Event Notification Report for September 05, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/04/2023 - 09/05/2023
Power Reactor
Event Number: 56714
Facility: McGuire
Region: 2 State: NC
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Eric Palmer
HQ OPS Officer: Brian P. Smith
Region: 2 State: NC
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Eric Palmer
HQ OPS Officer: Brian P. Smith
Notification Date: 09/05/2023
Notification Time: 17:05 [ET]
Event Date: 09/05/2023
Event Time: 12:00 [EDT]
Last Update Date: 09/05/2023
Notification Time: 17:05 [ET]
Event Date: 09/05/2023
Event Time: 12:00 [EDT]
Last Update Date: 09/05/2023
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Miller, Mark (R2DO)
FFD Group, (EMAIL)
Miller, Mark (R2DO)
FFD Group, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
FITNESS-FOR-DUTY VIOLATION
The following information was provided by the licensee via email:
A non-licensed contract supervisor had a confirmed positive for illegal drugs during a random fitness-for-duty test. The contract supervisor's access to the plant has been terminated.
The following information was provided by the licensee via email:
A non-licensed contract supervisor had a confirmed positive for illegal drugs during a random fitness-for-duty test. The contract supervisor's access to the plant has been terminated.
Power Reactor
Event Number: 56715
Facility: Comanche Peak
Region: 4 State: TX
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Matthew Karl
HQ OPS Officer: Ernest West
Region: 4 State: TX
Unit: [1] [] []
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: Matthew Karl
HQ OPS Officer: Ernest West
Notification Date: 09/05/2023
Notification Time: 17:22 [ET]
Event Date: 09/05/2023
Event Time: 09:52 [CDT]
Last Update Date: 09/05/2023
Notification Time: 17:22 [ET]
Event Date: 09/05/2023
Event Time: 09:52 [CDT]
Last Update Date: 09/05/2023
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Azua, Ray (R4DO)
FFD Group, (EMAIL)
Azua, Ray (R4DO)
FFD Group, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
FITNESS-FOR-DUTY VIOLATION
The following information was provided by the licensee via email:
A supplemental contract manager had a confirmed positive for an illegal substance during a random fitness-for-duty test. The employee's access to the plant has been terminated.
The following information was provided by the licensee via email:
A supplemental contract manager had a confirmed positive for an illegal substance during a random fitness-for-duty test. The employee's access to the plant has been terminated.
Part 21
Event Number: 56720
Rep Org: Paragon Energy Solutions, LLC
Licensee: Paragon Energy Solutions, LLC
Region: 1
City: York State: SC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Richard Knott
HQ OPS Officer: Ernest West
Licensee: Paragon Energy Solutions, LLC
Region: 1
City: York State: SC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: Richard Knott
HQ OPS Officer: Ernest West
Notification Date: 09/06/2023
Notification Time: 17:50 [ET]
Event Date: 09/05/2023
Event Time: 00:00 [EDT]
Last Update Date: 10/05/2023
Notification Time: 17:50 [ET]
Event Date: 09/05/2023
Event Time: 00:00 [EDT]
Last Update Date: 10/05/2023
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):
Young, Matt (R1DO)
Miller, Mark (R2DO)
Part 21/50.55 Reactors, - (EMAIL)
Young, Matt (R1DO)
Miller, Mark (R2DO)
Part 21/50.55 Reactors, - (EMAIL)
EN Revision Imported Date: 10/6/2023
EN Revision Text: PART 21 - CIRCUIT BREAKER POTENTIAL DEFECTS
The following is a synopsis of information from Paragon Energy Solutions, LLC received via email.
On 9/5/2023, Paragon was informed of two recent failures of Eaton JD/HJD series circuit breakers. In both cases, troubleshooting identified an OEM terminal lug (part number TA250KB) installed on the breaker line side connection point was loose creating a high resistance connection leading to breaker damage and interruption of power to the connected load. Paragon has taken action to identify and quarantine in-process work on these breakers until appropriate inspections can be performed and entered this issue into their non-conformance/corrective action process. Paragon is working with the breaker manufacturer to help in determination of cause and formal corrective action to prevent recurrence. Paragon is also developing tests to determine if the TA250KB terminal lug can be inadvertently loosened during normal breaker installation/replacement into its associated motor control center cubicle. Paragon Engineering and Quality Assurance departments are collaborating, and final corrective action should be completed by 10/5/2023.
Point of Contact:
Richard Knott
Vice President Quality Assurance
Paragon Energy Solutions LLC
817-284-0077
Affected plants:
Beaver Valley
Limerick
North Anna
Sequoyah
Susquehanna
* * * UPDATE ON OCTOBER 5, 2023 AT 1737 EDT FROM RICHARD KNOTT TO KAREN COTTON * * *
The results of Paragon Engineering and Quality Assurance departments' final corrective action plan regarding the Eaton JD/HJD series circuit breakers OEM terminal lug (part number TA250KB) collaboration are as follows:
Paragon has taken action to identify and quarantine in-process work on these breakers until appropriate inspections can are performed and is also working with the breaker manufacturer (Eaton) to help in determination of cause and formal corrective action to prevent any recurrence.
Paragon will also conduct torque checks of all breaker lugs installed on J Frame molded case circuit breakers (MCCBs) currently in inventory.
Paragon completed testing to determine if the TA250KB terminal lug can be inadvertently loosened during normal breaker installation/replacement into its associated motor control center cubicle. Results indicated that the lug remains tight to the required torque value during removal and installation.
To mitigate potential for recurrence regardless of what Eaton determines as the cause, Paragon Electrical Engineering group will conduct training on this issue and will revise commercial grade dedication plans (CGDs) for J Frame MCCBs containing these lugs to include a torque check.
These reported failures are the first reported to Paragon. For breakers installed prior to 2017, it is likely that routine surveillance or preventive maintenance activities on the motor control centers containing this series of MCCBs would have identified overheating conditions or nuisance tripping. Paragon recommends purchasers and licensees perform inspections of affected motor control center cubicles containing the JD/HJD series MCCBs and any spares contained in plant inventory. Additionally, the hold down screws for the terminal lugs should be checked for tightness during breaker replacement activities.
Notified: R1DO(Young), R2DO(Miller) and Part 21/50.55 Reactors
EN Revision Text: PART 21 - CIRCUIT BREAKER POTENTIAL DEFECTS
The following is a synopsis of information from Paragon Energy Solutions, LLC received via email.
On 9/5/2023, Paragon was informed of two recent failures of Eaton JD/HJD series circuit breakers. In both cases, troubleshooting identified an OEM terminal lug (part number TA250KB) installed on the breaker line side connection point was loose creating a high resistance connection leading to breaker damage and interruption of power to the connected load. Paragon has taken action to identify and quarantine in-process work on these breakers until appropriate inspections can be performed and entered this issue into their non-conformance/corrective action process. Paragon is working with the breaker manufacturer to help in determination of cause and formal corrective action to prevent recurrence. Paragon is also developing tests to determine if the TA250KB terminal lug can be inadvertently loosened during normal breaker installation/replacement into its associated motor control center cubicle. Paragon Engineering and Quality Assurance departments are collaborating, and final corrective action should be completed by 10/5/2023.
Point of Contact:
Richard Knott
Vice President Quality Assurance
Paragon Energy Solutions LLC
817-284-0077
Affected plants:
Beaver Valley
Limerick
North Anna
Sequoyah
Susquehanna
* * * UPDATE ON OCTOBER 5, 2023 AT 1737 EDT FROM RICHARD KNOTT TO KAREN COTTON * * *
The results of Paragon Engineering and Quality Assurance departments' final corrective action plan regarding the Eaton JD/HJD series circuit breakers OEM terminal lug (part number TA250KB) collaboration are as follows:
Paragon has taken action to identify and quarantine in-process work on these breakers until appropriate inspections can are performed and is also working with the breaker manufacturer (Eaton) to help in determination of cause and formal corrective action to prevent any recurrence.
Paragon will also conduct torque checks of all breaker lugs installed on J Frame molded case circuit breakers (MCCBs) currently in inventory.
Paragon completed testing to determine if the TA250KB terminal lug can be inadvertently loosened during normal breaker installation/replacement into its associated motor control center cubicle. Results indicated that the lug remains tight to the required torque value during removal and installation.
To mitigate potential for recurrence regardless of what Eaton determines as the cause, Paragon Electrical Engineering group will conduct training on this issue and will revise commercial grade dedication plans (CGDs) for J Frame MCCBs containing these lugs to include a torque check.
These reported failures are the first reported to Paragon. For breakers installed prior to 2017, it is likely that routine surveillance or preventive maintenance activities on the motor control centers containing this series of MCCBs would have identified overheating conditions or nuisance tripping. Paragon recommends purchasers and licensees perform inspections of affected motor control center cubicles containing the JD/HJD series MCCBs and any spares contained in plant inventory. Additionally, the hold down screws for the terminal lugs should be checked for tightness during breaker replacement activities.
Notified: R1DO(Young), R2DO(Miller) and Part 21/50.55 Reactors
Agreement State
Event Number: 56717
Rep Org: Colorado Dept of Health
Licensee: UC Health University
Region: 4
City: Aurora State: CO
County:
License #: CO 828-01
Agreement: Y
Docket:
NRC Notified By: Shiya Wang
HQ OPS Officer: Thomas Herrity
Licensee: UC Health University
Region: 4
City: Aurora State: CO
County:
License #: CO 828-01
Agreement: Y
Docket:
NRC Notified By: Shiya Wang
HQ OPS Officer: Thomas Herrity
Notification Date: 09/06/2023
Notification Time: 11:01 [ET]
Event Date: 09/05/2023
Event Time: 13:00 [MDT]
Last Update Date: 09/06/2023
Notification Time: 11:01 [ET]
Event Date: 09/05/2023
Event Time: 13:00 [MDT]
Last Update Date: 09/06/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Azua, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Azua, Ray (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - PATIENT RECEIVED 29 PERCENT OVERDOSE
The following was received from the Colorado Department of Public Health and Environment via email:
"The Radiation Safety Officer (RSO) reported at 1530 MDT on 9/5/23 that at about 1300 MDT on 9/5/23, a nuclear medicine technologist administered 206.7 mCi of Lu-177 PSMA (Pluvicto) to a patient, however the prescribed dosage on the written directive was only 160 mCi. The total dose delivered differed from the prescribed dose by 29 percent exceeding the threshold of 20 percent. The RSO indicated that the technician did not follow the written directive to verify the dose before injection because this type of treatment usually requires 200 mCi. At 1906 MDT on 9/5/23, the RSO provided a dose calculation that indicated the delivered dose differs from the prescribed dose by 0.49 Sv effective dose equivalent (more than the 0.05 Sv threshold) and 0.5-3.5 Sv to multiple organs (more than the 0.5 Sv threshold). A written report is required within 15 days of September 5, 2023."
Colorado Event Report ID No.: CO230028
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 was received from the Colorado Department of Public Health and Environment via email:
"The Radiation Safety Officer (RSO) reported at 1530 MDT on 9/5/23 that at about 1300 MDT on 9/5/23, a nuclear medicine technologist administered 206.7 mCi of Lu-177 PSMA (Pluvicto) to a patient, however the prescribed dosage on the written directive was only 160 mCi. The total dose delivered differed from the prescribed dose by 29 percent exceeding the threshold of 20 percent. The RSO indicated that the technician did not follow the written directive to verify the dose before injection because this type of treatment usually requires 200 mCi. At 1906 MDT on 9/5/23, the RSO provided a dose calculation that indicated the delivered dose differs from the prescribed dose by 0.49 Sv effective dose equivalent (more than the 0.05 Sv threshold) and 0.5-3.5 Sv to multiple organs (more than the 0.5 Sv threshold). A written report is required within 15 days of September 5, 2023."
Colorado Event Report ID No.: CO230028
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.