Event Notification Report for April 29, 2016

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

The following was received from Arizona via email:

"On April 29th, the licensee [Tucson Medical Center] discovered that a patient had received 37 percent more than the prescribed dose of Xofigo (Radium-223). The licensee had received two doses of Ra-223 for two patients the day prior. The technologist usually asks a patient their weight in order to re-calculate the dose, but forgot and accidently grabbed another Xofigo patient's dose on April 28th. The technologist realized the mistake when she went to inject the second patient on the 29th and the name on the patient's dose did not match the current patient's name. The prescribed dose was 86.7 microcuries and the actual administered dose was 119.3 microcuries.

"The investigation into this event is ongoing.

"The U.S. NRC and Arizona Governor's office are being notified of this event."

Arizona Incident # 16-008

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.

OFFSITE NOTIFICATION OF ONSITE CHEMICAL SPILL

"The licensee notified the Arkansas Department of Emergency Management, National Response Center, and Local Emergency Planning Committee regarding an onsite spill of 12 [percent] Sodium Hypochlorite (bleach solution). Approximately 2000 gallons of Sodium Hypochlorite solution leaked from a bulk tank within the protected area, outside the tank containment berm. Approximately 100 gallons were estimated to have entered the nearby storm drain. The estimate was based on preliminary chemistry samples. The quantity released exceeded the Reportable Quantity (RQ) for Sodium Hypochlorite (RQ of 100 pounds) and was therefore reported.

"There is no impact to the operation of the ANO units or personnel onsite or offsite. No harm to the environment is expected. No offsite emergency response is required.

"This event is reportable under 10 CFR 50.72(b)(2)(xi) as an event or situation related to the protection of the environment for which a notification to other government agencies have been made.

"The NRC Resident Inspector has been notified."

LOSS OF OFFSITE POWER TO THE A RESERVE STATION SERVICE TRANSFORMER

"At 2214 [EDT] on 4/29/16, with Unit 1 and Unit 2 operating at 100 [percent] power, the North Anna 34.5 kV Bus 5, off site power feed to the 'A' Reserve Station Service Transformer, was lost which resulted in the loss of power to the Unit 1 'J' Emergency Bus. Loss of Bus 5 is still undergoing investigation. As a result of the power loss, the 1J Emergency Diesel Generator automatically started as designed and restored power to the 1J Emergency bus. During the event, the Unit 1 'A' Charging Pump (1-CH-P-1A) automatically started as designed due to the loss of power event.

"The valid actuation of these ESF components due to the loss of electrical power is reportable per 10 CFR 50.72(b)(3)(iv)(A).

"The Unit 1 'J' Emergency Bus off-site power source was restored to service and the 1J Emergency Diesel Generator was secured and returned to automatic. Restoration of offsite power to Operable is complete. The Unit 1 'A' Charging Pump has been secured and returned to automatic.

"Both units are currently stable. An investigation is underway to determine the cause of the Bus 5 loss of power."

The NRC Resident Inspector was notified.

PART 21 - INSUFFICIENT VALVE CAGE HARDFACING

The following is excerpted from an email provided by the supplier:

"Items subject to this Fisher Information Notice (FIN) are confined to the equipment and orders referred to in Table 1 [see original submission]. Specifically, 'Equipment' refers to the eight inch sized hardfaced HPNS cages supplied per the order numbers listed in Table 1.

"The purpose of this FIN is to alert affected customers that, as of 29 April 2016, Fisher Controls International LLC ( Fisher) became aware of a situation which may affect the performance of the aforementioned Equipment, including its safety-related function.

"Fisher is informing affected customers of this circumstance in accordance with Section 21.21(b) of 10 CFR 21.

"The Equipment in question is subject to CoCr-A hardface overlay requirements. The CoCr-A overlay deposit thickness must be 0.060 inch minimum after machining. However, the cages supplied in fulfilment of the orders listed in Table 1 may have insufficient hardfacing depth on the inside bore diameter at the top of the cages (approximately 1.50 inches from top).

"This issue first came to Fisher's attention when a material grade inspection revealed insufficient cobalt. Subsequent PMI testing confirmed the upper section at the top of the cage fell short of expected CoCr-A. Two in-stock cages were sent to a third party accredited laboratory for macroetch examination and hardness survey. The results of this survey confirmed the top of the cages did not meet the minimum hardness requirement of 34 HRC and further confirmed the insufficiency is limited to the uppermost 1.50 inches of the inside bore diameter of the cages.

"The absence of hardfacing at the mating surface between cage and plug creates the potential for galling, which could prevent the valve from performing its intended safety function. Testing has been conducted to analyze the risk of galling. Typically, galling is observed in cycle tests well exceeding the 600 cycle recommended lifetime for the equipment. However, testing has proven galling to be an unpredictable phenomenon and could occur prior to the recommended lifetime of the equipment. There are no known field issues with the affected equipment.

"The problem of post-hardfacing material shrinkage is associated with the ratio of bore diameter to cage wall thickness. Large bore diameter thin-walled cages are at greater risk for material shrinkage. A third party accredited laboratory performed additional macroetch supplemental tests and evaluations on similar cages of varying bore sizes. It was determined that this issue is unique to the 8 inch sized HPNS cages.

"Fisher will provide the affected customers with a properly coated cages at Fisher's cost. In addition, a Corrective Action Request (CAR 1804) has been initiated by Fisher to prevent reoccurrence of this issue."

The US reactor sites affected by this issue include VC Summer and Vogtle. The foreign reactor sites include Sanmen and Haiyang.

FIN 2016-06 dated 20 June, 2016.

Point of Contact:
Ben Ahrens
Quality Manager
Emerson Process Management
Fisher Controls International LLC
30 1 South First Avenue
Marshalltown, IA 50 1 58
Phone: (64 1 ) 754-2249
Benjamin.ahrens@emerson.com