Event Notification Report for February 17, 2012

MISSING UPPER MOUNTING PADS ON SUBCOVER ASSEMBLIES

"Engine Systems Inc. (ESI) began a 10CFR21 evaluation on 12/20/11 upon notification of an issue with four subcover assemblies at Perry Nuclear Power Plant. It was reported that Perry was performing a maintenance activity whereby they were replacing four cylinder head subcover assemblies on their Enterprise diesel engine. During installation, it was noted that qty. 2 of 11 bolt holes were missing an upper mounting pad. This was visually apparent once the customer attempted to install the bolts, which have a 6" length. The two areas missing the upper landing pad did not have an area for the underside of the bolt head to rest upon.

"The evaluation was concluded on 2/17/12 and it determined that this issue is a reportable defect as defined by 10CFR21.

"DISCUSSION:

"Lack of the mounting pads alone will not result in a failure, however if a customer attempts to install the subcover without recognizing the missing material, there is the possibility that two of the eleven hold down bolts will provide no clamping function. This may result in loosening of the subcover mounting which could allow the cover to separate from the cylinder head.

"The subcover is a device that is fastened to the top of the cylinder head and provides support for the rocker arms and rocker shafts and encloses the valve stem area. There is one subcover per cylinder head and thus for a model DSRV-16-4 Enterprise engine there are 16 subcovers. Failure of a subcover would impact the ability of either of the corresponding rocker arms to provide the mechanical force to actuate the intake and exhaust valves. Without valve actuation, that particular power assembly would be unable to generate power which would reduce the output of the emergency diesel generator (EDG). Failure of the EDG to produce its nameplate rated power could prevent the safe shutdown of the nuclear power plant during an emergency situation.

"AFFECTED USERS AND SHIPMENTS:

"ESI has supplied subcovers with the incorrect mounting pad to the following customers [in USA]:
"Perry; Qty: 4; Date: October 2011.

"Note: The subcovers returned by Perry are the subject of this evaluation.

"CORRECTIVE ACTIONS:

"Customers may elect to justify use of a shorter bolt to facilitate installation of in-stock covers. Otherwise it is ESI's recommendation that customers return the subcovers for replacement.

"The root cause analysis determined that the cause of this issue was that the pattern for the casting is missing the portions that would ultimately form this upper mounting pad. In addition, the machining drawing was unclear in showing these locations. As a result, ESI's inspections did not specifically check for these locations and the non-conforming subcovers were shipped to the customer.

"The pattern is now being corrected to ensure the presence of the upper mounting pads. Also, ESI's dedication report is being revised to add specific checks to inspect for the presence of these pads. This will be completed prior to any future shipments of this item."

AGREEMENT STATE REPORT INVOLVING POTENTIAL RADIOGRAPHER OVEREXPOSURE

The following information was received from the State of Texas via email:

"On February 17, 2011, the Agency [State of Texas] was notified by the licensee of an overexposure event involving one of their radiographers. The radiographer was working in a shooting bay at the licensee's facility using a QSA D880 radiography camera serial number D7293 containing a 37 curie iridium 192 source. The radiographer entered the shooting bay to setup for their next shoot. They stated that they carried their dose rate meter with them but did not pay attention to the reading. The radiographer completed the setup and left the shooting bay. The radiographer attempted to crank the source out, but discovered that the source was already cranked fully out. The radiographer cranked the source back to the fully shielded position and notified their Radiation Safety Officer (RSO) of the event. The RSO questioned the radiographer and found that the radiographer had spent approximately 3 minutes within 10 inches of the source, and about 3 minutes at 3 feet from the source during the setup. Initial calculations by the licensee indicated that the radiographer may have received as much as 20 rem TEDE from the event. The RSO stated that the radiographer did not have to relocate the source to perform the shot so they do not believe there is any extremity dose involved. The RSO also stated that the electrical breaker that supplied power to the shooting bay had been opened therefore the alarm did not function. The RSO stated that they were going to review security video to determine who opened the breaker. The radiographer has been removed from all work involving exposure to radiation and their personal monitoring device will be sent to the licensee's processor. The Agency provided contact information for the Radiation Emergency Assistance Center/Training Site to the RSO. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: I-8934

* * * UPDATE FROM ART TUCKER (VIA EMAIL) TO HOWIE CROUCH @ 1727 EST ON 2/24/12 * * *

"On February 24, 2012, the licensee reported that after two reenactments of the event, the licensee now believes that the total exposure time to the radiographer to be 2 minutes and 30 seconds. The licensee was also able to use the radiographer's cell phone records as the radiographer was talking on their phone while setting up the shot. The distance for the radiographers TEDE dose was determined to be 12 inches. The licensee now estimates that the TEDE dose for the radiographer was 8.1 rem.

"The radiographer has provided three blood samples for evaluation. All three samples were determined to be normal. The radiographer's doctor is consulting with [name redacted] REAC/TS. Additional blood samples are scheduled in the future.

"The licensee determined that the power breaker to the alarming area radiation monitor was opened by a coworker who believed the breaker only supplied power to a ventilation fan. The operation of the alarm had been verified at the beginning of the start of that shift."

Notified R4DO (Deese) and FSME EO (O'Sullivan).

OFFSITE NOTIFICATION OF WASTE WATER POND TOXICITY LEVELS EXCEEDING LIMITS

"On 02/17/12, McGuire Environmental Management notified the North Carolina Department of Environment and Natural Resources located in Mooresville, NC of a failed toxicity test on our waste water discharge point 002 (WC Pond). This test is required quarterly by our NPDES (wastewater) Permit.

"Discharge was stopped yesterday (02/16/12) afternoon and we are currently pulling toxicity tests on the WC Pond and Initial Holdup Pond to determine if we still have toxicity. No WC Pond release will occur until toxicity results are known to be within acceptable limits."

The NRC Resident Inspector has been notified.