood barriers. Flooding of the Turbine Building conceivably could have resulted in the accumulation of water in sufficient quantities to fill the Turbine Building to the height of the external floodwaters which could enter the Auxiliary Building via one or more deficient flood barrier. These floodwaters would then potentially challenge equipment, located within the Auxiliary Building, which is required to remove residual heat.

"This condition has been determined to be reportable per 10CFR50.72(b)(3)(v)(B) and 10CFR50.72(b)(3)(ii)(B). This condition is a non-emergency condition. This condition has been entered into the Corrective Action Program.

"Barriers are being installed in these pathways as they are identified or compensatory measures implemented."

The walk downs were performed in response to Fukishima lessons learned.

The licensee notified the NRC Resident Inspector.

INADVERTENT ACTUATION OF THE EMERGENCY NOTIFICATION SYSTEM

"A planned actuation of the emergency sirens across the state of Ohio was scheduled as part of a Severe Weather Awareness activity. When Columbiana County, Ohio, was activating their county sirens at 0958 EST, they inadvertently depressed the button which activated all 120 sirens within the Beaver Valley Emergency Planning Zone, which included Beaver County, Pennsylvania and Hancock County, West Virginia sirens.

"This event is reportable as a 4-hour Non-Emergency Notification 10 CFR 50.72(b)(2)(xi) as 'A News Release or Notification of Other Government Agency.'

"The NRC Resident Inspector has been informed."

POTENTIAL IMPACT ON UNFUSED DIRECT CURRENT AMMETER CIRCUITS IN THE MAIN CONTROL ROOM

"A review of industry operating experience regarding the impact of unfused Direct Current (DC) ammeter circuits in the control room has determined that a similar condition is applicable to the Waterford 3 Nuclear Station resulting in a potentially unanalyzed condition with respect to 10 CFR 50 Appendix R requirements. The original plant wiring design and associated analysis for an ammeter measuring current from the train AB Class 1E battery to its associated power distribution panel does not include overcurrent protection features to limit the fault current and is routed through multiple fire areas. The ammeter is located on the train AB power distribution panel in the train AB switchgear room.

"In the postulated event, a fire could cause one of the ammeter wires to short to ground. Simultaneously, it is postulated that the fire could cause another DC wire from the opposite polarity on the same battery to also short to ground. This could cause a ground loop through the unprotected ammeter wiring. This event could result in excessive current flow (i.e., heating) in the ammeter wiring to the point of causing a secondary fire in the raceway system. The secondary fire could adversely affect safe shutdown equipment and potentially cause the loss of the ability to conduct a safe shutdown as required by 10 CFR 50 Appendix R.

"This condition is being reported in accordance with 10 CFR 50.72(b)(3)(ii)(B). There is no effect on plant operation. Fire watches have been implemented for affected areas of the plant as an interim compensatory measure."

The licensee notified the NRC Resident Inspector.

* * * RETRACTION ON 4/16/14 AT 1814 EDT FROM MARK CARTER TO DANIEL MILLS * * *

"Subsequent engineering evaluation has determined that the circuit for an ammeter measuring current from its Class 1E battery to its associated power distribution panel is not routed through multiple fire areas. Therefore, the IER 13-54 related condition is not, and was not, an unanalyzed condition at Waterford 3 that significantly degraded plant safety, and thus not required to be reported under 10 CFR 50.72(b)(3)(ii)(B)."

The licensee notified the NRC Resident Inspector.

Notified R4DO (Gaddy).

OFFSITE NOTIFICATION DUE TO DRY SHIELDED CANISTER TEST RESULTS

"This report is being made to provide information to the NRC regarding Monticello Dry Shielded Canister (DSC)-16.

"On February 17, 2014, dye penetrant examinations were performed on the outer top cover plate (OTCP) to shell weld on dry shielded canister (DSC)-16. This was a re-examination of a linear indication identified on January 24, 2014. The results of the re-examination identified a 1.6 inch linear indication that remained after surface conditioning. This indication had not been previously detected by nonconforming nondestructive examination previously reported by TriVis Inc.

"Xcel Energy is evaluating the condition and will remedy prior to moving the cask to the ISFSI [Independent Spent Fuel Storage Installation] pad.

"The associated DSCs loaded during the current campaign successfully passed their helium leak tests. Helium leak checks are performed to demonstrate confinement and boundary integrity. Thus, public health and safety is not affected.

"Since the licensee communication plan also notified other government agencies, this report is being made pursuant to 10CFR50.72(b)(2)(xi) and 72.75(b)(2)."

The above referenced dry shielded canister is currently located on the refuel floor in the reactor building.

The licensee notified the NRC Resident Inspector.