Event Notification Report for February 24, 2025

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was provided by the Massachusetts Radiation Control Program (MRCP) via email:

"On 02/13/25, at 1138 EST, the licensee, Beth Israel Deaconess Medical Center (Massachusetts license number: 60-0432) reported a medical event involving yttrium-90 Theraspheres (Manufacturer: Nordion BWXT ITG Canada, Inc.; Model: TheraSphere Y-90 glass microsphere system; sealed source and device registration number: NR-0220-D-131-S). The total administered activity differed from prescribed treatment activity as documented in the written directive by 20 percent or more.

"The medical event occurred on 2/11/25. The activity delivered was calculated to be 45.5 percent of the prescribed activity (prescribed activity: 4.13 GBq, delivered activity: 1.88 GBq). The event was identified on 2/12/25. The licensee reported that there was no adverse effect on the patient. The authorized user, referring physician, and patient have been notified.

"MRCP will follow up with the licensee's radiation safety officer (RSO) to determine event cause and corrective actions. The device has been taken out of service while the investigation remains open.

"The MRCP considers this event open. The MRCP will follow up with a special inspection of the licensee."

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 - LOST I-125 SEED

The following information was provided by the Illinois Emergency Management Agency (the Agency) via phone and email:

"The Agency was contacted on 2/13/25, by the University of Chicago to report the inadvertent disposal of a an I-125 brachytherapy seed down the facility's sink drain. The loss is believed to have occurred during sterilization prior to implant on 2/5/25. Five extra sterilized and packaged I-125 seeds were brought to the facility's radiation oncology department in the event they were needed for the procedure. The extra seeds were not needed and the unopened package was taken to the source storage room. It is unclear if surveys of the unused seeds were performed as required. On 2/12/25, the package believed to contain the five I-125 seeds was opened and found to be empty.

"Radiation safety staff surveyed applicable areas and located four of the five seeds in the sterilization area's sink drain. The fifth seed was not located and is being reported as lost, with the likely disposition of being inadvertently disposed of via the sanitary sewer.

"The brachytherapy seed has decayed to approximately 0.344 millicuries and would have an exposure rate of just over 2 millirem per hour at six inches. [The original activity of the I-125 brachytherapy seed was 0.405 millicuries.] The loss is reportable to the U.S. NRC within 30 days. Agency inspectors will conduct a reactive inspection to determine root cause and measures taken to prevent a recurrence. This report will be updated as additional information becomes available."

Illinois Item Number: IL250006

THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

AGREEMENT STATE REPORT - STUCK OPEN SHUTTER

The following information was provided by the Illinois Emergency Management Agency (the Agency) via phone and email:

"The Agency was contacted on 2/14/25 by representatives for ExxonMobil Oil Corp. (IL-01742-01) in Joliet, IL, to report a fixed gauge shutter stuck in the open position. The 20 mCi Cs-137 source is oriented into a process vessel that will not be entered. The gauge is normally in the `open' position and the vessel remains in use and full of commodity.

"The manufacturer's representative is being contacted to coordinate a site visit and make appropriate repairs. There are no exposures reported or anticipated as a result of this issue. The shutter condition was discovered [on 2/14/25] and reporting requirements were met. Inspectors are coordinating a site visit to gather supporting details. This matter is reportable within 24 hours under 32 Illinois Administrative Code 340.1220(c)(2). Updates will be provided as they become available."

Illinois Item Number: IL250007

AGREEMENT STATE REPORT - LOST SOURCE

The following information was received from the Wisconsin Department of Health Services (the Department) via email:

"On January 22, 2025, the Department received a telephone notification that the licensee was unable to locate a vial containing (as of January 1, 2025) 167 microcuries of cesium-137. The source was transferred to the licensee's possession with the return of a leased positron emission tomography-computed tomography (PET/CT) coach on January 25, 2024 and was stored on the coach. The licensee subsequently decommissioned and sold the coach and believed they had removed the source as part of the decommissioning. On January 10, 2025, the licensee's radiation safety officer observed that the source was not listed on inventory records. The licensee contacted the transferor of the source, the new purchaser of the vehicle, and searched their facility. Neither the licensee, transferor, nor the transferee could locate the source. On January 20, 2025, the licensee declared the source lost.

"The Department performed a reactive inspection on February 7, 2025. The vial source is an Eckert and Ziegler model RV-137-200U with serial number 1896-16-16 and contained 201 microcuries at manufacture on January 1, 2017."

WI Event Report ID No: WI250001.

THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

AGREEMENT STATE REPORT - DAMAGED FIXED GAUGE

The following information was provided by the South Carolina Department of Environmental Services (the Department) via phone and email:

"The licensee informed the Department on February 14, 2025, via telephone, that it had discovered damage (tear) to the film covering the window of the source side of a fixed gauging device. The licensee discovered this event on February 14, 2025. The licensee reported that a representative from the manufacturer of the fixed gauging device was on-site and repaired/replaced the source side window on February 14, 2025. The licensee reported that the the fixed gauging device shutter closed as expected, and the licensee did not report any ongoing health and safety concerns or overexposures.

"The fixed gauging device is a Thermo EGS Gauging LLC, Model TFC-185 (source holder serial number KA2196), housing a 1250 mCi Kr-85 sealed source. The sealed source is a Isotope Product Laboratories Model NER-588. This event is still under investigation by the Department."

South Carolina Event Number: TBD

PRIMARY CONTAINMENT DEGRADED

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

"At 1111 EST on 02/22/2025, while in mode 5 at 0 percent power, it was determined during local leak rate testing (LLRT) that the Unit 2 primary containment leakage rate exceeded the allowable limit (La) as defined in 10 CFR 50, Appendix J, `Primary Reactor Containment Leakage Testing for Water-Cooled Power Reactors' due to both primary containment isolation valves in a penetration failing LLRT requirements. This event is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(ii)(A).

"There was no impact on the health and safety of the public or plant personnel.

"The NRC Resident Inspector has been notified."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

The valves that failed the LLRT are located in the torus purge line. The licensee's corrective action is to remove and repair the valves.