Event Notification Report for December 11, 2019

AGREEMENT STATE REPORT - DOSE DELIVERED LESS THAN PRESCRIBED

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

"[The licensee] reported that during a prostate treatment using 50 I-125 seeds, 20 of the seeds became stuck in the applicator and only 30 were inserted into the patient. All of the seeds were accounted for and the patient did not receive any additional exposure or suffer any harm. The remaining treatment dose will be fractionated and delivered at a later time. An additional detailed report containing make, model of seeds, activity, etc. will be forwarded to the Bureau's office later this week."

Incident Number: FL19-146

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.

* * * UPDATE ON MAY 28, 2020 AT 0820 EDT FROM MATT SENISON TO BRIAN LIN * * *

The following update was received from the Bureau via email:

"[On December 11, 2019], the licensee reported that during a prostate treatment using 50 I-125 seeds, the two Mick applicators suffered jams that could not be cleared. After attempts were unsuccessful at restoring function, the user terminated the procedure before the full implant could be completed. Of the 50 Seeds planned for implantation, 30 were successfully inserted into the patient. No I-125 seeds were lost and no spills or contamination occurred. Radiological review of seed placement determined that an adequate number of seeds were placed and dosing achieved in the target area. No further surgical intervention indicated. The patient will be followed with radiological studies and with PSA [prostate specific antigen] labs as previously planned."

Notified R1DO (DeBoer) and NMSS Events Notification via e-mail.

POTENTIAL TORNADO MISSILE VULNERABILITIES

"On December 11, 2019, at 1356 EST, it was concluded that certain safety-related equipment is vulnerable to design basis tornado missiles which could render the equipment inoperable and not able to perform its design function. This applies to the following Technical Specification equipment:

"1. Component cooling water piping for the 'A' spent fuel cooling water system heat exchanger. This heat exchanger is vulnerable to a horizontal missile traveling through the roll-up door, which would challenge operability of the Technical Specification required component cooling system equipment.
2. All three emergency service water pumps and their diesel fuel oil supply tank. The emergency service water pumps and diesel fuel oil tank are vulnerable to a horizontal missile penetrating the missile screens.
3. Certain component cooling water system pump discharge piping is vulnerable from a vertical missile penetrating the auxiliary building roof.
4. The Unit 1 Auxiliary Feedwater (AFW) system pumps and the pump suction and discharge piping are vulnerable to a missile traveling through the screens on the sides and roof of the main steam valve house. This vulnerability also exists for the Unit 2 AFW.
5. The Unit 2 Service Water (SW) supply valves to the river water make-up pump are vulnerable to a vertical missile traveling through the turbine building roof. A missile strike on the piping or valves could cause an unisolable leak or pipe break on this non-essential SW piping which could result in inability to maintain Technical Specification required intake canal inventory.

"These conditions are reportable in accordance with 10 CFR 50.72(b)(3)(ii)(B) as a condition that results in the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety. There are no current operational challenges to either unit due to the tornado missile vulnerabilities.

"Identified SSCs [structures, systems, and components] were declared inoperable [at 1356] and NRC Enforcement Guidance Memorandum 15-002, Rev. 1, 'Enforcement Discretion for Tornado Generated Missile Protection Noncompliance,' was implemented. Initial compensatory measures were implemented, per the guidance of NRC Interim Staff Guidance DSS-ISG-2016-01 Appendix A, within the time allowed by the applicable Limiting Conditions for Operation (LCOs) and the associated systems were then declared operable, but nonconforming."

The NRC Resident Inspector has been notified.