Event Notification Report for June 05, 2020

AGREEMENT STATE REPORT - MEDICAL EVENT

The following was received via email from the Florida Bureau of Radiation:

"At 1605 [EDT], [on June 9, 2020, the University of Florida] RSO [Radiation Safety Officer] reported a radiation overdose at the Human Use Facility, Jacksonville, FL. The physicists began reviewing the patient's treatments on Friday, June 5, 2020. They were evaluating an Excel spreadsheet used to calculate monitoring units (MUs) for double scatter proton therapy and after 15 fractions caught an error. The intended dose was 80 Gy. At this point in the treatment 30 Gy should have been delivered, but instead the current total is approximately 50 Gy. The treating physician was informed and they informed the patient. It has been concluded that the patient will return to complete treatment and receive in total 59 Gy, which is a commonly used fractionation scheme. The doses to the organs at risk (OARs) are within the tolerance of the treatment goals of the delivered fractionation scheme. They are continuing to review the issue and will send a report as soon as possible."

Incident Number: FL20-066

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.

EN Revision Imported Date : 10/6/2020

EN Revision Text: CONTROL ROOM BOUNDARY DOOR FAILURE

"On June 5, 2020, at 0320 [EDT] a loss of control room envelope (CRE) was declared inoperable due to failure of door 204-36-007. The door was repaired at 0322 [EDT], restoring the CRE to operable.

"The NRC Resident Inspector, state, and local authorities were notified."

* * * RETRACTION ON 07/09/2020 AT 1443 EDT FROM GERALD A. BAKER TO OSSY FONT * * *

"The purpose of this call is to retract a report made on June 5, 2020, NRC Event Number EN54738.

"NRC Event Report number EN54738 describes a condition at Millstone Power Station Unit 2 (MPS2) in which a control room envelope boundary door was discovered to not be able to fully close due to the latching mechanism being stuck in the extended position.

"The condition was reported to the NRC pursuant to 10 CFR 50.72(b)(3)(v)(D) via an 8 hour prompt report as an event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.

"Upon further review, MPS2 determined that there was no loss of safety function. An engineering evaluation determined that even with the control room boundary door unable to be fully closed due to the latching mechanism being stuck in, the extended position, control room air in-leakage would not have been sufficient to prevent the control room emergency ventilation system from performing its safety function.

"Therefore, this condition is not reportable and NRC Event Number EN54738 is being retracted.

"The basis for this conclusion has been provided to the NRC Resident Inspector."

Notified R1DO (Dimitriadis).

* * * UPDATE FROM MICHAEL GAGNON TO BRIAN P. SMITH AT 1444 EDT ON 10/01/2020 * * *

"The purpose of this call is to provide an update to the retraction for a report made on June 5, 2020, NRC Event Number EN54738. The retraction being updated was made on 7/9/2020 at 1443 hours.

"NRC Event Report number EN54738 describes a condition at Millstone Power Station Unit 2 (MPS2) in which a control room envelope boundary door was discovered to not be able to fully close due to the latching mechanism being stuck in the extended position. The condition was reported to the NRC pursuant to 10 CFR 50.72(b)(3)(v)(D) via an 8 hour prompt report as an event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident (the Control Room Envelope).

"A subsequent engineering evaluation of the conditions that existed at the time, determined that the inability of the control room boundary door to fully close due to the latching mechanism being stuck in the extended position did not have an adverse impact upon the ability of the CRE to perform its safety function. The CRE remained operable throughout this event, and the ventilation system would have performed its safety function.
Therefore, this condition is not reportable and NRC Event Number EN54738 is being retracted.

"The basis for this conclusion has been provided to the NRC Resident Inspector."

Notified R1DO (Lally).