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Event Notification Report for March 6, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/05/2009 - 03/06/2009

** EVENT NUMBERS **


44883 44887

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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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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.

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