Event Notification Report for February 16, 2010

AGREEMENT STATE REPORT - MISPOSITIONED DOSE DURING MEDICAL TREATMENT

The following information was received from the State via e-mail:

"The two reported cases are single channel MammoSite patients. The errors resulted from erroneously placing the dwell position approximately 2 to 2.5 cm proximal to the correct position. The error was not noticed until 2/14/10 during a document review for [the second] patient after [the eighth] fraction. The last two fractions for [the second] patient were corrected. It appears that about 50% of the correct treatment volume received at least 50% of the prescribed dose. Some parts of the planned volume received greater than 700%. Also there are volumes that are not included in the planned treatment volume that exceed approximately 300% to 400% of the prescribed dose. The proximal skin received a small sliver of dose at the 125% the prescribed dose.

"First patient's treatment had been completed in January before the error was noticed. Probably 25% of the planned volume received the prescribed dose or higher. Probably 25% of the planned volume received 25% or less than of the prescribed dose. A large volume outside the planned treatment volume exceeded the prescribed dose. The maximum proximal skin dose was at approximately 220% of the prescribed dose. The desired dose was 340 cGy/fx * 10. Both doctors and patients have been notified.

"Health effects, if any, are still being determined. The licensee will send a written report on this incident."

The State of Florida is investigating. The isotope involved is 9.76 Curies of Ir-192.

Florida Incident Number: FL 10-027.

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.

FITNESS FOR DUTY EVENT - CONFIRMED POSITIVE FFD TEST

A licensed, non-supervisory employee had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's unescorted access to the facility has been suspended. Contact the Headquarters Operations Officer for additional details.

SCHEDULED MICROWAVE RADIO UPGRADES IMPACT TO THE CONTROL ROOM AND EMERGENCY OPERATIONS FACILITY

"This is an eight hour report per 10 CFR 50.72 (b)(3)(xiii). Calvert Cliffs will be implementing a scheduled modification to upgrade the microwave radio system to improve reliability of the system at the Emergency Operations Facility (EOF), State, and County facilities.

"This work will require that the microwave radio system at the EOF be removed for a period of approximately 4 to 6 hours. During this time, the following systems will be impacted for the duration of the upgrade:

"1. The plant's {e.g., Control Room, Technical Support Center (TSC), Simulator} Dedicated Offsite Agency telephones will be out of service. (EOF's system will continue to function)
"2. 800 MHz desk set radios at the EOF only will be out of service.
"3. 153.44 MHz frequency at the EOF only will be out of service. (backup for MEMA and MDE)
"4. MIDAS Terminal (Meteorological Data) located in the Dose Assessment Office at the EOF will be out of service.
"5. TSC Computer data transfer to the EOF only will be out of service.

"Once the upgrade starts the systems (listed above) can be returned to service within the first 2 hours. After the 2 hour timeframe, the upgrade must continue until completed.

"Should an emergency be declared during this period, the Control Room will continue to have the capability to make the notification to the offsite agencies using the direct line for the appropriate agencies. The emergency preparedness communications procedure provides a chart listing the communication devices available and the order in which the process is to be implemented. MIDAS (Meteorological Data) will continue to be operational at the site and can be obtained by contacting the Control Room or TSC. The ERPIPs also provide a backup process and the instructions necessary for the EOF Dose Assessment Office to obtain Meteorological Data. Plant data can be obtained from the CR or TSC and will continue to be downloaded from the plant computer to the ERO SharePoint site.

"All work associated with this microwave radio system upgrade will be performed in an expeditious manner consistent with the goal of minimizing unavailability of the systems listed above. A test of all systems will be performed at the completion of the upgrade.

"All EOF responders and Control Room personnel have been briefed on this work and expected contingent actions.

"This job will start on Wednesday, February 17, 2010 at approximately 7:00 am. We anticipate that all work will be completed by 5:00 pm on the same day, including testing of the system. We will provide a notification update upon completion of the job."

The licensee notified the NRC Resident Inspector.


* * * UPDATE FROM TOM JONES TO DONALD NORWOOD AT 1217 EST ON 2/17/2010 * * *

All communications systems were tested and returned to operable status as of 1200 EST.

The licensee notified the NRC Resident Inspector. Notified R1DO (Jackson).

AGREEMENT STATE REPORT - SHUTTER FOUND STUCK CLOSED ON PROCESS GAUGE

During the semi-annual inspection of the gasification facility's process gauges, a gauge was found with its shutter stuck closed. The gauge had not been used since the last licensee inspection so there would have been no indication from operation of the facility that there was a problem. The gauge was a Berthold Model P-2608-100 containing a 5 millicurie Co-60 source. The licensee has determined that the gauge is not really needed to support the process and has contacted Berthold to come to the facility and remove the gauge and take possession of it. The licensee has inactivated the gauge and, with the shutter stuck closed, considers that there is no risk to personnel.

INVALID ACTUATION OF A MOTOR DRIVEN AUXILIARY FEEDWATER PUMP

"This 60-day telephone notification is being made under reporting requirements specified by 10 CFR 50.73(a)(2)(iv)(A) and 10 CFR 50.73(a)(1).

"On 2/16/10 at 1122 EST, following maintenance activities on 'B' Emergency Safeguards Sequencer, Clearance Order 213623, was in the process of being lifted when an automatic start of 'B' Motor Driven Auxiliary Feedwater (MDAFW) pump occurred. Water flowed to all three Steam Generators resulting in an increase of reactor power by 0.1%. Isolation of Steam Generator Blowdown and Blowdown Sampling also occurred. The actuation occurred during work associated with replacement of relay 2-55/1163 which was installed incorrectly in the "B" Sequencer cabinet. At the time of the event, all Steam Generator levels were normal. No actual condition existed that would require an automatic start of the "B" MDAFW pump and therefore this event has been classified as an invalid actuation.

"All equipment operated properly. The 'B' MDAFW pump was secured by operations at 1123 EST.

"This invalid actuation was entered into the corrective action program as [Harris Nuclear Condition Report] NCR 381672.

"The safety significance of this event is considered to be minimal. The 'B' MDAFW pump started and operated normally and the 'A' MDAFW and Turbine Driven Auxiliary Feedwater (TDAFW) pumps were available.

"Immediate corrective actions were to secure the "B" MDAFW pump and restore Steam Generator Blowdown and Sampling."

The licensee has notified the NRC Resident Inspector.