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Event Notification Report for February 3, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/02/2010 - 02/03/2010

** EVENT NUMBERS **


45665 45672 45673

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General Information or Other Event Number: 45665
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: JEWISH HOSPITAL OF CINCINNATI
Region: 3
City: CINCINNATI State: OH
County:
License #: 02120310029
Agreement: Y
Docket:
NRC Notified By: MICHAEL SNEE
HQ OPS Officer: JOE O'HARA
Notification Date: 01/27/2010
Notification Time: 15:39 [ET]
Event Date: 01/27/2010
Event Time: [EST]
Last Update Date: 01/27/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTINE LIPA (R3DO)
MARK THAGGARD (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL MEDICAL EVENT INVOLVING A BRACHYTHERAPY UNDERDOSE EVENT

The following was received via e-mail:

"The BRP [Bureau of Radiation Protection] was informed on January 26, 2010 of a medical event that occurred at The Jewish Hospital of Cincinnati on December 28, 2009. A patient received a prostate I-125 seed implant on December 28, 2009. The post implant CT showed no problems but a follow-up CT performed on January 26, 2010 showed that the patient only received 75% of the prescribed dose to the prostate."

The intended dose was 144 Gy (14400 rad) and the actual received dose was 108 Gy (10800 rad). I-125 activity was 0.032 Ci per seed. The total dose delivered differs from the prescribed dose by twenty five percent. The state is investigating the matter.

Item Number: OH100002

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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Power Reactor Event Number: 45672
Facility: WATERFORD
Region: 4 State: LA
Unit: [3] [ ] [ ]
RX Type: [3] CE
NRC Notified By: JOE WILLIAMS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 02/02/2010
Notification Time: 20:37 [ET]
Event Date: 02/02/2010
Event Time: 14:00 [CST]
Last Update Date: 02/02/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
VINCENT GADDY (R4DO)

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

Event Text

PRIMARY EOF UNAVAILABLE DUE TO FAILURE OF VENTILATION DAMPER POSITION INDICATION

"On February 2, 2010, at approximately 1400 CST, Entergy personnel manually switched the Emergency Operations Facility (EOF) Ventilation System Panel to the isolation mode. This manual switching to the isolation mode will cause the isolation dampers to close and the movement of the dampers closing can normally be heard. An indication light on the ventilation panel will illuminate when the dampers close. For the manual isolation on February 2, 2010, these indications did not occur. Waterford 3 personnel have made a judgment that the isolation dampers may not be closed due the lack of the aforementioned indications. The EOF ventilation system is not able to perform its isolation function if the dampers are not closed. The ventilation system and associated dampers are designed to provide protection from radiological and toxic chemical release. This report is being made because the time to restore the ventilation system to functional status is indeterminate at this time, until the actual condition of the ventilation system can be established.

"The back up EOF facility is judged to be functional based on January 12, 2010 communications check and facility readiness verifications on January 28, 2010."

The licensee informed the NRC Resident Inspector.

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Power Reactor Event Number: 45673
Facility: FARLEY
Region: 2 State: AL
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: BILL ARENS
HQ OPS Officer: DONG HWA PARK
Notification Date: 02/03/2010
Notification Time: 03:14 [ET]
Event Date: 02/02/2010
Event Time: 20:15 [CST]
Last Update Date: 02/03/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
DAVID AYRES (R2DO)

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

TWO OF THREE TRAINS OF AUXILIARY FEED WATER DECLARED INOPERABLE

"On 2/2/10, at 1615 [CST], the Unit 1 TDAFW [Turbine Driven Auxiliary Feed Water] Pump was declared inoperable due to a high temperature identified on an electrical cable in the TDAFW UPS [Uninterrupted Power Supply]. The 1B Diesel Generator had previously been removed from service for scheduled maintenance. As required by the Diesel Generator LCO Required Action Statement, the Unit 1 'B' MDAFW [Motor Driven Auxiliary Feed Water] Pump was declared inoperable at 2015 [CST], on 2/2/10, due to the combination of its inoperable emergency power supply and inoperable redundant equipment. This resulted in two of three trains of Auxiliary Feed Water being inoperable. Because two out of the three trains of AFW [Auxiliary Feed Water] are required to meet flow requirements for limiting design basis accidents, this represents a condition that could have prevented the fulfillment of a safety function.

"Repairs to the electrical cable were immediately initiated. At 2216 [CST], on 2/2/10, the Unit 1 TDAFW Pump was returned to operable status, allowing the 1B MDAFW Pump to be declared operable, and restoring the safety function."

The licensee determined that the high temperature in the electrical cable was caused by a high resistance between the lug and cable connection.

The licensee will notify the NRC Resident Inspector.

Page Last Reviewed/Updated Thursday, March 29, 2012
Thursday, March 29, 2012