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Event Notification Report for July 22, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
7/19/2019 - 7/22/2019

** EVENT NUMBERS **

Part 21	Event Number: 54102
Rep Org: ENGINE SYSTEMS, INC Licensee: DRESSER-RAND Region: 1 City: ROCKY MOUNT State: NC County: License #: Agreement: Y Docket: NRC Notified By: DAN ROBERTS HQ OPS Officer: HOWIE CROUCH	Notification Date: 06/05/2019 Notification Time: 16:39 [ET] Event Date: 06/05/2019 Event Time: 00:00 [EDT] Last Update Date: 07/19/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 21.21(a)(2) - INTERIM EVAL OF DEVIATION 21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE	Person (Organization): RAY KELLAR (R4DO) - PART 21/50.55 REACTORS (EMAIL)

Event Text

PART 21 INTERIM NOTIFICATION - FAILURE OF A SIGNAL CONVERTER SUPPLIED TO COOPER NUCLEAR PLANT

The following is a summary of the information received from Engine Systems, Inc. via facsimile:

ESI was notified on April 6, 2019 that a signal converter (also called a signal conditioner) that sends the Reactor Core Isolation Cooling turbine speed to the turbine controller had failed. The converter is at the manufacturer's facility undergoing testing at this time and they have been unable to complete their evaluation within 60-days. The evaluation is expected to be completed by July 31, 2019.

The converter was only supplied to Cooper Nuclear Plant.

* * * UPDATE FROM DAN ROBERTS TO DONALD NORWOOD AT 1710 EDT ON 7/19/2019 * * *

The following is a synopsis of information received via facsimile:

On June 5, 2019, Engine Systems, Inc. (ESI) issued an interim report regarding an identified deviation for which ESI was unable to complete an evaluation within the 60-day requirement. Per the interim report, ESI committed to complete the evaluation by July 31, 2019. The evaluation is now complete and the deviation is determined to be reportable in accordance with 10 CFR Part 21.

ESI supplied the component which failed to comply or contained a defect. That part was a Signal Converter Transmitter, P/N SCT/4-20MA/4-20MA/24DC/-LIM-TA[DCM]. This component was only supplied to Cooper Nuclear Station.

The nature of the defect was that a power inverter transformer, internal to the signal converter transmitter, failed shorted. The transformer failure adversely affected other circuit board mounted components which prevented the device from functioning properly. The signal converter transmitter is a component of a turbine control panel. Within the panel, the transmitter is used to sense the customer's remote speed setpoint input signal and convert the signal which is transmitted to the turbine control. Since the signal converter transmits the customer's remote speed setpoint input to the turbine control, operability of the device is critical to operation of the RCIC turbine control system. Therefore, a failure of the signal converter would adversely affect the RCIC turbine control system and thus may affect the safe shutdown of the reactor.

At Cooper Nuclear Station, the failed component has been removed and replaced with a spare transmitter from a different batch. No further action is necessary.

For ESI, the previous design transformer (used in the failed transformer) was discontinued by the transformer manufacturer in 2016 which required the signal converter transmitter manufacturer to source a new transformer. The new transformer has the same functionality with a slightly different form factor which minimizes the potential for common cause failure with the original style transformer. Therefore, no additional actions are required since a different transformer is in current use. ESI has included a verification of the current transformer design in the commercial grade dedication package.

The name and address of the individuals reporting this information is:

John Kriesel
Engineering Manager
Engine Systems, Inc.;
175 Freight Rd.
Rocky Mount, NC 27804

Dan Roberts
Quality Manager
Engine Systems, Inc.;
175 Freight Rd.
Rocky Mount, NC 27804

Notified R4DO (Proulx) and the Part 21/50.55 Reactors E-mail group.

Agreement State	Event Number: 54158
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY Licensee: WEBER MARKING SYSTEMS, INC. Region: 3 City: ARLINGTON HEIGHTS State: IL County: License #: 9223671 Agreement: Y Docket: NRC Notified By: GARY FORSEE HQ OPS Officer: JEFF HERRERA	Notification Date: 07/11/2019 Notification Time: 15:02 [ET] Event Date: 07/11/2019 Event Time: 00:00 [CDT] Last Update Date: 07/11/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): AARON McCRAW (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE - THREE FIXED GAUGES UNACCOUNTED FOR DURING TRANSFER

The following report was received from the Illinois Emergency Management Agency (Agency) via email:

"During Agency efforts to pursue an annual self-inspection report from a general licensee (Weber Packaging Solutions, aka Weber Marking Systems), it was discovered (3) NDC model 103 fixed gauges, containing 150 mCi of Am-241 each could not be accounted for. The company provided a sales order, dated 3/9/17, showing the sale of the gauges (incorporated into machinery) to Margot Machinery in Scotia, New York. On July 11, 2019, the Agency determined through communications with State of New York program staff and Margot Machinery that the transfer of the devices out of Illinois was not to a licensed broker or another general licensee. Margot Machinery was unaware the machinery contained any radioactive sources. Weber indicated on the sale bill (NDC Model 5400 TC gauge) but did not verify the transfer was to another general licensee or someone specifically licensed and authorized to receive the sources. Margot Machinery states they were unaware sources were present and had never taken possession of the machinery. Margot Machinery had contracted a broker (Buckeye Business in Ohio) to rig and remove the equipment. Agency efforts are ongoing to contact Buckeye Business and determine the fate of the machinery and sources. Correspondence is ongoing with State of Ohio officials. This matter remains open and the report will be updated as details become available."

Illinois Item Number: IL190021

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: 54159
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY Licensee: JAN X-RAY SERVICES, INC. Region: 3 City: HERSCHER State: IL County: License #: IL-02168-01 Agreement: Y Docket: NRC Notified By: GARY FORSEE HQ OPS Officer: THOMAS KENDZIA	Notification Date: 07/12/2019 Notification Time: 10:03 [ET] Event Date: 07/11/2019 Event Time: 15:30 [CDT] Last Update Date: 07/12/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): AARON McCRAW (R3DO) PATRICIA MILLIGAN (INES) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - OVEREXPOSURE OF RADIOGRAPHER

The following report was received via email from the State of Illinois:

"The Agency [Bureau of Radiation Safety Illinois Emergency Management Agency] was notified after hours on 7/11/19 by Silver Cross Hospital in New Lenox, IL that a patient had self-reported to the emergency room for a potential exposure to an 88 Ci Ir-192 radiography source. Reportedly, the exposure happened earlier in the afternoon (approximately 15:30 CDT). The assistant radiographer stated he had been working in the subject area for approximately 2 minutes when a coworker arrived with radiation detection equipment and told him that he needed to self-report to the nearest ER to determine if he had received an overexposure (15:30 CDT). The assistant radiographer arrived at the hospital around 17:00 CDT. Notification to the Agency was only received from the hospital.

"Agency staff contacted the local RSO [Radiation Safety Officer], at approximately 19:00 CDT on 7/11/19 and confirmed that the assistant radiographer did in fact walk out to exchange film between shots thinking the source was retracted when in fact it was not. Shortly thereafter, the Corporate RSO, called and had additional information. The assistant radiographer worked for 2 minutes at 1 foot away from an 88 Ci Ir-192 source. This equates to about a 15 rem whole body dose. He reportedly did not grab anything with his hands that would generate blistering or erythema, but everyone will be monitoring over the next week.

"The Corporate RSO was still investigating and trying to determine the exact location of the event. The assistant radiographer is at home after his hospital visit with no ill effects, and the camera is secure in Mokena, IL. Agency staff called the hospital and made sure that they were analyzing the blood for white cell count abnormalities specifically drops in lymphocyte counts. They were not sure what to check for or how often so they were put in contact with REACTS Oak Ridge for analysis SOP at approximately 20:30 CDT on 7/11/19. The NRC region 3 liaison was notified shortly thereafter.

"The Corporate RSO will submit a final report and TLD results by 7/12/19. Agency staff are in route to the facility to perform a reactionary inspection and perform an onsite reenactment. This report will be updated as additional information becomes available. This investigation is ongoing."

Illinois report number: IL190022

Agreement State	Event Number: 54160
Rep Org: PA BUREAU OF RADIATION PROTECTION Licensee: ADVANCED INFRASTRUCTURE DESIGN Region: 1 City: PHILADELPHIA State: PA County: License #: Agreement: Y Docket: NRC Notified By: JOSHUA MYERS HQ OPS Officer: JEFF HERRERA	Notification Date: 07/12/2019 Notification Time: 14:35 [ET] Event Date: 07/10/2019 Event Time: 00:00 [EDT] Last Update Date: 07/12/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): ANTHONY DIMITRIADIS (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - TROXLER GAUGE DAMAGED AT JOB SITE

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

"On July 10, 2019, a Troxler gauge was hit by a roller while on a job site at the Philadelphia Airport. The area was secured, and the PA DEP responded to the site. The gauge was not found to be leaking and was secured for shipment back to the operators' office in New Jersey. Preliminary investigation indicates the gauge operator is licensed in New Jersey, but not licensed to operate within Pennsylvania. There was no exposure to workers or the public."

Gauge is a Troxler model 4640-B, Serial number: 72103 containing 8 milliCuries of Cs-137.

Event Report ID No.: PA190016

Power Reactor	Event Number: 54175
Facility: VOGTLE Region: 2 State: GA Unit: [] [2] [] RX Type: [1] W-4-LP,[2] W-4-LP NRC Notified By: KENNY MCKAY HQ OPS Officer: RICHARD SMITH	Notification Date: 07/19/2019 Notification Time: 13:05 [ET] Event Date: 07/19/2019 Event Time: 09:45 [EDT] Last Update Date: 07/19/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION	Person (Organization): GERALD MCCOY (R2DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

A/R

100

Power Operation

Hot Standby

Event Text

AUTOMATIC REACTOR TRIP DUE TO MAIN STEAM ISOLATION VALVE FAILING SHUT

"At 0945 [EDT] on July 19, 2019, with Unit 2 in Mode 1 and 100 percent power, the reactor automatically tripped due to Loop 2 'B' Main Steam Isolation Valve failing shut. The Auxiliary Feedwater system (AFW) started automatically as a result of the automatic reactor trip. The trip was not complex, with all systems responding normally. Operations stabilized the plant in Mode 3. Decay heat is being removed through the main steam lines through the steam dumps and into the condenser.

"Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(iv)(B). Due to the valid AFW actuation from the reactor trip, this event is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A).

"Unit 1 was not affected.

"There was no impact to the health and safety of the public or plant personnel.

"The NRC Resident Inspectors have been notified."

All control rods fully inserted.

Power Reactor	Event Number: 54176
Facility: COOK Region: 3 State: MI Unit: [] [2] [] RX Type: [1] W-4-LP,[2] W-4-LP NRC Notified By: PERRY GRAHAM HQ OPS Officer: RICHARD SMITH	Notification Date: 07/21/2019 Notification Time: 12:08 [ET] Event Date: 07/21/2019 Event Time: 08:26 [EDT] Last Update Date: 07/21/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION	Person (Organization): RHEX EDWARDS (R3DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

M/R

Power Operation

Hot Standby

Event Text

MANUAL REACTOR TRIP DUE NON-ESSENTIAL SERVICE WATER SYSTEM DEGRADED CONDITION

"On July 19, 2019, DC Cook Unit 2 started experiencing degraded performance on the Unit 2 Non-Essential Service Water System (NESW) which affected one (1) NESW pump. On July 21, 2019, a second NESW pump on Unit 2 experienced degradation. On July 21, 2019, DC Cook Unit 2 elected to do a rapid downpower over approximately 40 minutes and perform a Manual Reactor Trip from 17 percent [rated thermal power] to repair the condition before any threshold was exceeded. The manual reactor trip was completed at 0826 EDT on July 21, 2019.

"This notification is being made in accordance with 10 CFR 50.72(b)(2)(iv)(B), Reactor Protection System (RPS) actuation as a four (4) hour report, and under 10 CFR 50.72(b)(3)(iv)(A), Reactor Protection System (RPS), as an eight (8) hour report.

"The DC Cook NRC Resident Inspector has been notified.

"Unit 2 is being supplied by offsite power. All control rods fully inserted. Aux Feedwater pumps were started as required and are operating properly. Decay heat is being removed via the Steam Generator Power Operated Relief Valves following breaking Main Condenser Vacuum for expedited cooldown of the Main Turbine. Preliminary evaluation indicates all plant systems functioned normally following the reactor trip. DC Cook Unit 2 remains stable in Mode 3. No radioactive release is in progress as a result of this event."

Unit 1 was not affected.

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