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Event Notification Report for August 31, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/30/2017 - 08/31/2017

** EVENT NUMBERS **


52920 52937 52938 52940

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Agreement State Event Number: 52920
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: CHESAPEAKE UROLOGY
Region: 1
City: OWINGS MILLS State: MD
County:
License #: MD-05-208-01
Agreement: Y
Docket:
NRC Notified By: ALLEN GOLDERY
HQ OPS Officer: RICHARD SMITH
Notification Date: 08/23/2017
Notification Time: 10:45 [ET]
Event Date: 08/22/2017
Event Time: 09:30 [EDT]
Last Update Date: 08/23/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SILAS KENNEDY (R1DO)
NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT- MEDICAL EVENT MISADMINISTRATION

This following report was phoned in, followed by an email:

"On August 22, 2017, Chesapeake Urology, notified the Maryland Radiological Health Program (RHP) that a male patient was injected with 176.1 microCuries of Ra-223 (Xofigo) instead of 108.4 microCuries of Ra-223 (Xofigo); 62.5 percent greater than the prescribed dose. The wrong unit dose was handed to the authorized user for patient administration. The event occurred at approximately 0930 [EDT] hours on 08/22/2017 at the licensee's address of 21 Crossroads Drive, Suite 200, Owings Mills, MD 21117. Maryland RHP was notified by telephone at 1505 hours. Two patients were scheduled for treatment on August 22, 2017. Both doses were assayed in the morning. Each dose had the proper patient name on the lead pig and on each respective syringe. The incorrect dose was selected and injected without cross referencing the identity of the patient. The event was discovered at approximately 1130 hours when the second Xofigo dose was to be administered. The patient and the referring physician have been informed of the misadministration. A written notification from the licensee is expected in about a week. This is a preliminary notification."

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.

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Power Reactor Event Number: 52937
Facility: COMANCHE PEAK
Region: 4 State: TX
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN FALLETICH
HQ OPS Officer: JEFF HERRERA
Notification Date: 08/30/2017
Notification Time: 10:35 [ET]
Event Date: 08/30/2017
Event Time: 02:10 [CDT]
Last Update Date: 08/30/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
VINCENT GADDY (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

UNPLANNED LOSS OF EMERGENCY RESPONSE EQUIPMENT

"At 0210 CDT on August 30, 2017, Comanche Peak Nuclear Power Plant (CPNPP) Unit 2 experienced an unplanned loss of the Plant Computer System (PCS). The loss of the Unit 2 PCS resulted in a loss of emergency assessment capability to the CPNPP Technical Support Center (TSC) and Emergency Operations Facility (EOF) for greater than 60 minutes. As of 0530 CDT the Unit 2 PCS has been restored. Assessment capability has been verified to be available in the TSC and EOF.

"This report is being made pursuant to 10CFR50.72(b)(3)(xiii), any event that results in a loss of emergency assessment capability, off site response capability, or off site communications ability.

"The NRC Resident Inspector has been informed."

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Part 21 Event Number: 52938
Rep Org: NUTHERM INTERNATIONAL, INC
Licensee: NUTHERM INTERNATIONAL, INC
Region: 3
City: MOUNT VERNON State: IL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: THOMAS STERBIS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/30/2017
Notification Time: 11:33 [ET]
Event Date: 08/29/2017
Event Time: [CDT]
Last Update Date: 08/30/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
JAMNES CAMERON (R3DO)
VINCENT GADDY (R4DO)
PART 21/50.55 REACTO (EMAI)

Event Text

PART 21 REPORT - RELAY FAILURE NUTHERM MODEL 700DC

The following excerpted report was received via fax:

"On the basis of our evaluation, it is determined that Nutherm lnternational, Inc. does not have sufficient information to determine if the subject condition would, or has, created a Substantial Safety Hazard or would have created a Technical Specification Safety Limit violation as it relates to the subject plant applications.

"On 8/28/2017 Cooper notified the NRC of a reportable condition under 10CFR Part 21. An Allen Bradley relay base model 700DC exhibited early failure after 133 hours of service. This relay, model 700DC, has been dedicated/qualified for multiple applications for various plants.

"The Allen Bradley 700DC series relay coil failed after 133 hours of service. This failure was determined by Cooper Nuclear Station to have been a component infant mortality likely caused by a manufacturing flaw that likely occurred due to a tensioning issue at the start of the coil wire winding process. Failure of the coil will result in failure of the relay, which could result in a safety hazard.

"Nutherm International, Inc. has concluded its review of all procurements of the 700DC series relays that use the coil in question and have found forty-nine (49) units shipped to customers which could potentially have this defect: Nebraska Public Power Cooper Nuclear Station and Indiana Michigan Power Company Donald C. Cook Nuclear Plant.

"Initial actions of determining the units affected were completed 8/30/2017. The impacted customers were notified of this condition 8/30/2017. Nutherm International, Inc. does not have sufficient information to determine this condition would, or has, created a Substantial Safety Hazard or would have created a Technical Specification Safety Limit violation as it relates to the subject plant applications. Nutherm has no current orders for these units and has no units in stock. No further actions will be taken at this time.

"This issue has been identified as a 'component infant mortality' failure caused by a manufacturing flaw. The manufacturing flaw appears to be a random failure and was identified by Cooper Nuclear Station as likely to have occurred due to a tensioning issue at the start of the coil wire winding process. Failure of the coil would be expected to occur within a few days of operation. The units that have been installed and in operation for more than two months could be considered to not contain this random manufacturing flaw."

Point of Contact: Thomas Sterbis - 618-244-6000

See also NRC event: 52934

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Independent Spent Fuel Storage Installation Event Number: 52940
Rep Org: ZION
Licensee: ZION SOLUTIONS
Region: 3
City: ZION State: IL
County: LAKE
License #: GL
Agreement: Y
Docket: 05000295
NRC Notified By: ANTHONY MARTIN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/30/2017
Notification Time: 22:37 [ET]
Event Date: 08/30/2017
Event Time: 18:24 [CDT]
Last Update Date: 08/30/2017
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
ANN MARIE STONE (R3DO)

Event Text

INDEPENDENT SPENT FUEL STORAGE INSTALLATION FUEL OIL SPILL

"At approximately 1824 [CDT], the ISFSI was notified of a diesel spill of approximately 70 gallons onto gravel and concrete. The spill originated as a 500 gallon tank was being transported and fell from the forks. The pump on top of the tank was damaged causing the leak. No personnel were injured and there was no pathway to a waterway. Notification was made at 2045 to IEMA [Illinois Emergency Management Agency]. The reason for notification is due to 10CFR50.72(b)(xi), notification to off-site government agency. The spill was cleaned up by site personnel and supervised by the Environmental Manager."

The licensee will notify the NRC Resident Inspector.

Page Last Reviewed/Updated Thursday, August 31, 2017
Thursday, August 31, 2017