Event Notification Report for October 06, 2023

EN Revision Imported Date: 10/6/2023

EN Revision Text: PART 21 INTERIM REPORT - FAILURE OF CURTISS WRIGHT SUPPLIED SAFETY RELATED RELAY

The following is a summary of the Part 21 report provided by Curtiss Wright:

On June 20, 2023, Duke Energy sent a letter to Curtiss Wright (CW) to formally notify them that a Tyco (Agastat) relay had failed. Duke Energy had identified certain contacts that were found sticking in the open position.

The relay was returned to CW for evaluation; however, CW could not duplicate the failure. As the relay is questionable for reliable service, CW is having the relay returned to Tyco for their evaluation. Once the evaluation is complete, the current report will be updated. CW anticipates an update to the notification with final results by October 15th.

Affected plant: Catawba

* * * UPDATE ON OCTOBER 5, 2023 AT 1146 EDT FROM JENNIFER HARRISON TO KAREN COTTON * * *

The following information was provided by Curtiss Wright via email:

"The relay was subsequently returned to TYCO for their evaluation. TYCO tested the relay with and without the LL auxiliary switch option and could not duplicate the failure. In all tested conditions, the relay performed within manufacturer specifications, and with no contact binding.

"As the noted failure could not be reproduced by Curtiss-Wright or TYCO, there is no evidence of part malfunction and thus no further evaluation or notification applies."

Notified RDO2 (Miller) and Part 21/50.55 Reactors

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

NON-AGREEMENT STATE REPORT - STUCK OPEN SHUTTER

The following information was provided by the licensee via phone:

On September 27, 2023, at 1500 EDT, Marathon Pipe Line, LLC evaluated that a fixed density gauge device shutter (Ohmart/VEGA, SR-2, SN 3767GG, Cs-137 250 mCi) was stuck in the open position. The device is located in a locked location with controlled access. There was no personnel exposure. The vendor has been contacted for repairs.

AGREEMENT STATE REPORT - POSSIBLE MISADMINISTRATION

The following information was provided by the Kentucky Department for Public Health and Safety, Radiation Health Branch (KY RHB) via email:

"KY RHB was notified on 9/29/2023, by a representative from the University of Kentucky that two patients were scheduled for treatment with Lu-177, one with commercially available Lu-177 dotatate (Lutathera) and one under a research protocol also using Lu-177 dotatate but distributed under an investigational new drug label. Both vials contained the same drug and differed only in their label for distribution / intended use. The nuclear medicine technologist prepared and administered Lu-177 dotatate from the vial labeled for research to the standard of care patient instead of the correct (commercial) vial. The patient received the correct amount of drug (prescribed activity), the correct chemical form (identical Lu-177 dotatate) by the correct route of administration as intended for their treatment. However, since the drug was dispensed from the vial distributed under the investigational new drug application intended for the research study patient, KY RHB considers this to meet the reporting requirements in Part 35 for a medical event.

"The physician was informed, the patient was informed, and no harm is anticipated as a result of this incident. Additional notifications have also been made as required considering the involvement of investigational drug product and the Institutional Review Board.

"The incident remains under evaluation and investigation for corrective actions."

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.

AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT

The following was received from the Illinois Emergency Management Agency (the Agency) via email:

"On September 29, 2023, the Agency was contacted by Rush University Medical Center of a potential medical event. The administration was determined to be clinically effective with no adverse patient impact reported.

"The medical event took place on September 28, 2023. The patient and the referring physician were notified within 24 hours. The Y-90 Therasphere dose was 23.5 percent less than the prescribed dose. Agency inspectors are scheduled to perform a reactionary inspection on October 3, 2023. Additional information is forthcoming from the licensee and updates will be sent as they are available."

Illinois Item Number: IL230027

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.

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The following report summary was received by email from Virginia Radioactive Materials Program (VRMP):

"On September 29, 2023, at approximately 0930 EDT, a Troxler moisture density gauge (model number: 3430, serial number: 32732, 8 mCi Cs-137, 40 mCi Am-241:Be) was struck by a bulldozer while the rod was extended out into the soil for measurements. The area was secured. The gauge was left in place so that the source would remain shielded by the soil and the radiation safety officer (RSO) was notified. The impact cracked the plastic housing and significantly bent the source rod handle above the gauge. The RSO verified that the source rod below the gauge was still intact. They were unable to get the source to retract. With the source inserted back into the soil, survey readings were obtained by the licensee as follows: 1 mR/hr on top of the gauge on contact; @ 5 ft away to the side 0.1 mR/hr.

"According to the RSO, no public exposure occurred. The licensee has fitted a lead pig [lead shielded container] around the source for transport to a licensed nuclear gauge service company."

Virginia Event Report ID Number: VA230002

EN Revision Imported Date: 10/6/2023

EN Revision Text: 60-DAY OPTIONAL TELEPHONIC NOTIFICATION FOR AN INVALID SPECIFIED SYSTEM ACTUATION

The following information was provided by the licensee via phone and email:

"At 1439 EDT on August 7, 2023, a spurious level spike on the unit 4 reactor coolant system (RCS) level instrument (4-RCS-LT160A, 'Hot Leg 1 Level') caused actuation of containment isolation, reactor trip, automatic depressurization system (ADS) stage 4, and in containment refueling water storage tank (IRWST) isolation signals. The spurious level changes caused an invalid signal based on the incidental response of the 4-RCS-LT160A instrumentation due to water spray that was being used for reactor vessel cleaning (being performed prior to initial fuel loading). The level fluctuations resulted in engineered safety features actuation signals (containment isolation, ADS stage 4, and IRWST isolation signals) and a reactor trip signal, with the reactor trip signal already present. Three containment isolation valves closed due to the containment isolation signal that was generated. These valves were: 4-CAS-V014, 'instrument air supply containment isolation, air-operated valve,' 4-SFS-V034, 'spent fuel pool cooling system suction header containment isolation, motor-operated valve,' and 4-SFS-V035, 'spent fuel pool cooling system suction header containment isolation, motor-operated valve.' The other automatic containment isolation valves were either already closed at the time of the event or properly removed from service. All affected equipment functioned properly. The other actuation signals that were observed during this event (ADS stage 4, IRWST isolation, and reactor trip) did not result in any equipment changing position or automatically operating (i.e., the actuation signals occurred while the systems were properly removed from service).

"Units 1, 2, and 3 were not affected. This event did not result in any adverse impact to the health and safety of the public."

The NRC Resident Inspector was notified.