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At 0833 on 05/24/2012, an uncleared vendor employee was piggybacked by a cleared vendor employee through a security gate into the x3012 Security Area. The uncleared employee was removed from the area. There is no known compromise of classified information. This incident is reportable to the Nuclear Regulatory Commission as an 8 hour Security Event in accordance with American Centrifuge Administrative Procedure ACD2-RG-044, Nuclear Regulatory Event Reporting, Appendix B, Section K2, IMI-3#14, which states, 'Circumvention of established access control procedures into a security area (excluding Property Protection Area). The licensee notified NRC Region 2 (Hartland).

• * * RETRACTION AT 1100 EDT ON 07/18/12 FROM CHARLES SEIDEL TO S. SANDIN * * *

Update: On 07-18-12 at 1017 the NRC Event has been retracted on the guidance of the Regulatory Organization for the following reason: It has been determined that the two previously reported DOE IMI-3 events for 2012 did not meet the requirements for an NRC reportable event and should have been entered into the written log in accordance with 10 CFR 95.57. While they did meet the criteria for an 8-hr reportable event to the DOE they did not meet the NRC requirements for reporting to the NRC Operations Office. We hereby request that both NRC Events 48084 and 47956 be retracted." Notified R2DO (Desai).

The following was reported from the state via e-mail: A Kennewick licensee who manufactures and distributes hand-held devices used to analyze metal alloys notified the Materials Section of an incident that occurred with one of their General License customers in California. The shutter in the device which shields the radioactive material remained in the open position even after disengaging the trigger mechanism to close the shutter. This allowed radiation to stream from the device unabated. The California customer packaged the device for shipping knowing the shutter was open with nothing shielding the radiation and sent it back to the manufacturer in Kennewick for repairs. When the manufacturer received the device, a radiation reading in excess of the package limitations was noted and promptly reported to us. The licensee informed us this is the first shutter malfunction ever for this device model, which has been in service without any similar problems for many years. The Materials staff is working with the licensee to identify compliance issues and to prevent recurrence. The Bruker AXS hand held XRF analyzer contains 5.9 milliCuries of Co-57. Incident Number WA-12-037

• * * UPDATE FROM CRAIG LAWRENCE (VIA EMAIL) TO HOWIE CROUCH AT 1125 EDT ON 5/25/12 * * *

The XRF device is owned by Benchmark Environmental. Benchmark Environmental shipped the device to Bruker on May 22, 2012. Based on the dose rate measurement taken by Bruker prior to opening the package and removing the instrument, the Washington State Department of Health doesn't believe there were exposures to any member of the public in excess of regulatory limits. A dose rate measurement at 3 feet was 0.3 mR/hr as measured by their Bicron Surveyor 50 (cal date 1/19/12). Reading at approximately six inches from the surface pegged the dose rate meter on the 0 to 0.5 mR/hour scale. Bruker did not take measurements on higher scales. At that point, Bruker's shipping and receiving took the MAP FA4C1 analyzer out of the case and carried it at arm's length to the shielded source exchange pit. The instrument was evaluated inside the pit and the shutter was found partially open. The Co-57 source was removed from the analyzer and put into a shielded pig. Bruker examined the analyzer and found the source block was defective and (the analyzer was) sent to production for a replacement source block. The licensee provided corrective actions in the NMED data entry form. Notified R4DO (Spitzberg) and FSME (via email).

The following was received via e-mail: On 6/28/12 Saint Joseph Hospital personnel were surveying a packing materials used to ship I-125 seeds, for a procedure conducted earlier that day, when they noted elevated readings. Further surveys revealed that the elevated readings were not coming from the packing material associated with the 6/28/12 procedure but from packing material that was used to ship I-125 seeds for a previous procedure, which was in the area of the survey. Surveys of the packing material revealed no loose contamination on the exterior or interior of the box but elevated readings of 2500-350000 cpm and .2 mrem/hr. Receipt and post procedure surveys of the procedure associated with contaminated box did not reveal any abnormal readings. The Saint Joseph RSO assumes the material is I-125 but they do not have the capability to verify this. No loose seeds were found in any of the packing material. The I-125 seeds were accompanied by the manufacturers leak test report which indicated no contamination. The patient, whose procedure was associated with the contaminated packing material, will be evaluated on Monday 7/2/12 to determine if there was any uptake in his urine or thyroid of I-125 as a result of leaking seeds. CA Report Number: 062912 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.

• * * UPDATE ON 7/2/12 AT 1806 EDT FROM EUGENE FORRER TO DONG PARK VIA EMAIL * * *

This is a follow up of an incident, as information only, on Friday, June 29, 2012. Radiologic Health Branch reference would be 5010 #062912. The notification was about contaminated packaging that had contained Best Medical I-125 seeds. A thyroid count was performed on the patient who had the seeds implanted in May. The thyroid count verified that there had been an uptake of iodine by the thyroid. Below is the write up and preliminary dose estimate from the licensee regarding. Based upon this morning's patient measurements, instrument-manufacturer supplied efficiency data, and reference data for dose conversion, we estimate the patient involved received a thyroid uptake of 0.1 mCi of I-125 and a dose to the thyroid of 300 cGy. 1) Conversion of counts per minute (cpm) to activity Two(Pi) counting efficiency for I-125 (per manufacturer) is 133.5% fraction of 2(Pi) solid angle subtended by a 2 inch diameter detector at a distance of 30 cm from the thyroid is 10.13 squared cm / 5654.9 squared cm = 0.00179 overall efficiency = 1.335 x 0.00179 = 0.00239 (190493 - 30) net cpm / 0.00239 x 4.505x10-10 mCi/dpm = 0.0359 mCi present thyroid burden. Back-correcting 60 days to time of implantation (conservatively assuming that all uptake occurred at that time) with 42-day effective half-life, initial uptake given by 0.0359 / 0.3715 = 0.0967 approximately 0.1 mCi 2) Taking the value quoted by Chen et.al. (attached) from NUREG/CR-6345, we assume the dose to thyroid is 780 cGy per mCi of I-125 administered, and this value assumes 25% uptake into the thyroid. Our calculated estimated thyroid burden of 0.1 mCi then gives an estimated absorbed dose of 0.0967 mCi x 780 cGy/mCi / 0.25 (since we measured actual thyroid burden v. amount administered) = 302 cGy approximately 300 cGy (rad) to thyroid. 3) Whole body committed effective dose equivalent (CEDE) from a 300 rad dose to the thyroid (using a thyroid weighting factor of 0.04) would be 12 rem. Notified R4DO (Allen) and FSME (Einberg).

• * * UPDATE FROM GENE FORRER TO CHARLES TEAL ON 12/19/12 AT 1650 EST * * *

EVENT SUMMARY: While surveying an empty brachytherapy seeds package for return to Best Medical hospital personnel discovered contamination on the interior of the package. Follow up thyroid scans of the patient who was implanted with the seeds associated with the package verified an uptake of I-125 by the patient's thyroid. The initial report to RHB was intended, by the licensee, to be a notification of a Medical Event. REPORTING: This event was reported to the NRC, by phone, on 4/13/12, at 8:50 am via email. HEALTH AND SAFETY: Based on surveys of the packing material all contamination was contained within the package and did not pose a threat to hospital personnel. The estimated dose to the patient's thyroid was calculated to be approximately 330 rad with a CEDE of 12 rem. ADDITIONAL DETAILS: The RSO conducted an investigation of the incident and could not find any indication that there were any irregularities with the implantation procedures. Hospital personnel associated with the procedure indicated to the RHB inspector that there were no irregularities with the procedure. In addition receipt surveys of the package did not reveal any contamination of any of the packaging material. The RSO concluded that the cause of the contamination was due to a manufacturing error. The RSO of Best Medical conducted an investigation of the production of the seeds implanted in the patient. All records at Best Medical indicate that all QC tests of the seeds were done satisfactorily. The RSO concluded that the seeds had been damaged in transit or that Saint Joseph personnel must have damaged the seeds either during the initial surveys or during the implantation. The Best Medical RSO was unable to explain how the seeds could have been damaged and still be implantable. The Virginia Department of Health inspected the Best Medical facility and concluded that all QC testing on the seeds had been completed satisfactorily with no abnormalities noted. After interviewing Saint Joseph and Best Medical personnel RHB personnel concluded that the most logical explanation for the leaking seeds was a manufacturing error, however, without samples from the same lot of seeds implanted available for analysis this can not be proven conclusively. The hospital has changed suppliers for the brachytherapy seeds. In addition they have initiated a procedure where the needles containing the seeds are wiped after they have been removed from the shipping container. ENFORCEMENT ACTIONS: The hospital was not cited for this incident. INVESTIGATION STATUS: This investigation is closed. Notified R4DO (Spitzberg) and FSME Event Resource via email.

A patient received 100% more than the prescribed dose of thallium. The patient was to receive 3.5 milliCuries of thallium followed by 30 milliCuries of Cardiolite, a Tc-99M radiopharmaceutical. Instead, the patient received 3.5 milliCuries of thallium then received an additional 3.6 milliCuries of Thallium. The technician stated that he got confused where the patient was in the treatment process. The patient and physician have been informed. The licensee is awaiting dosimetry results to determine the organ dosage but does not believe there will be any recurring medical effects from this event.

• * * RETRACTION AT 1227 EST ON 1/27/12 FROM MUNDORF TO HUFFMAN * * *

The licensee is retracting this event report after a review and evaluation of the doses administered. The licensee has determined that this event is not reportable based on the unintended dose being less than 5 Rem effective dose equivalent and therefore not reportable under 10 CFR 35.3045. The licensee has discussed this conclusion with NRC Region 1 (Lanzisera). R1DO (Dental) and FSME (McIntosh) have been notified.

On 12/21/11 at 0046 Secondary Containment integrity was lost when both U2 Reactor Building interlock doors were open simultaneously. Interlock door electrical checks were in progress. TS LCORA 3.6.4.1.Condition A was entered. Reactor Building differential pressure remained within Tech Spec limits. The doors were both open for approximately 9 seconds. The cause of the event is being investigated. The NRC Resident Inspector has been notified. The State of Illinois Inspector will be notified.

• * * RETRACTION FROM KATHARINE NETEMEYER TO CHARLES TEAL ON 2/6/12 AT 1243 EST * * *

On 12/21/2011, EN 47540 was made describing a condition where secondary containment was declared inoperable due to not meeting the surveillance requirement for having one access door closed. This was reported as a loss of safety function for the secondary containment. This condition occurred during a planned maintenance activity. During a maintenance activity both doors unexpectedly opened. As a part of the maintenance, the inner door was opened by maintenance personnel using the normal control pushbutton. Upon personnel observing the outer door opening, the inner door button was released and the functional door automatically closed. Although both doors were briefly open, the negative pressure required to ensure secondary containment integrity was maintained at all times. Based on the door immediately closing and negative pressure being maintained, this is not considered a loss of safety function. Therefore this EN is being retracted. The NRC Resident Inspector has been notified. Notified R3DO (Giessner).

The St. Lucie Unit 1 Emergency Response Data Acquisition and Display System (ERDADS) will be removed from service for system modification following completion of core offload for the current cycle 24 refueling outage, currently scheduled for 12/15/2011 at 0900. The ERDADS system will be functional prior to core reload (Mode 6) and fully operational prior to the plant startup. This is an informational notification of a planned loss of emergency assessment capability. Control room indications including annunciators are available as alternate means to monitor critical data. An update to this notification will be provided when the system is restored to service. The NRC Resident Inspector has been notified.

• * * UPDATE FROM PORRO TO CROUCH AT 1703 EDT ON 3/14/12 * * *

The St. Lucie Unit 1 Emergency Response Data Acquisition and Display System (ERDADS) has been restored to service. Some area rad monitoring functional testing remains in progress; however full assessment capability is functional via the control room indications and alarms. All ERDS link data points provided by the Emergency Response Data Acquisition and Display System have been restored to service and fully operational to support plant start up. The licensee has notified the NRC Resident Inspector. Notified R2DO (Guthrie).

At 1430 (EDT) on 10/28/11, it was discovered that due to an Equipment Clearance Order (ECO), the HVAC recirculation capability of the Technical Support Center (TSC) was lost. The TSC dampers were deenergized in the non-emergency position while the ECO was in effect. The ECO was put into effect on 10/10/11. The ECO was released at 1630 (EDT) on 10/28/2011 and functionally tested restoring TSC HVAC recirculation capability. While the ECO was in effect and under certain accident conditions, the TSC may have been unavailable due to the inability of the charcoal filtration system to maintain a habitable atmosphere. The alternate TSC remained available, during the time the ECO was in effect, as defined in the Emergency Plan Implementing Procedures. This 8 hour notification is required per 10 CFR 50.72(b)(3)(xiii). The alternate TSC remained available during this period. The NRC Resident Inspector has been notified.

• * * RETRACTION FROM JOSE VASQUEZ TO VINCE KLCO ON 12/14/2011 AT 1852 EST * * *

A Functionality Assessment (FA) has concluded that the Turkey Point TSC was able to perform it's intended function of ensuring habitability to TSC responders during the period 10/10/11 through 10/28/11 with the TSC ventilation system in the degraded condition. A dose analysis was performed, modeled after the design basis LOCA analysis for the TSC, using alternate source term, no filtration, containment leakage based on the most recent ILRTs, current data on ECCS leakage, and meteorological conditions existent during the period. Dose to TSC responders would have been less than the general design criterion limit of 5 REM. The licensee notified the NRC Resident Inspector.