Event Notification Report for October 18, 2012
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/17/2012 - 10/18/2012
EVENT NUMBERS
48421484254845848591
Power Reactor
Event Number: 48421
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [] [2] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: ERIC STEELE
HQ OPS Officer: VINCE KLCO
Region: 2 State: AL
Unit: [] [2] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: ERIC STEELE
HQ OPS Officer: VINCE KLCO
Notification Date: 10/18/2012
Notification Time: 18:57 [ET]
Event Date: 10/18/2012
Event Time: 13:14 [CDT]
Last Update Date: 10/18/2012
Notification Time: 18:57 [ET]
Event Date: 10/18/2012
Event Time: 13:14 [CDT]
Last Update Date: 10/18/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION 50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION 50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
Person (Organization):
DANIEL RICH (R2DO)
DANIEL RICH (R2DO)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 3 | N | Y | 100 | Power Operation | 100 | Power Operation |
FIRE PROTECTION REVIEW IDENTIFIES A POTENTIAL UNANALYZED CONDITION
"During BFNP [Browns Ferry Nuclear Plant] NFPA [National Fire Protection Association] 805 transition review, it was determined in the event of an Appendix-R fire, fire induced circuit damage could potentially result in the Residual Heat Removal System Division II inboard isolation valve being prevented from opening or cause the valve to spuriously close on units 2 and 3. The current Appendix R safe shutdown analysis credits opening of these valves. Failure to open these valves results in loss of ability to provide long term cooling to the core.
"Compensatory actions in the form of fire watches to mitigate this condition are in place in accordance with the BFNP Fire Protection Report.
"This condition is being reported pursuant to 10CFR50.72(b)(3)(ii)(B) and 10CFR50.72(b)(3)(v).
"The NRC Resident Inspector has been notified."
"During BFNP [Browns Ferry Nuclear Plant] NFPA [National Fire Protection Association] 805 transition review, it was determined in the event of an Appendix-R fire, fire induced circuit damage could potentially result in the Residual Heat Removal System Division II inboard isolation valve being prevented from opening or cause the valve to spuriously close on units 2 and 3. The current Appendix R safe shutdown analysis credits opening of these valves. Failure to open these valves results in loss of ability to provide long term cooling to the core.
"Compensatory actions in the form of fire watches to mitigate this condition are in place in accordance with the BFNP Fire Protection Report.
"This condition is being reported pursuant to 10CFR50.72(b)(3)(ii)(B) and 10CFR50.72(b)(3)(v).
"The NRC Resident Inspector has been notified."
Agreement State
Event Number: 48425
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH
Licensee: UNIVERSITY OF IOWA HOSPITAL AND CLINIC
Region: 3
City: IOWA CITY State: IA
County:
License #: 0037-1-52-AAB
Agreement: Y
Docket:
NRC Notified By: MELANIE RASMUSSON
HQ OPS Officer: VINCE KLCO
Licensee: UNIVERSITY OF IOWA HOSPITAL AND CLINIC
Region: 3
City: IOWA CITY State: IA
County:
License #: 0037-1-52-AAB
Agreement: Y
Docket:
NRC Notified By: MELANIE RASMUSSON
HQ OPS Officer: VINCE KLCO
Notification Date: 10/19/2012
Notification Time: 17:34 [ET]
Event Date: 10/18/2012
Event Time: 00:00 [CDT]
Last Update Date: 11/02/2012
Notification Time: 17:34 [ET]
Event Date: 10/18/2012
Event Time: 00:00 [CDT]
Last Update Date: 11/02/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
STEVE ORTH (R3DO)
FSME EVENTS RESOURCE (EMAI)
STEVE ORTH (R3DO)
FSME EVENTS RESOURCE (EMAI)
AGREEMENT STATE REPORT - MEDICAL DOSAGE NOT DELIVERED AS PLANNED
A patient was being treated for a liver tumor and the dosage was delivered to the wrong lobe. The physician prescribed 17 mCi of Y-90 to the left lobe of the liver. The prescribing physician was not present during the dose administration procedure. The intervention radiologist examined a fluoroscope of the patient's liver and noted a larger tumor on the right lobe. The prescribed dosage was then delivered to the right lobe of the liver, not in accordance with the prescribed dosage plan. Patient examination detected no observable impact, and the physician is developing another dosage plan for the patient. The Iowa Department of Public Health will perform an onsite investigation.
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.
* * * UPDATE FROM RANDAL DAHLIN TO CHARLES TEAL ON 11/2/12 AT 1408 EDT * * *
The following was received from the State of Iowa via email:
"The University of Iowa nuclear medicine staff notified the Environmental Health & Safety (EHS) office on October 19, 2012 that they had discovered a reportable medical event that occurred during an October 18, 2012, therapy administration of Yttrium-90 microspheres (SIRSpheres) to a patient with liver metastases from a carcinoid tumor.
"The Nuclear Medicine authorized user had prescribed for the delivery of 17 millicuries of the Y-90 microspheres to the left lobe of the patient's liver with plans to also administer 34 millicuries of the Y-90 microspheres to the right lobe of the patient's liver at a later time. Y-90 activity to be administered was calculated based on body surface area and tumor involvement. However, the interventional radiologist performing the Y-90 microsphere administration under fluoroscopic guidance noted that the angiogram of the patient's liver showed more tumor blood flow in the right lobe of the patient's liver and decided it would be medically more advantageous for the patient to treat the right lobe of the liver first. He proceeded to treat the right lobe without consulting the authorized user.
"The interventional radiologist was only able to deliver 96% of the 17 millicurie Y-90 dose to the right lobe of the patient's liver before the right artery occluded. The authorized user discovered the administration discrepancy the next day when the patient was scheduled for post therapy imaging on October 19th. Both the patient and referring physician were informed of the medical event on October 19th. The physicians involved concluded that the patient's health and outcome were not affected by treating the right lobe of the liver first with only 17 millicuries of Y-90 microspheres since only 96% of activity could be injected before full embolization of the right hepatic artery occurred.
"The physicians plan to treat the left lobe of the patient's liver in approximately 4 weeks. The Iowa Department of Public Health (IDPH) performed an onsite investigation of this medical event on October 23, 2012. The IDPH inspector interviewed the University Radiation Safety Officer, the Nuclear Medicine Authorized User, the Interventional Radiologist performing the Y-90 administration, the Chief Nuclear Pharmacist, the Chairman of the Medical Radiation Protection Committee, and Hospital Radiation Safety Review Group. The cause of the event was a lack of understanding of the requirements for administering radioactive material under the supervision of an authorized user. The interventional radiologist made a medical decision to alter the administration site without consulting the prescribing authorized user.
"To avoid recurrence the following actions are being taken by the University of Iowa. All nuclear medicine authorized users prescribing Y-90 microsphere therapy will review the supervision requirements specified in Iowa Administrative Code 641-41.2(11) with all interventional radiologists on staff to ensure that they understand that they are required to follow the instructions of the prescribing authorized user. A roster of the individuals receiving this training will be forwarded to the IDPH upon completion. Additionally, nuclear medicine and interventional radiology will develop a written policy regarding the proper steps to be taken in the event that any deviation from the authorized user's written directive for the medical administration of radioactive materials is required. A copy of the policy will be forwarded to IDPH upon completion.
"Reporting Requirement: 35.3045(a)(1(i) - Total dose delivered that differs from the prescribed dose by 20% or more; and differs from the prescribed dose by more than 0.05 Sv (50 rem) SDE."
IA Report: IA120006
Notified R3DO (Kozak) and the FSME Event Resource via email.
A patient was being treated for a liver tumor and the dosage was delivered to the wrong lobe. The physician prescribed 17 mCi of Y-90 to the left lobe of the liver. The prescribing physician was not present during the dose administration procedure. The intervention radiologist examined a fluoroscope of the patient's liver and noted a larger tumor on the right lobe. The prescribed dosage was then delivered to the right lobe of the liver, not in accordance with the prescribed dosage plan. Patient examination detected no observable impact, and the physician is developing another dosage plan for the patient. The Iowa Department of Public Health will perform an onsite investigation.
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.
* * * UPDATE FROM RANDAL DAHLIN TO CHARLES TEAL ON 11/2/12 AT 1408 EDT * * *
The following was received from the State of Iowa via email:
"The University of Iowa nuclear medicine staff notified the Environmental Health & Safety (EHS) office on October 19, 2012 that they had discovered a reportable medical event that occurred during an October 18, 2012, therapy administration of Yttrium-90 microspheres (SIRSpheres) to a patient with liver metastases from a carcinoid tumor.
"The Nuclear Medicine authorized user had prescribed for the delivery of 17 millicuries of the Y-90 microspheres to the left lobe of the patient's liver with plans to also administer 34 millicuries of the Y-90 microspheres to the right lobe of the patient's liver at a later time. Y-90 activity to be administered was calculated based on body surface area and tumor involvement. However, the interventional radiologist performing the Y-90 microsphere administration under fluoroscopic guidance noted that the angiogram of the patient's liver showed more tumor blood flow in the right lobe of the patient's liver and decided it would be medically more advantageous for the patient to treat the right lobe of the liver first. He proceeded to treat the right lobe without consulting the authorized user.
"The interventional radiologist was only able to deliver 96% of the 17 millicurie Y-90 dose to the right lobe of the patient's liver before the right artery occluded. The authorized user discovered the administration discrepancy the next day when the patient was scheduled for post therapy imaging on October 19th. Both the patient and referring physician were informed of the medical event on October 19th. The physicians involved concluded that the patient's health and outcome were not affected by treating the right lobe of the liver first with only 17 millicuries of Y-90 microspheres since only 96% of activity could be injected before full embolization of the right hepatic artery occurred.
"The physicians plan to treat the left lobe of the patient's liver in approximately 4 weeks. The Iowa Department of Public Health (IDPH) performed an onsite investigation of this medical event on October 23, 2012. The IDPH inspector interviewed the University Radiation Safety Officer, the Nuclear Medicine Authorized User, the Interventional Radiologist performing the Y-90 administration, the Chief Nuclear Pharmacist, the Chairman of the Medical Radiation Protection Committee, and Hospital Radiation Safety Review Group. The cause of the event was a lack of understanding of the requirements for administering radioactive material under the supervision of an authorized user. The interventional radiologist made a medical decision to alter the administration site without consulting the prescribing authorized user.
"To avoid recurrence the following actions are being taken by the University of Iowa. All nuclear medicine authorized users prescribing Y-90 microsphere therapy will review the supervision requirements specified in Iowa Administrative Code 641-41.2(11) with all interventional radiologists on staff to ensure that they understand that they are required to follow the instructions of the prescribing authorized user. A roster of the individuals receiving this training will be forwarded to the IDPH upon completion. Additionally, nuclear medicine and interventional radiology will develop a written policy regarding the proper steps to be taken in the event that any deviation from the authorized user's written directive for the medical administration of radioactive materials is required. A copy of the policy will be forwarded to IDPH upon completion.
"Reporting Requirement: 35.3045(a)(1(i) - Total dose delivered that differs from the prescribed dose by 20% or more; and differs from the prescribed dose by more than 0.05 Sv (50 rem) SDE."
IA Report: IA120006
Notified R3DO (Kozak) and the FSME Event Resource via email.
Agreement State
Event Number: 48458
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: GOOLSBY TESTING LABORATORIES INC.
Region: 4
City: HUMBLE State: TX
County:
License #: 03115
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: VINCE KLCO
Licensee: GOOLSBY TESTING LABORATORIES INC.
Region: 4
City: HUMBLE State: TX
County:
License #: 03115
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: VINCE KLCO
Notification Date: 10/30/2012
Notification Time: 13:24 [ET]
Event Date: 10/18/2012
Event Time: 00:00 [CDT]
Last Update Date: 10/30/2012
Notification Time: 13:24 [ET]
Event Date: 10/18/2012
Event Time: 00:00 [CDT]
Last Update Date: 10/30/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
RICK DEESE (R4DO)
FSME EVENTS RESOURCE (EMAI)
RICK DEESE (R4DO)
FSME EVENTS RESOURCE (EMAI)
AGREEMENT STATE REPORT - RADIOGRAPHY DEVICE SOURCE DISCONNECTED
The following information was received by email:
"On October 18, 2012, the Agency [State of Texas Radiation Branch] received a request from an exposure device manufacturer for reciprocity to retrieve a . . . cobalt 60 source into a Spec 300 radiography device. The Agency contacted the Texas licensee and was told that the source had been retracted and that no reportable event had occurred. The licensee stated it needed assistance in disconnecting the drive cable from the source pig tail. On October 23, 2012, the Agency was informed by the manufacturer that the dose rates measured at the front of the exposure device indicated that the source may not be in the fully shielded position. On October 30, 2012, the Agency was informed by the manufacturer that the source was stuck inside the device approximately three inches from the locked and fully shielded position. The licensee has not reported this event to the Agency. The Agency will conduct an on-site investigation at the licensee's facility on November 1, 2012. There does not appear to have been any exposures to members of the general public. There were no overexposures to employees of the manufacturer. Exposures to the licensee's employees have not been determined. The investigation into this event is ongoing. Additional information will be provided as it is received in accordance with SA 300."
Texas Incident: I-9000
The following information was received by email:
"On October 18, 2012, the Agency [State of Texas Radiation Branch] received a request from an exposure device manufacturer for reciprocity to retrieve a . . . cobalt 60 source into a Spec 300 radiography device. The Agency contacted the Texas licensee and was told that the source had been retracted and that no reportable event had occurred. The licensee stated it needed assistance in disconnecting the drive cable from the source pig tail. On October 23, 2012, the Agency was informed by the manufacturer that the dose rates measured at the front of the exposure device indicated that the source may not be in the fully shielded position. On October 30, 2012, the Agency was informed by the manufacturer that the source was stuck inside the device approximately three inches from the locked and fully shielded position. The licensee has not reported this event to the Agency. The Agency will conduct an on-site investigation at the licensee's facility on November 1, 2012. There does not appear to have been any exposures to members of the general public. There were no overexposures to employees of the manufacturer. Exposures to the licensee's employees have not been determined. The investigation into this event is ongoing. Additional information will be provided as it is received in accordance with SA 300."
Texas Incident: I-9000
Part 21
Event Number: 48591
Rep Org: SHAW/AREVA MOX SERVICES, LLC
Licensee: FLANDERS CSC
Region: 1
City: AIKEN State: SC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DOUG YATES
HQ OPS Officer: STEVE SANDIN
Licensee: FLANDERS CSC
Region: 1
City: AIKEN State: SC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DOUG YATES
HQ OPS Officer: STEVE SANDIN
Notification Date: 12/14/2012
Notification Time: 09:18 [ET]
Event Date: 10/18/2012
Event Time: 00:00 [EST]
Last Update Date: 01/07/2016
Notification Time: 09:18 [ET]
Event Date: 10/18/2012
Event Time: 00:00 [EST]
Last Update Date: 01/07/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
ALAN BLAMEY (R2DO)
PART 21 MATERIALS (EMAI)
ALAN BLAMEY (R2DO)
PART 21 MATERIALS (EMAI)
PART 21 REPORT INVOLVING NONCONFORMING WELDS ON A PELLET HANDLING TRANSFER GLOVE BOX
The following information was provided by Shaw/AREVA via fax:
(i) Name and address of the individual or individuals informing the Commission.
"Kelly D. Trice
President and Chief Operating Officer
Shaw AREVA MOX Services
Savannah River Site
P.O. Box 7097
Aiken, SC 29804-7097
(ii) Identification of the facility, the activity, or the basic component supplied for such facility which fails to comply or contains a defect.
"The Mixed Oxide Fuel Fabrication Facility is addressing nonconforming welds and a weld process associated with the procurement of a pellet handling transfer glove box PML*GB100C.
(iii) Identification of the firm constructing the facility or supplying the basic component which fails to comply or contains a defect.
"The pellet handling glove box is being supplied to MOX Services as a basic component by Flanders CSC.
(iv) Nature of the defect or failure to comply and the safety hazard which is created or could be created by such defect or failure to comply.
"PML*GB100C has a total of 32 welds that will need repair which will require adding additional fillet welds on top of the current weld such that the weld is large enough to satisfy structural requirements. Each weld will have to have at least a 3mm fillet weld added. Adding these additional welds will most likely have to be applied in two or three weld passes per location to create the needed weld dimension.
"The boss was attached to the glove box using a fillet weld on top (Outer) and a single bevel weld on the inside. This does not allow for complete joint penetration between the fillet and bevel welds resulting in a weld with incomplete fusion. weakening the joint significantly and creating the possibility for high stress concentration areas in the weld joint.
"Furthermore, using the GMAW (Gas Metal Arc Welding) short circuit arc process in this joint design produces a joint that cannot be counted on to carry load. When the GMAW short circuit arc weld process is used on material of ¬" or less in thickness, it allows for adequate heat to be transferred into the material to provide proper fusion of the filler material into the base material. When using the GMAW short circuit arc weld process on material over ¬", the mass of the base material results in a heat sink that is too large for the process to adequately fuse the filler material with the base material creating a weld that looks acceptable but could fail under small loads. In the PML boxes, these bosses support internal equipment and also support the glove box itself. Under this condition during a seismic event, the bosses could break away from the glove box shell breaking the confinement boundary as well as the flanges on each end, possibly causing the box to fall which could affect its static confinement barrier safety function. An additional seventeen glove boxes previously received are being reviewed for similar issues.
(v) The date on which the information of such defect or failure to comply was obtained.
"The deviation was identified in a non-conformance report on October 18, 2012.
(vi) In the case of a basic component which contains a defect or fails to comply. the number and location of these components in use at, supplied for, being supplied for, or may be supplied for, manufactured, or being manufactured for one or more facilities or activities subject to the regulations in this part.
"MOX Services does not possess information as to whether other facilities have been supplied a similar basic component by Flanders CSC.
(vii) The corrective action. which has been, is being, or will be taken; the name of the individual or organization responsible for the action; and the length of time that has been or will be taken to complete the action.
"Non-Conformance Report NCR 12-4583 will disposition the repairs associated with Flanders glove box PML* GB100C. MOX Services will ensure repairs are performed by either the vendor, MOX Services or a third party. These repairs will be performed in support of the construction schedule.
(viii) Any advice related to the defect or failure to comply about the facility, activity, or basic component that has been, is being, or will be given to purchasers or licensees.
"None.
(ix) In the case of an early site permit, the entities to whom an early site permit was transferred.
"This is not an early site permit concern."
* * * UPDATE ON 1/7/16 AT 0921 EST FROM DOUG YATES TO DONG PARK * * *
The following information was provided by CB&I AREVA MOX Services via fax:
(i) Name and address of the individual or individuals informing the Commission.
"David Del Vecchio
President and Project Manager
CB&I AREVA MOX Services
Savannah River Site
P.O. Box 7097
Aiken, SC 29804-7097
(ii) Identification of the facility, the activity, or the basic component supplied for such facility which fails to comply or contains a defect.
"The Mixed Oxide Fuel Fabrication Facility is addressing the discovery of foreign liquid within the structural tube steel frames of ball milling gloveboxes NBX*GB1000 and NBY*GB1000.
(iii) Identification of the firm constructing the facility or supplying the basic component which fails to comply or contains a defect.
"Ball milling gloveboxes NBX*GB1000 and NBY*GB1000 were being supplied to MOX Services as a basic component by Flanders CSC.
(iv) Nature of the defect or failure to comply and the safety hazard which is created or could be created by such defect or failure to comply.
"Ball milling gloveboxes NBX*GB1000 and NBY*GB1000 were two of the seventeen additional gloveboxes that were identified in a December 14, 2012 Part 21 Report issued by MOX Services due to use of an incorrect welding process (Gas Metal Arc Welding) for certain welded connections during glovebox fabrication.
"During weld repairs associated with the earlier Part 21 report, MOX Services' third party vendor discovered foreign liquid trapped within a portion of the tube steel frames of the NBX and NBY gloveboxes. The foreign liquid and dried substances (remnants of the original fabrication processes) were determined to contain contaminates not allowed to be present during welding operations. Due to the presence of contaminants potentially in the vicinity of most of the structural weld heat affected zones, MOX Engineering determined it necessary to metallurgically examine, through additional sampling, some of these welds in order to obtain reasonable assurance the welds can perform their design function. However, MOX Services has concluded that removal of these welds as part of the sampling process would damage the structure of these GBs beyond practical repair. Therefore the decision was made to rebuild these gloveboxes rather than sample the welds to determine their adequacy.
"Although the NBX and NBY gloveboxes were part of the earlier 2012 Part 21 report, they are being reported as a defect herein because of the indeterminate nature of the glovebox welds and associated potential degradation of the gloveboxes confinement function. This functional degradation would not result from use of an improper weld process as identified in the earlier report but instead would result from the lack of maintaining cleanliness controls during fabrication.
(v) The date on which the information of such defect or failure to comply was obtained.
"Information related to the foreign liquid sampling was provided to MOX Services on November 12, 2015.
(vi) In the case of a basic component which contains a defect or fails to comply, the number and location of these components in use at, supplied for, being supplied for, or may be supplied for, manufactured, or being manufactured for one or more facilities or activities subject to the regulations in this part.
"MOX Services does not possess information as to whether other facilities have been supplied a similar basic component by Flanders CSC.
(vii) The corrective action, which has been, is being, or will be taken; the name of the individual or organization responsible for the action; and the length of time that has been or will be taken to complete the action.
"It is anticipated that ball milling gloveboxes NBX*GB1000 and NBY*GB1000 will be rebuilt rather than continuing with repairs by MOX Services' third party vendor. MOX Services anticipates that rebuild of the NBX and NBY glove boxes will be completed during fiscal year 2018.
(viii) Any advice related to the defect or failure to comply about the facility, activity, or basic component that has been, is being, or will be given to purchasers or licensees.
"None at this time.
(ix) In the case of an early site permit, the entities to whom an early site permit was transferred.
"Not applicable."
Notified R2DO (Masters) and Part 21 Group via Email.
The following information was provided by Shaw/AREVA via fax:
(i) Name and address of the individual or individuals informing the Commission.
"Kelly D. Trice
President and Chief Operating Officer
Shaw AREVA MOX Services
Savannah River Site
P.O. Box 7097
Aiken, SC 29804-7097
(ii) Identification of the facility, the activity, or the basic component supplied for such facility which fails to comply or contains a defect.
"The Mixed Oxide Fuel Fabrication Facility is addressing nonconforming welds and a weld process associated with the procurement of a pellet handling transfer glove box PML*GB100C.
(iii) Identification of the firm constructing the facility or supplying the basic component which fails to comply or contains a defect.
"The pellet handling glove box is being supplied to MOX Services as a basic component by Flanders CSC.
(iv) Nature of the defect or failure to comply and the safety hazard which is created or could be created by such defect or failure to comply.
"PML*GB100C has a total of 32 welds that will need repair which will require adding additional fillet welds on top of the current weld such that the weld is large enough to satisfy structural requirements. Each weld will have to have at least a 3mm fillet weld added. Adding these additional welds will most likely have to be applied in two or three weld passes per location to create the needed weld dimension.
"The boss was attached to the glove box using a fillet weld on top (Outer) and a single bevel weld on the inside. This does not allow for complete joint penetration between the fillet and bevel welds resulting in a weld with incomplete fusion. weakening the joint significantly and creating the possibility for high stress concentration areas in the weld joint.
"Furthermore, using the GMAW (Gas Metal Arc Welding) short circuit arc process in this joint design produces a joint that cannot be counted on to carry load. When the GMAW short circuit arc weld process is used on material of ¬" or less in thickness, it allows for adequate heat to be transferred into the material to provide proper fusion of the filler material into the base material. When using the GMAW short circuit arc weld process on material over ¬", the mass of the base material results in a heat sink that is too large for the process to adequately fuse the filler material with the base material creating a weld that looks acceptable but could fail under small loads. In the PML boxes, these bosses support internal equipment and also support the glove box itself. Under this condition during a seismic event, the bosses could break away from the glove box shell breaking the confinement boundary as well as the flanges on each end, possibly causing the box to fall which could affect its static confinement barrier safety function. An additional seventeen glove boxes previously received are being reviewed for similar issues.
(v) The date on which the information of such defect or failure to comply was obtained.
"The deviation was identified in a non-conformance report on October 18, 2012.
(vi) In the case of a basic component which contains a defect or fails to comply. the number and location of these components in use at, supplied for, being supplied for, or may be supplied for, manufactured, or being manufactured for one or more facilities or activities subject to the regulations in this part.
"MOX Services does not possess information as to whether other facilities have been supplied a similar basic component by Flanders CSC.
(vii) The corrective action. which has been, is being, or will be taken; the name of the individual or organization responsible for the action; and the length of time that has been or will be taken to complete the action.
"Non-Conformance Report NCR 12-4583 will disposition the repairs associated with Flanders glove box PML* GB100C. MOX Services will ensure repairs are performed by either the vendor, MOX Services or a third party. These repairs will be performed in support of the construction schedule.
(viii) Any advice related to the defect or failure to comply about the facility, activity, or basic component that has been, is being, or will be given to purchasers or licensees.
"None.
(ix) In the case of an early site permit, the entities to whom an early site permit was transferred.
"This is not an early site permit concern."
* * * UPDATE ON 1/7/16 AT 0921 EST FROM DOUG YATES TO DONG PARK * * *
The following information was provided by CB&I AREVA MOX Services via fax:
(i) Name and address of the individual or individuals informing the Commission.
"David Del Vecchio
President and Project Manager
CB&I AREVA MOX Services
Savannah River Site
P.O. Box 7097
Aiken, SC 29804-7097
(ii) Identification of the facility, the activity, or the basic component supplied for such facility which fails to comply or contains a defect.
"The Mixed Oxide Fuel Fabrication Facility is addressing the discovery of foreign liquid within the structural tube steel frames of ball milling gloveboxes NBX*GB1000 and NBY*GB1000.
(iii) Identification of the firm constructing the facility or supplying the basic component which fails to comply or contains a defect.
"Ball milling gloveboxes NBX*GB1000 and NBY*GB1000 were being supplied to MOX Services as a basic component by Flanders CSC.
(iv) Nature of the defect or failure to comply and the safety hazard which is created or could be created by such defect or failure to comply.
"Ball milling gloveboxes NBX*GB1000 and NBY*GB1000 were two of the seventeen additional gloveboxes that were identified in a December 14, 2012 Part 21 Report issued by MOX Services due to use of an incorrect welding process (Gas Metal Arc Welding) for certain welded connections during glovebox fabrication.
"During weld repairs associated with the earlier Part 21 report, MOX Services' third party vendor discovered foreign liquid trapped within a portion of the tube steel frames of the NBX and NBY gloveboxes. The foreign liquid and dried substances (remnants of the original fabrication processes) were determined to contain contaminates not allowed to be present during welding operations. Due to the presence of contaminants potentially in the vicinity of most of the structural weld heat affected zones, MOX Engineering determined it necessary to metallurgically examine, through additional sampling, some of these welds in order to obtain reasonable assurance the welds can perform their design function. However, MOX Services has concluded that removal of these welds as part of the sampling process would damage the structure of these GBs beyond practical repair. Therefore the decision was made to rebuild these gloveboxes rather than sample the welds to determine their adequacy.
"Although the NBX and NBY gloveboxes were part of the earlier 2012 Part 21 report, they are being reported as a defect herein because of the indeterminate nature of the glovebox welds and associated potential degradation of the gloveboxes confinement function. This functional degradation would not result from use of an improper weld process as identified in the earlier report but instead would result from the lack of maintaining cleanliness controls during fabrication.
(v) The date on which the information of such defect or failure to comply was obtained.
"Information related to the foreign liquid sampling was provided to MOX Services on November 12, 2015.
(vi) In the case of a basic component which contains a defect or fails to comply, the number and location of these components in use at, supplied for, being supplied for, or may be supplied for, manufactured, or being manufactured for one or more facilities or activities subject to the regulations in this part.
"MOX Services does not possess information as to whether other facilities have been supplied a similar basic component by Flanders CSC.
(vii) The corrective action, which has been, is being, or will be taken; the name of the individual or organization responsible for the action; and the length of time that has been or will be taken to complete the action.
"It is anticipated that ball milling gloveboxes NBX*GB1000 and NBY*GB1000 will be rebuilt rather than continuing with repairs by MOX Services' third party vendor. MOX Services anticipates that rebuild of the NBX and NBY glove boxes will be completed during fiscal year 2018.
(viii) Any advice related to the defect or failure to comply about the facility, activity, or basic component that has been, is being, or will be given to purchasers or licensees.
"None at this time.
(ix) In the case of an early site permit, the entities to whom an early site permit was transferred.
"Not applicable."
Notified R2DO (Masters) and Part 21 Group via Email.