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Event Notification Report for March 10, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/09/2009 - 03/10/2009

** EVENT NUMBERS **


44889 44890 44892 44893

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General Information or Other Event Number: 44889
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: ISORAY
Region: 4
City: RICHLAND State: WA
County:
License #: WN-L0213-1
Agreement: Y
Docket:
NRC Notified By: ANINE GRUMBLES
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/04/2009
Notification Time: 11:35 [ET]
Event Date: 02/19/2009
Event Time: [PST]
Last Update Date: 03/04/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID PROULX (R4)
ANGELA MCINTOSH (FSME)

Event Text

IMPROPERLY PACKAGED RADIOACTIVE MATERIAL

The following was provided by the state via email:

"A single Cs-131 Brachytherapy seed was put back into the 'mick' cartridge by Banner Baywood Medical Center in Mesa, AZ, - the medical customer and end-user - and then returned to the manufacturer, IsoRay, a Washington State seed manufacturing licensee. When the shipping container, holding the mick container, arrived at IsoRay, contamination was found on the inside of the shipping container but not on the outside. There was no damage to the shipping container.

"While unpacking the seed, a technician noticed there was visible damage to the seed. The tech monitored the packing material and found contamination. The RSO determined that a few microcuries of radioactive material leaked onto the packing material. The remaining millirem of material was in the damaged source and the pig. No material was missing. IsoRay called Washington State, Office of Radiation Protection, and reported the event that day.

"There was no contamination found at the customer's site. IsoRay's Radiation Safety Officer reported that the seed had been visibly damaged, as if sheared. This may have happened when it was returned to the mick container or when the mick cartridge was re-inserted into the pig. Since all the contamination was inside the shipping container, it is doubtful that any personnel exposure was received.

"The cartridge was a Mick Radio-Nuclear Instruments, Inc catalog number 0216-DS. The SS&D registration for the seed is WA-1220-S-101-S."

Incident Number: WA-09-006

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Fuel Cycle Facility Event Number: 44890
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: RANDY SHACKLEFORD
HQ OPS Officer: JOE O'HARA
Notification Date: 03/04/2009
Notification Time: 15:19 [ET]
Event Date: 03/04/2009
Event Time: 14:40 [EST]
Last Update Date: 03/05/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
70.74 APP. A - ADDITIONAL REPORTING REQUIREMENTS
Person (Organization):
DANIEL RICH (R2)
MICHAEL TSCHILTZ (NMSS)
FUELS GRP EMAIL ()

Event Text

GLOVEBOX OVERFLOW DRAINS MAY BE INADEQUATE TO PERFORM THEIR SAFETY FUNCTION

"Many gloveboxes in the processing areas are equipped with overflow drains to prevent solution from exceeding an unsafe depth. These overflow drains are sized to accommodate the credible flow rates into the associated gloveboxes. During the generation of set-point analyses for overflow drains in a new process area, questions arose regarding how the drain discharge flow rates are calculated. To resolve these questions, NFS performed field tests using a glovebox on 2/26/2009 and 2/27/2009. Initial results of these tests indicated that the discharge flow rates are sensitive to drain weir height and glovebox floor flatness. This caused NFS to question the ability of the drains to perform their intended function. NFS, therefore, generated a plant-wide list of all potentially affected gloveboxes and suspended operations in them on 2/27/2009. Uranium-bearing materials were removed from the gloveboxes and all of the affected gloveboxes were tagged out of service. Engineering evaluations of the affected gloveboxes were performed and proceeded through 3/4/2009. As a result of Engineering evaluations, it was determined that in some instances a single drain alone was not capable of maintaining a solution depth to within design parameters in some localized areas within the glovebox. Modifications are being made to the drains to restore their functionality.

"There were no actual or potential safety consequences to the public or the environment. The potential criticality consequences to the workers were low due to the conservatisms included in the analyses."

The licensee has notified the NRC Resident Inspector.

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Transportation Event Event Number: 44892
Rep Org: EDLOW INTERNATIONAL
Licensee: NOT APPLICABLE
Region: 1
City: BALTIMORE State: MD
County:
License #:
Agreement: Y
Docket:
NRC Notified By: FRANCHONE OSHINOWO
HQ OPS Officer: JOE O'HARA
Notification Date: 03/05/2009
Notification Time: 13:44 [ET]
Event Date: 03/05/2009
Event Time: 13:00 [EST]
Last Update Date: 03/09/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
INFORMATION ONLY
Person (Organization):
SAM HANSELL (R1)
DANIEL RICH (R2)
MICHAEL TSCHILTZ (NMSS)
ANGELA MCINTOSH (FSME)

Event Text

INDUSTRIAL SHIPPING INCIDENT CONTAINING UF6 (URANIUM HEXAFLUORIDE)

NRC Operations Center was notified by the Vice President for Operations at Edlow International of a marine incident at Dundalk Marine Terminal in Baltimore, MD. While offloading a flat rack containing UX30 protective overpacks with type 30B cylinders containing uranium hexafluoride from the MV Atlantic Conveyor, the rigging gear failed and the rack dropped onto the pier on top of another flat rack containing UX30 type 30B cylinders. There is no indication of a leak or release at this time. There were no injuries. Surveyor is at the scene.

* * * UPDATE FROM FRANCHONE OSHINOWO TO JOE O'HARA AT 1640 EST ON 03/05/09 * * *

Edlow confirms no material spill or damage to the packages. Damage was confined to the flat rack itself. Contrary to what was reported earlier, the mishap occurred onboard the vessel and NOT on the pier. Preliminary indications are that the spreader used to lift the flat rack was not engaged on all four lifting points prior to the lift commencing.

Notified R1DO (Hansell), R2DO(D. Rich), NMSS EO(M. Tschiltz), and FSME EO (McConnell).

* * * UPDATE FROM FRANCHONE OSHINOWO TO PETE SNYDER AT 1055 EST ON 03/06/09 * * *

Upon inspection of the shipping containers on land, Edlow personnel have verified that only cosmetic damage was caused to one flat rack by the mishap. The highest radiation readings on contact with the containers were 0.5 millirem/hour which were within expected levels.

Notified R1DO (Hansell), R2DO (Rich), NMSS EO (Tschiltz), and FSME EO (McIntosh).

* * * UPDATE FROM FRANCHIONE OSHINOWO TO PETE SNYDER AT 1139 EDT ON 03/09/09 * * *

Edlow stated that the information put into the last update above was incorrect. The previous update should have read that there was only cosmetic damage to one overpack however one flatrack was rendered unusable.

Notified R1DO (Dimitriadis), R2DO (Rich), NMSS EO (Tshiltz), and FSME EO (McIntosh).

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General Information or Other Event Number: 44893
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: UNIVERSITY OF NORTH CAROLINA HOSPITALS
Region: 1
City: CHAPEL HILL State: NC
County:
License #: 068-0565-1
Agreement: Y
Docket:
NRC Notified By: JAMES ALBRIGHT
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/06/2009
Notification Time: 10:47 [ET]
Event Date: 03/05/2009
Event Time: 12:00 [EST]
Last Update Date: 03/09/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SAM HANSELL (R1)
KEITH McCONNELL (FSME)

Event Text

UNDERDOSE TO PATIENT DIFFERS >20% OF INTENDED DOSE

The following was provided by the state via e-mail:

"Incident is a Medical Event per 15A NCAC 11.0364(a)(1)(A) where the EDE [effective dose equivalent] exceeds 5 Rem, and the total dose delivered differs from the prescribed dose by 20% or more.

"[This incident] occurred during the use of Y-90 theraspheres. It appears that the theraspheres became stuck in the source vial, and the entire dose could not be administered to the patient. This resulted in a 26.4% underdose to the patient. The licensee is investigating why the Medical Event occurred. The Agency [NCDENR] has requested that the licensee submit the source vial lot or batch number in the report to assist in the determination if it may have been a manufacturing error."

A Medical Event may indicate potential problems in a medical facilities use of radioactive materials. It does not necessarily result in harm to the patient.

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Thursday, March 29, 2012