| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
10/11/2018 - 10/12/2018 ** EVENT NUMBERS ** |
| Agreement State | Event Number: 53430 | Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSITY OF PENNSYLVANIA
Region: 1
City: PHILADELPHIA State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: STEVEN VITTO | Notification Date: 05/29/2018
Notification Time: 14:48 [ET]
Event Date: 05/25/2018
Event Time: 00:00 [EDT]
Last Update Date: 10/12/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
GLENN DENTEL (R1DO)
GRETCHEN RIVERA-CAPELLA (NMSS DAY)
NMSS_EVENTS_NOTIFICATION (EMAIL)
PATRICIA MILLIGAN (INES) | Event Text AGREEMENT STATE REPORT - PATIENT SKIN CONTAMINATION
The following was received from the Commonwealth of Pennsylvania via email:
"On May 29, 2018, the Department's [Bureau of Radiation Protection] staff in Central Office became aware of a medical event (ME) at U PENN hospital in Philadelphia. The ME is reportable as per 10 CFR 35.3045(a)(1)(i) and also meets criteria for an Abnormal Occurrence.
"On May 25, 2018, a 17 year old pediatric patient underwent an 834 millicurie metaiodobenzylguanidine (MIBG) lodine-131 (I-131) treatment for brain cancer. The dose was delivered in a 30 ml syringe and infused via an automatic pump. The nuclear medical technician present during the infusion reported seeing a small amount of blood, but other than that, nothing unusual was noted. However, upon completion of the infusion, meter readings noted high activities on the patient's clothing and bed linen. The possible reason given being a faulty connection line on the automatic pump. The contamination is believed to have also been present on the skin all weekend. Due to the large dose of I-131 infused, the licensee's staff were not able to see the contamination on the patient's skin until he developed erythema. The licensee is in the process of doing a dose reconstruction for the skin contamination. Based on the reading from the patient and estimated activity in the various contaminated items, the licensee currently estimates that approximately 50% of the intended dosage was successfully infused. The authorized user has been informed and is currently notifying the patient's parents and the referring physician.
"A reactive inspection is planned by the Department. More information will be provided upon receipt."
PA Event Report ID No: PA 180012
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.
* * * UPDATE FROM JOHN CHIPPO TO DONALD NORWOOD AT 1451 EDT ON 7/12/2018 * * *
"The University of Pennsylvania (U Penn) reported that a patient's skin became contaminated during medical treatment on 5/25/2018. The 17-year-old pediatric patient was scheduled to receive 30.86 GBq (834 mCi) of I-131 metaiodobenzylguanidine (MIBG) for treatment of brain cancer. The dosage was delivered in a 30 ml syringe and infused via an automatic pump. The nuclear medicine technician present during the infusion saw a small amount of blood, but nothing unusual other than that was noted. However, upon completion of the infusion, radiation surveys revealed high activities of I-131 on the patient's clothing and bed linen.
"U Penn stated that the patient's upper right thigh was cleaned. On 5/27/2018, the patient reported discomfort and reddening (i.e. erythema) on the skin of his upper right thigh, which developed into a lesion and further into desquamation (grade 3) the next day. Radioactive contamination is believed to have been present on the patient's skin for 24 to 48 hours.
"Based on U Penn measurements, nuclear medicine imaging, and the patient's clinical symptoms, the dose to the skin was estimated to be between 50,000 and 120,000 cGy (rad) to a 15 cm2 area. Radiation safety staff consulted with U.S. DOE's REAC/TS in Oak Ridge TN, to verify dose calculations. Calculations of the activity in the waste and the exposure rate from the patient in previous treatments estimated the activity delivered at 15.54 GBq (420 mCi). It was calculated that approximately 7.77 GBq (210 mCi) went to the waste.
"The cause of the incident is believed to be a faulty connection line on the automatic pump. The patient was also disconnected from the infusion pump at the 'Spiros tube' to use the lavatory part way through the procedure. Due to the large dosage of I-131 infused, U Penn staff were unable to detect the contamination on the patient's skin until he developed erythema.
"The authorized user was informed and notified the patient's parents and referring physician. Pennsylvania DEP, Bureau of Radiation Protection, performed a reactive inspection on 6/7 and 6/13/2018. U Penn is conducting a full root cause analysis to develop and implement corrective actions. Procedures that have already been implemented for I-131 MIBG patients included placing absorbent chucks between all parts of the infusion line and the patient's body and requiring an authorized user to be contacted for approval if it is necessary to disconnect a patient during the infusion.
"Root Cause(s): possible equipment failure, training, and/or human error in connecting the line to the infusion pump.
"Actions: A reactive inspection has been completed by the Department. More information will be provided upon receipt from U Penn."
Notified R1DO (Bower), NMSS Events Notification E-mail Group, and INES Coordinator (Milligan).
* * * UPDATE FROM JOHN CHIPPO TO HOWIE CROUCH AT 1102 EDT ON 8/7/18 * * *
The following update was received from the Commonwealth via fax:
"Licensee has provided additional information; Corrective Actions include:
"A complete evaluation is being performed of the infusion system used for this treatment to identify any deficiencies, including comparison of CT imaging of the Spiros connection used in this treatment and an unused one.
"A multidisciplinary I-131 MIBG team with representatives from Nuclear Medicine, Radiation Safety, Nursing and Oncology has been established. The team will meet regularly to review and update policies and procedures for I-131 MIBG therapies. Some immediate steps have included:
(1) use of absorbent material under the administration line over the patient's body,
(2) a change to the administration procedure to require that the infusion not be stopped unless medically necessary and determined by the Authorized User,
(3) planned implementation of continuous patient observation during administration including evaluation of the use of portable video monitoring,
(4) a new procedure has been implemented to address patient fluid management prior to and during infusion,
(5) a review of the infusion system has commenced with focus on the Spiros connector, including additional training on their use.
"Patient specific decontamination procedures have been developed for each treatment treated since the incident. Since decontamination procedures must take into account the patient's age and medical condition, it has been necessary that the medical staff have major input into the procedures for these patients. The knowledge gained from the patient-specific decontamination procedures will be used to refine the decontamination SOP.
"For therapeutic doses in which an activity on the skin that would result in desquamation can be two thousandths of a percent of the dose. It is important to be able to make measurements in these difficult environments. Testing has begun to determine the capabilities of systems that might be used to measure betas in environments in which gammas are several orders of magnitude more abundant than betas.
"Radiation Safety incident response procedures have been revised to include a time out and immediate involvement of additional Health Physics staff during incidents, including during possible Medical Events. The procedure is aimed at refocusing the attention of Health Physicists on all aspects of the incident response, and to prevent the Medical Event reporting requirements from distracting attention from other aspects of the response.
"CAUSE OF THE EVENT:
a) A leak in the system caused by a failure of the Spiros connection in the infusion line.
b) Policies and procedures relating to I-131 MIBG dose administration lacked coordination and oversight. SOPs have been managed separately by each Department (Nursing, Nuclear Medicine, Oncology, and EHRS).
c) Policies and procedures relating to patient contamination and decontamination during dose administration were incomplete.
"ACTIONS: A reactive inspection has been completed by the Department."
Notified R1DO (Cahill), NMSS Events Notification (email), and INES Coordinator (Milligan).
* * * UPDATE FROM JOHN CHIPPO TO OSSY FONT AT 0833 EDT ON 10/12/2018 * * *
The following was received from the Commonwealth of Pennsylvania via email:
"UPDATE 3, clarifications:
"The written directive prescribed 30.23 GBq (817 mCi) of I-131. The dosage administered measured 30.86 GBq (834 mCi) and was delivered over the course of 90 minutes.
"The estimated activity delivered to the correct treatment site was determined to be 22.68 GBq (613 mCi), not 15.54 GBq (420 mCi) as previously reported.
"No decontamination of the patient (right upper thigh) was performed at the time the contamination of bed linens and pants was discovered. This wasn't completed until signs of erythema were present."
PA Event Report ID No: PA 180012
NRC Item# 180252
Notified R1DO (Dentel), and NMSS Events Notification and INES Coordinator (Milligan) via email. |
| Agreement State | Event Number: 53638 | Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: GEOCON, INC.
Region: 4
City: SAN DIEGO State: CA
County:
License #: 3924-37
Agreement: Y
Docket:
NRC Notified By: L. ROBERT GREGER
HQ OPS Officer: RICHARD SMITH | Notification Date: 10/03/2018
Notification Time: 10:57 [ET]
Event Date: 09/28/2018
Event Time: 00:00 [PDT]
Last Update Date: 10/03/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB (EMAIL)
CNSNS (MEXICO) (EMAIL) | | This material event contains a "Less than Cat 3" level of radioactive material. | Event Text AGREEMENT STATE - STOLEN DENSITY GAUGE
The following was received via email from the State of California:
"On October 2, 2018, at approximately 0830 [PDT] the, Radiation Safety Officer (RSO) for Geocon, Inc. contacted [California Radiologic Health Branch] RHB Brea concerning the moisture/density gauge, Troxler, model 3440, serial #33877 (Cs-137, 0.333 gigaBecquerel; Am-241, 1.6 gigaBecquerel) that had been stolen along with a transport vehicle parked in San Ysidro, CA, at approximately 0600 to 0700 [PDT], on Friday morning, September 28, 2018.
"The authorized user whose truck was stolen did not inform the RSO until 1000 to 1030 [PDT] on Monday, October 1, 2018, of the stolen radioactive gauge. The RSO has contacted local law enforcement in San Diego and is awaiting the completed police report, a copy of which he will send to RHB Brea to be included as part of this report. The RSO will contact local newspapers to attempt to retrieve the stolen radioactive gauge as well as notifying local servicing vendors of radioactive gauges to be alert for the serial number of the stolen gauge in case it turns up for service. The investigation will continue to determine if the radioactive gauge can be recovered in a reasonable time frame. California Notices of Violation will be issued to the licensee for failure to report the loss in a timely manner, and loss of control of the radioactive material."
California Report No. 5010-100218
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 |
| Agreement State | Event Number: 53639 | Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: SANTA CLARA VALLEY HEALTH AND HOSPITAL SYSTEM
Region: 4
City: SAN JOSE State: CA
County:
License #: 0741-43
Agreement: Y
Docket:
NRC Notified By: ROBERT GREGER
HQ OPS Officer: RYAN ALEXANDER | Notification Date: 10/03/2018
Notification Time: 12:06 [ET]
Event Date: 09/28/2018
Event Time: 00:00 [PDT]
Last Update Date: 10/03/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL) | Event Text AGREEMENT STATE - UNDERDOSAGE OF YTTRIUM 90 THERASPHERES
The following was received via email from the State of California:
"On 09/28/18, [the Radiation Safety Officer] RSO initially contacted [Radiologic Health Branch] RHB to report a problem related to patient therapy treatment with Yttrium 90 TheraSpheres performed on 09/28/18. The intended activity of the dosage was 11.9 milliCurie, but only approximately 36 percent was delivered to the target tissue based on the measurement of activity remaining in the delivery system after the procedure. The desired dose for the target volume was 135 Gy and the dose delivered was 49 Gy. At the time of the RSO contact, the licensee was uncertain whether the problem was due to patient stasis or an issue with the delivery system (e.g., a kink in the catheter).
"On 10/02/18, RHB received an email from the RSO stating that the physician (Authorized User) had used a micro catheter on the thinner end and it was very tortuous and made the resistance in the circuit higher than the administration box can tolerate such that the delivery system was not able to work properly in this situation. Licensee stated that the problem was not due to patient stasis.
"The licensee will submit a written report in accordance with 10 CFR 35.3945(d)."
California Report No. 5010-092818
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. |
| Agreement State | Event Number: 53640 | Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: TERRACO CONSULTANTS INC
Region: 4
City: OMAHA State: NE
County:
License #: 01-58-01
Agreement: Y
Docket:
NRC Notified By: JULIA SCHMITT
HQ OPS Officer: RYAN ALEXANDER | Notification Date: 10/03/2018
Notification Time: 15:16 [ET]
Event Date: 10/03/2018
Event Time: 00:00 [CDT]
Last Update Date: 10/09/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL) | Event Text AGREEMENT STATE - LOSS OF CONTROL AND POSSIBLE DAMAGE OF MOISTURE DENSITY GAUGE
At 1355 CDT on 10/3/18, the Nebraska Office of Radiological Health was notified by the Corporate Radiation Safety Officer (RSO) that a licensed moisture density gauge was run over by a large piece of construction equipment on a construction site in Omaha, NE. At the time of the notification to the State, the Corporate RSO did not know which of the licensee's gauges was involved in the incident, nor the device model number, isotope, or quantity.
Staff from the Nebraska Office of Radiological Health were dispatched and are enroute to the event site to meet the licensee's Assistant RSO to assess the possible damage to the gauge and obtain further information. No injuries related to the event were reported to the State and no offsite emergency services support were requested.
* * * UPDATE ON 10/5/2018 AT 0945 EDT FROM HOWARD SHUMAN TO ANDREW WAUGH * * *
Contamination swipes verified the source of the gauge to be intact. The gauge's source rod was broken during the event and the source had to be manually retracted into the shielded position. The gauge is currently at Terraco.
The moisture density gauge is a Troxler Model 3440 (serial number: 30122).
Notified R4DO (Farnholtz) and NMSS Event Notifications (email).
* * * UPDATE ON 10/5/2018 AT 1725 EDT FROM LARRY HARISIS TO DONG PARK * * *
The following was received via email from the State of Nebraska:
"Nebraska Department of Health and Human Services, Office of Radiological Health was notified on October 3, 2018, by the Radiation Safety Officer (RSO) from Terracon, Inc (Nebraska license 01-58-01) that a portable nuclear moisture density gauge was damaged at a temporary job site. [The licensee authorized user] said that he arrived on the jobsite in Omaha, NE to perform moisture density measurements for Peter Kiewit Construction (general contractor) that was going to be pouring concrete later that afternoon by JR Barger & Sons Concrete Contractors (subcontractor). When [the licensee authorized user] arrived, he parked his vehicle near the work area and assessed the work area. He noticed that there were trucks and other heavy machinery working in the area. [The licensee authorized user] proceeded to take the Troxler portable nuclear moisture density gauge (model 3440, serial number 30122 containing 9 mCi of Cs-137 and 44 mCi of Am-241:Be) out of his vehicle and placed it on the ground where moisture density measurements were to be made. While performing a moisture density measurement with the Cs-137 source deployed from the protective housing, a skid loader backed up and hit the portable gauge. Fortunately, [the licensee authorized user] was able to dive out of the way with the back of the skid loader hitting the back of [the licensee authorized user's] arm. The extent of [the licensee authorized user's] injury is unknown.
"[The licensee authorized user] indicated he then proceeded to inform the skid loader to stop but said he continued without acknowledgement. [The licensee authorized user] was then able to get the attention of [the construction project supervisor] to inform him what just transpired. [The licensee authorized user] said that [the construction project supervisor] was not interested in stopping work for the damaged gauge and proceeded to tell [the licensee authorized user] [profanity] or we will call your boss . At this time, [the licensee authorized user] indicated that [an employee] picked up the damaged gauge and threw it to an area outside the work location. An assumption was made of the [the employee's] whole body dose of 571.1 millirem, assuming that he carried the gauge at one centimeter from the trunk of the body and that it took him one minute to move the gauge.
"[The licensee authorized user] said he then called [the Omaha RSO] and informed him of what just happened. [The Omaha RSO] then called the Corporate RSO. [The Omaha RSO] was then dispatched to the area with a survey meter and to assist [the licensee authorized user]. [The Corporate RSO] informed [the Nebraska Department of Health and Human Services (DHHS), Office of Radiological Health Manager]. [The Nebraska DHHS, Office of Radiological Health Manager] dispatched [personnel] to the scene.
"Meanwhile at the jobsite, [the licensee authorized user] maintained surveillance of the gauge and informed personnel to stay away from where the gauge was located. [The Omaha RSO] said that when he arrived, a radiation survey of the surveillance area and gauge was made. Radiation levels at the surveillance area was about 0.5 mR/hr and the gauge was 10 mR/hr, nearest to the extended Cs-137 source and the source was stuck into the ground to provide additional shielding. Calculations indicated that the exposure rate at the 15 foot exclusion boundary would have been 0.04 mR/hr.
"When Nebraska DHHS, Office of Radiological Health staff arrived, another confirmatory radiation survey of the gauge was completed with a result of 10.5 mR/hr. The gauge was also observed to have the source rod extended into the ground and part of the trigger mechanism was broken and sheared off. A wipe test was performed on the source rod with nip tongs and was reading the same as background. The portable gauge was then manipulated to place the Cs-137 source rod assembly back into the shielded position. After an unsuccessful attempt was made, the sliding spring lock was still open and was emitting 385 mR/hr on contact of the port hole. [The Omaha RSO] was able to clear off the excess mud and dirt on the port hole using the nip tongs and the sliding spring lock was shut. Another wipe test was completed and read at background. A radiation survey of the portable gauge confirmed that the Cs-137 source was in the shielded position and measured 20.8 mR/hr.
"[The Omaha RSO] placed the portable gauge back in the shipping container and duct tape was applied to prevent any movement of the source rod from the shielded position. A radiation survey of the transport case was performed with the portable gauge inside and the highest was 8.9 mR/hr on contact and 0.4 mR/hr at 3 feet. The listed TI [Transportation Index] of the package was labeled as 0.6 mR/hr. [The Omaha RSO] stated that he will contact InstroTek to either repair or dispose of the gauge upon their return to the Omaha office.
"An investigation is currently underway and the event is not closed."
Notified R4DO (Farnholtz) and NMSS Event Notifications (email).
* * * UPDATE ON 10/9/2018 AT 1624 EDT FROM HOWARD SHUMAN TO OSSY FONT * * *
The State of Nebraska submitted the full report. The detailed information was previously provided via email. The item is still open pending a reconstruction of the dose received by the employee who picked up the damaged gauge.
Incident Report No: NE180006
Notified R4DO (Gepford) and NMSS Event Notifications (email). |
| Agreement State | Event Number: 53641 | Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: DESERT NDT LLC
Region: 4
City: ABILENE State: TX
County:
License #: L06462
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: PHIL NATIVIDAD | Notification Date: 10/03/2018
Notification Time: 15:11 [ET]
Event Date: 10/02/2018
Event Time: 00:00 [CDT]
Last Update Date: 10/03/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
THOMAS FARNHOLTZ (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL) | Event Text AGREEMENT STATE REPORT - DAMAGED RADIOGRAPHY SOURCE
The following was received via email from the State of Texas:
"On October 3, 2018, the Agency [Texas Department of State Health Services] was notified by the licensee's radiation safety officer (RSO) that one of their radiography crews had reported they could not retract a 22 Curie Iridium-192 source into a SPEC 150 exposure device. The crew was working at a remote job site [in Carrizo Springs, TX]. The exposure device was sitting on a pipe rack. During an exposure (not the first one) the device fell off the pipe rack, hitting the guide tube, and crimping the tube to a point where the source could not be retracted back into the device.
"The crew contacted the RSO and a retrieval team was sent to the location. The source was positioned in the collimator and covered with bags of lead shot. The retrieval team was able to cut the protective coating off of the guide tube and, using a pair of pliers, reshape the guide tube until the source could be retracted to the fully locked position.
"No member of the general public received an exposure from this event. The highest dose received by an individual responding to this event was 40 millirem."
Texas Incident: I-9616 |
| 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 | 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 | Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
| Person (Organization):
AARON McCRAW (R3DO)
PART 21/50.55 REACTORS (EMAIL) | Event Text 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." |
| Power Reactor | Event Number: 53661 | Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [] [2] []
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: CHRIS BENNETT
HQ OPS Officer: BETHANY CECERE | Notification Date: 10/11/2018
Notification Time: 15:37 [ET]
Event Date: 08/16/2018
Event Time: 00:00 [CDT]
Last Update Date: 10/11/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
| Person (Organization):
ANTHONY MASTERS (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 INVALID ACTUATION OF A GENERAL CONTAINMENT ISOLATION SIGNAL AFFECTING MORE THAN ONE SYSTEM
"This 60-day telephone notification is being made per the reporting requirements specified by 10 CFR 50.73(a)(2)(iv)(A) and 10 CFR 50.73(a)(1) to describe an invalid actuation of a general containment isolation signal affecting more than one system.
"On August 16, 2018, at approximately 1736 CDT, Browns Ferry Nuclear Plant (BFN), Unit 2 experienced an unexpected loss of the 2B Reactor Protection System (RPS). This resulted in Primary Containment Isolation System (PCIS) groups 2, 3, 6, and 8 isolations, and initiation of Standby Gas Treatment Trains A, B, and C and Control Room Emergency Ventilation System Train A. All affected safety systems responded as expected with the exception of the Unit 1 Refuel Zone Supply Fan Outboard Isolation Damper, 1-FCO-64-5, that failed to indicate closed position.
"Plant conditions which initiate PCIS Group 2 actuations are Reactor Vessel Low Water Level (Level 3) or High Drywell Pressure. The PCIS Group 3 actuations are initiated by Reactor Vessel Low Water Level (Level 3) or Reactor Water Cleanup Area High Temperature. The PCIS Group 6 actuations are initiated by Reactor Vessel Low Water Level (Level 3), High Drywell Pressure, or Reactor Building Ventilation Exhaust High Radiation (Reactor Zone or Refuel Zone). The PCIS Group 8 actuations are initiated by Low Reactor Vessel Water Level (Level 3) or High Drywell Pressure. At the time of the event, these conditions did not exist; therefore, the actuation of the PCIS was invalid.
"The cause of the RPS MG [Motor Generator] Set trip was a failed (shorted) operating coil associated with the 480 VAC motor starter inside the control box.
"There were no safety consequences or impact to the health and safety of the public as a result of this event.
"This event was entered into the Corrective Action Program as Condition Reports 1440047 and 1440050.
"The NRC Resident Inspector has been notified of this event." |
| Power Reactor | Event Number: 53662 | Facility: SURRY
Region: 2 State: VA
Unit: [1] [] []
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: JEREMY RIDDICK
HQ OPS Officer: OSSY FONT | Notification Date: 10/12/2018
Notification Time: 01:14 [ET]
Event Date: 10/11/2018
Event Time: 00:00 [EDT]
Last Update Date: 10/12/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
| Person (Organization):
ANTHONY MASTERS (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 ACTUATION OF EMERGENCY DIESEL GENERATOR DUE TO TRANSFORMER TRIP
"On 10/11/18 at 2304, with both Surry Units at 100% power, the 'A' Reserve Station Service Transformer (RSST) tripped on a pilot wire lockout. This resulted in electrical isolation of the 'A' RSST, the 'D' Transfer Bus and the Unit 1 'J' Emergency Bus. The #3 Emergency Diesel Generator (EDG) started and loaded on the Emergency Bus, as designed. Operations entered the appropriate Abnormal Procedures and stabilized the unit. All equipment operated as expected during the event.
"A report of a flash at the 'A' RSST was received (at approximately the time of the initiating event) but there were no reports of visible damage, smoke or fire from the RSST or any associated breakers on subsequent investigation. The #3 EDG is running with normal parameters.
"There was heavy wind/rain in the area associated with Tropical Storm Michael.
"All other electrical distribution systems are in a normal alignment.
"The organization is staffing to evaluate the lockout and required actions for recovery.
"No radiological consequences resulted from this event.
"This event is being reported IAW [in accordance with] 10 CFR 50.52(b)(3)(iv)(A) due to the actuation of the #3 EDG.
"The NRC Resident [Inspector] was notified" |
| Power Reactor | Event Number: 53663 | Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [] [2] []
RX Type: [1] CE,[2] CE
NRC Notified By: KEVIN DOUGHERTY
HQ OPS Officer: KAREN COTTON | Notification Date: 10/12/2018
Notification Time: 03:58 [ET]
Event Date: 10/11/2018
Event Time: 00:00 [EDT]
Last Update Date: 10/12/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
| Person (Organization):
GLENN DENTEL (R1DO) | | 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 AIR START SOLENOID CLOSURE FAILURE
"During a post maintenance start of the 1B diesel generator, the air start solenoid valves did not close as expected. This resulted in lowering air pressure in the common air start headers causing inoperability of the 2A and 2B diesel generators at time 23:03. The 1B diesel generator was isolated from the common air start header, which restored the air start header pressure to the 2A and 2B diesel generators. The 2A and 2B diesel generators were declared operable at 23:34."
The NRC Resident Inspector was notified. |
| 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: 03/04/2019 | 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).
* * * CLOSEOUT RECEIVED AT 1642 EST ON 3/4/20119 FROM SHELDON THOMAS TO MARK ABRAMOVITZ * * *
The following closeout was received by fax:
"ABB has completed the evaluation of the abnormal appearance of the three motors identified in this notification with the determination that this condition does not constitute a defect that would affect the safety related function of the motor."
Notified the R1DO (Werkheiser) and Part 21 Reactors Group (via e-mail). |
| Power Reactor | Event Number: 53665 | Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [] [2] []
RX Type: [1] CE,[2] CE
NRC Notified By: CHARLES PIKE
HQ OPS Officer: BETHANY CECERE | Notification Date: 10/12/2018
Notification Time: 16:54 [ET]
Event Date: 10/12/2018
Event Time: 00:00 [EDT]
Last Update Date: 10/12/2018 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
| Person (Organization):
ANTHONY MASTERS (R2DO) | | Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 2 | A/R | Y | 100 | Power Operation | 0 | Hot Standby | Event Text AUTOMATIC REACTOR TRIP
"On October 12, 2018 at 1353 EDT, St. Lucie Unit 2 experienced an automatic RPS actuation and Reactor Trip due to a fault on the 2A1 6.9kv bus during a transfer of the bus power supply from the 2A Auxiliary Transformer to the 2A Startup Transformer. The bus fault caused a fire in the 2A1 6.9kv switchgear that has been extinguished. Offsite support was not required to extinguish the fire. The specific cause of the fault is currently under investigation.
"Following the reactor trip, both Steam Generators are being supplied by main feedwater. All [Control Element Assemblies] (CEAs) fully inserted into the core. Decay Heat removal is being accomplished through forced circulation. Main Feedwater and Steam Bypass Control Systems are maintaining stable conditions in Mode 3.
"St. Lucie Unit 1 was unaffected and remains in Mode 1 at 100 percent power.
"This report is submitted in accordance with 10 CFR 50.72(b)(2)(iv)(B) for the Reactor Trip."
The fire was extinguished within 28 minutes. Plant loads are being supplied by the 2B Auxiliary Transformer.
The licensee notified the NRC Resident Inspector. | |