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Event Notification Report for March 5, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/04/2009 - 03/05/2009

** EVENT NUMBERS **


44876 44883 44884 44887 44888 44891

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General Information or Other Event Number: 44876
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: NDE, INCORPORATED
Region: 1
City: TAMPA State: FL
County:
License #: 3404-1
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: KARL DIEDERICH
Notification Date: 02/25/2009
Notification Time: 11:18 [ET]
Event Date: 02/25/2009
Event Time: [EST]
Last Update Date: 03/04/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1)
ANGELA McINTOSH (FSME)
PATRICE BUBAR (FSME)

Event Text

POSSIBLE OVER EXPOSURE DURING RADIOGRAPHY

"Employee's TLD recorded an overexposure of 6.381 rem whole body deep dose; shallow was 6.061 rem. Date [exposure occurred] was between 10 Jan 2009 to 9 Feb 2009. [The] affected employee claims he left his shirt with TLD in area where radiography was being performed. Pocket dosimeter reading was no more than 20 mr. Other employees who worked with him during [the] same time period 10 Jan 2009 to 9 Feb 2009 have no excessive exposures. RSO calculates dose should be approximately 205 mr during month as per records. RSO believes [this is] not an occupational overexposure. Employee's TLD report received today 25 Feb 2009."

Isotope(s): Ir-192 from two (2) separate radiography cameras with activities of 24 Ci and 77 Ci.

State radiation personnel plan to investigate the event.

Florida incident number FL09-020.

* * * UPDATE AT 0730 EST ON 03/04/09 FROM STEVE FURNACE TO S. SANDIN * * *

The State of Florida is updating this report to provide the results of their onsite investigation:

"[The] Tampa office investigator performed an onsite interview, and concurred with [the] RSO findings. [The] Owner's corrective actions consists of training employees in personnel monitoring, and procured a belt pouch for holding [the] TLD and dosimetrv. No further action to be taken on this incident."

Notified R1DO (Hansell) and FSME (McIntosh).

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Hospital Event Number: 44883
Rep Org: UNION HOSPITAL INC
Licensee: UNION HOSPITAL INC
Region: 3
City: TERRE HAUTE State: IN
County:
License #: 13-1645701
Agreement: N
Docket:
NRC Notified By: DEAN TAYLOR
HQ OPS Officer: JOE O'HARA
Notification Date: 02/27/2009
Notification Time: 15:32 [ET]
Event Date: 02/26/2009
Event Time: [EST]
Last Update Date: 03/02/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(2) - DOSE > SPECIFIED EFF LIMITS
Person (Organization):
HIRONORI PETERSON (R3)
PATRICE BUBAR (FSME)

Event Text

POTENTIAL LEAKING I-125 PROSTATE CANCER THERAPY SEED

A patient was being treated for prostate cancer. After a treatment of (15) I-125 seeds, the magazine used to inject the seeds into the patient was surveyed and the survey indicated that the magazine was contaminated. Initially, the staff believed that a seed may have been stuck inside the magazine. However, upon disassembly the staff determined that the magazine was empty. The prostate cancer therapy treatment continued without incident. The patient was x-rayed, and all seeds were accounted for. A survey of the room, instruments, and packaging material revealed no loose surface contamination. The contamination is confined to the inside of the magazine. The staff believes there are two potential scenarios to explain the contamination inside the magazine: (1) the seeds had external contamination when placed inside the magazine, or (2) during the autoclave a weak weld failed and the seed began to leak. If a seed is leaking iodine into the patient, then if left untreated, the patient could potentially receive a dose of 50 Rem to the thyroid gland. A physician has prescribed a treatment to block uptake to the thyroid, and the blood and urine samples thus far are inconclusive in determining if iodine is leaking into the patient. I-125 seed activity is .302 millicuries per seed. The patient is aware of the issue. Thyroid scans and urine assays will continue for the next four weeks to determine if radioactive iodine is present in sufficient quantities to indicate a leaking seed.

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General Information or Other Event Number: 44884
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: RADIATION DETECTION COMPANY
Region: 4
City: GILROY State: CA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: KEN PRENDERGAST
HQ OPS Officer: JOE O'HARA
Notification Date: 02/28/2009
Notification Time: 13:56 [ET]
Event Date: 02/27/2009
Event Time: [PST]
Last Update Date: 02/28/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4)
PATRICE BUBAR (FSME)

Event Text

PERSONNEL CONTAMINATION FROM PACKAGE CONTAINING DOSIMETERS

The following was received form the state via facsimile:

"RHB [California Radiologic Health Branch] was informed on 2/27/09 that contamination was detected on 3 packages delivered on the 26th of February at Radiation Detection Company [RDC]. One RDC employee was contaminated with an unknown isotope who received the packages and placed them into the lab for scanning. It is not known if all 3 packages were contaminated or if only 1 was and it cross contaminated the other 2 at Radiation Detection Company. The contamination levels were low, around 100 cpm above background (Ludlum with a pancake). An approximate 10% efficiency is likely reasonably valid, yielding contamination of 1000 dpm per probe area. The resulting contamination level likely exceeded DOT's 2200 dpm/100 cm^2 acceptance criteria for shipments.

"The contamination of the person who handled the packages was low (60 cpm) on her arm and clothes. REAC/TS [Radiation Emergency Assistance Center/Training Site] was contacted by the licensee and the contaminated person was decontaminated and her clothes were placed in a drum with the package material and decon supplies and liquids that were used for other decontamination efforts for later inspection if necessary. Nasal smears were negative with regards to contamination. The minor contamination on this person was significantly below levels that would cause negative health effects.

"Two carriers were involved in the 3 packages. One carrier's package originated in San Diego, CA and in Vermont, and another carrier's package originated from Honduras. It is possible that one package was contaminated at the shipper's facility, and cross contaminated the others at Radiation Detection Company. It is also possible that 1 or 2 of the packages was cross contaminated in the shipment stream, and the other 1 or 2 were subsequently cross contaminated at Radiation Detection Company. The 3 facilities that shipped the dosimetry badges will be contacted to check their respective facilities.

"Radiation surveys using alpha, beta, and gamma, and some gross wipes were conducted during the evening of 2/27/09 on the driver and the carrier's truck used to deliver 2 packages to RDC yesterday. The surveys were negative. All readings were at background. Consequently, the carrier's vehicle that delivered one international package from Honduras is suspect regarding the contamination. [The State of CA] has not been able to get the information from that carrier regarding the truck or driver who made the delivery. [DELETED] is also the RSO for one of the carrier's and he is also working on getting the carrier's info to set up some surveys.

"Radiation Detection Company appears to have discarded the contaminated packaging, so it may be difficult to ascertain which of the above scenarios occurred based on the contamination levels (or nuclides) on the packaging."

CA (5010) Number: 022709

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Fuel Cycle Facility Event Number: 44887
Facility: NUCLEAR FUEL SERVICES INC.
RX Type: URANIUM FUEL FABRICATION
Comments: HEU CONVERSION & SCRAP RECOVERY
                   NAVAL REACTOR FUEL CYCLE
                   LEU SCRAP RECOVERY
Region: 2
City: ERWIN State: TN
County: UNICOI
License #: SNM-124
Agreement: Y
Docket: 07000143
NRC Notified By: JENNIFER WHEELER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/03/2009
Notification Time: 15:32 [ET]
Event Date: 03/03/2009
Event Time: [EST]
Last Update Date: 03/03/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(2) - LOSS OR DEGRADED SAFETY ITEMS
Person (Organization):
RANDY MUSSER (R2)
MICHAEL TSCHILTZ (NMSS)
FUELS GRP VIA EMAIL ()

Event Text

DEGRADATION OF ITEM RELIED ON FOR SAFETY (IROFS)

"Area F is part of the solvent extraction uranium recovery process. The solvent extraction process removes usable uranium and strips out impurities from the solution. An organic solvent and nitric acid are used as part of this process. Column-0F13 is a strip column which has organic solvent flowing into the bottom and usable uranium/nitric acid entering from the top. After passing down through the solvent, the nitric acid exits Column-0F13 from the bottom, into feed Column-0G04. Column-0G04 then feeds into evaporator Column-0G05. If solvent were to enter Column-0G05 and begin reacting with the heated nitric acid while the system was closed (i.e., no vent relief) then a potential overpressurization or 'red oil' accident could occur. The scenario assumes that the reaction continues (self-heating) even though the heaters are shut off.

"IROFS FAF-19 consists of flow switch FS-0F13, located in Column-0F13, which is interlocked to PUMPMT-0F19. This IROFS is in place to prevent a red oil accident by isolating organic solvent in-flow to evaporator Column 0G05 (via feed Column 0G04) upon loss of solvent-nitric acid interface in strip Column 0F13. If flow switch FS-0F13 senses loss of Column 0F13 interface, PUMPMT-0F19 shuts off which stops flow into Column 0G04 and thus into Column-0G05.

"The equipment associated with IROFS FAF-19 is designated as Safety Related Equipment (SRE) and is functionally tested monthly. The regularly scheduled SRE Test was performed on March 3, 2009, and the purpose of the test is to demonstrate that the flow switch will fall when interface is lost and thus will shut off PUMPMT-0F13. The test failed because the flow switch did not fall, so the pump did not stop (PIRCS Problem #17584). Though there are defense in depth factors such as procedural requirements for operators to verify that no solvent is present in feed Column-0G04 prior to operation of evaporator Column-0G05, it was determined that IROFS FAF-19 was degraded and that the performance criteria of 10CFR70.61 were not met.

"IROFS FAG-12 is an open vent that is credited as an additional control that is in place to prevent overpressurization due to self-heating. However IROFS FAF-19 is also required to be available in order to the performance criteria.

"Previous SRE testing of the flow switch in January 2009 identified a potential problem with the flow switch sticking. As follow-up to that occurrence, the area process engineer reduced the SRE testing frequency from semi-annual to its current frequency of monthly in order to provide better indication if a problem was developing. Area F is currently in a safe condition and is operating under approved compensatory measures."

The licensee has notified the NRC Resident Inspector.

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Other Nuclear Material Event Number: 44888
Rep Org: KAKIVIK ASSET MANAGEMENT, LLC
Licensee: KAKIVIK ASSET MANAGEMENT, LLC
Region: 4
City: ANCHORAGE State: AK
County:
License #: 50-27667-01
Agreement: N
Docket:
NRC Notified By: KEENAN REMELE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/03/2009
Notification Time: 19:47 [ET]
Event Date: 03/03/2009
Event Time: 13:06 [YST]
Last Update Date: 03/04/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
DAVID PROULX (R4)
KEITH McCONNELL (FSME)

Event Text

FAILURE TO FULLY RETRACT SOURCE OF RADIOGRAPHY CAMERA

Radiography technicians were performing pipeline corrosion shots on piping in the North Slope of Alaska when they inadvertently locked the source outside of the shielded position in the camera while retracting the source. The technicians were using an Industrial Nuclear Corporation (INC) IR-100 camera which contains a nominal 120 Curie (original strength) Ir-192 source.

When the technicians realized what had occurred, they immediately cordoned off the area and requested help. A trained camera technician arrived and, after shielding the source, was able to manipulate the key lock and retract the source into the safe (shielded) position. The highest radiation reading observed behind the camera was 40 mR/hr. Exposures to all personnel involved in the recovery of the source was less than 20 mR. Since the radiography was being performed in a remote location, there was no chance of exposure to any members of the general public.

Currently, the camera has been removed from service and is being sent to INC for inspection and maintenance.

* * * RETRACTION FROM KEENAN REMELE TO JOE O'HARA VIA E-MAIL ON 3/4/09 AT 1443 * * *

"After receiving all the reports by the parties concerned it was not a malfunction of the exposure device that caused this event. The event occurred due to snow and ice build up in the locking mechanism and the radiographer turning the key inadvertently.

"This report will be forwarded to Region IV."

Notified R4DO (Proulx) and FSME (McIntosh)

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Power Reactor Event Number: 44891
Facility: SURRY
Region: 2 State: VA
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: THOMAS OLIVER
HQ OPS Officer: JOE O'HARA
Notification Date: 03/04/2009
Notification Time: 15:53 [ET]
Event Date: 03/04/2009
Event Time: 14:40 [EST]
Last Update Date: 03/04/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
DANIEL RICH (R2)

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

Event Text

RELIEF VALVE FAILURE RESULTS IN TRITIUM AND CESIUM SPILL

"At 1100 on March 3rd, 2009 the Main Control Room received a report from the Health Physics Shift Supervisor that 1-BR-RV-114B ( 'B' PG tank heater relief valve) was relieving to the RCA yard near the Primary Grade (PG) tanks. At 1115 an operator confirmed the initial report, stating the relief valve appeared to be full open and relieving at approximately 20 gallons per minute. 0-AP-35.01 (Radioactive Liquid Release Control) was then entered and executed. At 1120 the PG line was then isolated by closing isolation valves, thereby stopping the release.

"The release amount was then determined per 0-AP-35.01. Using the tank level initial indication of 87.5% taken on operator rounds at 1050 and a final level indication of 87.25%, approximately 450 gallons of water was released. This volume of water coincides with the initial report of an approximate 20 gpm release rate over the 20 minute duration of the event.

"A sample of the water released was evaluated for tritium and cesium as part of the Nuclear Energy Institute (NEI) Ground Water Protection Initiative. Sample analysis results showed that tritium concentration was 4,810 picoCuries per liter and cesium concentration was 25.1 picoCuries per liter. These concentrations of tritium and cesium pose no threat to employees or the public. Even though the concentrations are well below reportable limits for groundwater, a spill or leak to soil greater than 100 gallons containing licensed material requires that notification be made per VPAP-2103S (Offsite Dose Calculation Manual) as part of our commitment to the NEI Ground Water Protection Initiative.

"This leak has been contained and relief valve will remain isolated until repaired.

"This notification is being transmitted due to Notification of Other Government Agencies under 10CFR50.72(b)(2)(xi). The Surry County Administrator was notified. The Senior NRC Resident, Virginia Department of Health, Virginia Department of Emergency Management and Virginia Department of Environmental Quality has or will be notified."

Page Last Reviewed/Updated Thursday, March 29, 2012
Thursday, March 29, 2012