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Event Notification Report for May 6, 2009

U.S. Nuclear Regulatory Commission
Operations Center

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

** EVENT NUMBERS **


44912 45034 45043

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General Information or Other Event Number: 44912
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: UNION CARBIDE CORPORATION
Region: 4
City: SEADRIFT State: TX
County:
License #: 00051
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/18/2009
Notification Time: 09:44 [ET]
Event Date: 03/17/2009
Event Time: [CDT]
Last Update Date: 05/05/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - PROCESS GAUGE SHUTTER HANDLE BROKE

"On the afternoon of 3/17/09, while closing the shutter of a Ohmart/Vega SH-F1 level detection gauge, the handle separated from the shutter closure device. The gauge contains a 10 milliCurie Cesium (Cs) - 137 source serial # 5747 GK. The license can not confirm the exact position of the shutter, but they are sure that it is not closed yet. Lubricants have been used on the shutter mechanism to aid in its operation. The licensee will continue their attempts to close the shutter on 3/18/09. If unable to close, they will request assistance from the manufacturer. Additional information will be provided as it is received."

Texas Event: I-8620

* * * UPDATE FROM ART TUCKER TO HOWIE CROUCH VIA EMAIL @1745 ON 3/18/09 * * *

"The Radiation Safety Officer notified the [State of Texas] that the gauge had not been fully closed yet, but area dose rates were normal therefore the gauge does not create additional risk of exposure to their workers."

Notified R4DO (Hay) and FSME EO (Camper).

* * * UPDATE FROM ART TUCKER TO JOE O'HARA VIA EMAIL AT 1021 ON 5/5/09 * * *

"The licensee reported [to the State of Texas] that on April 28, 2009, a technician from the manufacturer installed a shield over the source and removed the gauge from the vessel. The gauge has been placed in a radioactive material storage area until it can be packaged and returned to the manufacturer."

Notified R4DO (Pick) and FSME EO (McIntosh).

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Hospital Event Number: 45034
Rep Org: INDIANA UNIVERSITY MEDICAL CENTER
Licensee: INDIANA UNIVERSITY MEDICAL CENTER
Region: 3
City: INDIANAPOLIS State: IN
County:
License #: 13-02752-03
Agreement: N
Docket:
NRC Notified By: MACK RICHARD
HQ OPS Officer: DONALD NORWOOD
Notification Date: 04/30/2009
Notification Time: 14:51 [ET]
Event Date: 04/29/2009
Event Time: 13:30 [EDT]
Last Update Date: 04/30/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
DAVID HILLS (R3DO)
CHRISTEPHER MCKENNEY (FSME)

Event Text

MEDICAL EVENT INVOLVING AN UNDERDOSAGE DURING TREATMENT FOR LIVER CANCER

"At approximately 1:30 pm, on April 29, 2009 a medical event occurred at Indiana University Medical Center, NRC License No. 13-02752-03. This medical event involved the treatment of a patient with Y-90 microspheres (Nordion TheraSpheres). A dosage of 61.3 mCi was prescribed by the Authorized User. TheraSpheres are provided as a unit dosage and said dosage was assayed at 12:15 pm (4/29/09) to contain 60.1 mCi. Based upon a radiation monitoring device affixed to the TheraSphere delivery system, the pre-treatment reading was 7 milliroentgens per hour (mR/hr). Following the administration of the microspheres and four subsequent flushings of the delivery system, the radiation monitor exhibited a reading of 2 mR/hr, indicating that approximately 28.6% (17.2 mCi) of the dosage remained in the delivery system. When the subsequent flushing failed to reduce the remaining activity in the system, an independent measurement of the residual activity was performed to confirm that the entire dosage had not been delivered as prescribed.

"The vendor (Nordion) was notified of this event earlier today (4/29/09). Based upon discussions with their technical representatives, it is their opinion that the residual microspheres may be attached to the septum of the dose vial. For future treatments, the vendor representative suggested that the dose vial be given a good shake during the check-in and assay procedure to help dislodge any microspheres that may have adhered to the vial septum during shipment. They also suggested that during the administration process if the residual dosage appears to be present in the dose vial, tilting and tapping the dose vial and/or the acrylic box containing the dose vial may dislodge any microspheres that may adhere to the vial septum. These suggestions are being incorporated into the written procedures for TheraSphere treatments.

"The Radiation Safety Office attempted to perform some radiation measurements of the delivery system to determine the location of the residual activity. Due to the relatively high exposure rates from the residual radioactivity in the delivery system, it was not possible to definitively determine the distribution of the residual activity in the system at this time, mainly due to the potential for contamination and elevated radiation levels to RSO staff. More thorough evaluations may be possible once the radioactivity in the system diminishes due to radioactive decay.

"Notification of the referring physician of the occurrence of this medical event was made at 10:25 am today (4/30/09). The patient's wife was notified of the occurrence of the medical event at 10:30 am today."

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.

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Power Reactor Event Number: 45043
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [3] [ ] [ ]
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: ED TREMBLAY
HQ OPS Officer: JOE O'HARA
Notification Date: 05/05/2009
Notification Time: 05:41 [ET]
Event Date: 05/05/2009
Event Time: 03:30 [EDT]
Last Update Date: 05/05/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
MIKE ERNSTES (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 2 Startup 0 Hot Standby

Event Text

3C MAIN STEAM ISOLATION VALVE PROBLEMS

"While preparing to perform main turbine testing prior to returning Unit 3 to service, a possible weld defect was identified by plant personnel during a main steam system walk down. This defect appears to be on a small bore section of pipe upstream of a steam trap on a socket weld. This resulted in a small steam leak on the upstream side of the 'C' main steam isolation valve. The repair must be completed with the steam line depressurized and, as such, the plant is in the process of reducing temperature to less than 200 degrees F. Based on previous interpretations of TS 3.4.10 and the applicability to ASME Class 2 piping, TS 3.0.3 has been entered based on current plant conditions.

"At 0348 on 5/5/09, while bringing the Unit 3 to Mode 3 to comply with TSAS [Technical Specification Action Statement] 3.0.3, the 3C MSIV failed to close when demanded. The 3C MSIV was declared inoperable and Unit 3 entered TSAS 3.7.1.5 due to the inability to fulfill its safety function. The unit is required to be in Mode 3 in 6 hours and Mode 4 within the following 6 hours.

"At 0437, the 3C MSIV was closed. This is in compliance with TSAS 3.7.1.5. An investigation is in progress as to the cause of the failure of the 3C MSIV to close when demanded.

"Plant shutdown continues to comply with TSAS 3.0.3."

All other safety systems are operable and there is no impact on Unit 4.

The licensee notified the NRC Resident Inspector.

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