United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2009 > March 11

Event Notification Report for March 11, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/10/2009 - 03/11/2009

** EVENT NUMBERS **


44890 44893

To top of page
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.

To top of page
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.

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