Event Notification Report for May 27, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
5/26/2020 - 5/27/2020

** EVENT NUMBERS **

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	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
Emergency Class: Non Emergency 10 CFR Section: Agreement State	Person (Organization): FRED BOWER (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

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.

Power Reactor	Event Number: 54726
Facility: Fermi Region: 3 State: MI Unit: [2] [] [] RX Type: [2] GE-4 NRC Notified By: Kelley Belenky HQ OPS Officer: Jeffrey Whited	Notification Date: 05/26/2020 Notification Time: 13:17 [ET] Event Date: 05/26/2020 Event Time: 10:04 [EDT] Last Update Date: 05/26/2020
Emergency Class: Non Emergency 10 CFR Section: 26.719 - Fitness For Duty	Person (Organization): LAURA KOZAK (R3DO) FFD GROUP (EMAIL)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

Defueled

Event Text

FITNESS FOR DUTY (FFD) POSITIVE TEST

A non-licensed employee supervisor had a confirmed positive for alcohol during a follow-up fitness-for-duty test. The employee's access to the plant has been terminated.

The licensee notified the NRC Resident Inspector.

Power Reactor	Event Number: 54727
Facility: Surry Region: 2 State: VA Unit: [1] [2] [] RX Type: [1] W-3-LP,[2] W-3-LP NRC Notified By: Alan Bialowas HQ OPS Officer: Jeffrey Whited	Notification Date: 05/26/2020 Notification Time: 15:55 [ET] Event Date: 05/25/2020 Event Time: 19:38 [EDT] Last Update Date: 05/26/2020
Emergency Class: Non Emergency 10 CFR Section: 26.719 - Fitness For Duty	Person (Organization): MARK MILLER (R2DO) FFD GROUP (EMAIL)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

100

Power Operation

Cold Shutdown

Event Text

FITNESS FOR DUTY (FFD) POSITIVE TEST

A contract foreman had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.

The licensee notified the NRC Resident Inspector.

Power Reactor	Event Number: 54729
Facility: Cook Region: 3 State: MI Unit: [1] [2] [] RX Type: [1] W-4-LP,[2] W-4-LP NRC Notified By: Jim Havlik HQ OPS Officer: Brian Lin	Notification Date: 05/27/2020 Notification Time: 11:35 [ET] Event Date: 05/27/2020 Event Time: 09:12 [EDT] Last Update Date: 05/27/2020
Emergency Class: Non Emergency 10 CFR Section: 50.72(b)(2)(xi) - Offsite Notification	Person (Organization): LAURA KOZAK (R3DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

100

Power Operation

100

Power Operation

100

Power Operation

Event Text

OFFSITE NOTIFICATION DUE TO INADVERTENT ACTUATION OF SIRENS

"On 5/27/20 at approximately 0912 EDT, the Operations Shift Manager was made aware that the Berrien County Sheriff's Department (BCSD) inadvertently actuated the emergency sirens during a planned weekly test. BCSD notified Cook Nuclear Plant that an audible test was initiated instead of a silent test. All Emergency Notification sirens remain in service. No press release is planned by the licensee at this time.

"This notification is being made under 10 CFR 50.72(b)(2)(xi), Offsite Notification, as a four (4) hour report.

"The licensee has notified the NRC Resident Inspector."

Page Last Reviewed/Updated Wednesday, March 24, 2021