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Event Notification Report for February 11, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
2/8/2019 - 2/11/2019

** EVENT NUMBERS **

Part 21	Event Number: 51611
Rep Org: QUALTECH NP Licensee: QUALTECH NP Region: 3 City: CINCINNATI State: OH County: License #: Agreement: Y Docket: NRC Notified By: MARGIE HOVER HQ OPS Officer: DONG HWA PARK	Notification Date: 12/18/2015 Notification Time: 15:50 [ET] Event Date: 10/06/2015 Event Time: 00:00 [EST] Last Update Date: 02/08/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE	Person (Organization): LADONNA SUGGS (R2DO) RAY AZUA (R4DO) PART 21/50.55 REACTORS (EMAIL)

Event Text

EN Revision Imported Date : 2/11/2019

EN Revision Text: POTENTIAL PART 21 INVOLVING A200 SERIES STARTERS

The following is excerpted from a report submitted by QualTech NP, Nuclear Division, Curtiss-Wright Corporation:

"Pacific Gas and Electric (PG&E) reported to QTNP [QualTech NP] that they have had eight Cutler Hammer A200 series starter failures since September 15, 2008. The failures would remain in the operated/energized contact state with power removed for some period of time. All starters impacted with this failure were continuously energized. The concern was that if tripped, that the main contacts would not open to protect the motor.

"Testing was performed by Eaton Industrial Controls Division after receiving defective samples from PG&E. The test report from Eaton was received by QTNP for further review and evaluation. On October 6, 2015 QTNP determined that the Cutler Hammer A200 series starter failures may be reportable and an extent of condition review needed to be done.

"The root cause was a silicon based mold release that remained on the molded parts and would come between the moving (magnet) & fixed armatures. When heated for an extended period of time, this material would become sticky causing anywhere from a minor delay in opening, up to a frozen closed condition.

"Cutler Hammer has determined that the silicone mold release was first introduced into the manufacturing facility in May, 2008, due to a shortage of the Zinc Stearate Mold release that was traditionally used. The silicon based mold release was periodically used until October 2012. According to Cutler Hammer, anything made after January 1, 2013 should definitely be silicon mold release free.

"Thus any starters/contactors of the CH A200 series manufactured between May 2008 & December 31 , 2012 could have this concern. This failure has only been reported for continuously energized applications. The end user should evaluate their applications for this potential failure mechanism."

QTNP has notified North Anna, H. B. Robinson, Diablo Canyon, and Hatch.

Agreement State	Event Number: 53857
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY Licensee: MIDWEST REGIONAL MEDICAL CENTER Region: 3 City: ZION State: IL County: License #: IL-01104-01 Agreement: Y Docket: NRC Notified By: C. GIBB VINSON HQ OPS Officer: OSSY FONT	Notification Date: 02/01/2019 Notification Time: 17:22 [ET] Event Date: 02/01/2019 Event Time: 12:00 [CST] Last Update Date: 02/01/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JAMNES CAMERON (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNDER DOSE ADMINISTRATION OF Y-90 SIR-SPHERES

The following was received via email from the state of Illinois:

"Midwestern Regional Medical Center, Inc. (Zion, IL) administered an under dose of Y-90 SIR-Spheres to a patient. The intended dose was 21.06 mCi but only 10.10 mCi was administered. The imaging supervisor called on 02/01/19 to report a possible medical event. The event occurred today at 1200 CST. During the administration the licensee began to feel pressure in the syringe. A smaller gauge syringe was used but made no difference so the treatment was aborted. Clumping of the microspheres in the catheter is suspected as the cause. Only about 52 percent of the dose was delivered. The licensee is still working on the dosimetry, but it appears that a medical event has occurred in any case.

"They intend to treat the patient again after an investigation."

Illinois Item Number: IL 190005

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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