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Event Notification Report for March 2, 2005

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/01/2005 - 03/02/2005

** EVENT NUMBERS **


41438 41452 41453

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General Information or Other Event Number: 41438
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: BAYSTATE HEALTH SYSTEMS
Region: 1
City: SPRINGFIELD State: MA
County:
License #: 60-0095
Agreement: Y
Docket: 02-5457
NRC Notified By: MIKE WHALEN (VIA FAX)
HQ OPS Officer: BILL HUFFMAN
Notification Date: 02/24/2005
Notification Time: 12:41 [ET]
Event Date: 01/07/2005
Event Time: 10:35 [EST]
Last Update Date: 02/24/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAMELA HENDERSON (R1)
CHARLES MILLER (NMSS)

Event Text

AGREEMENT STATE MEDICAL EVENT

The following report was received from the Massachusetts Department of Public Health and Radiation Control via facsimile:

"Endocrinologist ordered thyroid uptake study on a patient - dose to be 17 uCi of I-131. The Central Booking Department scheduled the patient to arrive in the Nuclear Medicine Department for an I-131 'total body scan.' On 1/4/05, CNMT 1 received the appointment roster form for 1/7/05, posted it on exam scheduling bulletin board, and placed the order for a total body scan - which is generally 3.7 mCi of I-131 - without looking at the diagnosis. Total body scan ordered on roster was reviewed by Nuclear Medicine Physician and checked off for that day's activity. On the day of the exam, CNMT 2 retrieved the paper work and administered the 3.7 mCi, I-131 whole body scan. Patient sent home and came back 2 days later for thyroid scan. The imaging CNMT 3 noted that the thyroid scan did not look as expected, thus, reviewed all the paperwork and discovered that the wrong procedure (and dose) was administered. The Nuclear Medicine Physician and the RSO were then immediately notified by the CNMT 3, who in turn, notified the prescribing Endocrinologist. The Nuclear Medicine Physician then notified the patient (on 1/7/05) and the Department Administration. A summary report will be sent to the patient which will include notification that a formal report has been submitted to the Massachusetts Radiation Control Program.

"The patient ultimately received 3.6 mCi of I-131, had a thyroid uptake of 70% which resulted in a thyroid dose of 13,111 rads and a TEDE of 2.6 rads. This dose will be taken into consideration when the patient is treated next for hyperthyroidism."

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Power Reactor Event Number: 41452
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [1] [ ] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: BOB PACE
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 03/01/2005
Notification Time: 02:51 [ET]
Event Date: 03/01/2005
Event Time: 00:43 [EST]
Last Update Date: 03/01/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
DANIEL HOLODY (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 15 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR SCRAM FROM 15% POWER DUE TO HIGH TURBINE VIBRATION

The following details were provided by the licensee via fax as part of their telephonic notification:

"Manual reactor scram due to high turbine generator vibration during a planned Unit 1 power reduction to Mode 2 to perform maintenance to replace the vent line piping on 11 MSR drain tank. The manual reactor scram was initiated per AOP-7E, section V, 'High Turbine Vibration' trip criteria when bearing #5 exceeded 12 mils vibration. This event meets NUREG-1022 Rev. 2, Section 3.2.6 'System Actuation' Part 50.72(b)(2)(iv)(B) 'Any event or condition that results in actuation of the reactor protection system (RPS) when the reactor is critical except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation.'"

All rods fully inserted and no ECCS or relief valve actuations occurred. Heat sink is the condenser and turbine bypass valves.

The NRC resident inspector was notified.

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Power Reactor Event Number: 41453
Facility: MCGUIRE
Region: 2 State: NC
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: AL YODER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/01/2005
Notification Time: 16:19 [ET]
Event Date: 03/01/2005
Event Time: 15:45 [EST]
Last Update Date: 03/01/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
CAROLYN EVANS (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 20 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP DURING A RAPID SHUTDOWN FOR STEAM LEAK REPAIR

The following information was provided by the licensee via facsimile (licensee text in quotes):

"[The licensee] reduced power on Unit 2 due to a steam leak on a moisture separator reheater vent line. The reactor was manually tripped at 20% reactor power per normal shutdown sequence. All systems and components operated correctly. Unit restart will commence following completion of a planned refueling outage."

All rods fully inserted. One steam line secondary PORV lifted and reseated. Decay heat removal is via AFW and steam bypass valves to the main condenser. The steam leak was reported to be on a 2-inch MSR vent line elbow.

The licensee has notified the NRC Resident Inspector.

Page Last Reviewed/Updated Friday, March 30, 2012
Friday, March 30, 2012