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Event Notification Report for December 21, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/20/2006 - 12/21/2006

** EVENT NUMBERS **


42751 43057

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Power Reactor Event Number: 42751
Facility: GINNA
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: DOUG GOMEZ
HQ OPS Officer: BILL GOTT
Notification Date: 08/02/2006
Notification Time: 18:41 [ET]
Event Date: 08/02/2006
Event Time: 11:27 [EDT]
Last Update Date: 12/20/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
Person (Organization):
PAT FINNEY (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

POST CONTINGENCY LOW VOLTAGE ALARM

"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 off site 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 Energy Control Center (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 345 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 1408 EDST on 08/02/2006 and the LCO for ITS 3.8.1 was exited at 1704 after observation of grid stability. The plant was maintained at 100% steady state conditions throughout the event."

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM KYLE GARNISH TO W. GOTT AT 1430 ON 08/03/06 * * *

"This is an additional notification for EN #42751 that was reported on 8/2/06 for offsite power being declared inoperable. A subsequent investigation revealed that offsite power was also inoperable on 7/17/2006 from 1427 to 1448 and on 8/1/2006 from 1022 to 1843 for which a notification was not completed."

The licensee notified the NRC Resident Inspector.

Notified R1DO P. Finney

* * * RETRACTION OF JULY 17, 2006 PORTION OF EVENT FROM D. DEAN TO MACKINNON ON 12/20/06 AT 1435 EST * * *

"The purpose of this report is to retract one of the events discussed in ENS report #42751 (August 2 and 3, 2006). The ENS report covered three separate off site power related events which occurred on July 17, 2006, August 1, 2006 and August 2, 2006. For each of the events, both sources of off-site power were declared inoperable following notification to R.E. Ginna Nuclear Power Plant that the calculated post contingency off-site system voltage was below the required value necessary to ensure that off-site power would remain available following a design basis accident.

"Since the ENS report, an engineering analysis of the July 17, 2006 event has been completed. The analysis determined that the off site power system was actually operable at all times on July 17, 2006, The 'post contingency low voltage alarm (PCLVA)' computer model that is being utilized by Rochester Gas & Electric to calculate the post contingency off site system voltage is inherently conservative in that many of the automatic voltage regulators associated with the other generating units are assumed to be in the manual mode. The computer simulation that resulted in the alarm was repeated and by 'turning on' the voltage regulators for four of the nearby generator units, the post contingency voltage improved to above the alarm set point. The four voltage regulators that were turned on in the computer simulation were confirmed to be in the automatic mode on July 17, 2006. As such, the July 17, 2006 event is being retracted.

"The licensee notified the NRC Resident Inspector."

NRC R1DO (Ray Powell) notified.

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Hospital Event Number: 43057
Rep Org: COOPER HEALTH SYSTEM
Licensee: COOPER HEALTH SYSTEM
Region: 1
City: CAMDEN State: NJ
County:
License #: 29-08285-01
Agreement: N
Docket:
NRC Notified By: ED GOLDSCHMIDT
HQ OPS Officer: JOHN MacKINNON
Notification Date: 12/19/2006
Notification Time: 14:41 [ET]
Event Date: 11/09/2006
Event Time: 11:00 [EST]
Last Update Date: 12/20/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
RAY POWELL (R1)
GREG MORELL (NMSS)

Event Text

DISCOVERED THAT A PATIENT RECEIVED AN UNDERDOSAGE

"During a routine NRC inspection on 12/18/06 Sandra Gabriel Ph.D, Senior Health Physicist from Region I, discovered a medical event that occurred on 11/9/06 involving a HDR (35.600) treatment.

"On 11/9/06 an HDR treatment patient received a dose of 1.37 Gy to Point A when the prescribed intended dose was 6.0 Gy.

"The following scenario lead to the medical event.

"A 6.0 cm tandem was inserted into the patient, however, the Authorized User asked the Authorized Medical Physicist to treat only a length of 4.0 cm to spare excess dose to normal structures. After the patient was treated, the Authorized Medical Physicist told the Authorized User he miscalculated the appropriate treatment length and what he thought was 2.0 cm from the end of the tandem was actually 20 cm from the tip of the tandem. The Authorized User and Authorized Medical Physicist calculated where 20 cm was, and this point was in fact outside of the patient's body, thus the patient only received dose from the ring portion of the applicator, resulting in a dose of 1.37 Gy to point A of the prescription plan.

"Since this dose was subtherapeutic, the Authorized User added an extra HDR treatment (during the course of treatments) and the patient received a total dose to point A of 31.37 Gy which was within 20% of the original intended total dose. The patient was made aware of the extra treatment that was necessary because of the under dosage on 11/9/06.

"A full written report will follow within 15 days as required by 10 CFR 35.3045."

* * UPDATE FROM FLANNERY (FSME) TO KOZAL AT 1213 ON 12/20/06 * * *

This event has been reviewed by the NRC medical review committee and determined to be a reportable medical event.

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.

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Friday, March 30, 2012