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Event Notification Report for July 23, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/22/2010 - 07/23/2010

** EVENT NUMBERS **


46101 46115

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General Information or Other Event Number: 46101
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSITY OF PENNSYLVANIA
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: JOHN KNOKE
Notification Date: 07/16/2010
Notification Time: 15:44 [ET]
Event Date: 07/07/2010
Event Time: [EDT]
Last Update Date: 07/16/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JUDY JOUSTRA (R1DO)
GLENDA VILLAMAR (FSME)

Event Text

AGREEMENT STATE REPORT - DELIVERED DOSE DIFFERED FROM THE PRESCRIBED DOSE BY GREATER THAN 50%

The following was received via fax from the Pennsylvania Department of Environmental Protection:

"On July 7, 2010 a patient was beginning the first of three vaginal treatment fractions with an Ir-192 HDR. It was discovered on July 14, 2010 that the end of the treatment tube was placed 3.5 cm short of its intended location. When the patient returned for the second treatment, she was imaged again, and staff noticed the treatment tube was in a different location from the previous treatment. Licensee estimates that, for the first fraction, the intended treatment volume received only about 10% of the intended dose for that fraction. Per 10CFR35.3045(a)(1)(iii), it is required for the licensee to report any event in which the fractionated dose delivered differs from the prescribed dose, for a single fraction, by 50% or more.

"It is believed the medical staff mis-identified the treatment location and the end of the treatment tube was placed 3.5cm short of its intended location. The licensee is considering making up this dose by adding a fourth treatment fraction. There is no anticipated adverse effect to the patient.

"There is a PaDEP/BRP reactive inspection scheduled to investigate this ME at U Penn. The patient and the referring physician were notified. A follow-up written report from the licensee is expected."

PA Report # PA100015

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: 46115
Facility: HATCH
Region: 2 State: GA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: FRANK G. GORLEY
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/22/2010
Notification Time: 08:32 [ET]
Event Date: 05/29/2010
Event Time: 08:49 [EDT]
Last Update Date: 07/22/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
Person (Organization):
JONATHAN BARTLEY (R2DO)

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

Event Text

INVALID ACTUATION OF PRIMARY CONTAINMENT ISOLATION VALVES DUE TO A FAULTY TRANSISTOR

"This report is being made under 10CFR50.73(a)(2)(iv)(A). On May 29,2010, at 0849 EDST Unit 2 received a trip of the 'B' RPS alternate supply. This trip was due to a faulty transistor on the internal circuit board for the voltage regulator. The transistor was replaced, the voltage regulator tested and replaced in the system. The trip of the 'B' RPS alternate supply resulted in isolation of Primary Containment Isolation Valves in more than one system. The systems that were isolated due to this event were Reactor Water Clean-up and Fission Products Monitoring. Except for critical scrams, invalid actuations are not reportable by telephone under 50.72. NUREG 1022 defines by examples given that actuation of the reactor protection system constitutes actuation of RPS full scram signal when the reactor is critical. In the condition that occurred during day shift on Saturday, May 29, 2010 only one channel of RPS actuated on failure of the Unit 2 'B' RPS alternate supply. That being the case there was not sufficient logic made up to result in a reactor scram or RPS actuation. An RPS actuation would be considered a reportable event; however, the trip of only the 'B' alternate RPS supply would not be considered an RPS actuation. This condition did involve the initiation of some containment isolation signals resulting in containment isolation valves in more than one system since RWCU and fission product monitor isolation valves closing as a result of the loss of the 'B' RPS system. Valid signals are those signals that are initiated in response to actual plant conditions or parameters satisfying the requirements for initiation of the safety function of the system. In this case the isolation signal was caused by the loss of power to the affected instrumentation rather than response to required conditions or parameters which makes this an 'invalid' isolation signal. For this event, Plant Hatch has chosen to make this telephone notification to the NRC Operations Center within 60 days after discovery of the event instead of submitting a written LER.

"All actuations above were complete.

"No system actuations resulted from the trip of the 'B' RPS alternate supply."

The licensee has notified the NRC Resident Inspector.

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