Event Notification Report for May 03, 2013

AGREEMENT STATE REPORT - MISSING TROXLER GAUGE

The following information was received via E-mail:

"After conducting a recent inventory, the licensee called in to report that one of their portable radiation gauges was missing and/or stolen. Specifically, a Troxler gauge, model 3430, serial number 27283 cannot be currently accounted for."

The Georgia Radioactive Materials Program will update this event when more information is available.

Georgia Incident Summary: GA-CTS-07990


* * * UPDATE FROM ERIC JAMESON TO DONALD NORWOOD AT 1532 ON 5/7/2013 * * *

The following report was received via e-mail:

"The licensee reports that the gauge's last recorded use was on 4/24/2013. The licensee made the report of the lost or stolen gauge to both the Department [Georgia Radioactive Materials Program] and local law enforcement on 5/2/2013. The licensee also stated the gauge has a sticker on it indicating a reward if found and returned."

Notified R1DO (Dwyer) and FSME Events Resource.


THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

LOST TROXLER MOISTURE DENSITY GAUGE

The licensee from Chambersburg, PA, was doing work in West Virginia under a reciprocity agreement. The authorized user was conducting a reading when he was asked by his supervisor to pick-up a fellow employee at the construction yard approximately 1.5 miles from the reading site. After the reading was done, the user placed the gauge in the back of his pickup truck and proceeded to the construction yard. Once he arrived at the yard, he saw that his truck tailgate was down and the gauge was missing. The gauge was not in its shipping container. The user and his co-worker doubled back in search of the gauge but did not find it. When the RSO arrived, another employee told him that he saw someone stopping along the highway to pick up what appeared to be the gauge and then driving off. At that time, the employee was unaware a gauge was missing so he didn't pay much attention to the vehicle.

The gauge is identified as a Troxler Electronics Laboratories Model # 3430, Serial # 32506. It contains 8 mCi of Cs-137 and 40 mCi of Am-241.

The RSO notified the West Virginia State Police, the local newspaper and the regional television station. The licensee is considering offering a reward for the return of the gauge.


* * * UPDATE AT 2244 EDT ON 5/15/13 FROM THE PENNSYLVANIA DEPARTMENT OF ENVIRONMENTAL PROTECTION TO SNYDER * * *

The gauge has been recovered and is now in the possession of the licensee. Notified R1DO (Schroeder), ILTAB (Hahn), and FSME Events Resource (E-Mail).


THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

PART 21 REPORT - FUEL INJECTORS FAILED PRESSURE TEST

The following is a summary of information received via fax:

"Engine Systems Inc. (ESI) began a 10CFR21 evaluation on 02/19/13 upon pressure leakage testing of three (3) fuel injectors, part number 40084720 (s/n 11K23136, 12K20318 & 12K20385), that were returned by TVA-Browns Ferry because they failed a pressure test at the site prior to installation in the engine. Another fuel injector was later returned by TVA (s/n 12K20330) for the same reason. On 3/11/13, ESI received a fuel injector (s/n 12H23003) from First Energy-Davis Besse because the injector failed their on-site pressure leakage test. The pressure test specifies applying 2000 psi to the fuel injector and verifying the pressure does not fall below 1500 psi after 30 seconds.

"TVA has been working with ESI to evaluate the reported deviation. ESI has also been working with EMD and EMD's fuel injector supplier to determine the cause of the injector leakage. All parties involved were not able to complete the deviation evaluation within the 60 day time period specified in 10CFR Part 21; therefore, TVA issued an interim report to the NRC about this issue on March 22, 2013 [NRC EN No. 48844]. This report is a follow-up to TVA's interim report.

"This evaluation was concluded on 05/02/13 and it was determined that this issue is a reportable defect as defined by 10CFR Part 21. The fuel injector pressure leakage has been attributed to debris that entered the injectors during assembly of the filter elements into the injector body at the manufacturer. A leaking or otherwise improperly functioning fuel injector could affect the load carrying capability of the diesel engine. Fuel dilution of the engine lubricating oil could also occur as a result of a leaking fuel injector. Either of these conditions could impact the operability of the diesel engine and thereby prevent the diesel generator from performing its safety related function."

The following licensees may potentially be affected: FP&L-St. Lucie, Energy Northwest-Columbia, Nextera-Point Beach, Exelon-Dresden, TVA-Browns Ferry, First Energy-Davis Besse, Dominion Va. Power-Surry, Entergy-ANO, and First Energy-Beaver Valley.

OUTAGE OF FT. CALHOUN STATION SIRENS FOR PLANNED MAINTENANCE

"A planned outage of all FCS [Ft. Calhoun Station] sirens will occur today at 0530 CDT to transfer in-service zone controllers. During the planned maintenance, all sirens for the Alert Notification System within the Emergency Planning Zone (EPZ) are nonfunctional. Prior notifications and coordination with Local Law Enforcement have been completed with compensatory measures established to support notification of the public in case of an actual emergency during the scheduled maintenance."

The licensee has notified the NRC Resident Inspector, Washington, Harrison, and Pottawattamie counties.

* * * UPDATE FROM SCOTT MOECK TO CHARLES TEAL ON 5/3/13 AT 0641 EDT * * *

"The maintenance has been completed and the EPZ sirens have been returned to service. Local Law Enforcement has been notified that the scheduled maintenance is complete and the primary method of alerting the public with sirens is restored."

The licensee has notified the NRC Resident Inspector.

Notified R4DO (Haire).

TEMPORARY LOSS OF BOTH TRAINS OF EMERGENCY GAS TREATMENT SYSTEM

"On May 3, 2013, at 0111 [EDT], Technical Specification Limiting Condition of Operation (TS LCO) 3.0.3 was entered due to the loss of both trains of Emergency Gas Treatment System (EGTS). The Train B EGTS had been removed from service for scheduled maintenance and at 0111 the Train A auxiliary air dryer stopped functioning. On May 3, 2013, at 0155, Train B EGTS was restored to service and declared Operable, and TS LCO 3.0.3 was exited.

"The auxiliary air system is required to support multiple safety related systems. The auxiliary air system is the safety grade air supply for EGTS. As Train A auxiliary air was no longer Operable, and the B train EGTS system was inoperable, the safety function supported by EGTS was not available. The EGTS establishes a negative pressure in the annulus between the shield building and the steel containment vessel. Filters in the system then control the release of radioactive contaminants to the environment.

"Watts Bar Unit 1 remained in Mode 1 at 100% power. No reactivity was added to the plant.

"This event is reportable under 10 CFR 50.72(b)(3)(v)(C) and (D) as a condition that could have prevented the fulfillment of a safety function.

"The NRC Resident Inspector has been notified."

INTERIM PART 21 REPORT OF POTENTIAL DEFECT IN A RELIEF VALVE BELLOWS

The following was excerpted from a fax:

(ii) Identification of the basic component supplied for such facility or such activity within the United States which may fail to comply or contains a potential defect.

Target Rock P/N: 303480-1, Bellows, Manufactured by Target Rock.

(iii) Identification of the firm supplying the basic component which fails to comply or contains a defect.

Target Rock, Business Unit of Curtiss-Wright Flow Control Corporation
1966E Broadhollow Road
East Farmingdale, NY 11735

(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.

During as-found steam testing on March 5, 2013 of a Pilgrim Main Steam Safety Relief Valve (MS-SRV) (TR Model 09J-001, valve assembly S/N 5, pilot assembly S/N 23, bellows PIN 303480-1 S/N 607) a loud pop was heard and as-found testing was secured. Subsequently, the pilot assembly was removed from the valve assembly and subjected to a leak test and would not hold pressure. The pilot assembly was disassembled and a visual inspection of the P/N 303480-1 bellows convolutions revealed a through wall failure in one of the convolutions. It is noted the steam testing was performed at an offsite test facility and the valve did not fail installed in the plant.

The bellows acts as a pressure sensor responsible for initiating the opening of the MS-SRV at set pressure. Failure of the bellows does not directly impact the integrity of the Reactor Coolant System (RCS) pressure boundary, which is maintained by the bonnet assembly that surrounds it, but does impair the ability of the MS-SRV to provide over-pressure protection of the RCS. This technology has an extensive history of reliability in nuclear power systems and has been used in Commercial Nuclear Power Plants (NPPs) since the 1970s. This is the first reported incident regarding a thru wall bellows failure.

Target Rock initiated a comprehensive root cause evaluation pursuing several areas of investigation. In parallel, Entergy is conducting an independent investigation and we are cooperating with them. A complete review of our paperwork confirms all manufacturing procedures and processes were performed in accordance with all specified requirements. This includes:

- Raw material analysis
- Dimensional inspections
- Cleaning
- Heat Treatment
- Manufacturing processes
- Testing
- Review of design stresses

Preliminary metallurgical analysis of the failed bellows indicates cracks forming in an inter-granular manner as would be expected from Inter Granular Stress Corrosion Cracks (IGSCC) originating at pit like location on the interior pressurized surface. The source of this cracking is the focus of on going investigations. Target Rock has also visually inspected two other bellows of the same part number, one manufactured from the same material lot and another manufactured from an earlier material lot. Both of these bellows were installed in valves steam tested at Target Rock. One of these valves bellows was also full flow tested at Wyle Labs. Neither of these additional bellows contained pit-like locations and may indicate this potential failure mechanism is an isolated incident. However, to date, neither Target Rock nor Pilgrim can draw final conclusions with the information collected and analyzed.

The mode of failure has not been determined; however, in order to address the potential for a common mode failure, Target Rock is continuing metallurgical testing of the failed bellows and the two other bellows with the same part number. Based on these results, it is likely we will need to evaluate bellows that have been installed in other NPP as they become available.

(v) The date on which the information of such defect or failure to comply was obtained.

The as-found steam test and identification of the potential defect occurred on March 5, 2013.

(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.

The following plants are running with bellows P/N 303480-1 installed: Limerick 1 & 2, Pilgrim, and J.A. Fitzpatrick.

(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.

The root cause of the potential defect is not yet known as of the date of this report. Therefore, no specific corrective actions have been initiated. Target Rock Corrective Action Request CAR 13-013 will document the corrective actions when they are determined. This determination will be based on further mechanical and material evaluations. TR anticipates completing these evaluations within 45 days; however, in the event the evaluations are not completed, TR will forward another interim report within 45 days.

(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.

Target Rock will recommend that the end user perform a detailed visual inspection of the interior convolutions of installed bellows P/N 303480-1 at the next opportunity to determine if any areas of pitting or cracking exist on the interior walls of the bellows. This is a difficult inspection to perform due to the following: internal geometry of the convolutions, a trained inspector is required and specific inspection technology is needed to yield reliable results.

* * * UPDATE FROM JOHN DEBONIS TO HOWIE CROUCH VIA EMAIL AT 1109 EDT ON 6/17/13 * * *

The following are excerpts from an email sent by Target Rock, a business unit of Curtiss-Wright Flow Control Corporation:

Our [Target Rock] investigation indicates the bellows failed due to in-situ hydrogen embrittlement and this hydrogen embrittlement may have been promoted by inadequate cleaning of the bellows. The inadequate cleaning may have induced formation of surface pits during heat treatment providing for localized concentration of hydrogen.

Based on these results, we [Target Rock] are notifying end users with the P/N 303480-1 bellows in service (listed below) to perform field inspections at the next available opportunity. Note, the ASME Code requires these valves to be as-found tested at a maximum 5-year interval. A procedure to inspect the bellows will be forwarded to the applicable plants in parallel with this notification.

In addition to this inspection Target Rock recommends, as a preventive measure, the P/N 303480-1 bellows be replaced with a P/N 300083-1 or -3 bellows, as applicable, to negate the effects of hydrogen embrittlement. Finite element analysis of the P/N 300083-1 or -3 bellows shows significantly lower stresses at plant operating conditions. The lower stress levels provide an incremental increase in safety margin so that hydrogen embrittlement need not be considered a significant degradation mechanism.

Target Rock is implementing corrective actions to improve in-process cleaning and inspection, with emphasis on cleaning prior to heat treatment, to address this root cause.

The corrective actions will be completed within 60 days of this letter.

Should you have any questions regarding this matter, please contact Steven Pauly, Vice President Energy Products at (631) 293-3800, ext. 4640.

Limerick 1 & 2 has 28, Pilgrim has 4, and FitzPatrick has 3 of these items.

Notified NRR Part 21 Group (email), R1DO (Rogge) and R3DO (Daley) via email.

LOSS OF MAIN CONTROL ROOM ANNUNCIATORS DURING PLANNED SPDS MAINTENANCE

"On May 3, 2013 at 0542 [EDT] hours with the reactor in Cold Shutdown and Reactor Mode Switch in Refuel, the Safety Parameter Display System (SPDS) was removed from service as part of a preplanned activity in order to repair the associated 120VAC instrument power supply transfer switching scheme. The reactor cavity is flooded the fuel pool gates are removed and refueling activities are in progress. Station risk is green and all key safety functions are green as well. It is anticipated the repair will be completed in approximately ten hours.

"Following the planned de-energization, it was determined that an apparent equipment failure resulted in the loss of main control room annunciator system. The appropriate abnormal procedure was entered and compensatory actions including periodic monitoring of bus voltages and field annunciator panels implemented for systems in service at the time of the loss. The annunciator system was restored on May 3, 2013 at 0640 hours.

"This USNRC Senior Resident Inspector has been notified.

"This event has no impact on the health and safety of the public."

The licensee will notify the Commonwealth of Massachusetts.

PART 21 REPORT - INSUFFICIENT PROCESS CONTROL ON PUMP IMPELLER

The following is a summary of information received via fax:

"In January 2013, Curtiss-Wright Electro Mechanical Corporation completed final testing on AP1000 Reactor Coolant Pump (RCP) Serial Number 9, part number 6D70795G05, Revision 8, which contained a sand cast impeller (S/N 3021) cast by Wollaston Alloys of Braintree, MA. When it was disassembled for inspection it was discovered that a piece of an impeller blade approximately 3 inches by 2 1/2 inches had separated from the main impeller casting. The separated piece was the leading edge of one blade, and it was subsequently recovered intact from the pump test loop.

"This incident was investigated as a significant condition adverse to quality with the potential to create a substantial safety hazard; but, was deemed not a reportable incident since all cast impellers were either:
1) in CW-EMD control, or
2) exported to customers in the People's Republic of China.

"Our customers (Westinghouse Electric Company and the Chinese customers and regulatory authorities) were kept informed as the investigation progressed and root cause was identified.

"The physical cause of the failure is most likely due to a flaw present in both the cast material and weld overlay applied to the impeller blade. The original flaw was most likely a consequence of tensile overload failure due to cooling stresses introduced by the welding process. Subsequent weld repairs were insufficient in remediating the original flaw, which went undetected by NDT methods. Ultimately, AP1000 RCP Serial Number 3021 failed by high cycle fatigue followed by ductile failure.

"As a result of the above investigation, CW-EMD is concerned that the identified lack of process control at Wollaston Alloys, Inc., could result in other significant conditions adverse to quality with the potential to create a substantial safety hazard.

"Because of the nature of the issue, CW-EMD is unable to complete a full extent of condition investigation, and is reporting this issue to the Commission to ensure full awareness within the industry.

"Name and address of the individual or individuals informing the Commission:

James A. Drake, General Manager
Curtiss-Wright Electro-Mechanical Corporation
1000 Wright Way
Cheswick, Pa 15024"

* * * UPDATE FROM STEVE GRIEF TO JOHN SHOEMAKER ON 5/17/13 AT 1549 EDT * * *

Subject: Report of Potential Substantial Safety Hazard in accordance with Title 10 Code of Federal Regulations, Part 21.

Wollaston Alloys is submitting this interim report as a result of product concerns discovered by Curtiss Wright EMD during the investigation of an impeller blade failure occurring during testing as noted in Curtiss Wright EMD's notification to the NRC dated May 3, 2013. Wollaston is requesting an additional 30 days to identify any current or previous orders where 10 CFR 21 is invoked and to determine if there is evidence that a condition exists that could create a substantial safety hazard.

Notified R1DO (Schroeder), R2DO (Bartley), R3DO (Riemer), R4DO (Walker), and Part 21 Reactors via email.

* * * UPDATE FROM STEPHEN GRIEF TO PETE SNYDER ON 6/17/13 AT 1752 EDT * * *

Subject: Report of Potential Substantial Safety Hazard in accordance with Title 10 Code of Federal Regulations, Part 21.

"Wollaston Alloys, Inc. is submitting this report as an update to the interim report submitted on May 17, 2013 resulting from product concerns identified by Curtiss Wright EMD during the investigation of an impeller blade failure as noted in Curtiss Wright EMD's notification to the Nuclear Regulatory Commission (NRC), dated May 3, 2013. This investigation did not include the Curtiss Wright impeller failure since it is not considered a reportable incident, but addresses the identified concerns with regards to other products supplied to domestic users. The previously submitted interim report requested an additional 30 days to identify basic components supplied under the requirements of 10 CFR Part 21 and to determine if there is evidence that a defect or failure to comply exists.

"Name and address of the individual or individuals informing the Commission:

Stephen M. Grief, Quality Manager
Wollaston Alloys, Inc.
205 Wood Road
Braintree, MA 02184"

The complete report has been summarized as follows:

Wollaston Alloys, Inc. determined the cases in which Wollaston Alloys, Inc. supplied components to which the requirements of 10 CFR Part 21 applied. After a review of all records pertaining to those purchase orders, Wollaston Alloys, Inc. found no evidence of a defect or failure to comply.

Notified R1DO (Rogge), R2DO (Ehrhardt), R3DO (Daley), R4DO (Walker), and Part 21 Reactors via email.