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Event Notification Report for February 13, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/12/2009 - 02/13/2009

** EVENT NUMBERS **


44834 44846 44849 44850

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General Information or Other Event Number: 44834
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: CITY OF HOPE/BECKMAN RESEARCH INSTITUTE
Region: 4
City: DUATE State: CA
County:
License #: 0307-19
Agreement: Y
Docket:
NRC Notified By: L. ROBERT GREGER
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/06/2009
Notification Time: 13:26 [ET]
Event Date: 02/04/2009
Event Time: 18:00 [PST]
Last Update Date: 02/06/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JEFF CLARK (R4)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT INVOLVING A DOSE DELIVERED TO THE WRONG TREATMENT SITE

The following information was received from the State of California via email:

"On February 5, 2009, [the Radiation Safety Officer (RSO) for the] City of Hope/Beckman Research Institute, contacted LA County Radiation Management regarding a misadministration that occurred at approximately 6:00 pm on February 4, 2009. The incident involved HDR treatment of the wrong site.

"Using HDR, a patient was scheduled for groin sarcoma therapy treatment. The treatment planning comprised of administration of approximately 4000 cGy to the tumor. The dose is to be administered in 10 fractions of 400 cGy/fraction; 2 fractions per day for 5 days. Six catheters to be administered/fraction. Per [the RSO], an error was made in the interpretation of the CT data, and therefore, the wrong distance was calculated. On February 4, 2009, the first day of the treatment, the catheters administered went to the body, past the tumor site, then to the outside of the thigh. [The RSO] stated that there was no dose administered to the tumor. All the dose was administered to the skin of the thigh. The patient had two treatments, and received approximately 800 cGy to the skin of the thigh.

"A written report will be submitted by the licensee within 15 days.

"Based on the current report of 800 rad to the wrong treatment site (skin), this medical event does not meet the criteria for an Abnormal Occurrence (see SA-300, Appendix section 6.3.IV)."

CA 5010 Number: 020509

A Medical Event may indicate potential problems in a medical facilities use of radioactive materials. It does not necessarily result in harm to the patient.

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 44846
Facility: PALO VERDE
Region: 4 State: AZ
Unit: [1] [2] [3]
RX Type: [1] CE,[2] CE,[3] CE
NRC Notified By: TIM GAFFNEY
HQ OPS Officer: PETE SNYDER
Notification Date: 02/11/2009
Notification Time: 19:31 [ET]
Event Date: 02/11/2009
Event Time: 13:18 [MST]
Last Update Date: 02/12/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
GEOFFREY MILLER (R4)

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

Event Text

POSSIBLY INADEQUATE BACKUP NITROGEN SUPPLY FOR ATMOSPHERIC DUMP OPERATION

"The following event description is based on information currently available. If through subsequent reviews of this event, additional information is identified that is pertinent to this event or alters the information being provided at this time, a follow-up notification will be made via the ENS of under the reporting requirements of 10 CFR 50.73.

"Palo Verde Nuclear Station declared all three Unit's atmospheric dump valves (ADV) inoperable at 1318 MST. The reason for the inoperability is the discovery by engineering personnel that the ADV backup nitrogen capacity, required to operate the valves to mitigate certain accident scenarios, was not adequate.

"There are 4 ADVs (one on each steam line with two steam lines per steam generator) for each of the three units. Engineering review of a loss of offsite power event determined that the current nitrogen supply of 13.3 hours will not be adequate to get the plant to shutdown cooling entry conditions during a natural circulation asymmetric cooldown (i.e. Feedwater Line Break, Main Steam Line Break, and Steam Generator Tube Rupture).

"Actions are in progress to restore the operability of the ADVs. If unsuccessful, all three units will be required by the Technical Specifications to be in Mode 3, Hot Shutdown, by 1918 MST on February 12, 2009."

The licensee notified the NRC Resident Inspector.

* * * RETRACTION FROM RAY BUZARD TO PETE SNYDER AT 1840 ON 2/12/09 * * *

"This is a retraction of the condition reported in EN # 44846 on February 11, 2009 at 19:31 EST. Upon further review of the condition, engineering personnel have determined that the ADV nitrogen supply was adequate to mitigate the consequences of the postulated events and the ADVs were declared operable at 04:30 MST on February 12, 2009. Therefore, no reportable condition existed."

The licensee notified the NRC Resident Inspector. Notified R4DO (Miller).

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Power Reactor Event Number: 44849
Facility: HATCH
Region: 2 State: GA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: EDWIN URQUHART
HQ OPS Officer: PETE SNYDER
Notification Date: 02/12/2009
Notification Time: 16:56 [ET]
Event Date: 02/12/2009
Event Time: 12:30 [EST]
Last Update Date: 02/12/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JONATHAN BARTLEY (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling

Event Text

HIGH PRESSURE COOLANT INJECTION SUCTION SOURCE INSTRUMENT MALFUNCTION

"Unit 2 HPCI (High Pressure Coolant Injection system) is being considered inoperable due to the following information: (Condition Report 2009101257) The instrumentation associated with the automatic suction swap for Unit 2 HPCI was reviewed as a result of CR 2009100480 to confirm the set points that determine the condensate storage tank (CST) level at which the suction swap would occur. During the course of this review, the corporate design engineer contacted the level switch vendor to review the configuration of the level switches and to confirm the expected operation of the switches (2E41-N002 & 2E41-N003) given their configuration. Based on the configuration of the instrument lines and physical location of the level switches, the vendor reported that either liquid or gas would most likely be entrapped in the external cage of the Magnetrol level switches. This would prevent the instruments from performing their automatic swap function. Based on this information the 'as found' condition of the switches indicate that this condition has been present since the installation of the switches when implementing the DCP in 1991 which affects the operability of this instrumentation.

"Even though the suction swap instrumentation on low CST level is considered inoperable, there is no apparent actual adverse impact on nuclear safety. However, the instrumentation is included in the Technical Specifications and its inoperability would make HPCI inoperable if it is aligned to the CST rather than being aligned to the suppression pool. The normal system alignment is with its suction source to the CST, therefore HPCI is being considered as inoperable.

"Until the configuration of the level switches has been addressed, these Magnetrol level switches must be considered inoperable, the appropriate Technical Specification RAS [Required Action Statement] will be entered and the suction source for HPCI should be aligned to the suppression pool when HPCI is required to be operable. This condition only applies to Unit 2."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 44850
Facility: HOPE CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: MICHAEL REED
HQ OPS Officer: PETE SNYDER
Notification Date: 02/12/2009
Notification Time: 19:22 [ET]
Event Date: 02/12/2009
Event Time: 15:00 [EST]
Last Update Date: 02/12/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
LAWRENCE DOERFLEIN (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

US COAST GUARD AND NEW JERSEY ENVIRONMENTAL HOTLINE NOTIFIED DUE TO CAPSIZED BOAT

"This notification is based on 10 CFR 50.72(b)(2)(xi) HCGS RAL 11.8.2.a Unusual Conditions Warranting a News Release or Notification of Government Agencies. The US Coast Guard and New Jersey State Environmental Hotline were contacted and provided the following communication.

"Between 14:00 and 15:00 hours today, an unmanned 25' boat owned by Atlantic Subsea (a PSEG Nuclear contractor) that was tied in the Hope Creek Generating Station barge slip, which is on the Delaware River, at Hope Creek Generating Station overturned and became partially submerged. There were no passengers onboard at the time. Atlantic Subsea reports that the boat contains approximately 40 gallons of gas in a sealed fuel system and 5 gallons of oil in a sealed oil system. Atlantic Subsea does not believe the sealed fuel or oil systems will leak, and there is NO indication of gas or oil leaking into the Delaware River. The gas tank does have a vent, but this vent is fitted with a mechanical vacuum breaker that is not expected to leak.

"Because of the wind and high seas, PSEG and Atlantic Subsea are unable to safely remove the boat or its contents from the water at this time. It is expected that the boat will be removed from the water tomorrow when the weather improves. PSEG is presently deploying absorbents into the entrance of the barge slip to contain any oil or gas that does leak. In addition, inspections of the water in and around the barge slip will be performed hourly. A notification will be made in the event that a discharge occurs.

"Atlantic Subsea has informed the Coast Guard.

"This is a courtesy notification only from PSEG Nuclear LLC's Hope Creek Generating Station. There is no evidence of a leak of petroleum products into the Delaware River."

The licensee notified the NRC Resident Inspector.

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Thursday, March 29, 2012