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Event Notification Report for March 3, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/28/2014 - 03/03/2014

** EVENT NUMBERS **


48745 49847 49849 49862 49864 49865 49866

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Part 21 Event Number: 48745
Rep Org: DRESSER-RAND
Licensee: DRESSER-RAND
Region: 1
City: WELLSVILLE State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: D. G. MARTIN
HQ OPS Officer: DONALD NORWOOD
Notification Date: 02/12/2013
Notification Time: 16:52 [ET]
Event Date: 02/01/2013
Event Time: [EST]
Last Update Date: 02/28/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
BOB HAGAR (R4DO)
PART 21 RX GROUP (E-MA)

Event Text

PART 21 REPORT - DEFECTIVE RAW MATERIAL USED TO MANUFACTURE VALVE STEMS

Dresser-Rand is reporting that one of its vendors supplied annealed material instead of the specified heat-treated material. Dresser-Rand used the defective raw material to manufacture valve stems for Terry Type Emergency Feedwater pump drive turbines. Dresser-Rand has verified that the annealed material is not acceptable for the finished product.

The two customers (Wolf Creek Nuclear Plant and Callaway Nuclear Plant) that received the affected parts have been notified of this issue and have confirmed that the components in question are not in service at their facilities. The remaining material and affected parts have been quarantined at the Dresser-Rand plant in Wellsville, NY.

All questions should be addressed to:
Joe Menichino
Manager, Navy/Nuclear Product Engineering
37 Coat Street
Wellsville, New York, 14895
Phone: (585) 596-3406
jamenichino@dresser-rand.com

* * * UPDATE FROM JOE MENICHINO TO CHARLES TEAL ON 3/11/13 AT 1614 EDT * * *

The following was excerpted from a facsimile received from Dresser-Rand:

"DESCRIPTION OF DEFECT OR NON-COMPLIANCE

"Specific designs of steam turbine control valve stems are made from heat treated ASM 5663M Inconel Bar raw material. Certifications associated with heat numbers of certain inventory of this material indicate that the material vendor incorrectly supplied material in an annealed condition (AMS 5662M).

"POTENTIAL SAFETY HAZARD OR NON-COMPLIANCE

"Valve stems are used to control steam turbine speed and power. The valve stems must be free to move within the guiding assembly during operation. Stems are made using materials that have the correct material properties to reduce the risk of failure. The use of inconel raw stock in an annealed condition is unacceptable for steam turbine valve stems due to the risk of unacceptable wear and strength characteristics which could lead to sticking or tensile failure in the mating guide bushings within the valve assembly.

"ADVICE TO EFFECTED CLIENT RELATED TO THIS REPORT

"For those affected sites identified, locate and return the material to Dresser-Rand immediately."

Affected facilities include Point Beach, Clinton, Wolf Creek, Cooper, Callaway, San Onofre, and Prairie Island.

Notified R1DO (Dentel), R3DO (Dickson), R4DO (Powers), and the Part 21 Group via email.

* * * UPDATE FROM ED GRANDUSKY TO CHARLES TEAL AT 1510 EST ON 2/28/14 * * *

The following was excerpted from a facsimile received from Dresser-Rand:

"DESCRIPTION OF DEFECT:

"This is an addendum to Part 21 Reports Log# 2013-008-00 and Log# 2013-008-01. Another Vendor certification has been discovered for valve stem material that indicates the annealed condition-lnconel was supplied in lieu of the heat treated that is specified.

"ENGINEERING EVALUATION & RECOMMENDATIONS:

"1- Complete review of all Vendor certification for this material to make certain no more.
Discrepant material was used in the manufacture of these stems.

"2- Identify all DR part numbers that were made using the affected heat numbers.

"3- Notify affected customers and recall non-compliant parts.

"Potential Affected Part Numbers:

"800777-001 Rev. NA
"800768-701 Rev. A
"800768-702 Rev. A
"800858-001 Rev. E
"800740-701 Rev. A
"800746-001 Rev. B
"800739-001 Rev. NA
"800743-001 Rev. A
"801061-701 Rev. A
"800741-701 Rev. B
"800744-001 Rev. NA
"800745-001 Rev. NA
"800748-001 Rev. A
"800742-001 Rev. B"

Notified R1DO (DeFrancisco), R3DO (Kunowski), R4DO (Hagar), and the Part 21 Group via email.

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Agreement State Event Number: 49847
Rep Org: MAINE RADIATION CONTROL PROGRAM
Licensee: TEXAS INSTRUMENTS, INC
Region: 1
City: SOUTH PORTLAND State: ME
County:
License #: 05851G
Agreement: Y
Docket:
NRC Notified By: TOM HILLMAN
HQ OPS Officer: DANIEL MILLS
Notification Date: 02/21/2014
Notification Time: 10:33 [ET]
Event Date: 02/13/2014
Event Time: [EST]
Last Update Date: 02/21/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TODD JACKSON (R1DO)
FSME EVENTS RESOURCE (EMAI)

This material event contains a "Less than Cat 3 " level of radioactive material.

Event Text

AGREEMENT STATE REPORT - MISSING TRITIUM EXIT SIGN

The following was received from the State of Maine via fax:

"An emergency exit sign was lost. A portion of the Texas Instruments facility at 5 Foden Road in South Portland, Maine, where emergency exit signs are in use, was in the process of being renovated by a construction contractor. The contractor removed the sign from the wall unaware that this exit sign was not an electric exit sign. The sign was removed and its location has not been identified."

Event Report ID No. ME-14-0001

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

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Agreement State Event Number: 49849
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: MASSACHUSETTS GENERAL HOSPITAL
Region: 1
City: BOSTON State: MA
County:
License #: 60-0055
Agreement: Y
Docket:
NRC Notified By: JOSHUA DAEHLER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/21/2014
Notification Time: 16:28 [ET]
Event Date: 02/19/2014
Event Time: [EST]
Last Update Date: 02/21/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TODD JACKSON (R1DO)
FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE OF Y-90 TO A PATIENT

The following information was obtained from the Commonwealth of Massachusetts via email:

"Report of medical event. A dose that differs from the prescribed dose by more than 50 rem to an organ, the liver, and the total dose delivered differs from the prescribed dose by 20% or more.

"The licensee reported to the Agency [Massachusetts Radiation Control Program] on 2/21/2014 that on 2/19/2014 licensee administered yttrium-90 SIR-Spheres to patient's left lobe of liver and that treatment was palliative in nature; that 7.2 millicuries of yttrium-90 was prescribed; and that 5.06 millicuries was administered resulting in an underdose of 29.7 percent.

"The licensee reported that the dose administered differs from the dose prescribed by more than 50 rem to the liver and that licensee will determine what the likely dose difference actually was.

"The licensee reported that during the procedure it was apparent that spheres were collecting on the tubing between the stop cock and the source vial and that when procedure was concluded, assays were performed of treatment apparatus and source vial and licensee determined that only 5.06 millicuries of the 7.2 millicuries prescribed was administered.

"The licensee reported that the manufacturer, Sirtex, will be onsite on February 24th to begin a joint investigation.

"The licensee reported that the referring physician has been notified and it is unknown at time of report whether referring physician has elected to notify patient.

"The licensee reported that they do not anticipate any adverse effects on the patient's treatment outcome.

"The licensee will submit a written report within 15 days in accordance with the requirements of 105 CMR 120.594(A)(4).

"Root cause and corrective action are not known at this time and the Massachusetts Radiation Control Program continues to investigate."

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.

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Power Reactor Event Number: 49862
Facility: FARLEY
Region: 2 State: AL
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: CHARLES BAREFIELD
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/28/2014
Notification Time: 11:02 [ET]
Event Date: 02/28/2014
Event Time: 08:42 [CST]
Last Update Date: 02/28/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
GERALD MCCOY (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

PYRO PANEL REMOVED FROM SERVICE FOR MAINTENANCE

"At 0842 CST on February 28, 2014, the Unit 1 Pyro Panel (fire/smoke detection panel) was removed from service for required maintenance. The Pyro Panel was declared non-functional when it was removed from service. Compensatory measures have been established for all affected areas except the Unit 1 Containment Building. Since a fire in the Containment Building is an entry condition for the site's Emergency Plan, this is considered a loss of emergency assessment capability and is being reported per 10CFR50.72(b)(3)(xiii). Containment temperature is being monitored while the pyro panel is out of service, however this is not considered a satisfactory compensatory measure for maintaining effective assessment capability. A courtesy follow up notification will be sent when the pyro panel is returned to service and functional.

"The NRC Resident Inspector has been informed."

* * * UPDATE FROM RICHARD LULLING TO CHARLES TEAL AT 2215 EST ON 2/28/14 * * *

"At 1704 CST on 2/28/2014 the Unit 1 Pyro Panel was declared functional following the return of the fire indicating unit (FIU) to the original status. The Pyro Panel fire detection system was successfully tested following the maintenance. The emergency assessment capability for the site's Emergency Plan has been fully restored concerning a containment fire.

"The Senior NRC Resident Inspector has been informed."

Notified R2DO (McCoy).

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Power Reactor Event Number: 49864
Facility: PEACH BOTTOM
Region: 1 State: PA
Unit: [2] [3] [ ]
RX Type: [2] GE-4,[3] GE-4
NRC Notified By: MIKE WEAVER
HQ OPS Officer: CHARLES TEAL
Notification Date: 03/01/2014
Notification Time: 14:19 [ET]
Event Date: 03/01/2014
Event Time: 11:25 [EST]
Last Update Date: 03/01/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
ANNE DeFRANCISCO (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 51 Power Operation 51 Power Operation
3 N Y 100 Power Operation 100 Power Operation

Event Text

LOSS OF SAMPLE FLOW FOR MAIN STACK WIDE RANGE RADIATION MONITOR

"At 1125 [EST] on Saturday, March 1st, 2014, the Peach Bottom Atomic Power Station Main Stack Wide Range Radiation monitor was declared inoperable due to a loss of sample flow.

"This event is being reported as a loss of emergency assessment capability in accordance with 10 CFR 50.72(b)(3)(xiii). The inoperability would impact the ability to declare an Emergency Action Level at a level of an Alert or higher based on Main Stack radiation release.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 49865
Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: ANDREW DOBY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/02/2014
Notification Time: 00:45 [ET]
Event Date: 03/02/2014
Event Time: 00:13 [EST]
Last Update Date: 03/02/2014
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
ANNE DeFRANCISCO (R1DO)
HO NIEH (NRR)
JENNIFER UHLE (NRR)
WILLIAM DEAN (R1RA)
JEFFERY GRANT (IRD)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

UNUSUAL EVENT DECLARED DUE A FIRE ALARM IN THE CONTAINMENT BUILDING

"An Unusual Event (NOUE) was declared at 0013 EST on 3/2/2014 due to a possible fire in the protected area inside containment which could not be verified within 15 minutes (EAL HU4). A containment building smoke alarm was received at 2120 on 3/1/14 after indications that a relief valve lifted during a safety injection accumulator fill evolution. Diverse containment instrumentation was checked and showed that containment dew point was elevated while containment temperature and pressure remained steady. The fire alarm was reset and did not reflash. A containment entry will be made to investigate the alarm. There are no requests for the local fire department to respond and there are no indications of a radiological release to the environment.

"The NRC Resident Inspector has been notified."

The licensee notified the Commonwealth of Pennsylvania Emergency Management Agency, Beaver County in Pennsylvania, the State of Ohio, Columbiana County in Ohio, the State of West Virginia and Hancock County in West Virginia.

Notified DHS SWO, FEMA, NICC and Nuclear SSA (via email).

* * * UPDATE FROM BRIAN STROBEL TO HOWIE CROUCH AT 0211 EST ON 3/2/14 * * *

The licensee terminated the NOUE at 0205 EST after a containment entry determined no fire or indications of fire existed.

Notified R1DO (DeFrancisco) IRD (Grant), NRR EO (Nieh), DHS SWO, FEMA, DHS NICC, and Nuclear SSA (via email).

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Power Reactor Event Number: 49866
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: NEEL SHUKLA
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 03/02/2014
Notification Time: 22:10 [ET]
Event Date: 03/02/2014
Event Time: 16:30 [CST]
Last Update Date: 03/02/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
DANIEL RICH (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

DISCOVERED A POSTULATED HOT SHORT OF A CABLE DURING EXTENT OF CONDITION REVIEW

"On March 2, 2014, during an extent of condition review for a separate problem evaluation report (PER) for the Browns Ferry Nuclear Plant (BFN), it was discovered that a postulated worst case failure hot short of cable PP679-IA associated with 4kV Shutdown Board 'A' cross-tie breaker 1824 may cause spurious opening of breaker 1824.

"4KV Shutdown Board 'A' breaker 1824 is required to be closed during an Appendix R safe shutdown event in fire area 2-3. The action taken by 0-SSI-2-3 is to assure breaker 1824 is closed after placing '43 switch' (Breaker Control Transfer switch) and '43AR switch' (Appendix R Isolation switch) in the emergency position. Cable PP679-IA is routed in fire area 2-3 and fire damage resulting in a hot short could prevent closing breaker 1824 upon demand.

"Therefore, this condition could result in a loss of power to credited safe shutdown equipment used for Unit 1 that would challenge the ability to provide adequate core cooling during performance of BFN Safe Shutdown Instructions.

"This condition is being reported pursuant to 10 CFR 50.72(b)(3)(ii)(B), 'Any event or condition that results in the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety.'. This is also reportable as a 60-day written report in accordance with 10 CFR 50.73(a)(2)(ii)(B). This item has been entered into the Corrective Action Program as PER# 853503.

"The NRC Resident Inspector has been notified of this event."

The licensee has established compensatory actions to ensure breaker 1824 remains closed.

Page Last Reviewed/Updated Wednesday, May 14, 2014
Wednesday, May 14, 2014