Home NRC Library Document Collections Events, Reports Associated with Event Notification Reports 2019

Event Notification Report for January 14, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
1/11/2019 - 1/14/2019

** EVENT NUMBERS **

Part 21	Event Number: 53664
Rep Org: ABB MOTORS AND MECHANICAL Licensee: ABB MOTORS AND MECHANICAL Region: 1 City: FLOWERY BRANCH State: GA County: License #: Agreement: Y Docket: NRC Notified By: SHELDON THOMAS HQ OPS Officer: BETHANY CECERE	Notification Date: 10/12/2018 Notification Time: 15:04 [ET] Event Date: 08/02/2018 Event Time: 00:00 [EDT] Last Update Date: 01/11/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 21.21(a)(2) - INTERIM EVAL OF DEVIATION	Person (Organization): GLENN DENTEL (R1DO) PART 21/50.55 REACTORS (EMAIL)

Event Text

INTERIM PART 21 REPORT - EVALUATION OF MOTORS

The following information was received by from ABB Motors and Mechanical INC by facsimile:

"Pursuant to 10 CFR 21.21(a)(2) this letter provides an interim report concerning an evaluation being performed by ABB Motors and Mechanical Inc. (formerly Baldor Electric Company) on three 40 ft-lb, 56 frame, 2-pole AC electric motors. The issue being evaluated pertains to the abnormal appearance of cracked paint and minor deformation around the stator pin which is located in the motor housing shell.

"The three motors were supplied to Flowserve - Limitorque on a single purchase order in April 2013. The issue being evaluated was identified after MOV production set-up and testing at the valve manufacturing facility. The equipment had not been supplied to a nuclear power plant and thus had not been placed into service.

"The discovery date of the condition being evaluated is August 2, 2018. Evaluation of reportability cannot be completed within the initial evaluation period due to the need to perform additional inspections of motors manufactured in the same period. ABB is working with Flowserve - Limitorque to expedite the additional inspections and testing. It is anticipated that this will be completed by 01/11/2019.

"An initial review of ABB's records indicate that since 1998 ABB has supplied approximately 670, 56-frame AC electric motors of 40 and 60 ft-lb. to Flowserve - Limitorque. Flowserve - Limitorque communicated to ABB that there have been no previously reported occurrences of this issue nor any reported motor failures related to this issue.

"(i) Name and address of the individual or individuals informing the Commission.

"Sheldon Thomas
QA Manager
ABB Motors and Mechanical Inc.
Flowery Branch, GA 30542
(678) 947 7350

"(ii) Identification of the facility, the activity, or the basic component supplied for such facility which fails to comply or contains a defect.

"The basic components being evaluated are Class 1E 40 ft-lb, 56 frame, 2-pole motors supplied to Flowserve - Limitorque for installation on valve actuators to be supplied into nuclear plant applications, to date, no basic components have been determined to contain a defect.

"(iii) Identification of the firm constructing the facility or supplying the basic component which fails to comply or contains a defect.

"The basic components being evaluated were supplied by ABB Motors and Mechanical Inc. (formerly Baldor Electric Company) ("ABB"), No basic components have been determined to contain a defect. This is an interim report.

"(iv) Nature of the defect or failure to comply and the safety hazard which is created or could be created by such defect or failure to comply

"ABB was contacted by our customer Flowserve - Limitorque regarding three 40 ft-lb, 56 frame, 2-pole AC electric motors which were reported to have an abnormal visual appearance of cracked paint and minor deformation of the motor housing material around the stator pin. The motor stator pin is installed through the motor housing shell into the stator assembly. ABB's initial inspection of the three motors suggested that the deformation around the pin may have occurred when the motor was operated during actuator and/or MOV production testing. ABB is evaluating whether this abnormal condition of the stator pin interface with the motor frame constitutes a defect that could potentially affect the safety related function of the motor. To date, no basic components have been determined to contain a defect. This is an interim report.

"(v) The date on which the information of such defect or failure to comply was obtained.

"The discovery date of the condition being evaluated is August 2, 2018,

"(vi) In the case of a basic component which contains a defect or fails to comply, the number and location of these components in use at, supplied for, being supplied for, or may be supplied for, manufactured, or being manufactured for one or more facilities or activities subject to the regulations in this part.

"At this time, no basic components have been determined to contain a defect.

"(vii) The corrective action, which has been, is being, or will be taken; the name of the individual or organization responsible for the action; and the length of time that has been or will be taken to complete the action.

"None at this time,

"(viii) Any advice related to the defect or failure to comply about the facility, activity, or basic component that has been, is being, or will be given to purchasers or licensees.

"None at this time."

* * * UPDATE AT 0815 EST ON 1/11/2019 FROM SHELDON THOMAS TO MARK ABRAMOVITZ * * *

The following information was received via fax:

"This letter is a follow-up to the initial Interim Notification dated October 12, 2018 (Ref. ML18302A229).
ABB continues to work with Flowserve-Limitorque to expedite the additional inspections of motors in the field and testing of motors pulled from inventory. The testing is necessary to assist in determination if the abnormal appearance and deformation constitutes a defect which would cause a substantial safety hazard.

"It is anticipated that this will be completed by February 28, 2019. At that time, motor testing should be complete and analysis of results conducted. ABB will then be able to determine if the nature of the condition is a substantial safety hazard and reportable. If further time is necessary for evaluation, a follow-up to this report will be filed.

"Since discovery of the condition, and to the date of this report, ABB and Flowserve-Limitorque are not aware of any confirmed field inspections by Flowserve-Limitorque's customer or the results of such inspections."

Notified the R1DO (Bower) and Part 21 Reactors Group (via e-mail).

Agreement State	Event Number: 53812
Rep Org: PA BUREAU OF RADIATION PROTECTION Licensee: ENGINEERING AND INSPECTIONS HAWAII, INC. Region: 1 City: SUGAR GROVE State: PA County: License #: PA-1080 Agreement: Y Docket: NRC Notified By: JOHN CHIPPO HQ OPS Officer: BRIAN P. SMITH	Notification Date: 01/03/2019 Notification Time: 14:05 [ET] Event Date: 11/30/2018 Event Time: 00:00 [EST] Last Update Date: 01/03/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): ANTHONY DIMITRIADIS (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - INABILITY TO RETRACT RADIOGRAPHY SOURCE

The following report was received from the Commonwealth of Pennsylvania via fax:

"The licensee reported that on November 30, 2018, while using a Sentinel Model 880 Delta, Serial Number D-11934, containing a 39.2 Curie source of iridium-192, the guide tube had come unbound from the strapping used to hold the collimator and guide tube to the weld being inspected and fell approximately the full length of the guide tube. This left the guide tube hanging at a 90-degree angle from the exposure camera which proved too great to let the source be retracted into a shielded position inside the exposure device and left the source inside the collimator.

"The technicians secured the area by adjusting their 2 mR/hr boundaries to an unshielded source distance and immediately contacted their Operations Manager. Once on scene, the Operations Manager utilized various tools to straighten the guide tube enough for the source to be fully retracted into a shielded position.

"The device was taken back to the licensee's storage vault in Sugar Grove, PA for inspection and possible repair or disposal by the manufacturer. Direct read dosimetry showed exposures of 18 mR for the Operations Manager, 18 mR for the radiographer and 5 mR for the radiography assistant, thus no overexposures have occurred because of this event. Corrective actions include retraining on suspended exposure procedures and future discussion of this event at monthly staff meetings. The Department will perform a reactive inspection. More information will be provided upon receipt."

Pennsylvania Report ID: PA190001

!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State	Event Number: 53814
Rep Org: WASHINGTON UNIVERSITY IN ST. LOUIS Licensee: WASHINGTON UNIVERSITY IN ST. LOUIS Region: 3 City: ST. LOUIS State: MO County: License #: 24-00167-11 Agreement: N Docket: NRC Notified By: MAXWELL AMURAO HQ OPS Officer: DONALD NORWOOD	Notification Date: 01/04/2019 Notification Time: 12:15 [ET] Event Date: 01/03/2019 Event Time: 16:00 [CST] Last Update Date: 01/14/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS	Person (Organization): ERIC DUNCAN (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

MEDICAL EVENT - Y-90 THERASPHERES ADMINISTERED TO THE WRONG LIVER SEGMENT

A medical event occurred on 1/3/2019 at Washington University in St. Louis. The patient treatment plan called for 1.06 GBq of Y-90 TheraSpheres to be administered to Segments 6 and 7 of the patient's liver. However, 1.02 GBq of Y-90 TheraSpheres were administered to Segments 5 and 8 of the patient's liver instead.

The patient and the referring physician were notified of the event. Washington University in St. Louis has initiated an investigation of the event.

* * * RETRACTION ON 1/14/19 AT 1256 EST FROM MAXWELL AMURAO TO THOMAS KENDZIA * * *

The following was received via email from the licensee:

"As a follow up to the phone call placed today (1/14/19) at 12:56 pm EST, [the licensee radiation safety officer] is writing to retract the report of a event number 53814. The initial report of a suspected medical event with the administration of Y-90 microspheres to a patient was made on 1/4/19 at 12:15 pm EST. After taking the limitations of the imaging software into account, the reviewing team of clinicians have evaluated that the Y-90 microspheres were administered to the correct patient, with the correct dosage and correct route of administration, and in agreement with the Written Directive."

Notified R3DO (PELKE) and NMSS vis email.

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.

Power Reactor	Event Number: 53822
Facility: FERMI Region: 3 State: MI Unit: [2] [] [] RX Type: [2] GE-4 NRC Notified By: GREG MILLER HQ OPS Officer: MARK ABRAMOVITZ	Notification Date: 01/11/2019 Notification Time: 10:07 [ET] Event Date: 01/11/2019 Event Time: 09:11 [EST] Last Update Date: 01/11/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 26.719 - FITNESS FOR DUTY	Person (Organization): DAVID HILLS (R3DO) FFD GROUP (EMAIL)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

100

Power Operation

Event Text

FITNESS FOR DUTY

A non-licensed employee disclosed that he had previously used illegal drugs. The employee's access to the plant has been terminated.

The licensee notified the NRC Resident Inspector.

!!!!! THIS EVENT HAS BEEN RETRACTED.THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor	Event Number: 53824
Facility: CLINTON Region: 3 State: IL Unit: [1] [] [] RX Type: [1] GE-6 NRC Notified By: TIM LANIER HQ OPS Officer: MARK ABRAMOVITZ	Notification Date: 01/13/2019 Notification Time: 17:49 [ET] Event Date: 01/13/2019 Event Time: 08:30 [CST] Last Update Date: 03/07/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(v)(D) - ACCIDENT MITIGATION	Person (Organization): DAVID HILLS (R3DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

Power Operation

Event Text

HIGH PRESSURE CORE SPRAY SELF TEST FAILURE

"On January 13, 2019, the Self Test System reported a fault associated with the logic system for the High Pressure Core Spray (HPCS) high reactor water level closure function that could prevent the system from performing its safety function. The HPCS system was subsequently declared inoperable with actions taken per LCO [Limiting Condition for Operation] 3.6.1.3 to close and deactivate the 1E12-F004 valve, a primary containment isolation valve.

"Since HPCS is an emergency core cooling system and is a single train safety system, this condition is reportable under 10 CFR 50.72(b)(3)(v)(D) 'Any event or condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.'

"The NRC Resident Inspector has been notified."

HPCS is in a 14-day technical specification LCO action statement.

* * * RETRACTION AT 1908 EST ON 3/7/19 FROM JAMES FORMAN TO JEFF HERRERA * * *

"Testing of the logic system load driver card for the High Pressure Core Spray (HPCS) high reactor water level closure function was completed both on site and at General Electric Hitachi (GEH). This testing determined the cause of the self-test system fault report was limited to the self-test portion of the load driver card and did not impact the ability of HPCS system to perform its specified safety function.

"Based on the testing results, this event is not reportable under 10 CFR 50.72(b)(3)(v)(D), 'Any event or condition that could have prevented the fulfillment of the safety function of structures or systems that are needed to mitigate the consequences of an accident.' Therefore, EN 53824 is being retracted.

"The NRC Resident Inspector has been notified."

Notified the R3DO (Hills).

Power Reactor	Event Number: 53825
Facility: FERMI Region: 3 State: MI Unit: [2] [] [] RX Type: [2] GE-4 NRC Notified By: JEFF MYERS HQ OPS Officer: THOMAS KENDZIA	Notification Date: 01/14/2019 Notification Time: 13:12 [ET] Event Date: 01/14/2019 Event Time: 09:58 [EST] Last Update Date: 01/14/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE	Person (Organization): PATRICIA PELKE (R3DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

100

Power Operation

100

Power Operation

Event Text

ACTIVE SEISMIC MONITORING SYSTEM INOPERABLE

"On 01/11/2019 at 0958 EST, the Fermi 2 Active Seismic Monitoring system was taken out of service for planned maintenance. During the maintenance activity, the Active Seismic Monitoring System failed a planned surveillance test and was not restored to operability within 72 hours. Compensatory measures to provide alternative methods for event classification of a seismic event were implemented in accordance with the Fermi 2 Emergency Plan procedures prior to the start of the planned maintenance outage. The planned outage time to restore operability exceeded 72 hours on January 14th, 2019, at 0958 EST. Repairs have been completed, the Active Seismic Monitoring System has been declared Functional at 1037 EST, January 14th, 2019, and declared Operable at 1109 EST, January 14th, 2019.

"The loss of the Active Seismic Monitoring System is reportable to the NRC within 8 hours of discovery in accordance with 10 CFR 50.72(b)(3)(xiii).

"No seismic activity has been felt onsite and the United States Geological Survey (USGS) recorded no seismic activity in the area.

"The NRC Resident Inspector has been notified."

Femi 2 has two seismic monitors, one on the Reactor Pressure Vessel Pedestal and one in the High Pressure Core Injection (HPCI) room. Only the HPCI room monitor was inoperable.

Page Last Reviewed/Updated Thursday, March 25, 2021