Event Notification Report for March 25, 2025

AGREEMENT STATE REPORT - LOST SEED

The following is a summary of information provided by the New York City (NYC) Department of Health via email:

The licensee reported a loss of licensed material in quantity more than 10 times the value in 10 CFR Part 20 Appendix C. Memorial Sloan-Kettering reported via email on 5/22/2025 that a I-125 localization seed was discovered to be lost by the licensee on 3/26/2025 during an inventory. A discarded seed from a procedure done on 1/23/2025 was not able to be located. The activity was estimated as 98 microcuries on the date of use.

New York Identification Number: NY250005

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 - MEDICAL EVENT

"The licensee initially reported an underdose event that involved a CyberKnife (linear accelerator), and the event was referred to our X-ray inspection unit. On 4/11/25, our X-ray unit informed us that the underdose event involved an Elekta Gamma Knife Perfexion (Co-60) that experienced an electrical sensor failure that caused the patient's treatment to be interrupted.

"The original planned treatment using stereotactic radiosurgery to the right trigeminal nerve using a single 4 mm collimator open shot to deliver a maximum of 80 Gy (76 Gy at the 95 percent isodose line). The treatment time was to take 49.24 minutes. However, after 12.47 minutes of treatment, a system error on the GK unit triggered a stop in treatment. All radiation sources (Co-60) were retracted to home positions and the patient was automatically removed from the treatment bore by the robotic couch with the shielding doors automatically closing. The patient only received 25 percent of the dose on 3/26/25, or about 20 Gy.

"On 3/27/25, the machine was successfully repaired by an Elekta engineer and the patient came back to the facility to complete treatment. The authorized user physicians modified their written directive and treatment plan to give an additional maximum dose of 70 Gy (66.5 Gy at the 95 percent isodose line) to the same treatment area. The patient successfully completed the treatment."

California 5010 Number: 032625

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 - MEDICAL EVENT

The following information was provided by the New Jersey Department of Environmental Protection via email:

"On 3/26/25, a patient at Robert Wood Johnson University Hospital was underdosed by approximately 50 percent when the Y-90 Therasphere delivery kit malfunctioned. The tubing will be kept and sent to Boston Scientific [manufacturer] for further information.

"The target organ was the liver."

NJ Event Report ID number: To be determined.

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.

PART 21 - SOFTWARE ERROR IN TRANSIENT STABILITY PROGRAM

The following information was provided by Southern Nuclear Operating Company via email:

"This is a non-emergency notification required by 10 CFR 21.21(d)(3)(i). A written report in accordance with 10 CFR 21.21(d)(3)(ii) will be provided within 30 days.

"Based upon the information provided by Operation Technology, Inc. (OTI) in [electrical transient analyzer program] (ETAP) error report ERCA-24-003, revision 1, Southern Nuclear Operating Company (SNC) has determined that a substantial safety hazard could have been created by the error introduced in the transient stability program in the current release of ETAP software utilized at Edwin I. Hatch Nuclear Plant (HNP) and Vogtle Electric Generating Plant Units 1 and 2 (VEGP1-2) were it to go uncorrected. While the nature of the software error detailed by OTI in ETAP error report ERCA-24-003, revision 1 had the potential to impact bus transfers and degrade essential safety-related equipment, SNC has verified that none of the HNP or VEGP1-2 calculations that utilized the transient stability program had false favorable results.

"The NRC Senior Residents at HNP and VEGP1-2 have been notified."

Affected plants:
Hatch Nuclear Plant Units 1 and 2
Vogtle Electric Generating Plant Units 1 and 2

AGREEMENT STATE REPORT - LOST MATERIAL

The following information was provided by the New York City (NYC) Department of Health via email:

"The licensee reported a loss of licensed material in quantity more than 1000 times the value in 10 CFR part 20 appendix C.

"The radiation safety officer for New York University (NYU) Langone Hospitals (NYC license number: 75-2955-01) reported on the phone that they misplaced a shipment of Lu-177 for medical use. The material was delivered yesterday morning [03/24/25], but this morning they could not locate it. They think it may have been put in the trash, and they are following up with their waste company to try to track it down. The activity was about 200 millicuries as of yesterday.

"A written report is expected with more information from the licensee."

* * * UPDATE ON 03/31/2025 AT 1317 EDT FROM ERIK FINKELSTEIN TO OSSY FONT * * *

The following summary was provided by the New York City (NYC) Department of Health via email:

The licensee located the material inside a large garbage dumpster on their property. They will be working to retrieve it.

Notified R1DO (Bickett), NMSS Events Notifications (email), ILTAB (email), and CNSC (Canada) (email).

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

UNANALYZED CONDITION

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

"The facility is in a safe and stable configuration and no accident has occurred. A non-conservative value was found in a calculation used to model the foam tank connected to the liquid effluent collection and treatment system (LECTS) slab tank. There is no immediate concern to criticality safety and additional conservatism exists in the calculation. The LECTS system was secured and signs were posted on the doors to prevent personnel from entering the room."

NRC Regional office will be notified.

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

The LECTS and foam tanks are currently empty and are normally empty tanks.

AGREEMENT STATE REPORT - LOST SOURCE

The following information was provided by the New York State Department of Health (NYSDOH) via email:

"NYSDOH received a phone report of a missing source on March 25, 2025, from PharmaLogic Holdings, Corp.'s corporate radiation safety officer. An email with additional details was received shortly after the phone report at approximately [1700] EDT.

"On March 3, 2025, a Co-57 flood source (activity: 15 mCi on 10/20/23 decayed to 4.19 mCi or 155 MBq on 03/03/25, manufacturer: RadQual, serial number: BM01L152326102) was shipped from Pharmalogic in Syracuse, NY to International Isotopes in Idaho Falls, ID. The package was shipped by [common carrier] on 3/03/25, with a specific tracking number.

"The package measured 29 by 19 by 4 inches and weighed 23 pounds at the time of shipment. A package with the same tracking number arrived at the destination in Idaho on 3/25/25, however, the dimensions were different than the original package and the yellow-II label on the package indicated it contained a Cs-137 source with an activity of 1.45 GBq (approximately 39 mCi). There is also a label on the package that indicates the package was being shipped to and from Technical Resources Group, Inc., in Idaho Falls, ID.

"The NYSDOH is tracking this event under incident number 1525. NYSDOH will provide an update to this notification once additional information is available."

NYSDOH is reporting per 10 CFR 20.2201(a)(1)(ii) for the theft or loss of licensed material in a quantity greater than 10 times the Appendix C value of 100 microcuries.

Event Report ID No.: NY-25-05

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 - MEDICAL EVENT

The following information was received by the Ohio Department of Health via email:

"A patient was scheduled to receive 200 mCi of PLUVICTO [Lu-177], however, they only received approximately 130 mCi [administered to the prostate]. The injection was through a three-way stopcock; one port was for the saline solution, the other for the PLUVICTO. Near the end of the injection, the material back flowed into the syringe and leaked onto the chucks under the patient's arm.

"Based on surveys of the syringe and chucks, approximately 70 mCi had leaked which resulted in a 35 percent underdose. The patient was surveyed and there was no indication the patient's skin was contaminated or signs of extravasation.

"The patient's physician was notified of the event.

"An investigation by Ohio is pending."

NMED Report Number: OH250003

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 SEED

The following is a summary of information provided by the New York City Department of Health via email:

The licensee reported a loss of licensed material in quantity more than 10 times the value in 10 CFR Part 20 Appendix C. Memorial Sloan-Kettering reported via email on 5/22/2025 that a I-125 localization seed was discovered to be lost by the licensee on 3/25/2025 during a routine reconciliation. The seed had been implanted in a patient on 3/20/2025 and explanted on 3/21/2025. The activity was estimated as 115 microcuries on the date of clinical use.

New York Identification Number: NY250004

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