Event Notification Report for May 12, 2020
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/11/2020 - 05/12/2020
Power Reactor
Event Number: 54707
Facility: Catawba
Region: 2 State: SC
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Walter Hunnicutt
HQ OPS Officer: Brian P. Smith
Region: 2 State: SC
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Walter Hunnicutt
HQ OPS Officer: Brian P. Smith
Notification Date: 05/13/2020
Notification Time: 01:14 [ET]
Event Date: 05/12/2020
Event Time: 22:20 [EDT]
Last Update Date: 05/13/2020
Notification Time: 01:14 [ET]
Event Date: 05/12/2020
Event Time: 22:20 [EDT]
Last Update Date: 05/13/2020
Emergency Class: Non Emergency
10 CFR Section:
50.72(b)(3)(ii)(A) - Degraded Condition
10 CFR Section:
50.72(b)(3)(ii)(A) - Degraded Condition
Person (Organization):
MARK MILLER (R2DO)
MARK MILLER (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Refueling | 0 | Refueling |
REACTOR COOLANT SYSTEM PRESSURE BOUNDARY DEGRADED
"During the performance of reactor vessel closure head (RVCH) inspections, at 2220 EDT on May 12, 2020, it was determined that the Unit 1 RVCH penetration nozzle number 18 did not meet ASME code case N-729-4 requirements. A surface examination (penetrant test) identified a linear indication on nozzle number 18. The indication was not through-wall as determined by ultrasonic testing. The condition of the Unit 1 reactor vessel head penetration nozzle number 18 will be resolved prior to re-installation of the Unit 1 reactor vessel head. This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A).
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
"During the performance of reactor vessel closure head (RVCH) inspections, at 2220 EDT on May 12, 2020, it was determined that the Unit 1 RVCH penetration nozzle number 18 did not meet ASME code case N-729-4 requirements. A surface examination (penetrant test) identified a linear indication on nozzle number 18. The indication was not through-wall as determined by ultrasonic testing. The condition of the Unit 1 reactor vessel head penetration nozzle number 18 will be resolved prior to re-installation of the Unit 1 reactor vessel head. This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A).
"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."
Agreement State
Event Number: 54717
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: Lynn Cancer Institute - Boca Raton Regional Hospital
Region: 1
City: Boca Raton State: FL
County:
License #: 0550-2
Agreement: Y
Docket:
NRC Notified By: Matt Senison
HQ OPS Officer: Brian P. Smith
Licensee: Lynn Cancer Institute - Boca Raton Regional Hospital
Region: 1
City: Boca Raton State: FL
County:
License #: 0550-2
Agreement: Y
Docket:
NRC Notified By: Matt Senison
HQ OPS Officer: Brian P. Smith
Notification Date: 05/19/2020
Notification Time: 07:38 [ET]
Event Date: 05/12/2020
Event Time: 00:00 [EDT]
Last Update Date: 05/19/2020
Notification Time: 07:38 [ET]
Event Date: 05/12/2020
Event Time: 00:00 [EDT]
Last Update Date: 05/19/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
FRED BOWER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
FRED BOWER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL EVENT
The following was received via report from the Florida Bureau of Radiation:
"On May 15, 2020 at 1530 EDT, the Bureau of Radiation Control (BRC) received a call from the medical physicist at the Lynn Cancer Institute regarding the following narrative which was received this morning, May 18, 2020 at 1000 EDT, from the Chief Medical Physicist. On May 12, 2020, a patient presented for a Vaginal Cylinder treatment utilizing the Elekta Ir-192 high dose rate remote afterloader. The written directive was initially written for 7 Gy [Ir-192] x 3 fractions to a depth of 0.5cm (5mm) and a 20mm diameter cylinder was chosen to treat the patient. Due to the relatively small diameter of the cylinder, the Radiation Oncologist decided to change the written directive to 7 Gy x 3 fractions to the surface of the cylinder. The treatment plan was created and the doses to the normal tissues (bladder, rectum and bowel) were accepted by the Radiation Oncologist and the treatment plan was subsequently approved. The approved treatment plan was then delivered to the patient.
"On May 14, 2020 it was discovered that the prescription isodose line did not appear to fall on the surface of the cylinder and on May 15, 2020, it was discovered that the 7 Gy isodose line was at about 4.2mm from the surface of the cylinder, and the dose to the points on the surface of the cylinder was found to be 158.3 percent of the prescription, on average. In the professional opinion of the Radiation Oncologist, the dose delivered did not negatively affect the patient and the doses to the normal tissues were acceptable dose levels for this type of treatment. It should be reiterated that the initial intent was to deliver the 7 Gy per fraction to a depth of 0.5cm (5mm) which would have fallen close to the 4.2mm at which the prescription dose was actually delivered. Additionally, had the plan been normalized to the surface of the cylinder the Radiation Oncologist would more than likely have increased the dose and he stated that the dose would have been too low for the intended treatment."
Incident Number: FL20-060
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.
The following was received via report from the Florida Bureau of Radiation:
"On May 15, 2020 at 1530 EDT, the Bureau of Radiation Control (BRC) received a call from the medical physicist at the Lynn Cancer Institute regarding the following narrative which was received this morning, May 18, 2020 at 1000 EDT, from the Chief Medical Physicist. On May 12, 2020, a patient presented for a Vaginal Cylinder treatment utilizing the Elekta Ir-192 high dose rate remote afterloader. The written directive was initially written for 7 Gy [Ir-192] x 3 fractions to a depth of 0.5cm (5mm) and a 20mm diameter cylinder was chosen to treat the patient. Due to the relatively small diameter of the cylinder, the Radiation Oncologist decided to change the written directive to 7 Gy x 3 fractions to the surface of the cylinder. The treatment plan was created and the doses to the normal tissues (bladder, rectum and bowel) were accepted by the Radiation Oncologist and the treatment plan was subsequently approved. The approved treatment plan was then delivered to the patient.
"On May 14, 2020 it was discovered that the prescription isodose line did not appear to fall on the surface of the cylinder and on May 15, 2020, it was discovered that the 7 Gy isodose line was at about 4.2mm from the surface of the cylinder, and the dose to the points on the surface of the cylinder was found to be 158.3 percent of the prescription, on average. In the professional opinion of the Radiation Oncologist, the dose delivered did not negatively affect the patient and the doses to the normal tissues were acceptable dose levels for this type of treatment. It should be reiterated that the initial intent was to deliver the 7 Gy per fraction to a depth of 0.5cm (5mm) which would have fallen close to the 4.2mm at which the prescription dose was actually delivered. Additionally, had the plan been normalized to the surface of the cylinder the Radiation Oncologist would more than likely have increased the dose and he stated that the dose would have been too low for the intended treatment."
Incident Number: FL20-060
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.