Event Notification Report for March 13, 2025

AGREEMENT STATE REPORT - LOST IODINE-125 SEED

The following information was provided by the Wisconsin Department of Health Services, Radiation Protection Section (the Department), via phone and email:

"On February 7, 2025, the Department received a notification that Gundersen Clinic, Ltd (the licensee) was unable to locate a radioactive seed containing a maximum of 100 microcuries of iodine-125. The seed was identified by the licensee as missing on February 4, 2025. The licensee completed an investigation by February 7, 2025, and submitted a written report to the Department. The licensee determined that the seed was likely disposed of as non-radioactive waste following the successful implantation of other seeds. The exact date of the disposal is unknown, but the licensee determined it occurred between November 20, 2024, and February 4, 2025, which are dates when the licensee's seed inventory was fully reconciled. The Department performed a reactive inspection on February 27, 2025, and considers this event closed. The seed is an IsoAid model IAI-125A from lot number 95130; the seeds are not assigned individual serial numbers."

Wisconsin event report ID: WI250002

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 - ELUATE EXCEEDED PERMISSIBLE CONCENTRATION

The following information was summarized from an email submitted by the Kentucky Department of Radiation Control:

An eluate exceeded the permissible concentration listed in 10 CFR 35.3204(a) at the time of generator elution. The permissible concentration cannot exceed a ratio of 0.15 microcuries of molybdenumm-99 per millicurie of technetium-99m. The eluate measured 34.6 microcuries Mo-99 to 16.6 millicuries Tc-99m which is a ratio of 2.1.

No doses went out to patients from this elution. The generator had been eluted earlier in the week without incident.

The manufacturer of the generator (Curium, lot number 914-025-023) was notified. The generator has been segregated awaiting return to Curium.

AGREEMENT STATE REPORT - LEAKING SEALED SOURCE

The following information was provided by the Massachusetts Division of Radiation Control, Bureau of Climate and Environmental Health (the Agency), via email:

"On 3/5/2025 at 1549 EST, QSA Global, Inc. notified the Agency that a source imported from India was leaking. QSA Global performed two leak tests on the source upon receipt. The results of the leak tests were 0.008 micro-curies and 0.004 micro-curies. QSA Global confirmed that no contamination exists outside of the container where the source is stored."

"Isotope: Co-60
"Source model number: A424-13
"Source serial number: 102732(B)
"Form: sealed source
"Activity: 13 Ci

"The reporting requirement is immediate [per] 105 CMR 120.288, reports of leaking or contaminated sources."

AGREEMENT STATE REPORT - STUCK OPEN GAUGE SHUTTER

The following information was provided by the Texas Department of State Health Services (the Department) via phone and email:

"On March 5, 2025, the Department was notified by Honeywell International Inc (the licensee) that prior to performing maintenance on a vessel, it was found that the shutter on an Ohmart model SH-F2 gauge was stuck in the open position. Open is the normal position for the gauge. The gauge contains a 375 millicurie (original activity) cesium-137 source. The licensee reported that a service provider has been contacted, and the gauge should be repaired by March 7, 2025. The licensee reported the area around the vessel the gauge is mounted to has been isolated and posted 'No Entry'. The licensee reported that there is no risk of additional radiation exposure to members of the general public or radiation workers, due to this on/off mechanism failure. Additional information will be provided as it is received in accordance with SA-300."

Texas incident number: 10178
NMED number: TX250015

AGREEMENT STATE REPORT - LOST X-RAY FLUORESCENCE ANALYZER

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

"On March 6, 2025, the Agency made the determination that Days & Crawford Scrap Metal (GL 9223735), lost an X-Ray fluorescence analyzer device (Thermo Niton Analyzers, LLC, XLp-828q, s/n 11540). The Agency reached out to the registrant on February 11, 2025, to inquire about delinquent payments for the device's registration. The registrant responded to the Agency on March 5, 2025, that they were unable to locate the device. The device contains three sealed sources: 14 mCi of americium-241; 40 mCi of cadmium-109; and 0.005 mCi of americium-241. At this time, this is considered an accidental loss due to poor oversight and is not related to any criminal theft or diversion. This event is currently under Agency investigation. Further details will be entered as they are received."

Item Number: IL250010

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 - LOST RADIOGRAPHY CAMERA

The following information was provided by the Texas Department of State Health Services (the Department) via phone and email:

"On March 6, 2025, the Department received a call from the licensee's radiation safety officer (RSO). He reported that at around 1600 hours a radiography crew reported losing a SPEC 150 exposure device containing a 95.4 curie iridium-192 source. The RSO stated that the source was in the fully shielded position. The RSO stated that the radiographers had completed an exposure on a pipeline and the radiographer trainer told the trainee to store the exposure device. [The radiographer trainer] then went to the cab of the truck to do some paperwork. The trainee set the exposure device on the back of the truck with the guide tube removed but the 35-foot crank outs still attached. The trainee failed to secure the device in the truck. The radiographers drove [toward] the next site. The RSO stated that they traveled about a mile and realized the exposure device was no longer on the back of the truck. The radiographers turned around and retraced the path they had traveled. They did not find the device. The RSO stated that while looking for the device [the radiographers] passed two trucks, which they stopped and asked if anyone had seen the device. Both said they had not seen it. The RSO stated that they have 4 radiography crews searching in the area for the device. The operations manager is also in the area searching for the device. The RSO stated that he has tried to contact the sheriff for the area and has not been able to do so. He stated he will continue to call them until he reaches someone. The radiographers were working approximately 10 miles east of Mentone, Texas, north of state highway 302. The RSO said he would provide GPS coordinates as soon as he received them.

"Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: 10179

Notified: DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, DHS CISA Central, EPA EOC, FDA EOC, FEMA NWC, Nuclear SSA (email), CWMD Watch Desk (email), CNSNS (Mexico) email.

THIS MATERIAL EVENT CONTAINS A 'Category 2' LEVEL OF RADIOACTIVE MATERIAL

Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

PART 21 INTERIM REPORT OF DEVIATION

The following is a synopsis of information provided by Curtiss-Wright via email:

On January 7, 2025, Rosemount notified Curtiss-Wright Middleburg Heights regarding Generation 3 quick disconnect connectors (QDCs) with no connection on at least one wire, with the bad connection not favoring one specific wire. Rosemount identified five Generation 3 QDCs out of 122 tested, where the issue is specifically in the continuity of the wires. All Generation 3 QDCs from the order are currently on hold at Rosemount and have not been shipped to any customer.

On January 9, 2025, Rosemount sent Curtiss-Wright two of the five questionable Generation 3 QDCs. Curtiss-Wright performed an initial evaluation to confirm the issue. The results were initially confirmed, but with minor manipulation the Generation 3 QDCs no longer showed negative results. Curtiss-Wright and Rosemount have agreed to send all the questionable Generation 3 QDCs to an outside testing entity to help perform a failure analysis to assist in determining the root cause.

Curtiss-Wright anticipates completing the evaluation by Tuesday, May 6, 2025.

There are no known plants affected.

Contact Information:
Tim Franchuk
Curtiss-Wright Nuclear Division
Director of Quality Assurance
(513) 201-2176
tfranchuk@curtisswright.com

FITNESS FOR DUTY

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

A non-licensed contract supervisor had a confirmed positive for illegal drugs during a random fitness-for-duty test. The employee's access to the plant has been terminated.

The NRC Resident Inspector has been notified.