Event Notification Report for September 03, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/02/2021 - 09/03/2021
Part 21
Event Number: 55497
Rep Org: Paragon Energy Solutions
Licensee: Paragon Energy Solutions
Region: 4
City: Fort Worth State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Tracy Bolt
HQ OPS Officer: Kerby Scales
Licensee: Paragon Energy Solutions
Region: 4
City: Fort Worth State: TX
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Tracy Bolt
HQ OPS Officer: Kerby Scales
Notification Date: 09/28/2021
Notification Time: 18:00 [ET]
Event Date: 09/03/2021
Event Time: 00:00 [CDT]
Last Update Date: 09/28/2021
Notification Time: 18:00 [ET]
Event Date: 09/03/2021
Event Time: 00:00 [CDT]
Last Update Date: 09/28/2021
Emergency Class: Non Emergency
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
10 CFR Section:
21.21(d)(3)(i) - Defects And Noncompliance
Person (Organization):
SCHROEDER, DAN (R1DO)
MILLER, MARK (R2DO)
PART 21/50.55 REACTORS, - (EMAIL)
SCHROEDER, DAN (R1DO)
MILLER, MARK (R2DO)
PART 21/50.55 REACTORS, - (EMAIL)
EN Revision Imported Date: 10/28/2021
EN Revision Text: PART 21 REPORT - DEVIATION IN DC-DC CONVERTER RECTIFIERS IN INVERTER ASSEMBLIES
The following is a synopsis of information received from Paragon Energy Solutions via email:
On 9/3/2021, Paragon Energy Solutions determined that they did not have sufficient information to determine if the inverter assemblies would, or has, created a substantial safety hazard or would have created a technical specification safety limit violation as it relates to plant applications. Exelon (Limerick and Peach Bottom) were notified on 9/3/2021. Duke (Brunswick) was notified on 9/7/2021.
On 9/28/2021, Exelon Peach Bottom provided information indicating the failure of the unit in service could cause a substantial safety hazard in their application.
Quantity of Inverters: Brunswick (7), Limerick (6), Peach Bottom (4).
Component Description: Inverter Assembly 1000VA (Model CSI-K-B-Q9573-1), Nuclear Logistics part number: NLI-072034-CSI-K-5-A. The failed component is the DC-DC converter output rectifiers.
Nature of Defect: The deviation relates to failure of the installed Absopulse 1000VA inverter (Model CSI-K-B-Q9573-1). The extent of condition is currently limited to Absopulse inverters manufactured or repaired in 2015 and later. The root cause of the failure is currently under investigation. The failed component is the DC-DC converter output rectifiers.
Advice Related to Defect: Paragon recommends the identified plants evaluate their specific application and determine whether the condition described in this notice affects their design basis. If the licensee determines that it does, please contact Paragon to determine appropriate corrective action.
Tracy Bolt
Chief Nuclear Officer, CNO
817-284-0077
Paragon Energy Solutions, LLC
7410 Pebble Drive
Ft. Worth, TX 76118
EN Revision Text: PART 21 REPORT - DEVIATION IN DC-DC CONVERTER RECTIFIERS IN INVERTER ASSEMBLIES
The following is a synopsis of information received from Paragon Energy Solutions via email:
On 9/3/2021, Paragon Energy Solutions determined that they did not have sufficient information to determine if the inverter assemblies would, or has, created a substantial safety hazard or would have created a technical specification safety limit violation as it relates to plant applications. Exelon (Limerick and Peach Bottom) were notified on 9/3/2021. Duke (Brunswick) was notified on 9/7/2021.
On 9/28/2021, Exelon Peach Bottom provided information indicating the failure of the unit in service could cause a substantial safety hazard in their application.
Quantity of Inverters: Brunswick (7), Limerick (6), Peach Bottom (4).
Component Description: Inverter Assembly 1000VA (Model CSI-K-B-Q9573-1), Nuclear Logistics part number: NLI-072034-CSI-K-5-A. The failed component is the DC-DC converter output rectifiers.
Nature of Defect: The deviation relates to failure of the installed Absopulse 1000VA inverter (Model CSI-K-B-Q9573-1). The extent of condition is currently limited to Absopulse inverters manufactured or repaired in 2015 and later. The root cause of the failure is currently under investigation. The failed component is the DC-DC converter output rectifiers.
Advice Related to Defect: Paragon recommends the identified plants evaluate their specific application and determine whether the condition described in this notice affects their design basis. If the licensee determines that it does, please contact Paragon to determine appropriate corrective action.
Tracy Bolt
Chief Nuclear Officer, CNO
817-284-0077
Paragon Energy Solutions, LLC
7410 Pebble Drive
Ft. Worth, TX 76118
Agreement State
Event Number: 55987
Rep Org: Alabama Radiation Control
Licensee: Southeast Health
Region: 1
City: Dothan State: AL
County:
License #: 448
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Brian Lin
Licensee: Southeast Health
Region: 1
City: Dothan State: AL
County:
License #: 448
Agreement: Y
Docket:
NRC Notified By: Cason Coan
HQ OPS Officer: Brian Lin
Notification Date: 07/08/2022
Notification Time: 18:17 [ET]
Event Date: 09/03/2021
Event Time: 00:00 [CDT]
Last Update Date: 07/08/2022
Notification Time: 18:17 [ET]
Event Date: 09/03/2021
Event Time: 00:00 [CDT]
Last Update Date: 07/08/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Arner, Frank (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Williams, Kevin (NMSS)
Arner, Frank (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Williams, Kevin (NMSS)
AGREEMENT STATE REPORT - RADIOPHARMACEUTICAL MISADMINISTRATION
The following information was received from the Alabama Department of Public Health Office of Radiation Control (the Agency) via email:
"Licensee emailed 9/3/2021 that a patient received the wrong radiopharmaceutical. The patient was prescribed PYP [pyrophosphate] with 15 millicuries Tc-99m; the patient received 15 mCi of Tc-99m sodium pertechnetate. The licensee reported that the nuclear medicine technologist thought the dose was mislabeled, and administered 15 mCi of the sodium pertechnetate dose. The dose to the patient appeared to be 721.5 mrem effective dose. The writer did not report this matter to the NRC Headquarters Operations Officer at the time of occurrence. The matter has been reviewed during inspection on 3/7 and 3/9/2022, and the licensee appears to have implemented corrective actions."
AL incident no.: 21-29
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.
The following information was received from the Alabama Department of Public Health Office of Radiation Control (the Agency) via email:
"Licensee emailed 9/3/2021 that a patient received the wrong radiopharmaceutical. The patient was prescribed PYP [pyrophosphate] with 15 millicuries Tc-99m; the patient received 15 mCi of Tc-99m sodium pertechnetate. The licensee reported that the nuclear medicine technologist thought the dose was mislabeled, and administered 15 mCi of the sodium pertechnetate dose. The dose to the patient appeared to be 721.5 mrem effective dose. The writer did not report this matter to the NRC Headquarters Operations Officer at the time of occurrence. The matter has been reviewed during inspection on 3/7 and 3/9/2022, and the licensee appears to have implemented corrective actions."
AL incident no.: 21-29
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.