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Event Notification Report for July 15, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
7/12/2019 - 7/15/2019

** EVENT NUMBERS **


54118 54150 54161 54162

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Part 21 Event Number: 54118
Rep Org: ITT ENGINEERED VALVES, LLC
Licensee: ITT ENGINEERED VALVES, LLC
Region: 1
City: LANCASTER   State: PA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: STEPHEN DONOHUE
HQ OPS Officer: MICHAEL BLOODGOOD
Notification Date: 06/14/2019
Notification Time: 16:45 [ET]
Event Date: 06/14/2019
Event Time: 00:00 [EDT]
Last Update Date: 07/12/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
- PART 21/50.55 REACTORS (EMAIL)
- PART 21 MATERIALS (EMAIL)

Event Text



EN Revision Imported Date : 7/15/2019

EN Revision Text: INITIAL PART 21 REPORT - POTENTIAL PREMATURE FAILURE OF AIRMOTOR ACTUATOR DIAPHRAGM

The following is a summary of the information received from ITT Engineered Valves, LLC (ITT) via facsimile:

ITT discovered one batch of ten actuator diaphragms (five at the licensee's facility and five sent to Korea) for a No. 25 Airmotor which have demonstrated a potential to fail prematurely during operation. ITT has no evidence to show that any other batch of diaphragms are at risk. ITT is in the process of determining how to evaluate the effect of the diaphragm anomaly, while determining how to define the scope of the potential defect.

This initial notification will be followed by a written notification by July 14, 2019.

None of the actuator diaphragms were supplied to U.S. facilities.

POC:
Stephen Donohue
(717) 509-2200
stephen.donohue@itt.com.

* * * UPDATE AT 1152 EDT ON 7/12/2019 FROM STEPHEN DONOHUE TO JEFF HERRERA * * *

The following is a synopsis of a report received via email:

"Initial notification of the potential defect was made to the NRC via fax on 6/14/19. The potential defect report was designated Event 54118 shortly thereafter. Per 10 CFR Part 21 requirements, this report is the 30-day written notification to support the initial fax notification.

"This potential defect is limited to the #25 airmotor diaphragm only. This issue is in no way related to any other size of airmotor diaphragm, and does not have any effect on the weir diaphragm within the diaphragm valve itself (the diaphragm identified as ITT's M1 diaphragm).

"Potential impact of nonconformance:

"The #25 airmotor diaphragm is designated as a safety related part when the valve to which it is assembled is identified as an active valve. The normal function of the airmotor diaphragm is to seal the airmotor chamber in order to permit conversion of air pressure to a thrust that can operate (open or close) the valve. The safety function is the same as the normal function. If the diaphragm should fail, the valve would not be capable of actuation, would not be capable of producing a force that would open or close the valve, so the safety function of an active valve would be compromised if the actuator diaphragm were to fail.

"The #25 airmotor diaphragm is not designated as a safety related part when the valve to which it is assembled is identified as a passive valve. A passive valve only needs to fulfill its basic valve function (to open or close at loss of air power) and is not required to operate. That is, a fail-to-close valve will still close (still maintain its primary function) if its airmotor diaphragm has failed, it will just not be able to actuate. Therefore, no safety function is compromised if the actuator diaphragm is part of a passive valve.

"Affected customers:

"There were two sets of valves that were constructed at the same time (late May of 2018) from the same lot of #25 airmotor diaphragms, and using the same assembly procedures. One set of five valves was never shipped, was disassembled, and found to reveal the potential defect. The other set also consisted of five valves and was shipped to a customer in South Korea. At this time, ITT does not consider any other customers to be potentially affected.

"Preliminary Root Cause:

"At this point in time, it is believed that the cause of the delamination of the diaphragm is excessive assembly torque upon original construction. For the five disassembled valves, during the 110 psig production test the assembler noted that an excessive amount of bolt torque was required to attain a leak-free joint at 110 psig. It was observed that the preload force continued to act upon the already extruded diaphragm edge over time, causing eventual cracking and delamination. While we have not been able to observe for an entire year, we have been able to simulate the same effect in a limited fashion on a brand new diaphragm using the same valve hardware over the last four weeks.

"Future plan of action:

"1. Complete testing on the fifth of five damaged diaphragms.

"2. Continue to evaluate the effects of excessive torque on the #25 airmotor joint. A second valve assembly will be built with a diaphragm from stock with intentionally high assembly torque, while the first unit mentioned above will be disassembled and examined.

"3. The customer noted in [the above] section will be notified and given instructions on how to assess whether the damage observed in Lancaster is also possible on the other five valves that were built in the same time period.

"4. Develop a means to identify problematic diaphragms after assembly, taking advantage of the fact that excessive torque on the joint in question will result in extrusion of the diaphragm beyond the outer diameter of the covers.

"5. Prepare and submit a report or interim report within 60 days of date of discovery, which will be August 13, 2019."

Notified the Part 21 Reactors and Materials group (via email).

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Agreement State Event Number: 54150
Rep Org: VIRGINIA DEPARTMENT OF HEALTH
Licensee: ECS MID-ATLANTIC, LLC
Region: 1
City: RICHMOND   State: VA
County:
License #: 760-114-4
Agreement: Y
Docket:
NRC Notified By: MICHAEL FULLER
HQ OPS Officer: BETHANY CECERE
Notification Date: 07/06/2019
Notification Time: 11:01 [ET]
Event Date: 07/05/2019
Event Time: 00:00 [EDT]
Last Update Date: 07/08/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER LALLY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
JIM WHITNEY (ILTAB)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - LOST AND RECOVERED NUCLEAR GAUGE

On July 5, 2019, the licensee discovered that a nuclear gauge was missing from their inventory. The gauge contained a Cs-137 source of approximately 10 mCi and an Am-241 source of approximately 25 mCi. The licensee notified the Virginia Department of Health and the Virginia Emergency Operations Center.

On July 6, 2019, the gauge was found in a parking lot of a funeral home in Hampton, VA. The Hampton Police were notified. Following their procedures, they notified the FBI. The gauge was undamaged. The Radiation Safety Officer for the licensee is en route to retrieve the gauge.

The Virginia Department of Health will supply additional details when they become known.

* * * UPDATE ON 7/8/2019 AT 1156 EDT FROM MICHAEL FULLER TO JEFFREY WHITED * * *

The following information was received via e-mail:

"On Friday, July 5, 2019 at approximately 1600 EDT, the Virginia Office of Radiological Health (VORH) Duty Officer was notified by the Virginia Emergency Operations Center Duty Officer that a Virginia licensee, ECS-Mid Atlantic, located in Richmond, VA (Virginia radioactive materials license # 760-114-4) had reported a missing portable nuclear gauge. The gauge particulars are as follows:
Manufacturer: CPN
Model: MC1DR-P
Serial Number: MD60303074
Source: Cs-137 containing 370 MBq (10 mCi); serial number: 2149GQ
Source: Am-241 containing 1.85 GBQ (50 mCi); serial number: 5396NK

"On Saturday, July 6, 2019 at approximately 1030 EDT, the VORH Duty Officer was informed that the missing gauge had been found in the parking lot of a funeral home in Hampton, VA and that local law enforcement, fire department, and Hazmat personnel were on the scene. Also, in accordance with their procedures, the local police department informed the FBI. The local Hazmat officer performed a visual and radiological survey of the transportation package (labeled Radioactive - Yellow II) and observed that everything appeared to be intact and the radiation readings indicted that the source was in the shielded position (approximately 1.6 mR/hr on contact with the transportation package). Once this information was obtained, the Hazmat officer advised the FBI of the situation (through local law enforcement) and the FBI terminated their involvement. The licensee's identity was determined from the visual inspection and was contacted immediately. The licensee's [Radiation Safety Officer] RSO immediately traveled to the scene, and at 1219 EDT informed the VORH Duty Officer that he (the RSO) had possession of the gauge and was en route back to Richmond, VA.

"The licensee is conducting an investigation into the incident and believes that an employee failed to check out the gauge properly and return it to the storage location in Richmond on Wednesday, July 3, 2019 as required by company procedure, and thought that they could return it after the holiday without being detected. When the gauge was observed to be missing on Friday, July 5, 2019 by the Assistant RSO, she texted all technicians and asked who might have failed to return it. The RSO believes that the technician that failed to properly check out the gauge and check it back in panicked and abandoned it at the funeral home on Friday or Saturday. Once the investigation is completed, the licensee will provide the Virginia Office of Radiological Health with their findings. Future updates, based upon that investigation will be made."

Notified R1DO (Dimitriadis) and NMSS Events Notification and ILTAB via 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.

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Fuel Cycle Facility Event Number: 54161
Facility: WESTINGHOUSE ELECTRIC CORPORATION
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 to UO2)
COMMERCIAL LWR FUEL
Region: 2
City: COLUMBIA   State: SC
County: RICHLAND
License #: SNM-1107
Docket: 07001151
NRC Notified By: GERARD COUTURE
HQ OPS Officer: JEFF HERRERA
Notification Date: 07/12/2019
Notification Time: 16:13 [ET]
Event Date: 07/12/2019
Event Time: 01:52 [EDT]
Last Update Date: 07/12/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
70.50(b)(4) - FIRE/EXPLOSION
Person (Organization):
FRANK EHRHARDT (R2DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
KATHRN BROCK (FCSE)

Event Text

WASTE DRUM DAMAGED DUE TO OVER PRESSURIZATION

"On July 12, 2019, at approximately 0152 EDT operations personnel in the Uranium Recycle and Recovery area of the plant reported an incident. Production packaged wet recoverable material on July 12 (3rd shift) into a closed drum at the designated drum loading station, performed the required assay measurement and placed the drum into storage. Shortly afterward, the drum pressurized forcing the lid off and some contents to disperse into the immediate vicinity. The drum contents were smoldering, smoke was observed and the smoke detector activated. Dry paper in the drum created a small fire, which was promptly extinguished without use of a water hose or a fire extinguisher. A small portion of the drums content was impacted. The drum was then separated from other stored material. There were no personnel injuries. Health Physics monitored the area with no airborne results approaching radiological limits and no personnel were affected.

"The drum contained production-related contaminated wet recoverable material (e.g., mop heads, filters, and rags) and laboratory waste. The assay results showed a Uranium 235 content of 71.45 Grams. This quantity of material meets the reporting threshold noted above.

"Immediate Corrective Actions.

"Loading operations of wet recoverable material have been suspending pending further evaluation. Operations checked the other drums in the area with heat monitoring equipment and no additional heat generation issues were identified. This incident has been entered into the facility's corrective action program.

"This incident had no impact on the health and safety of the employees, the public or the environment."

The licensee notified the South Carolina Department of Health and Environmental Control and will be notifying the NRC Region II office.

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Power Reactor Event Number: 54162
Facility: BROWNS FERRY
Region: 2     State: AL
Unit: [1] [] []
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: TODD CHRISTENSEN
HQ OPS Officer: MICHAEL BLOODGOOD
Notification Date: 07/12/2019
Notification Time: 22:50 [ET]
Event Date: 07/12/2019
Event Time: 16:40 [CDT]
Last Update Date: 07/12/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
FRANK EHRHARDT (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

INVALID AUTO ISOLATION SIGNAL OF HIGH PRESSURE COOLANT INJECTION

"At 1640 CDT on 7/12/19, Unit 1 High Pressure Coolant Injection (HPCI) received an invalid auto isolation signal which closed the HPCI steam supply valves rendering HPCI inoperable. This condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D), as an event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.

"The isolation occurred while performing a calibration and functional check of a level switch for the Unit 1 Core Spray system. Continuity was checked across the incorrect set of contacts which completed the circuit in logic bus 'A' for the auto isolation signal in the HPCI system. There was no impact to the safety of the public or plant personnel during the time HPCI system was isolated. HPCI was returned to operable at 2110 CDT on 7/12/19.

"CR 1532094 documents this condition in the Corrective Action Program."

The licensee has notified the NRC Resident Inspector


Page Last Reviewed/Updated Monday, July 15, 2019
Monday, July 15, 2019