Event Notification Report for April 21, 2021

EN Revision Imported Date: 4/21/2021

EN Revision Text: PART 21 REPORT - ACTUATOR FAILURE DUE TO LOOSE CAM PINS

The following is a summary of the report provided by the supplier:

Flowserve - Limitorque was informed that during testing of a SMB-0 actuator prior to installation, the actuator failed to return from the manual handwheel mode to motor operation mode. Site personnel removed the electric motor from the actuator and discovered that the worm shaft gear cam pin had become detached from the worm shaft clutch gear. The actuator was one of six identical actuators supplied to Ontario Power Generation by Limitorque in January 2020. Subsequent site inspection of five other actuators received on the order revealed that the cam pins were loose in the worm shaft clutch gear. The issue was discovered prior to placing any of the actuators into service. The defect was the result of improper assembly of the worm shaft clutch gear. The machinist manufacturing the component failed to complete the step require to permanently retain the cam pin in position.

Although no other occurrences of this issue have been reported, Flowserve is continuing to evaluate this issue regarding the potential extent of condition. Currently, there are no recommended actions for the nuclear plants concerning this Part 21 notification.

The supplier has not identified any affected plants at this time and continue to evaluate the extent of condition.

Part number containing the worm shaft clutch gear: 60-420-0130-1

Corrective Actions:

The six gears affected were returned to Limitorque for evaluation and replacement. All SMB worm shaft gears of similar design were placed on temporary quality assurance hold for enhanced inspection. No defective parts were found. All worm shaft gears currently being manufactured will have an additional quality control inspection point for proper cam pin installation.

Point of contact: Kyle Ramsey, Senior Product Engineer at Flowserve-Limitorque Actuation Systems, 5114 Woodall Road, Lynchburg, VA 24502, Office number: 434-522-4138


* * * UPDATE ON 4/20/2021 AT 1009 EDT FROM CHRIS SHAFFER TO BRIAN LIN * * *

Flowserve's investigation has concluded that the assembly error that resulted in the defect being reported was an isolated incident affecting the six parts identified below that were manufactured on a single work order in January 2020. No other gears were manufactured on that work order. Production records indicate that approximately 400 SMB-0 worm shaft clutch gears have been manufactured for nuclear and commercial applications in the past four years. No other instances of loose cam pins have been reported.


Notified R1DO (Arner), R2DO (Miller), R3DO (Peterson), R4DO (Azua), and Part 21 Reactors Group (email).

EN Revision Imported Date: 4/20/2021

EN Revision Text: STUCK SHUTTER

The following information was received from the licensee via email:

"At 0745 CDT, a Systems employee was in #14BF stock house performing lockout tagout procedures in preparation for an outage. As the employee was attempting to close the shutter on the north Berthold gauge, the handle broke leaving the shutter stuck in the open position. No personnel were exposed to the source. Under normal operating conditions the shutter remains open and doesn't pose an immediate hazard while following established procedures.

"Initial Corrective Actions:
- Performed a survey in the work area. No readings above background.
- Posted signage indicating that the shutter is inoperable, stuck in the open position, and informing employees not to enter.
- Contact manufacturer representative (Radiametrics) to schedule assessment and repairs."

The Berthold gauge contas a 300 milliCurie Am-241/Be source.

EN Revision Imported Date: 4/20/2021

EN Revision Text: AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The following information was received from the Washington State Department of Health:

"University of Washington broad scope license C001 reported a medical event. The event involves y-90 microspheres contained in two vials of different activity. Vial A and Vial B were to be delivered to different treatment sites. However, the vials were mixed up and the lower activity vial was delivered to the wrong site, the Authorized User (AU) realized it was the wrong vial and did not inject the second vial. This resulted in an underdose of more than 20 percent. A full report is expected in 15 days and will be forwarded."

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.

EN Revision Imported Date: 4/20/2021

EN Revision Text: AGREEMENT STATE REPORT - PATIENT RECEIVES WRONG DOSE

The following was received via e-mail from the State of Texas:

"On April 14, 2021, the licensee reported that a patient who was to receive 200 micro Ci of I-123 as a diagnostic procedure instead received 150 milli Ci I-131. The patient apparently left the hospital but is on their way back to receive [potassium iodine, (KI)] KI treatment and will remain in the hospital. The licensee will conduct investigation into how incident occurred and what the dose to the patient was.

"Additional information will be provided as it is received in accordance with SA-300.

"Texas Incident #: 9840"

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.

EN Revision Imported Date: 4/20/2021

EN Revision Text: AGREEMENT STATE - BROKEN RADIOGRAPHY CAMERA
The following was received via e-mail from the Texas Department of State Health Services:

"On April 14, 2021, the licensee reported to the agency [Texas Department of State Health Services] that one of its crews had been unable to retract a source while working at a temporary job site. They were using a QSA Delta 880 exposure device with a 96.7 curie iridium-192 source. The radiographers were cranking in the source and it did not feel right but it retracted and locked in inside the camera. They performed a survey of the camera and guide tube and found the source was in the fully shielded position. They cranked out for the next shot without issue but when they attempted to retract the source it was no longer on the end of the drive cable. The radiographers set a barricade and called the radiation safety officer (RSO). The RSO responded and performed a source retrieval. His electronic dosimeter indicated he received 70 mrem and there were no other exposures as a result of this event. The RSO reported that the drive cable had broken below the shank. The equipment will be sent to the manufacturer for evaluation. More information will be provided as it is obtained in accordance with SA-300.

"Equipment information:
QSA Delta 880 exposure device SN: D8849
96.7 curie iridium-192 source SN: 30413M

"Texas Incident no.: 9841"

FITNESS-FOR-DUTY REPORT - EMPLOYEE SUPERVISOR CONFIRMED POSITIVE FOR ALCOHOL

A non-licensed, employee supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.

The licensee notified the NRC Resident Inspector.