Event Notification Report for February 20, 2019

PART 21 REPORT - FLOWSERVE VALVE ASSIST SPRINGS MAY PREVENT FULL CLOSURE

The following report was received via fax:

"Description: GE BWXT, acting on behalf of Ontario Power sent five valves back to the Flowserve facility for evaluation of the spring which could spread apart when the flapper rotates open and wedge between the valve body and flapper, creating the potential for the valve flapper to stick open.

"Evaluation: Shop inspections of the returned valves confirmed the potential for the spring legs to rotate outwards and potentially wedge between the flapper and seat retainer. Of the five valves evaluated, two of the valves had the spring legs rotate outward and after repeated cycles got caught between the flapper and disc; on one of the instances the spring legs prevented full closure of the flapper.

"If the valves have a safety-related function to isolate flow and must transfer closed, then the springs could prevent the valve from performing its safety related function.

"The evaluation determined the cause is an inadequate spring design which allows the spring to deflect and permit the legs to move outward.

"Extent of Condition: In discussion with the customer, it is believed the problem did not exist with valves originally supplied from the Worcester, Scarborough Canada facility; although this cannot be confirmed by Flowserve. It is believed the extent of condition resides with valves and replacement springs supplied from the Flowserve Raleigh, NC facility when the product line was transferred and the spring vendors changed; even though it has been confirmed that the springs supplied out of the Raleigh, NC facility comply with the product drawing requirements. The springs were first sold in valve assemblies or as replacement parts from the Raleigh facility starting in 2008.

"Valve Scope: The scope of impacted valves is the Worcester series 44 swing check valves. (Please note Worcester also has a series 44 three piece ball valve, which is not in the scope.} The Raleigh facility has supplied parts or valves for four Worcester series 44 swing check valves assemblies which use these springs. The drawings numbers for these valve assemblies are listed below:

Drawing Valve Size Customer
KN44-0590 1.5 X 1 X 1.5 Bruce Power, GE BWXT & Ontario Power
KN44-0630 2 Comanche Peak
14-107362-001 1.5 X 1 X 1.5 GE BWXT
16-118733-001 1.5 X 1 X 1.5 GE BWXT

"Corrective Actions:
1) Owner's may remove the springs. The valves will check-off and seal under low pressure conditions without the assistance of the spring; this was demonstrated in shop tests using tap water pressure (approximately 60 psig) and will initiate closure when full open without the assistance of the spring.
2) Flowserve is evaluating alternate spring designs along with the possibility of adding guides to prevent the undesired spring movement. Any new design will be proof tested.

"Respectfully submitted,
Mark Rain, PE
Product/Design Engineering Specialist
Flowserve Corporation
Flow Control Division
1900 S. Saunders St.
Raleigh, NC 27603"

REPORT OF LOSS OF NI-63 SOURCES USED IN IMPROVED CHEMICAL AGENT MONITORS

The following was received from the licensee via e-mail:

"The concerned radioactive material is part of an Army Chemical Detection Equipment (CDE) and is called an Improved Chemical Agent Monitor (ICAM) NSN [National Stock Number] 6665-01-357-8502 and Chemical Agent Monitor (CAM), NSN 6665-01-199-4153. Each ICAM and CAM contains 10 mCi of Ni-63. The items with the radioactive material are under US Army NRC License 21-32838-01 issued to the Tank-Automotive and Armaments Command (TACOM). TACOM is located in Warren, MI.

"The reporting was based on 10 CFR 20.2201(a)(ii) (Reports of Theft or Loss of Licensed Material). Licensed material in a quantity greater than 10 times the quantity specified in Appendix C. The quantity specified in Appendix C is 100 microCi. One ICAM/CAM containing 10 mCi is 10,000 microCi. [The Radiation Safety Officer (RSO)] had reported nine CDE, but after confirming the serial numbers, we determined that one of the CDE (serial number 11769) was under another NRC license 19-10306-01 issued to the US Army Edgewood Chemical Biological Center (ECBC) located in Aberdeen Proving Ground (APG), Maryland. This report is for eight CDE under TACOM's NRC license. We have six ICAMs and two CAMs that are lost for a total of 80,000 microCi. The serial numbers for the ICAMs are Z47-M-13972, Z47-M-13526, Z47-M-01859, Z47-M-15832, Z47-M-21980 and Z47-M-18759. The serial numbers for the CAMs are Z16-M-01075 and Z16-M-01025.

"The ICAMs/CAMs are not known to leak and do not have a leak test requirement. The Ni-63 is inside the ICAM/CAM.

"[The RSO] was notified via e-mail on February 19, 2019, at 1545 EST, by the Army Rad waste agency (Joint Munitions Command [JMC] located in Rock Island, IL) of the following:

"'A package containing nine each CDE was in route from APG, Maryland to Pine Bluff Arsenal (PBA), Alabama via [a Common Carrier] and was lost in the possession of [the Common Carrier]. The CDE were being sent for demilitarization and eventual disposal of the Ni-63. The subject package was dropped off at [the Common Carrier] in Baltimore, MD on 26 Nov 2018. The tracking system showing the package as 'In [Common Carrier] Possession'.'

"Prior to the notification on February 19, 2019, JMC called PBA shipping and receiving. PBA personnel indicated that subject package was not received at their location. Also, APG personnel traveled to the [Common Carrier] facility where the items were dropped off. Personnel confirmed that the package was not at that facility.

"As of February 19, 2019, JMC indicated that [the Common Carrier] has not formally issued the a statement of loss, but that JMC will continue to track this for APG. It was a Local Project for JMC with ID number of APG 2018-001.

"On February 20, 2019, at 0847 EST, the [RSO] called [the Common Carrier] with the tracking number. [The RSO] spoke to [an individual] who indicated that a case was assigned to the shipment and a claim was put in. [The RSO] was put in contact with the Trace Department, and was then told that the shipment was considered lost. Shipments after 14 days are considered lost."

This event is related to NRC Event Number 53888.

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

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following report was received from the State of California via email:

"On February 20, 2019, the RSO [Radiation Safety Officer] of G3SoilWorks, Inc. contacted the California Office of Emergency Services about a moisture density gauge that was stolen from the operators vehicle at an apartment complex [in] Newport Beach, CA. The gauge was a CPN MC-3, Serial Number M390705215 (10 mCi Cs-137, 50 mCi Am:Be-241). The incident was reported to the Newport Beach Police Department. The gauge has not been found at this time."

California 5010 number: 022019

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

PATIENT RECEIVED DOSE GREATER THAN PRESCRIBED DOSE

Summary via phone call:

This is a notification of a medical event that occurred on February 20, 2019 at 1205 MDT, in which 81 microCi of Radium-223 (Xofigo) was administered intravenously to the patient for metastatic prostate cancer that had spread to the bone. The original written directive from the patient's physician was for 56 microCi of Radium-223, however the pharmacy label was written for 81 microCi. The medical event was discovered during the Radiation Safety Officer's internal audit with the conclusion that the 81 microCi was the correct dosage at the intended organ. No adverse effect is expected for the patient.


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.