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Event Notification Report for June 9, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/08/2010 - 06/09/2010

** EVENT NUMBERS **


45973 45986 45987 45989

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Hospital Event Number: 45973
Rep Org: BRISTOL HOSPITAL
Licensee: BRISTOL HOSPITAL
Region: 1
City: BRISTOL State: CT
County:
License #: 06-02057-01
Agreement: N
Docket:
NRC Notified By: BERNARD PERCARPIO
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/02/2010
Notification Time: 15:46 [ET]
Event Date: 01/12/2010
Event Time: [EDT]
Last Update Date: 06/02/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
GLENN DENTEL (R1DO)
LARRY CAMPER (FSME)

Event Text

DOSE LESS THAN PRESCRIBED DOSE IN TWO SEPARATE BRACHYTHERAPY TREATEMENTS

"[Patient #1], with localized prostate cancer, had an ultrasound directed transperineal implant with 60 I-125 seeds on 1/12/2010. The total activity implanted was 20.4 mCi. Final dosimetry was based on a CT scan performed on 2/16/2010. This revealed a D90 of 8400 cGy which was lower than the prescribed dose of 14500 cGy. The patient and referring physician were notified and the patient then received supplemental external beam irradiation of the prostate with 3000 cGy delivered between 3/11/2010 and 4/08/2010. The patient is currently doing well with minimal treatment related symptoms.

"[Patient #2], with localized prostate cancer, had an ultrasound directed transperineal implant with 66 Cs-131 seeds on 1/12/2010. The total activity implanted was 186 mCi. Final dosimetry was based on a CT scan performed on 2/16/2010. This revealed a D90 of 6500 cGy which was lower than the prescribed dose of 11000 cGy. All seeds were accounted for in the final review. However, careful review of the isodose lines revealed adequate coverage of the involved areas of the prostate. The patient and referring physician were notified and the prescribing physician indicated that additional treatment was not necessary.

"[Both] events occurred due to unexpected displacement of the seeds in an inferior (caudal) direction.

"[The licensee] continues to use preplanning for all prostate brachytherapy patients with careful direct supervision of needle and seed placement. Six (6) patients have been treated with brachytherapy at Bristol Hospital since January 2010 and the final dosimetry has been acceptable for all."

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: 45986
Facility: SURRY
Region: 2 State: VA
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: ALAN BIALOWAS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 06/08/2010
Notification Time: 12:00 [ET]
Event Date: 06/08/2010
Event Time: 09:48 [EDT]
Last Update Date: 06/08/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(2)(iv)(A) - ECCS INJECTION
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
STEVEN VIAS (R2DO)
JOHN THORP (NRR)
WILLIAM GOTT (IRD)

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

Event Text

AUTOMATIC REACTOR TRIP WITH SAFETY INJECTION DUE TO LOSS OF VITAL AC BUS

"At 0948 hours [EDT] on 6/8/10, a Unit 1 vital AC bus was lost when the uninterruptible power supply inverter failed while the alternate AC source was out of service for scheduled maintenance. The loss of the vital bus inverter caused a loss of 120 VAC vital bus 1-III. The loss of this vital bus caused the 'A' main feed pump recirculation valve to fail open and also caused 2 of the 3 main feedwater regulating valves to fail to automatic-hold mode of operation. This combination of as designed failures resulted in a reduction in main feedwater flow and resulted in an automatic reactor trip due to a feed flow steam flow mismatch in conjunction with low steam generator level.

"The loss of vital bus 1-III also resulted in initiation of safety injection due to loss of vital bus 1-III instrumentation in conjunction with the expected momentary RCS cooldown below 543 DEG-F. The safety injection resulted from the high steam flow in conjunction with low RCS T-ave actuation signal. The safety injection actuation also resulted in automatic start of the #1 Emergency Diesel and the #3 Emergency Diesel Generators. Neither EDG was required to load since off-site power remained operable.

"The loss of vital bus 1-III also resulted in loss of numerous field inputs to the Plant Computer System [PCS] and resulted in non-functionality of the SPDS [Safety Parameter Display System]. The PCS itself remains functional along with MCR [Main Control Room] annunciators and sufficient MCR instrumentation to monitor critical safety functions. All three auxiliary feedwater pumps automatically initiated as designed on low-low steam generator level following the trip. Currently, RCS temperature is being maintained stable at 547 degrees. All systems functioned as required following the reactor trip. During the post-trip transient, pressurizer PORV [Power Operated Relief Valve], PCV-1455C, cycled as required to maintain RCS pressure due to the safety injection and the loss of normal letdown.

"There were no radiation releases due to this event, nor were there any personnel injuries or contamination events. This event is being reported in accordance with 10CFR50.72(b)(2)(iv)(B), 10CFR50.72(b)(2)(iv)(A), 10CFR50.72(b)(3)(iv)(A), and 10CFR50.72(b)(3)(xiii).

"The NRC Resident Inspector was notified of this event."

During the trip, all rods inserted into the core. In addition to the pressurizer PORV lifting, a secondary main steam relief valve lifted. All relief valves properly reseated and there is no known primary to secondary leakage. The plant is in its normal shutdown electrical lineup. Main steam trip valves were isolated during the transient. Decay heat is being removed via main steam bypasses to the condenser and steam generator power operated relief valves.

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Power Reactor Event Number: 45987
Facility: VERMONT YANKEE
Region: 1 State: VT
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: JAMES KRITZER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/08/2010
Notification Time: 15:10 [ET]
Event Date: 06/08/2010
Event Time: 11:26 [EDT]
Last Update Date: 06/08/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
PAMELA HENDERSON (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 99 Power Operation

Event Text

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO PRIMARY CONTAINMENT LEAK GREATER THAN LIMITS

"On 6/8/10 at 10:15, primary containment was declared inoperable and a 24 [hour] Limiting Condition for Operation (LCO) was entered due to Engineered Safety Features leakage in excess of the 1.0 gpm value assumed in the Alternative Source Term (AST) analysis as described in the UFSAR.

"The leakage was from the 'B' RHR heat exchanger relief valve (SR-10-86B) and was estimated at 1.25 gpm.

"On 6/8/10 at 11:26, commenced a power reduction for a Technical Specification required shutdown per TS 3.7.A.8.

"Actions Taken:

"Isolating the 'B' RHR system per Technical Specifications that will allow us to exit the 24 hour LCO.

"Planning to replace the relief valve.

"Verified relief valve on 'A' RHR system is not leaking."

The licensee has notified State and local authorities and the NRC Resident Inspector. The licensee also anticipates a press release.


* * * NOTIFICATION FROM KRITZER TO CROUCH AT 1553 EDT ON 6/8/10 * * *

The licensee exited the 24 hour LCO TS required shutdown condition at 1548 EDT based on isolation of the 'B' RHR system.

R1DO (Henderson) notified.

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Power Reactor Event Number: 45989
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: MARK COVEY
HQ OPS Officer: BILL HUFFMAN
Notification Date: 06/08/2010
Notification Time: 19:57 [ET]
Event Date: 06/08/2010
Event Time: 04:30 [CDT]
Last Update Date: 06/08/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
DALE POWERS (R4DO)

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

Event Text

OFFSITE NOTIFICATION OF MINOR HYDAZINE SPILL

"At approximately 0430 CDT on June 8, 2010, during restoration following an addition of 10 gallons of hydrazine and a flush of 2 gallons of demineralized water to the Condensate Storage Tank (CST), a water-hydrazine mixture began to leak from check valve KHV0179. KHV0179 is a nitrogen supply check valve that can also be used for hydrazine addition.

"Chemistry technicians estimated that a water-hydrazine mixture on the order of 2 gallons leaked through KHV0179 before the line could be isolated. Samples taken from the atmosphere above the spill contained 0.25 ppm hydrazine. The fluid on the ground was measured to contain 15% hydrazine.

"The Department of Natural Resources (DNR) was notified of this event at approximately 1000 CDT on June 8, 2010.

"The Nuclear Regulatory Commission (NRC) Resident Inspectors will be notified."

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