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Event Notification Report for February 19, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/18/2010 - 02/19/2010

** EVENT NUMBERS **


45695 45704 45709 45710

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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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General Information or Other Event Number: 45704
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: GEORGIA PACIFIC CORPORATION
Region: 4
City: MONTICELLO State: MS
County:
License #: MS-188-01
Agreement: Y
Docket:
NRC Notified By: DANNY BRANGLEY
HQ OPS Officer: DONALD NORWOOD
Notification Date: 02/16/2010
Notification Time: 17:16 [ET]
Event Date: 02/11/2010
Event Time: [CST]
Last Update Date: 02/16/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GEOFFREY MILLER (R4DO)
MARK SHAFFER (FSME)

Event Text

AGREEMENT STATE REPORT - FAILURE OF FIXED GAUGE SHUTTER MECHANISMS TO CLOSE

The following excerpted information was received via e-mail:

During shutter checks performed by the licensee, it was discovered that four of their fixed gauge shutter mechanisms were unable to be closed. The following is information on those gauges: (1) Berthold, Model LB-7440-D, source SN FR288, Cs-137, 30 mCi; (2) Berthold, Model LB-300-L, source SN 1080/1-05-98, Co-60, 1.16 mCi; (3) Berthold Model LB-7440-D, source SN 1080/2-05-98, Co-60, 1.65 mCi; and (4) Berthold, Model LB-7442-D, source SN 2572-8-90, Cs-137, 250 mCi. On gauge 1 the shutter handle broke off. On gauges 2, 3, and 4 the shutter stuck open. The licensee has requested service from the gauge manufacturer.

Mississippi Incident Number: MS-10002.

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Power Reactor Event Number: 45709
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [1] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: KENT MILLS
HQ OPS Officer:
Notification Date: 02/18/2010
Notification Time: 11:47 [ET]
Event Date: 02/18/2010
Event Time: 08:24 [EST]
Last Update Date: 02/18/2010
Emergency Class:
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
TODD JACKSON (R1DO)
JOHN THORP (NRR)
JEFFERY GRANT (IRD)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 93 Power Operation 0 Hot Standby
2 A/R Y 100 Power Operation 0 Hot Standby

Event Text

DUAL UNIT AUTOMATIC REACTOR TRIPS DUE TO PARTIAL LOSS OF OFFSITE POWER

"Both U-1 and U-2 automatically tripped due to valid actuation of the Reactor Protection Systems (RPS). U-1 due to loss of 12B Reactor Coolant Pump (RCP) which resulted in a RCS Low Flow RPS Trip. Cause for loss of 12B RCP is currently not known but is suspected to be related to the electrical transient that occurred on U-2. U-2 tripped due to Loss of Load RPS Trip when the main turbine tripped due to an electrical malfunction and partial loss of offsite power. The electrical malfunction resulted in loss of power to all 4 Kv buses on U-2 with the exception of 21 4Kv bus (ZA train power) (Lost 22-26 4Kv buses) and the loss of 14 Kv bus (ZB train power) on U-1. All the buses lost are powered from the same in house service transformer, P-13000-2, which was lost due to the electrical transient. Cause of the electrical transient is being pursued but is unknown at this time. Loss of the 14 4Kv bus on U-1 and the 24 4Kv bus on U-2 resulted in an Engineered Safeguards Actuation System (ESFAS) valid actuations on both units due to Under Voltage (UV) conditions on those buses. The 1B [Diesel Generator] DG started automatically due to the 14 bus UV and is carrying that bus. The 2B DG received an automatic start signal due to the 24 bus UV but failed to start as expected. No other system actuations occurred. Both units are currently stable in Mode 3 at normal operating temperature (532 degrees) and pressure (2250 PSIA) with no other significant equipment malfunctions. Due to the loss of P-13000-2 [transformer], U-2 sustained a loss of normal heat removal due to loss of the main condenser cooling and the loss of secondary pumps. U-2 is removing heat with auxiliary feedwater pumps and [Steam Generator] SG atmospheric dump valves without issues. Current plans are to cool U-2 down to 445 degrees to maintain RCP seals cool until RCP's can be restarted. A decision on U-1 cool down has not yet been made."

There is no primary to secondary leakage. U-2 is currently in a 12 hour LCO due to the partial loss of offsite power and 2B DG failing to start.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 45710
Facility: CATAWBA
Region: 2 State: SC
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: TOM POETZSCH
HQ OPS Officer: DONG HWA PARK
Notification Date: 02/18/2010
Notification Time: 19:42 [ET]
Event Date: 02/18/2010
Event Time: 19:15 [EST]
Last Update Date: 02/18/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
JONATHAN BARTLEY (R2DO)
MELANIE GALLOWAY (NRR)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Hot Shutdown 0 Hot Shutdown

Event Text

RCS PRESSURE BOUNDARY LEAKAGE IDENTIFIED ON RTD WELD

"Catawba Nuclear Station is making an 8 hour notification due to a pressure boundary leak on the A loop of the Unit 1 Reactor Coolant System. The leak was found to be originating from 1A Reactor Coolant System hot leg [Resistance Temperature Detector] RTD penetration. Since the allowance for pressure boundary leakage is zero, this is being considered a degraded principal safety barrier. No safety signals were received and no actuations occurred as a result of this leak. The amount of the leak is small and is contained inside containment. No release to the environment occurred and there is no danger to the public. Repair will require the plant to enter Mode 5."

The pressure boundary leakage is 0.08 GPM. The licensee is in a 36 hour LCO 3.4.13(B)(2), and plans to be in Mode 5 this evening. The licensee has notified the NRC Resident Inspector.

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