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Event Notification Report for August 21, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
8/20/2019 - 8/21/2019

** EVENT NUMBERS **


53464 54118 54213 54214 54216 54217 54232 54233

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Part 21 Event Number: 53464
Rep Org: AAF FLANDERS
Licensee: AAF FLANDERS
Region: 1
City: WASHINGTON   State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: SHAWN WINDLEY
HQ OPS Officer: RICHARD SMITH
Notification Date: 06/20/2018
Notification Time: 20:55 [ET]
Event Date: 05/02/2018
Event Time: 00:00 [EDT]
Last Update Date: 08/20/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
Person (Organization):
KENNETH RIEMER (R3DO)
PART 21/50.55 REACTORS ()

Event Text



EN Revision Imported Date : 8/21/2019

EN Revision Text: PART 21 - INTERIM REPORT NOTIFICATION

The following was received via phone call and email:

This report provides notification and interim information concerning an evaluation being performed by AAF Flanders for an unapproved design change in a High Efficiency Particulate Air Filter.

"An evaluation is underway for filters that underwent a non-approved design change. AAF Flanders has determined that an evaluation cannot be completed within the 60 day period. Discovery of the potential deviation was May 2, 2018.

"The information required for the 60-Day Interim Report Notification 21.21(a)(2) was provided. We anticipate that the evaluation will be completed by Sept 15, 2018.

"AAF Flanders is evaluating a potential nonconforming condition associated with filters (model number 0-007-C-42-03-NU-11-13-GG FU5) supplied to Prairie Island Nuclear Generating Plant (PINGP) / Xcel Energy."

AAF Flanders notified Prairie Island Nuclear Plant of this potential defect.

* * * UPDATE ON 9/14/2108 AT 1129 EDT FROM SHAWN WINDLEY TO ANDREW WAUGH * * *

The following information was received via email:

"A notification was submitted to the Commission with the subject matter of, 'Unapproved Design Change in a High Efficiency Particulate Air Filter.' At this time, the evaluation is pending third party qualification testing of the product. Information obtained from the qualification will be used in the determination of a defect. AAF Flanders had anticipated this process to have been completed by Sept 15, 2018 but because it is still on-going, we request an extension until October 31, 2018 to submit a final report to the Commission.

"The subject filters (model number 0-007-C-42-03-NU-11-13-GG FU5) supplied to Prairie Island Nuclear Generating Plant (PINGP)/ Xcel Energy had not been installed. AAF Flanders has recalled the subject filters and currently have them segregated and stored at our facility. They pose no threat public safety."

Notified R3DO (Hanna) and Part 21/50.55 Reactors Group (email).

* * * UPDATE ON 10/31/18 AT 1545 EDT FROM SHAWN WINDLEY TO HOWIE CROUCH * * *

The following information was excerpted from information received via email:

"AAF Flanders had anticipated the qualification process for said filters to have been completed by Sept 15, 2018. AAF requested a second extension by October 31, 2018 to submit a final report to the Commission, however; at this time our qualification is still pending third party approval. AAF Flanders is requesting another extension on the basis of an incomplete qualification of these filters. We anticipate qualification and a completed report on or before 12/15/2018."

Notified R3DO (Stoedter) and Part 21/50.55 Reactors Group (email).

* * * RETRACTION ON 08/20/19 AT 1140 EDT FROM SHAWN WINDLEY TO JEFFREY WHITED * * *

The following information was received via e-mail:

"AAF Flanders' evaluation of the condition identified in the interim report has been completed. The condition reported has been determined to be not reportable in accordance with 10 CFR 21.

"The subject filters (model number 0-007-C-42-03-NU-11-13-GG FU5) have passed qualification testing in accordance with the American Society of Mechanical Engineers (ASME) AG-1, Section FC with the new urethane and are fully qualified and listed on the Qualified Products List.

"The subject filters (model number 0-007-C-42-03-NU-11-13-GG FU5) supplied to Prairie Island Nuclear Generating Plant (PINGP)/Xcel Energy prior to this qualification test had not been installed and were subsequently returned to AAF Flanders. PINGP/Xcel Energy has been notified of the qualification status of the filter model."

Notified R3DO (Riemer) and Part 21/50.55 Reactors Group (email).

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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: 08/20/2019
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 : 8/21/2019

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).

* * * UPDATE AT 1725 EDT ON 8/13/2019 FROM STEPHEN DONOHUE TO THOMAS KENDZIA * * *

The following is a synopsis of conclusions from the final report received via email:

Testing confirmed that the cause of the diaphragm failure was due to excessive torque applied to the bolts used on the #25 airmotor joint. The excessive torque was applied due to poor finish (not flat) of the sealing surfaces. Only a batch of five valves shipped to a customer in South Korea is affected. Directions on how to inspect the supplied valves for this defect were provided as follows:

"1. Measure the bolt torque on the joint. If the value for each cap screw is measured to be 72-79 in-lb, the joint was assembled correctly and the diaphragm is likely to be functional.
"2. Observe whether there is significant extrusion of the outer perimeter of the diaphragm. If the diaphragm extends beyond the OD of the covers by 0.12 in. around most of the circumference, the diaphragm is likely to be overtorqued.
"3. Observe the edge of the diaphragm. The edge of the diaphragm should be square and straight. Examine the edge closely, looking for splitting lines within the elastomer or separation of the elastomer from the fabric outboard of each bolt. Any such damage indicates excessive torque."

Valve assembly process will be changed to ensure flat sealing surfaces and to not exceed the specified torque.

The South Korea customer will be notified and provided a copy of the report.

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

* * * UPDATE AT 0847 EDT ON 8/20/2019 FROM STEPHEN DONOHUE TO THOMAS KENDZIA * * *

ITT Engineered Valves, LLC, revised the final report with the end user specific site information and address of company, and provided precise valve identification information.

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

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Agreement State Event Number: 54213
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: ROBERT PACKER HOSPITAL SAYRE, PA
Region: 1
City: SAYRE   State: PA
County:
License #: PA-0012
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 08/12/2019
Notification Time: 14:05 [ET]
Event Date: 02/21/2019
Event Time: 00:00 [EDT]
Last Update Date: 08/12/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JONATHAN GREIVES (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - EQUIPMENT FAILURE DURING MEDICAL TREATMENT

The following report was received from the Pennsylvania Bureau of Radiation Protection (PA DEP) via facsimile:

"As a result of a Departmental [PA DEP] inspection the licensee reported an equipment failure event that occurred on February 21, 2019. The equipment was a Varian GammaMed Plus, Serial #641017, containing 6.518 Ci of lr-192. A patient was receiving her last of three fractions of treatment with total treatment time for this fraction being 222.6 seconds divided through a total of eight positions. Twenty-five seconds into treatment the unit issued an inactive source error and retracted the source. The physicist entered the room to confirm that the source was retracted. The manufacturer was called. At the manufacturer's recommendation, the console key was powered off, then back on, and the remaining treatment was initiated to continue with the untreated area. This time at 25.8 seconds into the treatment the same error occurred. The remaining treatment plan was saved into the planning computer, and the patient had the applicator removed and was sent home. Varian sent a field service representative who successfully replaced the Geiger-Muller board and functionality was verified. The patient was then rescheduled. The continued treatment on February 25, 2019 accurately reflected the partial treatment and was appropriately scaled to reflect the source decay from the previous treatment. The final portion of the treatment was delivered without incident. There was no harm or overexposure to the patient. The patient was informed at the time. The attending physician has not been notified."

Event Report ID No.: PA190018

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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Agreement State Event Number: 54214
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: D & S ENGINEERING LABS LLC
Region: 4
City: GREENVILLE   State: TX
County:
License #: LL06677
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 08/12/2019
Notification Time: 14:22 [ET]
Event Date: 08/12/2019
Event Time: 00:00 [CDT]
Last Update Date: 08/12/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY KELLAR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The following report was received via e-mail:

"On August 12, 2019, the licensee's radiation safety officer (RSO) reported to the Agency [Texas Department of State Health Services] that while one of its technician's was using a Troxler Model 3440 moisture/density gauge [device #21053] to perform density testing at a temporary job site in Greenville, Texas, the tip of the insertion rod, which holds an 8 millicurie cesium-137 source, came off in the test hole. The RSO and a representative from a licensed gauge service company met at the site and recovered the source. The RSO stated the source holder, which is screwed onto the end of the insertion rod then welded, was intact with the source, spring, and spacer in place. However, it had broken off approximately 1/4 inch below the weld (below the threads). A survey of the test hole and surrounding area found no readings above background. A wipe test was taken which will be analyzed at the service company's facility, where the source and gauge are being taken for evaluation/repair, before the source is removed from the recovery pig. No overexposures are expected from this event. An investigation into this event is ongoing. Information will be provided as it is obtained in accordance with SA-300."

Texas Incident: 9700

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: 54216
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: VERSA INTEGRITY GROUP INC (VIG)
Region: 4
City: NORCO   State: LA
County:
License #: LA-11235-LOI
Agreement: Y
Docket:
NRC Notified By: JOSEPH NOBLE
HQ OPS Officer: KERBY SCALES
Notification Date: 08/13/2019
Notification Time: 12:19 [ET]
Event Date: 08/12/2019
Event Time: 16:19 [CDT]
Last Update Date: 08/13/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RAY KELLAR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - RADIOGRPAHY CAMERA SOURCE WOULD NOT RETRACT

The following report was received from Louisiana Department of Environmental Quality (LDEQ) via facsimile:

"On August 12, 2019, at 1619 CDT, the licensee called LDEQ to report that a source would not retract back into the shielded position. The event happened approximately at 1330 at a temporary jobsite within the Shell Refinery, Airline Highway, Norco, LA. in St. Charles Parish.

"The camera was being used at this temporary jobsite. The exposure was made and the source would not retract into the shielded position. The problem was detected during the post exposure survey. The exposure levels indicated the source was still in the collimator. The reportable event was the 'drive cable' broke in the associated equipment being used with this QSA Global, Model 880 Delta exposure device. The serial number for the 880 Delta is D-7906. The source was a 91.0 Ci of Ir-192, model number A424-9, and serial number 86571G.

"The [industrial radiography] crew followed the [Versa Integrity Group] VIG Safety Procedures securing and shielding the radiography source and then contacted the [Radiation Safety Officer] RSO. The three-man site crew performed the preliminary source retrieval procedures. QSA Global was contacted by the RSO to assist with the source retrieval. QSA Global arrived approximately at 1811 CDT and the source recovery ended at 1930 CDT. The drive cable and source assembly were taken to QSA Global for an equipment evaluation.

"VIG personnel involved in this retrieval received a maximum exposure of 40 mrem and the other individual's exposures were less. There were no excessive exposures associated with this event. At no time did the general public receive an exposure to the source of radiation."

Louisiana Event Report ID No: LA 190011

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Agreement State Event Number: 54217
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: FRANCIS O. DAY
Region: 1
City: ROCKVILLE   State: MD
County:
License #: MD-31-172-01
Agreement: Y
Docket:
NRC Notified By: ALAN GOLDEY
HQ OPS Officer: CATY NOLAN
Notification Date: 08/13/2019
Notification Time: 16:15 [ET]
Event Date: 08/12/2019
Event Time: 13:00 [EDT]
Last Update Date: 08/13/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JONATHAN GREIVES (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - TRANSPORTATION ACCIDENT INVOLVING A DENSITY GAUGE

The following was received from the Maryland Department of the Environment Radiological Health Program (MDE RHP) via phone:

"On August 12, 2019, at approximately 1330 [EDT] hours, the Maryland Department of the Environment (MDE) Hazardous Waste Enforcement Division contacted the MDE Radiological Health Program (RHP) concerning a vehicular accident that involved a nuclear density gauge.

"The initial transportation accident, as logged in at 1300 hours, indicated the accident location near the 70-mile marker on west-bound I-70, near Lisbon, MD. The vehicle, identified as a box truck, was carrying a density gauge that was ejected during the accident. The gauge was observed not in its transportation case at time of arrival of Fire/EMS and Maryland State police. The company Radiation Safety Officer from Francis O. Day, Inc. responded to the scene and verified that the source was in the shielded position. The gauge was taken to Northeast Technical Services for evaluation.

"The gauge was identified as a Troxler model 4640 surface thin-layer gauge, S/N 2399. This gauge has a Cs-137 sealed source with a nominal activity of 8 mCi and was last leak tested on July 14, 2019. The State trooper on scene stated that the vehicle was actually a pickup truck. The transportation case was ejected from the pickup truck along with the truck cap and the driver. The gauge left the confines of the transportation case and came to rest approximately 10 feet from the case. The chain that held the case to the truck bed broke. The driver did not survive the accident.

"MDE/RHP will further investigate this event. "

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Power Reactor Event Number: 54232
Facility: COOPER
Region: 4     State: NE
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: ROY GILES
HQ OPS Officer: KERBY SCALES
Notification Date: 08/20/2019
Notification Time: 18:28 [ET]
Event Date: 08/19/2019
Event Time: 09:39 [CDT]
Last Update Date: 08/20/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
CALE YOUNG (R4DO)
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

LOSS OF PUBLIC PROMPT NOTIFICATION SYSTEM

"At 0939 CDT, on 8/19/19, the National Weather Service reported to Cooper Nuclear Station that the National Warning System (NAWAS) Radio would neither transmit nor receive. The system has been intermittently available since then, but never declared fully functional. The backup notification system has been verified to be available throughout this period. Additional information from the National Weather Service received 8/20/19 at 1414 determined that the Shubert Tower transmitter is non-functional and would not be repaired until 8/21/19. The transmission outage is conservatively assumed to have begun at the first notification on 8/19/19 at 0939. The Shubert Tower transmitter activates the [EMERGENCY ALERT SYSTEM] EAS/Tone Alert Radios used for public notification. This is considered to be a major loss of the Public Prompt Notification System capability and is reportable under 10 CFR 50.72(b)(3)(xiii) when the primary notification system is or will be unavailable for greater than 24 hours with the backup system available.

"The NRC Senior Resident has been informed."

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Power Reactor Event Number: 54233
Facility: CATAWBA
Region: 2     State: SC
Unit: [] [2] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: WALTER HUNNICUTT
HQ OPS Officer: PHIL NATIVIDAD
Notification Date: 08/20/2019
Notification Time: 20:00 [ET]
Event Date: 08/18/2019
Event Time: 17:00 [EDT]
Last Update Date: 08/20/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
RANDY MUSSER (R2DO)
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation

Event Text

REFUELING WATER STORAGE TANK LEVEL LOWER THAN REQUIRED

"While performing a purification on the Unit 2 Refueling Water Storage Tank (FWST), it was discovered that the single train system was inoperable due to the level being less than the required volume per SR [Surveillance Requirement] 3.5.4.2. The condition was discovered on 8/18/19 at 1700 [EDT]. The FWST level was restored to greater than the required volume per SR 3.5.4.2 at 1744 on 8/18/19. This condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D) for an event or condition that could have prevented the fulfillment of a safety function. There was no impact on the health and safety of the public or plant personnel.

"The NRC Resident Inspector has been notified."


Page Last Reviewed/Updated Wednesday, August 21, 2019
Wednesday, August 21, 2019