Event Notification Report for October 22, 2001
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/21/2001 - 10/22/2001
EVENT NUMBERS
3842138412384133841538416
General Information or Other
Event Number: 38421
Rep Org: DRESSER-RAND
Licensee: GIMPEL
Region: 1
City: WELLSVILLE State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: GEORGE HERMANN
HQ OPS Officer: FANGIE JONES
Licensee: GIMPEL
Region: 1
City: WELLSVILLE State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: GEORGE HERMANN
HQ OPS Officer: FANGIE JONES
Notification Date: 10/24/2001
Notification Time: 05:05 [ET]
Event Date: 10/22/2001
Event Time: 00:00 [EDT]
Last Update Date: 10/24/2001
Notification Time: 05:05 [ET]
Event Date: 10/22/2001
Event Time: 00:00 [EDT]
Last Update Date: 10/24/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
LAWRENCE DOERFLEIN (R1)
EDWARD MCALPINE (R2)
BRENT CLAYTON (R3)
WILLIAM JOHNSON (R4)
VERN HODGE (FAX) (NRR)
LAWRENCE DOERFLEIN (R1)
EDWARD MCALPINE (R2)
BRENT CLAYTON (R3)
WILLIAM JOHNSON (R4)
VERN HODGE (FAX) (NRR)
10 CFR PART 21 REPORT CONCERNING TERRY TURBINE TRIP & THROTTLE VALVE SCREW SPINDLE
The following is from a facsimile report:
DESCRIPTION OF DEFECT:
Material substitution of grade 1212 Steel in place of grade 1018 carbon steel specified by design.
ENGINEERING EVALUATION & RECOMMENDATIONS:
Following the failure of an installed Trip/Throttle valve screw spindle on the Catawba unit #2 AFW Pump Turbine (Terry Turbine S/N 40096A or B) on May 25, 2000, the material of the failed screw was analyzed and found to be Grade 1212 steel. Gimpel gave verbal confirmation that the screw material was incorrect (Grade 1213 and 1215 steel) at the Terry Turbine Users Group meeting on July 18, 2001 Gimpel has traced the supplied material to a single lot of approximately 50 original screw spindles manufactured in 1974, and has identified the originally affected Trip & Throttle valve serial numbers as 74-12201-01 to 74-12244-02, 78-13136-01, 78-13215-01, and 78-13091-01. Written confirmation of this defect and a listing of affected valves was received by Dresser-Rand 10/11/01.
Following this incident, additional information was received indicating that a screw spindle installed in Palo Verde Unit 1 was found cracked In 1992, and was determined to be grade 1213 steel.
Dresser-Rand tested the material of a functional screw spindle removed from an in-house test valve (Gimpel serial number 74-12243) and determined the material was grade 1212.
It is unknown whether the material substitution was a contributing factor in the failures of the screw spindles at these sites. The trip valves in question have been in operation for many years, and although the material used is less desirable in this application than the design specified material, the limited number of failures indicates that the immediate risk of continued operation is minimal. It is acknowledged however, that a substantial safety hazard may exist due to this defect in that failure of this component can result in steam isolation preventing the emergency feedwater turbine from performing its safety-related function.
Recommendations:
1) Units using Gimpel T&T valves in the serial number series listed above which may have the original Screw spindle installed should replace their screw spindles at the next maintenance opportunity. The original spindles should be destroyed.
2) It is additionally recommended that any Gimpel screw spindles in-stock or in-service which may have been manufactured in the 1974-75 timeframe be treated as suspect and be tested to confirm that the material is correct (Grade 1018 carbon steel).
A written Final Report will be submitted no later than 11/21/01.
The following is from a facsimile report:
DESCRIPTION OF DEFECT:
Material substitution of grade 1212 Steel in place of grade 1018 carbon steel specified by design.
ENGINEERING EVALUATION & RECOMMENDATIONS:
Following the failure of an installed Trip/Throttle valve screw spindle on the Catawba unit #2 AFW Pump Turbine (Terry Turbine S/N 40096A or B) on May 25, 2000, the material of the failed screw was analyzed and found to be Grade 1212 steel. Gimpel gave verbal confirmation that the screw material was incorrect (Grade 1213 and 1215 steel) at the Terry Turbine Users Group meeting on July 18, 2001 Gimpel has traced the supplied material to a single lot of approximately 50 original screw spindles manufactured in 1974, and has identified the originally affected Trip & Throttle valve serial numbers as 74-12201-01 to 74-12244-02, 78-13136-01, 78-13215-01, and 78-13091-01. Written confirmation of this defect and a listing of affected valves was received by Dresser-Rand 10/11/01.
Following this incident, additional information was received indicating that a screw spindle installed in Palo Verde Unit 1 was found cracked In 1992, and was determined to be grade 1213 steel.
Dresser-Rand tested the material of a functional screw spindle removed from an in-house test valve (Gimpel serial number 74-12243) and determined the material was grade 1212.
It is unknown whether the material substitution was a contributing factor in the failures of the screw spindles at these sites. The trip valves in question have been in operation for many years, and although the material used is less desirable in this application than the design specified material, the limited number of failures indicates that the immediate risk of continued operation is minimal. It is acknowledged however, that a substantial safety hazard may exist due to this defect in that failure of this component can result in steam isolation preventing the emergency feedwater turbine from performing its safety-related function.
Recommendations:
1) Units using Gimpel T&T valves in the serial number series listed above which may have the original Screw spindle installed should replace their screw spindles at the next maintenance opportunity. The original spindles should be destroyed.
2) It is additionally recommended that any Gimpel screw spindles in-stock or in-service which may have been manufactured in the 1974-75 timeframe be treated as suspect and be tested to confirm that the material is correct (Grade 1018 carbon steel).
A written Final Report will be submitted no later than 11/21/01.
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital
Event Number: 38412
Rep Org: CABELL HUNTINGTON HOSPITAL
Licensee: CABELL HUNTINGTON HOSPITAL
Region: 2
City: HUNTINGTON State: WV
County:
License #: 47-00404-02
Agreement: N
Docket:
NRC Notified By: FRED PEATROSS
HQ OPS Officer: STEVE SANDIN
Licensee: CABELL HUNTINGTON HOSPITAL
Region: 2
City: HUNTINGTON State: WV
County:
License #: 47-00404-02
Agreement: N
Docket:
NRC Notified By: FRED PEATROSS
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/22/2001
Notification Time: 08:16 [ET]
Event Date: 10/22/2001
Event Time: 00:00 [EDT]
Last Update Date: 10/22/2001
Notification Time: 08:16 [ET]
Event Date: 10/22/2001
Event Time: 00:00 [EDT]
Last Update Date: 10/22/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
35.33 - MED MISADMINISTRATION
10 CFR Section:
35.33 - MED MISADMINISTRATION
Person (Organization):
R2 IRC TEAM MANAGER (R2)
PAT RATHBUN (NMSS)
R2 IRC TEAM MANAGER (R2)
PAT RATHBUN (NMSS)
MEDICAL MISADMINISTRATION INVOLVING A DIAGNOSTIC GIVEN TO THE WRONG PATIENT
At approximately 1400EDT on Friday,10/19/01, a 12.2 millicurie Tc-99m cardiolite dose for a resting cardiolite study was administered to a 70-year old female patient. The technologist administering the diagnostic dose relied on oral confirmation as to the patient's identity since the patient's wristband was missing. The patient responded "right" several times when asked if she was patient "x." When she was taken to the treadmill area she identified herself as patient "y." The Director of Nuclear Medicine was informed this morning when he returned to work of the error and has informed the referring physician. The patient will be notified later today. There are no adverse effects anticipated from this incident. Corrective action includes verification of identity using wristbands.
* * * UPDATE 1205EDT ON 10/22/01 FROM PEATROSS TO S. SANDIN * * *
The licensee is retracting this report in that it does not meet the criteria for reporting as a misadministration. Notified R2IRC and NMSS(Frant).
At approximately 1400EDT on Friday,10/19/01, a 12.2 millicurie Tc-99m cardiolite dose for a resting cardiolite study was administered to a 70-year old female patient. The technologist administering the diagnostic dose relied on oral confirmation as to the patient's identity since the patient's wristband was missing. The patient responded "right" several times when asked if she was patient "x." When she was taken to the treadmill area she identified herself as patient "y." The Director of Nuclear Medicine was informed this morning when he returned to work of the error and has informed the referring physician. The patient will be notified later today. There are no adverse effects anticipated from this incident. Corrective action includes verification of identity using wristbands.
* * * UPDATE 1205EDT ON 10/22/01 FROM PEATROSS TO S. SANDIN * * *
The licensee is retracting this report in that it does not meet the criteria for reporting as a misadministration. Notified R2IRC and NMSS(Frant).
Other Nuclear Material
Event Number: 38413
Rep Org: UNDERWOOD ENGINEERING
Licensee: UNDERWOOD ENGINEERING
Region: 1
City: MT. EPHRAIM State: NJ
County:
License #: 29-23425-01
Agreement: N
Docket:
NRC Notified By: CRIS OSLUND
HQ OPS Officer: STEVE SANDIN
Licensee: UNDERWOOD ENGINEERING
Region: 1
City: MT. EPHRAIM State: NJ
County:
License #: 29-23425-01
Agreement: N
Docket:
NRC Notified By: CRIS OSLUND
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/22/2001
Notification Time: 11:10 [ET]
Event Date: 10/22/2001
Event Time: 07:45 [EDT]
Last Update Date: 10/22/2001
Notification Time: 11:10 [ET]
Event Date: 10/22/2001
Event Time: 07:45 [EDT]
Last Update Date: 10/22/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
R1 IRC TEAM MANAGER (R1)
SUSAN FRANT (NMSS)
R1 IRC TEAM MANAGER (R1)
SUSAN FRANT (NMSS)
REPORT INVOLVING A STOLEN TROXLER GAUGE
A Troxler Gauge, Model 3430 S/N 31156, containing 8 millicuries Cs-137 and 40 millicuries Am-241/Be was stolen from the bed of a company truck at a construction site on Ruan Street, off of Frankfurt, in the northeast District of Philadelphia, PA. The employee parked the truck at approximately 0730EDT and discovered both the gauge and it's case missing at 0745EDT when he returned. The device was properly stowed for transport with indication of forcible removal. The licensee notified both Troxler and the Philadelphia Police Department.
A Troxler Gauge, Model 3430 S/N 31156, containing 8 millicuries Cs-137 and 40 millicuries Am-241/Be was stolen from the bed of a company truck at a construction site on Ruan Street, off of Frankfurt, in the northeast District of Philadelphia, PA. The employee parked the truck at approximately 0730EDT and discovered both the gauge and it's case missing at 0745EDT when he returned. The device was properly stowed for transport with indication of forcible removal. The licensee notified both Troxler and the Philadelphia Police Department.
General Information or Other
Event Number: 38415
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: BOWSER-MORNER, INC
Region: 3
City: TOLEDO State: OH
County:
License #: OH-3121058000
Agreement: Y
Docket:
NRC Notified By: SNEE
HQ OPS Officer: CHAUNCEY GOULD
Licensee: BOWSER-MORNER, INC
Region: 3
City: TOLEDO State: OH
County:
License #: OH-3121058000
Agreement: Y
Docket:
NRC Notified By: SNEE
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 10/22/2001
Notification Time: 12:02 [ET]
Event Date: 10/22/2001
Event Time: 00:00 [EDT]
Last Update Date: 09/16/2003
Notification Time: 12:02 [ET]
Event Date: 10/22/2001
Event Time: 00:00 [EDT]
Last Update Date: 09/16/2003
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
BRENT CLAYTON (R3)
SUSAN FRANT (NMSS)
BRENT CLAYTON (R3)
SUSAN FRANT (NMSS)
THE STATE REPORTED A STOLEN TROXLER MOISTURE/DENSITY GAUGE FROM ONE OF THEIR LICENSEES
Bowser-Morner, Inc (State of Ohio licensee) reported the theft of a Troxler moisture/density gauge (model 3430, serial 31270) containing a 1.44 GBq (38.9 mCi Am-Be sealed source and a 0.28 GBq (7.7 mCi) Cs-137 sealed source. The gauge was stolen from the back of a truck parked at an employee's residence in Toledo, Ohio. The gauge was stolen in the time period between the evening of 10/20/01 and the morning of 10/22/01. The handle of the gauge case had been pried off, leaving the handle and locked chain. The licensee notified the Toledo and Oregon, Ohio police departments.
* * * UPDATE ON 09/16/2003 AT 1110 EDT BY MIKE SNEE TO MACKINNON * * *
On 09/12/2003, the Troxler moisture density gauge was found in an abandoned building in Toledo, Ohio by the police. It has been returned to the licensee. The gauge was still inside the case and locked. The licensee will perform a leak test of the gauge then will start using it again. Mike Snee is with the Ohio Bureau of Radiation Protection. R3DO (Lanksbury) & NMSS EO (Doug Broaddus).
Bowser-Morner, Inc (State of Ohio licensee) reported the theft of a Troxler moisture/density gauge (model 3430, serial 31270) containing a 1.44 GBq (38.9 mCi Am-Be sealed source and a 0.28 GBq (7.7 mCi) Cs-137 sealed source. The gauge was stolen from the back of a truck parked at an employee's residence in Toledo, Ohio. The gauge was stolen in the time period between the evening of 10/20/01 and the morning of 10/22/01. The handle of the gauge case had been pried off, leaving the handle and locked chain. The licensee notified the Toledo and Oregon, Ohio police departments.
* * * UPDATE ON 09/16/2003 AT 1110 EDT BY MIKE SNEE TO MACKINNON * * *
On 09/12/2003, the Troxler moisture density gauge was found in an abandoned building in Toledo, Ohio by the police. It has been returned to the licensee. The gauge was still inside the case and locked. The licensee will perform a leak test of the gauge then will start using it again. Mike Snee is with the Ohio Bureau of Radiation Protection. R3DO (Lanksbury) & NMSS EO (Doug Broaddus).
Power Reactor
Event Number: 38416
Facility: THREE MILE ISLAND
Region: 1 State: PA
Unit: [1] [] []
RX Type: [1] B&W-L-LP,[2] B&W-L-LP
NRC Notified By: MILLER
HQ OPS Officer: CHAUNCEY GOULD
Region: 1 State: PA
Unit: [1] [] []
RX Type: [1] B&W-L-LP,[2] B&W-L-LP
NRC Notified By: MILLER
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 10/22/2001
Notification Time: 18:48 [ET]
Event Date: 10/22/2001
Event Time: 13:57 [EDT]
Last Update Date: 10/24/2001
Notification Time: 18:48 [ET]
Event Date: 10/22/2001
Event Time: 13:57 [EDT]
Last Update Date: 10/24/2001
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
R1 IRC TEAM MANAGER (R1)
WILLIAM BECKNER (NRR)
R1 IRC TEAM MANAGER (R1)
WILLIAM BECKNER (NRR)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | N | 0 | Refueling | 0 | Refueling |
DISCOVERY OF A THROUGH-WALL LEAK AROUND 3 (THREE) CONTROL ROD DRIVE MECHANISM NOZZLES (REACTOR COOLANT SYSTEM PRESSURE BOUNDARY LEAK)
On October 11 and 12, 2001, following shutdown for a scheduled refueling outage, Three Mile Island Unit 1 (TMI-1) performed a visual inspection of the Reactor Vessel (RV) Control Rod Drive Mechanism (CRDM) nozzles per NRC Bulletin 2001-01. The inspection revealed evidence of boric acid buildup around 12 CRDM nozzles. No other CRDM nozzles showed similar boron buildup. After the RV head was removed and placed on the storage stand, additional inspections were performed. At approximately 1357 on October 22, 2001, Engineering evaluation of the visual inspection, Liquid Penetrant Test (PT) data and Ultrasonic Test (UT) data identified through-wall indications on three CRDM nozzles. This engineering evaluation concluded that the visual indications around CRDMs 44, 35, and 37 indicate a Reactor Coolant System (RCS) pressure boundary leak. The inspection is not yet completed, thus additional CRDM through-wall indications may be identified. This condition is consistent with industry experience with Primary Water Stress Corrosion Cracking (PWSCC) in similar components that have been evaluated as part of the NRC Generic Letter 97-01 and NRC Bulletin 2001-01. Additional nozzles may be examined by UT in accordance with TMl-1's response to NRC Bulletin 2001-01. This condition did not pose a significant safety risk during plant operation. TMl-1 plans to perform CRDM nozzle repairs during the current refueling outage. Since the condition resulted in leakage through the RCS pressure boundary, it is being reported as a non-emergency [8-hour] report in accordance with 10 CFR 50.72(b)(3) (ii)(A) and 50.73(a)(2)(ii) (A).
The NRC resident inspector has been notified.
* * * UPDATED AT 1015 EDT ON 10/24/01 BY ADAM MILLER TO FANGIE JONES * * *
Two additional CRDMs (29 and 64) indicate a RCS pressure boundary leak. This brings the total to 5 CRDM nozzles showing through-wall leaks. The licensee notified the NRC Resident Inspector.
The R1DO (John Kinneman) and the NRR EO (William Beckner) have been informed.
On October 11 and 12, 2001, following shutdown for a scheduled refueling outage, Three Mile Island Unit 1 (TMI-1) performed a visual inspection of the Reactor Vessel (RV) Control Rod Drive Mechanism (CRDM) nozzles per NRC Bulletin 2001-01. The inspection revealed evidence of boric acid buildup around 12 CRDM nozzles. No other CRDM nozzles showed similar boron buildup. After the RV head was removed and placed on the storage stand, additional inspections were performed. At approximately 1357 on October 22, 2001, Engineering evaluation of the visual inspection, Liquid Penetrant Test (PT) data and Ultrasonic Test (UT) data identified through-wall indications on three CRDM nozzles. This engineering evaluation concluded that the visual indications around CRDMs 44, 35, and 37 indicate a Reactor Coolant System (RCS) pressure boundary leak. The inspection is not yet completed, thus additional CRDM through-wall indications may be identified. This condition is consistent with industry experience with Primary Water Stress Corrosion Cracking (PWSCC) in similar components that have been evaluated as part of the NRC Generic Letter 97-01 and NRC Bulletin 2001-01. Additional nozzles may be examined by UT in accordance with TMl-1's response to NRC Bulletin 2001-01. This condition did not pose a significant safety risk during plant operation. TMl-1 plans to perform CRDM nozzle repairs during the current refueling outage. Since the condition resulted in leakage through the RCS pressure boundary, it is being reported as a non-emergency [8-hour] report in accordance with 10 CFR 50.72(b)(3) (ii)(A) and 50.73(a)(2)(ii) (A).
The NRC resident inspector has been notified.
* * * UPDATED AT 1015 EDT ON 10/24/01 BY ADAM MILLER TO FANGIE JONES * * *
Two additional CRDMs (29 and 64) indicate a RCS pressure boundary leak. This brings the total to 5 CRDM nozzles showing through-wall leaks. The licensee notified the NRC Resident Inspector.
The R1DO (John Kinneman) and the NRR EO (William Beckner) have been informed.