Event Notification Report for March 26, 2025

THEFT OR LOSS OF LICENSED MATERIAL

The following is a summary of the information provided by the licensee via phone:

During a shipment from Wilmington, Delaware to Albuquerque, New Mexico, a 0.63 millicurie iron-55 (Fe-55) source was lost or stolen in transit. The last known location was Wilmington, Delaware. The source was shipped on March 27, 2025, and was identified as lost on April 10, 2025. The shipping package was delivered to the intended recipient, but the shipping package was compromised with the source missing. The shipper and the common carrier are investigating.

Model Number: FE5VZ29120005M
Serial Number: NK772

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 - RECOVERED SOURCES

The following report was received by the Georgia Radioactive Materials Program via email:

"On March 27, 2025, two sources (Ge-68) were found at a car repossession lot. It was determined the sources had been at that car repossession lot since sometime in October of 2024 and remained there until March 27, 2025, at which time GFD Hazmat recovered them and handed them off to EPD. The original activity was 1.49 mCi per source. The estimated decayed value was 0.05 mCi at the time of discovery and 0.04 mCi to date. The manufacturer confirmed the shipping location (GA 1490-1) and date of the source with a serial number.

"The licensee responded with disposal records to Sanders Medical (Tennessee licensed facility). Sanders was able to confirm receipt of the material on April 15, 2025. It was determined the serial numbers listed on the lead pigs did not match the serial number of the enclosed sources.

"On April 15, 2025, GA 2047-1 (Training Facility) gained possession of the found sources. The manufacturer (EZ) confirmed the same shipment location and licensee with the accurate serial numbers. After several attempts to reach out to Sanders, for confirmation of receipt, the State of Georgia could not get a response until July 15, 2025. At that time, a staff member from Sanders confirmed they did not receive, nor have they ever received the two sources.

"The licensee was unable to provide disposal records for the sources, although routinely uses Sanders for disposal services. The licensee received a notice of violation on July 23, 2025."

Georgia Incident Number: 102

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 SOURCES

The following information was provided by the California Radiation Control Program via email:

"The licensee's contract physicist reported that two Cs-137 attenuation correction sources with approximate activities of 13 mCi each were missing when the licensee went to conduct an inventory in March 2025. The licensee has searched their facility but could not locate the sources."

California Report ID Number: 072825

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 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