Event Notification Report for September 10, 2018
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/09/2018 - 09/10/2018
Part 21
Event Number: 53660
Rep Org: ABB INC
Licensee: ABB INC
Region: 1
City: BLAND State: VA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JOEY CHANDLER
HQ OPS Officer: VINCE KLCO
Licensee: ABB INC
Region: 1
City: BLAND State: VA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: JOEY CHANDLER
HQ OPS Officer: VINCE KLCO
Notification Date: 10/11/2018
Notification Time: 09:39 [ET]
Event Date: 09/10/2018
Event Time: 00:00 [EDT]
Last Update Date: 10/11/2018
Notification Time: 09:39 [ET]
Event Date: 09/10/2018
Event Time: 00:00 [EDT]
Last Update Date: 10/11/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
AARON McCRAW (R3DO)
PART 21/50.55 REACTORS (EMAIL)
AARON McCRAW (R3DO)
PART 21/50.55 REACTORS (EMAIL)
PART 21 REPORT - DEFECT ASSOCIATED WITH DRY TYPE TRANSFORMER
The following information was received by from ABB INC by facsimile:
"1. This letter provides a notification of a defect associated with dry type transformer serial # 24-26458. The failure was caused by the breakdown of layer to layer insulation within the 4160 volt winding due to dielectric stress. Deterioration of the insulation resulted in an internal fault within the bravo phase 4160 volt winding, triggering a ground fault trip shutdown of equipment. This failure was reported by Exelon's Clinton Nuclear Station and it is the only known reported occurrence of safety related transformer failure caused by the breakdown of layer to layer insulation. Information is provided as specified in 10 CFR 21 paragraph 21.21(d)(4).
"2. Notifying individual: Joey Chandler, Plant Manager, ABB ([PGTR] Power Grids Transformer Division, US), 171 Industry Drive, Bland, VA 24315.
"3. Identification of the Subject component: ABB P/N 24-26458 dry type transformer. This transformer is used for stepping down voltage and was intended for providing power to safety related electrical equipment.
"4. Nature of the deviation: The Exelon Clinton Nuclear Generating Station shut down due to a ground fault alarm on the 4160 volt side of the stepdown transformer that provides power to numerous safety-related components at the plant. Subsequent troubleshooting of the problem revealed that the dry-type transformer supplying 480 volt power had dielectrically failed due to apparent internal fault within the Bravo phase. Further investigation of this failure revealed an operational voltage design stress on the Nomex 410 insulation between the 4160 volt winding's layers of conductor of greater than recommended by the manufacturer (DuPont) for a 40 year design life. At the time of failure, the subject transformer had been in operation for approximately 33.5 years and had progressed 37 years and two months into its intended 40 year life given the 10/1980 ship date. ABB has no knowledge of any adverse operational variances over the course of the approximate 33.5 year life of operation to be able to assess or comment on this potential impact in terms of life.
"5. The function of this dry type transformer is to step voltage down from 4160 volts to 480 volts while providing transfer of power to safety related components. Exelon's Clinton Nuclear Power Station has identified this transformer's power transfer to feed safety related equipment. An interruption of this transfer in power would result in a loss of power to the safety related equipment downstream and could potentially result in a compromise in safety.
"6. ABB was notified of this transformer failure on 12/9/2017. This notification was delayed while the failure was being investigated. This investigation is documented in report: Exelon Clinton Failure Analysis_26458_011218 rev5.doc.pdf dated 09/10/2018.
"7. Corrective actions include:
a. Reviewed and verified current electrical engineering safety related design standard for allowable design stress on insulation per DuPont's recommendation for 40 year life. (Complete.)
b. Reviewed the material used for transformer 24-26458. Found only affected safety related product to be isolated to Clinton Nuclear Station, though records may be incomplete as these records have been archived for over 35 years. (Complete.)
c. Re-trained all involved personnel of the 10 CFR 21 reporting requirements, and the need to provide an interim report within 60 days of discovery.
d. ABB worked directly with Clinton Nuclear to ensure all transformers of respective design was replaced with new transformers following ABB's Technical Evaluation for Nuclear 1E Transformer, Rev. 18 which documents operational design stresses be less than or equal to 30 volts / mil of Nomex 410 insulation between layer to layer of conductor for 40 year life.
"8. Recommendation: Because of the possible existence of additional affected transformers, ABB (PGTR) cannot determine the potential for a substantial safety hazard exists at any other licensee's facility. Licensees are requested to evaluate any Gould-Brown Boveri/ITE dry type transformer with the following nameplate identification below. Transformers associated with this identification are recommended to be replaced.
"kVA: 750AA/ 1000 FA
HV: 4160 Delta Connected
LV: 480 Wye Connected
Class: AA/ FA
Type: Vent
Frequency: 60 Hz
Temp Rise: 80 degrees C
Date of Manufacture: 10/1988 and older models
"Questions concerning this notification should be directed to the Quality Manager (Rick Kinder) at the ABB transformer plant in Bland, VA at (276) 688 -3325."
The following information was received by from ABB INC by facsimile:
"1. This letter provides a notification of a defect associated with dry type transformer serial # 24-26458. The failure was caused by the breakdown of layer to layer insulation within the 4160 volt winding due to dielectric stress. Deterioration of the insulation resulted in an internal fault within the bravo phase 4160 volt winding, triggering a ground fault trip shutdown of equipment. This failure was reported by Exelon's Clinton Nuclear Station and it is the only known reported occurrence of safety related transformer failure caused by the breakdown of layer to layer insulation. Information is provided as specified in 10 CFR 21 paragraph 21.21(d)(4).
"2. Notifying individual: Joey Chandler, Plant Manager, ABB ([PGTR] Power Grids Transformer Division, US), 171 Industry Drive, Bland, VA 24315.
"3. Identification of the Subject component: ABB P/N 24-26458 dry type transformer. This transformer is used for stepping down voltage and was intended for providing power to safety related electrical equipment.
"4. Nature of the deviation: The Exelon Clinton Nuclear Generating Station shut down due to a ground fault alarm on the 4160 volt side of the stepdown transformer that provides power to numerous safety-related components at the plant. Subsequent troubleshooting of the problem revealed that the dry-type transformer supplying 480 volt power had dielectrically failed due to apparent internal fault within the Bravo phase. Further investigation of this failure revealed an operational voltage design stress on the Nomex 410 insulation between the 4160 volt winding's layers of conductor of greater than recommended by the manufacturer (DuPont) for a 40 year design life. At the time of failure, the subject transformer had been in operation for approximately 33.5 years and had progressed 37 years and two months into its intended 40 year life given the 10/1980 ship date. ABB has no knowledge of any adverse operational variances over the course of the approximate 33.5 year life of operation to be able to assess or comment on this potential impact in terms of life.
"5. The function of this dry type transformer is to step voltage down from 4160 volts to 480 volts while providing transfer of power to safety related components. Exelon's Clinton Nuclear Power Station has identified this transformer's power transfer to feed safety related equipment. An interruption of this transfer in power would result in a loss of power to the safety related equipment downstream and could potentially result in a compromise in safety.
"6. ABB was notified of this transformer failure on 12/9/2017. This notification was delayed while the failure was being investigated. This investigation is documented in report: Exelon Clinton Failure Analysis_26458_011218 rev5.doc.pdf dated 09/10/2018.
"7. Corrective actions include:
a. Reviewed and verified current electrical engineering safety related design standard for allowable design stress on insulation per DuPont's recommendation for 40 year life. (Complete.)
b. Reviewed the material used for transformer 24-26458. Found only affected safety related product to be isolated to Clinton Nuclear Station, though records may be incomplete as these records have been archived for over 35 years. (Complete.)
c. Re-trained all involved personnel of the 10 CFR 21 reporting requirements, and the need to provide an interim report within 60 days of discovery.
d. ABB worked directly with Clinton Nuclear to ensure all transformers of respective design was replaced with new transformers following ABB's Technical Evaluation for Nuclear 1E Transformer, Rev. 18 which documents operational design stresses be less than or equal to 30 volts / mil of Nomex 410 insulation between layer to layer of conductor for 40 year life.
"8. Recommendation: Because of the possible existence of additional affected transformers, ABB (PGTR) cannot determine the potential for a substantial safety hazard exists at any other licensee's facility. Licensees are requested to evaluate any Gould-Brown Boveri/ITE dry type transformer with the following nameplate identification below. Transformers associated with this identification are recommended to be replaced.
"kVA: 750AA/ 1000 FA
HV: 4160 Delta Connected
LV: 480 Wye Connected
Class: AA/ FA
Type: Vent
Frequency: 60 Hz
Temp Rise: 80 degrees C
Date of Manufacture: 10/1988 and older models
"Questions concerning this notification should be directed to the Quality Manager (Rick Kinder) at the ABB transformer plant in Bland, VA at (276) 688 -3325."
Non-Agreement State
Event Number: 53592
Rep Org: NUCOR STEEL CORPORATION
Licensee: NUCOR STEEL CORPORATION
Region: 3
City: CRAWFORDSVILLE State: IN
County:
License #: 13-25975-01
Agreement: N
Docket:
NRC Notified By: SHAWN AKER
HQ OPS Officer: ANDREW WAUGH
Licensee: NUCOR STEEL CORPORATION
Region: 3
City: CRAWFORDSVILLE State: IN
County:
License #: 13-25975-01
Agreement: N
Docket:
NRC Notified By: SHAWN AKER
HQ OPS Officer: ANDREW WAUGH
Notification Date: 09/10/2018
Notification Time: 16:02 [ET]
Event Date: 09/10/2018
Event Time: 00:00 [EDT]
Last Update Date: 09/10/2018
Notification Time: 16:02 [ET]
Event Date: 09/10/2018
Event Time: 00:00 [EDT]
Last Update Date: 09/10/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
10 CFR Section:
30.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
JOHN HANNA (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
JOHN HANNA (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
DAMAGED GAUGE
On September 10, 2018 at approximately 0130 EDT a gauge containing a 1 Curie Am-241 source fell and was damaged. The area surrounding the gauge was isolated and the gauge was locked in a secure cabinet. On contact readings were 420 microR/hr and readings at 1 foot were 35 microR/hr. The gauge shutter has been repaired and the gauge has been reinstalled. There were no overexposures as a result of this event.
On September 10, 2018 at approximately 0130 EDT a gauge containing a 1 Curie Am-241 source fell and was damaged. The area surrounding the gauge was isolated and the gauge was locked in a secure cabinet. On contact readings were 420 microR/hr and readings at 1 foot were 35 microR/hr. The gauge shutter has been repaired and the gauge has been reinstalled. There were no overexposures as a result of this event.
Agreement State
Event Number: 53602
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: THE POLYCLINIC
Region: 4
City: Seattle State: WA
County:
License #: WN-M0218-1
Agreement: Y
Docket:
NRC Notified By: RAJ MAHARJAN
HQ OPS Officer: PHIL NATIVIDAD
Licensee: THE POLYCLINIC
Region: 4
City: Seattle State: WA
County:
License #: WN-M0218-1
Agreement: Y
Docket:
NRC Notified By: RAJ MAHARJAN
HQ OPS Officer: PHIL NATIVIDAD
Notification Date: 09/13/2018
Notification Time: 12:11 [ET]
Event Date: 09/10/2018
Event Time: 00:00 [PDT]
Last Update Date: 09/13/2018
Notification Time: 12:11 [ET]
Event Date: 09/10/2018
Event Time: 00:00 [PDT]
Last Update Date: 09/13/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL VASQUEZ (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MICHAEL VASQUEZ (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - REPORT OF LEAKING MEDICAL SOURCE
The following excerpted information was obtained from the State of Washington via email:
"On 8/31/2018, two [70 microCurie] I-125 seeds were implanted into a patient's breast associated with an RSL [radioactive seed localization] procedure; they were explanted on 9/4/2018. On 9/5/2018, [the State of Washington] was notified by a Nuclear Medicine Technician from Polyclinic-Madison Center (904 Seventh Avenue, Seattle) that I-125 seeds had been returned to them following a pathologic exam at the Polyclinic Histology Laboratory."
"The leaking seeds and surgical clips were placed in a shielded container that housed multiple seeds undergoing decay-in-storage prior to disposal. The three plastic containers that were used (specimen cup, sentinel node container, and breast tissue container) have sealed lids and are presently located in the shielded Biodex storage locker located in Polyclinic's nuclear cardiology Hot Lab at Madison Center. All three containers have internal I-125 contamination from the leaking seed. In an attempt to establish a mechanism of action for the leaking source, the surgeon was interviewed and nothing in the way of an apparent cause was identified. Additionally, the surgical notes did not identify any anomalies."
"Although a breach of source containment occurred for an unknown cause, the radiation exposures received by personnel involved with handling of the leaking seed and the patient that had the seed implanted in breast tissue for four days were assessed as not representing a safety issue for any individual."
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
The following excerpted information was obtained from the State of Washington via email:
"On 8/31/2018, two [70 microCurie] I-125 seeds were implanted into a patient's breast associated with an RSL [radioactive seed localization] procedure; they were explanted on 9/4/2018. On 9/5/2018, [the State of Washington] was notified by a Nuclear Medicine Technician from Polyclinic-Madison Center (904 Seventh Avenue, Seattle) that I-125 seeds had been returned to them following a pathologic exam at the Polyclinic Histology Laboratory."
"The leaking seeds and surgical clips were placed in a shielded container that housed multiple seeds undergoing decay-in-storage prior to disposal. The three plastic containers that were used (specimen cup, sentinel node container, and breast tissue container) have sealed lids and are presently located in the shielded Biodex storage locker located in Polyclinic's nuclear cardiology Hot Lab at Madison Center. All three containers have internal I-125 contamination from the leaking seed. In an attempt to establish a mechanism of action for the leaking source, the surgeon was interviewed and nothing in the way of an apparent cause was identified. Additionally, the surgical notes did not identify any anomalies."
"Although a breach of source containment occurred for an unknown cause, the radiation exposures received by personnel involved with handling of the leaking seed and the patient that had the seed implanted in breast tissue for four days were assessed as not representing a safety issue for any individual."
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