Event Notification Report for June 08, 2010

AGREEMENT STATE REPORT - WRONG DOSE

The following information was received via e-mail:

"On June 8, 2010 at approximately 9:45 am, a patient scheduled for a 30 mCi TC-99m Myoview cardiac scan was mistakenly administered a 27.1 mCi Tc-99m Medronate bone dose. The mistake was discovered shortly after the administration of the dose when the technician noticed the name on the dose did not match that of the patient. The bone scan patient and cardiac patient had very similar sounding last names, which contributed to the error. The patient was notified of the error when he returned for his cardiac scan 45 minutes after injection. The actual bone scan patient was sent home without any scan and was not injected with any dose because they caught the error before he arrived for scanning."

Event No.: WA 100041

AUTOMATIC REACTOR TRIP WITH SAFETY INJECTION DUE TO LOSS OF VITAL AC BUS

"At 0948 hours [EDT] on 6/8/10, a Unit 1 vital AC bus was lost when the uninterruptible power supply inverter failed while the alternate AC source was out of service for scheduled maintenance. The loss of the vital bus inverter caused a loss of 120 VAC vital bus 1-III. The loss of this vital bus caused the 'A' main feed pump recirculation valve to fail open and also caused 2 of the 3 main feedwater regulating valves to fail to automatic-hold mode of operation. This combination of as designed failures resulted in a reduction in main feedwater flow and resulted in an automatic reactor trip due to a feed flow steam flow mismatch in conjunction with low steam generator level.

"The loss of vital bus 1-III also resulted in initiation of safety injection due to loss of vital bus 1-III instrumentation in conjunction with the expected momentary RCS cooldown below 543 DEG-F. The safety injection resulted from the high steam flow in conjunction with low RCS T-ave actuation signal. The safety injection actuation also resulted in automatic start of the #1 Emergency Diesel and the #3 Emergency Diesel Generators. Neither EDG was required to load since off-site power remained operable.

"The loss of vital bus 1-III also resulted in loss of numerous field inputs to the Plant Computer System [PCS] and resulted in non-functionality of the SPDS [Safety Parameter Display System]. The PCS itself remains functional along with MCR [Main Control Room] annunciators and sufficient MCR instrumentation to monitor critical safety functions. All three auxiliary feedwater pumps automatically initiated as designed on low-low steam generator level following the trip. Currently, RCS temperature is being maintained stable at 547 degrees. All systems functioned as required following the reactor trip. During the post-trip transient, pressurizer PORV [Power Operated Relief Valve], PCV-1455C, cycled as required to maintain RCS pressure due to the safety injection and the loss of normal letdown.

"There were no radiation releases due to this event, nor were there any personnel injuries or contamination events. This event is being reported in accordance with 10CFR50.72(b)(2)(iv)(B), 10CFR50.72(b)(2)(iv)(A), 10CFR50.72(b)(3)(iv)(A), and 10CFR50.72(b)(3)(xiii).

"The NRC Resident Inspector was notified of this event."

During the trip, all rods inserted into the core. In addition to the pressurizer PORV lifting, a secondary main steam relief valve lifted. All relief valves properly reseated and there is no known primary to secondary leakage. The plant is in its normal shutdown electrical lineup. Main steam trip valves were isolated during the transient. Decay heat is being removed via main steam bypasses to the condenser and steam generator power operated relief valves.

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO PRIMARY CONTAINMENT LEAK GREATER THAN LIMITS

"On 6/8/10 at 10:15, primary containment was declared inoperable and a 24 [hour] Limiting Condition for Operation (LCO) was entered due to Engineered Safety Features leakage in excess of the 1.0 gpm value assumed in the Alternative Source Term (AST) analysis as described in the UFSAR.

"The leakage was from the 'B' RHR heat exchanger relief valve (SR-10-86B) and was estimated at 1.25 gpm.

"On 6/8/10 at 11:26, commenced a power reduction for a Technical Specification required shutdown per TS 3.7.A.8.

"Actions Taken:

"Isolating the 'B' RHR system per Technical Specifications that will allow us to exit the 24 hour LCO.

"Planning to replace the relief valve.

"Verified relief valve on 'A' RHR system is not leaking."

The licensee has notified State and local authorities and the NRC Resident Inspector. The licensee also anticipates a press release.


* * * NOTIFICATION FROM KRITZER TO CROUCH AT 1553 EDT ON 6/8/10 * * *

The licensee exited the 24 hour LCO TS required shutdown condition at 1548 EDT based on isolation of the 'B' RHR system.

R1DO (Henderson) notified.

TEXAS AGREEMENT STATE REPORT - MEDICAL EVENT

On June 8, 2010, the State of Texas was notified by the licensee that during routine chart review, they determined that over a six month period, five patients received 30% to 50% less than prescribed dose. All the patients underwent High Dose Rate Brachytherapy using a Ir-192 Gammamed device. The licensee is still investigating an evaluating patient outcomes due to the under dosages. It is unknown whether the patients and their prescribing physicians were notified.

Texas Incident No.: I-8751

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 OF MINOR HYDAZINE SPILL

"At approximately 0430 CDT on June 8, 2010, during restoration following an addition of 10 gallons of hydrazine and a flush of 2 gallons of demineralized water to the Condensate Storage Tank (CST), a water-hydrazine mixture began to leak from check valve KHV0179. KHV0179 is a nitrogen supply check valve that can also be used for hydrazine addition.

"Chemistry technicians estimated that a water-hydrazine mixture on the order of 2 gallons leaked through KHV0179 before the line could be isolated. Samples taken from the atmosphere above the spill contained 0.25 ppm hydrazine. The fluid on the ground was measured to contain 15% hydrazine.

"The Department of Natural Resources (DNR) was notified of this event at approximately 1000 CDT on June 8, 2010.

"The Nuclear Regulatory Commission (NRC) Resident Inspectors will be notified."