Event Notification Report for July 06, 2010
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/05/2010 - 07/06/2010
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor
Event Number: 46073
Facility: GINNA
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] W-2-LP
NRC Notified By: BENJAMIN CHANG
HQ OPS Officer: DONG HWA PARK
Region: 1 State: NY
Unit: [1] [] []
RX Type: [1] W-2-LP
NRC Notified By: BENJAMIN CHANG
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/06/2010
Notification Time: 18:02 [ET]
Event Date: 07/06/2010
Event Time: 13:05 [EDT]
Last Update Date: 08/20/2010
Notification Time: 18:02 [ET]
Event Date: 07/06/2010
Event Time: 13:05 [EDT]
Last Update Date: 08/20/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
ANTHONY DIMITRIADIS (R1DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
POST CONTINGENCY LOW VOLTAGE ALARM RECEIVED FOR OFFSITE POWER
"The Rochester Gas and Electric (RG&E) Energy Control Center (ECC) notified Ginna Operations that the Post Contingency Low Voltage Alarm was received for the offsite power system. Ginna Operations entered procedure O-6.9, Operating Limits for Ginna Station Transmission, and declared the offsite power inoperable per ITS 3.8.1 [72 hour LCO]. Per NUREG-1022, section 3.2.7, if either offsite power or onsite emergency power is unavailable to the plant, it is reportable per 50.72(b)(3)(v)(A) regardless of whether the other system is available.
"The RG&E ECC monitors 115 kV voltage using their State Estimation and Contingency Analysis System. The State Estimation portion of the system evaluates real time system power flow and voltages on the 115 and 34.5 kV transmission systems. The Contingency Analysis portion analyzes the voltage effect of a Ginna main generator trip concurrent with worst case accident loading. If the Station 13A voltage would drop below the minimum required voltage for offsite power alignment a Ginna Post Contingency Low Voltage Alarm occurs.
"If the main generator should trip, then the absence of a Post Contingency Low Voltage Alarm on the RG&E State Estimation and Contingency Analysis System will ensure that the subsequent offsite 115kV system voltage transient will not result in Ginna Station experiencing an under voltage condition on the 480V Safeguard Busses.
"The RG&E ECC notified Ginna operations that the Post Contingency Low Voltage Alarm cleared at 1311 EDST on 07/06/2010. The plant was maintained at 100% steady state conditions throughout the event. Both circuits remain inoperable but available for use. And will be restored to operable status when the system reliability is assured.
"The licensee notified the NRC Resident Inspector."
* * * RETRACTION AT 0852 ON 8/20/10 FROM DETTMAN TO HUFFMAN * * *
"The purpose of this report is to retract the event discussed in ENS report #46071 (July 6, 2010). The ENS report covered an offsite power related event which occurred on July 6, 2010. In this event, both sources of offsite power were declared inoperable following notification to the R.E. Ginna Nuclear Power Plant that the calculated post contingency off-site system voltage was below the required value necessary to ensure that offsite power would remain available following a design basis accident.
"Since the ENS report, an engineering analysis of the event has been completed. The analysis determined that the offsite power system was actually operable at all times on July 6, 2010. The 'Post Contingency Low Voltage Alarm (PCLVA)' computer model that is being utilized by the transmission system provider, Rochester Gas & Electric, to calculate the post contingency offsite system voltage, is inherently conservative in that it assumes the site is relying on a worst case single source of offsite power. However on July 6, 2010, both offsite power sources were available and the site was aligned in the 50/50 Normal offsite power configuration. The engineering analysis calculated the acceptable voltage in this configuration and identified that at no point did the calculated post contingency voltage decrease below the 50/50 Normal offsite power configuration's acceptable value. As such, the July 6, 2010 event is being retracted.
"The licensee notified the NRC Resident Inspector."
R1DO (Burritt) was notified.
"The Rochester Gas and Electric (RG&E) Energy Control Center (ECC) notified Ginna Operations that the Post Contingency Low Voltage Alarm was received for the offsite power system. Ginna Operations entered procedure O-6.9, Operating Limits for Ginna Station Transmission, and declared the offsite power inoperable per ITS 3.8.1 [72 hour LCO]. Per NUREG-1022, section 3.2.7, if either offsite power or onsite emergency power is unavailable to the plant, it is reportable per 50.72(b)(3)(v)(A) regardless of whether the other system is available.
"The RG&E ECC monitors 115 kV voltage using their State Estimation and Contingency Analysis System. The State Estimation portion of the system evaluates real time system power flow and voltages on the 115 and 34.5 kV transmission systems. The Contingency Analysis portion analyzes the voltage effect of a Ginna main generator trip concurrent with worst case accident loading. If the Station 13A voltage would drop below the minimum required voltage for offsite power alignment a Ginna Post Contingency Low Voltage Alarm occurs.
"If the main generator should trip, then the absence of a Post Contingency Low Voltage Alarm on the RG&E State Estimation and Contingency Analysis System will ensure that the subsequent offsite 115kV system voltage transient will not result in Ginna Station experiencing an under voltage condition on the 480V Safeguard Busses.
"The RG&E ECC notified Ginna operations that the Post Contingency Low Voltage Alarm cleared at 1311 EDST on 07/06/2010. The plant was maintained at 100% steady state conditions throughout the event. Both circuits remain inoperable but available for use. And will be restored to operable status when the system reliability is assured.
"The licensee notified the NRC Resident Inspector."
* * * RETRACTION AT 0852 ON 8/20/10 FROM DETTMAN TO HUFFMAN * * *
"The purpose of this report is to retract the event discussed in ENS report #46071 (July 6, 2010). The ENS report covered an offsite power related event which occurred on July 6, 2010. In this event, both sources of offsite power were declared inoperable following notification to the R.E. Ginna Nuclear Power Plant that the calculated post contingency off-site system voltage was below the required value necessary to ensure that offsite power would remain available following a design basis accident.
"Since the ENS report, an engineering analysis of the event has been completed. The analysis determined that the offsite power system was actually operable at all times on July 6, 2010. The 'Post Contingency Low Voltage Alarm (PCLVA)' computer model that is being utilized by the transmission system provider, Rochester Gas & Electric, to calculate the post contingency offsite system voltage, is inherently conservative in that it assumes the site is relying on a worst case single source of offsite power. However on July 6, 2010, both offsite power sources were available and the site was aligned in the 50/50 Normal offsite power configuration. The engineering analysis calculated the acceptable voltage in this configuration and identified that at no point did the calculated post contingency voltage decrease below the 50/50 Normal offsite power configuration's acceptable value. As such, the July 6, 2010 event is being retracted.
"The licensee notified the NRC Resident Inspector."
R1DO (Burritt) was notified.
Agreement State
Event Number: 48488
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: PIEDMONT FAYETTE HOSPITAL
Region: 1
City: FAYETTEVILLE State: GA
County:
License #: GA 1340-1
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: PETE SNYDER
Licensee: PIEDMONT FAYETTE HOSPITAL
Region: 1
City: FAYETTEVILLE State: GA
County:
License #: GA 1340-1
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: PETE SNYDER
Notification Date: 11/07/2012
Notification Time: 11:38 [ET]
Event Date: 07/06/2010
Event Time: 00:00 [EDT]
Last Update Date: 11/07/2012
Notification Time: 11:38 [ET]
Event Date: 07/06/2010
Event Time: 00:00 [EDT]
Last Update Date: 11/07/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
GLENN DENTEL (R1DO)
FSME EVENT RESOURCE (EMAI)
GLENN DENTEL (R1DO)
FSME EVENT RESOURCE (EMAI)
AGREEMENT STATE REPORT - DELIVERED DOSE DIFFERENT THAN PRESCRIBED
The following was received from the State of Georgia via email:
"The Licensee reported to the Department [state of Georgia] on July 14, 2010 that a patient who received a prostate seed implant procedure on July 6, 2010 resulted in a medical incident. The patient was scheduled to receive a Cs-131 Isoray seed implantation for the prostate with a total planned activity of 194.3 mCi. During the procedure on July 6, 2010 it was noticed that many of the seeds implanted were not visible on ultrasound. Following final implantation of all the seeds, a cystoscopy was performed on the patient where it was revealed that 19 seeds were implanted in the bladder and not the prostate which was the intended implant site. All 19 seeds were removed from the bladder without difficulty. A post plan evaluation was completed the same day of the treatment. The total activity implanted (seeds implanted to the prostate) was determined to be 140 mCi with a difference of -54.3 mCi deviation from the total planned activity. Post plan D90 for the prostate was calculated to be 62.68% with a D90 deviation of 53.28 Gy from the dose prescribed of 85 Gy. An additional procedure was scheduled for the patient on July 12, 2010 where 18 seeds were implanted to bring the combined dose distribution to the prescribed amount.
"The department [Georgia Radioactive Materials] reported the incident to NMED in November 2012."
Georgia Incident Summary: GA-2010-07i
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.
The following was received from the State of Georgia via email:
"The Licensee reported to the Department [state of Georgia] on July 14, 2010 that a patient who received a prostate seed implant procedure on July 6, 2010 resulted in a medical incident. The patient was scheduled to receive a Cs-131 Isoray seed implantation for the prostate with a total planned activity of 194.3 mCi. During the procedure on July 6, 2010 it was noticed that many of the seeds implanted were not visible on ultrasound. Following final implantation of all the seeds, a cystoscopy was performed on the patient where it was revealed that 19 seeds were implanted in the bladder and not the prostate which was the intended implant site. All 19 seeds were removed from the bladder without difficulty. A post plan evaluation was completed the same day of the treatment. The total activity implanted (seeds implanted to the prostate) was determined to be 140 mCi with a difference of -54.3 mCi deviation from the total planned activity. Post plan D90 for the prostate was calculated to be 62.68% with a D90 deviation of 53.28 Gy from the dose prescribed of 85 Gy. An additional procedure was scheduled for the patient on July 12, 2010 where 18 seeds were implanted to bring the combined dose distribution to the prescribed amount.
"The department [Georgia Radioactive Materials] reported the incident to NMED in November 2012."
Georgia Incident Summary: GA-2010-07i
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.