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Event Notification Report for February 18, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/17/2010 - 02/18/2010

** EVENT NUMBERS **


45695 45705 45706

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General Information or Other Event Number: 45695
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: MASS GENERAL HOSPITAL
Region: 1
City: BOSTON State: MA
County:
License #: 60-0055
Agreement: Y
Docket:
NRC Notified By: TONY CARPENITO
HQ OPS Officer: JOE O'HARA
Notification Date: 02/12/2010
Notification Time: 10:45 [ET]
Event Date: 02/10/2010
Event Time: [EST]
Last Update Date: 02/17/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES TRAPP (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL MEDICAL EVENT DUE TO UNDERDOSE GREATER THAN 50%

The following was received from the Commonwealth of Massachusetts via e-mail:

"On 2/12/10, licensee reported to this Agency [Commonwealth of Massachusetts] the 2/11/10 discovery of a medical event that occurred on 2/10/10. The situation [was] described as two treatment fraction underdoses, delivered on the same day to the same patient, that differed from the prescribed dose, per fraction, by more than 50%. Initial indication [is] that [the] event was caused by [an] equipment software bug. Two fractions of 0.4 Gy were delivered on the first day of treatment. The prescription was for two treatments of 4 Gy per fraction per day for two days and one final 4 Gy treatment on the third day. [The] prescribing physician and equipment manufacturer [were] notified. This is a preliminary report; investigation [is] ongoing; more information to follow.

"The Agency considers this event OPEN and ONGOING."

* * * UPDATE FROM TONY CARPENITO TO JOE O'HARA VIA E-MAIL AT 1007 ON 2/17/10 * * *

"[The] equipment manufacturer found the software issue to be 'reproducible' and therefore may be classified as a 'potential' (patient) safety issue.

"[The] suspect portion of software will not be used again until [the] program [is] debugged and documented to be correct. [The] suspect portion of the software had not been used in the past by the licensee; no previous patients were affected."

The device has been identified as a Nucletron HDR V3, and the software program is named Oncentra.

Event docket #02-8893.

Notified R1DO(T. Jackson) and FSME EO(McIntosh)

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: 45705
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [1] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: KEVIN UMPHREY
HQ OPS Officer: PETE SNYDER
Notification Date: 02/16/2010
Notification Time: 22:18 [ET]
Event Date: 02/16/2010
Event Time: [EST]
Last Update Date: 02/17/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
TODD JACKSON (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
2 N Y 99 Power Operation 99 Power Operation

Event Text

SCHEDULED MICROWAVE RADIO UPGRADES IMPACT TO THE CONTROL ROOM AND EMERGENCY OPERATIONS FACILITY

"This is an eight hour report per 10 CFR 50.72 (b)(3)(xiii). Calvert Cliffs will be implementing a scheduled modification to upgrade the microwave radio system to improve reliability of the system at the Emergency Operations Facility (EOF), State, and County facilities.

"This work will require that the microwave radio system at the EOF be removed for a period of approximately 4 to 6 hours. During this time, the following systems will be impacted for the duration of the upgrade:

"1. The plant's {e.g., Control Room, Technical Support Center (TSC), Simulator} Dedicated Offsite Agency telephones will be out of service. (EOF's system will continue to function)
"2. 800 MHz desk set radios at the EOF only will be out of service.
"3. 153.44 MHz frequency at the EOF only will be out of service. (backup for MEMA and MDE)
"4. MIDAS Terminal (Meteorological Data) located in the Dose Assessment Office at the EOF will be out of service.
"5. TSC Computer data transfer to the EOF only will be out of service.

"Once the upgrade starts the systems (listed above) can be returned to service within the first 2 hours. After the 2 hour timeframe, the upgrade must continue until completed.

"Should an emergency be declared during this period, the Control Room will continue to have the capability to make the notification to the offsite agencies using the direct line for the appropriate agencies. The emergency preparedness communications procedure provides a chart listing the communication devices available and the order in which the process is to be implemented. MIDAS (Meteorological Data) will continue to be operational at the site and can be obtained by contacting the Control Room or TSC. The ERPIPs also provide a backup process and the instructions necessary for the EOF Dose Assessment Office to obtain Meteorological Data. Plant data can be obtained from the CR or TSC and will continue to be downloaded from the plant computer to the ERO SharePoint site.

"All work associated with this microwave radio system upgrade will be performed in an expeditious manner consistent with the goal of minimizing unavailability of the systems listed above. A test of all systems will be performed at the completion of the upgrade.

"All EOF responders and Control Room personnel have been briefed on this work and expected contingent actions.

"This job will start on Wednesday, February 17, 2010 at approximately 7:00 am. We anticipate that all work will be completed by 5:00 pm on the same day, including testing of the system. We will provide a notification update upon completion of the job."

The licensee notified the NRC Resident Inspector.


* * * UPDATE FROM TOM JONES TO DONALD NORWOOD AT 1217 EST ON 2/17/2010 * * *

All communications systems were tested and returned to operable status as of 1200 EST.

The licensee notified the NRC Resident Inspector. Notified R1DO (Jackson).

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Power Reactor Event Number: 45706
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: MARTIN LICHTNER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 02/17/2010
Notification Time: 16:24 [ET]
Event Date: 02/17/2010
Event Time: 14:20 [EST]
Last Update Date: 02/17/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
TODD JACKSON (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 86 Power Operation 86 Power Operation
2 N Y 94 Power Operation 94 Power Operation

Event Text

NOTIFICATION TO PENNSLYVANIA DEPARTMENT OF ENVIRONMENTAL PROTECTION CONCERNING DRINKING WATER QUALITY

"The following is a 4-hour non-emergency notification in accordance with 10CFR50.72(b)(2)(xi), Offsite Notification.

"At 1420, February 17, 2010, Susquehanna LLC notified the Pennsylvania Department of Environmental Protection (DEP) of an issue with the domestic water supply system at the Susquehanna facility. This notification was made via telephone.

"The notification to Pennsylvania DEP was in accordance with 25 PA Code 109.1307 due to circumstances that exist that adversely affect the quality of drinking water. Specifically, no residual chlorine was detectable in the domestic water system. The Pennsylvania DEP contact was the Pennsylvania DEP Sanitarian.

"Required compensatory actions have been initiated, including planned repairs of the domestic water chlorination system."

The licensee notified the NRC Resident Inspector

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Thursday, March 29, 2012