Event Notification Report for April 04, 2025

EN Revision Imported Date: 4/4/2025

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was provided by the Georgia Radioactive Materials Program via email:

"Licensee contact stated the following: On March 12, 2025, a 71-year-old female patient received an administration of 1.98 millicuries (mCi) of sodium iodide I-123 for nuclear medicine thyroid imaging with uptake. The standard prescribed dose for this study is approximately 200 microcuries. Initial dose calculations, based on the package insert and a measured thyroid uptake of 64.7 percent, estimate the absorbed thyroid dose to be 1.67 Gy (167 rad). These calculations assume administration occurred near the end of the drug's expiration period. Further clarification regarding the exact dosing time will assist in refining the thyroid dose assessment.

"An investigation is ongoing to determine the source of this dosing discrepancy. A formal written report will be submitted by the licensee on Friday, March 28, 2025."

GA NMED Report Incident #92

* * * UPDATE ON 03/31/2025 AT 1551 EDT FROM ANASTASIA BENNETT TO KERBY SCALES * * *

The following update is a summary of information received from the Georgia Radioactive Materials Program via email:

A patient was supposed to receive 200 microcuries of iodine-123 but instead received 1.98 mCi for a thyroid imaging study. The administered dose was approximately ten times higher than intended. This error resulted from miscommunication and mislabeling of the dose. The authorized user assessed the situation and determined that the risk of thyroid harm was minimal. The hospital calculated the thyroid dose to be approximately 1.74 Gy (174 rad) and has since implemented new safety measures. These include requiring faxed orders for radiopharmaceuticals and instituting multiple reviews for dose inspections to prevent future errors.

Notified R1DO (Bickett), NMSS Coordinator (Allen), NMSS (Silberfeld) and NMSS Events_Notification (email).

* * * UPDATE ON 04/03/2025 AT 1033 EDT FROM ANASTASIA BENNETT TO JORDAN WINGATE * * *

The following update is a summary of information received from the Georgia Radioactive Materials Program via email:

On April 2, 2025, a phone call was made to the radiation safety officer (RSO) for further clarification. The error originated from an incorrect recording of the dose units by the nuclear technician. The misrecorded information was then relayed to RLS Radiopharmacies, resulting in a labeling discrepancy. The technician did not verify or cross-check the recorded units before confirming the prescribed dose. The licensee is working to acquire an electronic tracking system like Epic within the next two months to ensure that miscommunications are limited. The radiation safety officer submitted a follow-up email to provide further clarification.

Notified R1DO (Bickett), NMSS Coordinator (Allen), NMSS (Silberfeld) and NMSS Events_Notification (email).

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 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 - IMPROPER SHIPMENT OF BYPRODUCT MATERIALS

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 was contacted by Customs and Border Protection regarding a shipment that was passing through their checkpoint in the port of Houston, Texas. The shipment set off their radiation monitors and the radionuclides were identified as americium-241 and radium-226. When the Department contacted the shipper, the shipper stated that part of the shipment was smoke detectors. The shipper made arrangements for the shipment to be returned to the originating location in Farmers Branch, Texas. On March 14, 2025, a Department investigator went to the shipper's location and confirmed that the shipment contained two boxes with smoke detectors. On March 27, 2025, a Department investigator went back to the location to inspect the materials and perform radiological surveys. The investigator verified that the two boxes contained approximately 3,200 smoke detectors. The investigator noted that a large number of the americium-241 sources had been separated from the smoke detectors and were laying free inside the boxes. The investigator found that the dose rates on contact with the outside of the box were around 75 uR/hr. A gamma spectroscopy reading of the box determined the radionuclides to be americium-241 and radium-226. The investigator did not detect any loose surface contamination. The owner (shipper) of the package was directed to secure the packages containing the smoke detectors in a secure location. Based on the radiological surveys performed by the Department, no individual would have received a significant exposure as a result of this event. The owner of the material has agreed to impound all the sources and secure them in an area not easily accessible to an individual. The Department will assist the owner of the smoke detectors in finding a contractor to properly dispose of the material."

Texas incident number: 10185
NMED number: TX250020

There was no indication that any foils were separated from the shipping packages. The owner of the shipment does not have a Texas license for the possession of byproduct materials. The Department will continue to investigate this incident.

AGREEMENT STATE REPORT - LOST SOURCE

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

"On March 21, 2025, the Illinois Emergency Management Agency received a notification from G. E. Healthcare in Arlington Heights, IL to advise of a radiopharmaceutical package missing in transit. The package was shipped via [common carrier] on March 19, 2025, to the San Francisco International Airport (SFO) for delivery on March 20, 2025, to RLS Radiopharmacy in Sacramento, CA. The lost package contained two vials of iodine-123 DaTscan, containing 40 mCi at the time of shipment. The last documented scan shows no movement after an arrival scan at the SFO cargo station on the evening of March 19th at 2005 PDT. At this time, the [common carrier] conducted searches at both the O'Hare International and SFO airports along with ramps and gates with no developments.

"The package contents have since decayed to less than 2 mCi and do not represent a public exposure hazard. This package would be considered an IAEA Category 5 source, meaning it is the least likely to be dangerous, and even if dispersed would not cause permanent injury.

"Illinois Emergency Management Agency will be contacting California to make them aware."

Illinois Item Number: IL250015

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

"On March 28, 2025, the Department was contacted by the radiation safety officer (RSO) of an industrial radiography company licensed in the state of Texas. The RSO stated they were contacted by a local fire chief about a device found on the side of the road in Texas City, Texas. The RSO went to the location and identified the device as a Troxler model 3411-B moisture density gauge. The RSO stated he measured 1.4 mR/hr at the surface of the gauge. The radionuclide was identified as cesium-137. The RSO stated he transported the gauge to their facility to store it in their vault. The gauge label plate states the gauge contains an 8 millicurie cesium - 137 source and a 40 millicurie americium - 241 source. The gauge cesium operating rod was fully retracted, and a lock was in place on the cesium source operating rod. The operating rod and lock were very corroded. The storage case the gauge was contained in looked to be in very good condition. The RSO provided pictures of the gauge to the Department. The RSO also provided the serial number for the gauge. The Department searched both its local and the national Nuclear Materials Event Database and did not find a record of the gauge being reported as lost in the State of Texas. The Department contacted the RSO for the gauge manufacturer and was provided with the name of the licensee the gauge had been sold to. A search of the Department's licensing records found the license of the company who had purchased the gauge had been revoked by the Department on July 1, 1991. The Department has arranged to take possession of the gauge on Monday March 31, 2025. Additional information will be provided as it is received in accordance with SA-300."

Texas incident number: 10187
NMED number: TX250021

EN Revision Imported Date: 4/7/2025

EN Revision Text: SECONDARY CONTAINMENT BOUNDARY INOPERABLE

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

"At 1026 [EDT] on March 18, 2025, it was discovered that the secondary containment boundary door was found fully open, rendering the secondary containment boundary inoperable, therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72 (b)(3)(v). The door was closed at 1029 on March 18, 2025, and the secondary containment boundary was declared operable.

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

"The NRC Resident Inspector has been notified.

"There has been no impact to Unit 2 and Unit 3 continues to operate at 100 percent power."


* * * RETRACTION ON 04/04/25 AT 1049 EDT FROM RYAN ROBILLARD TO JOSUE RAMIREZ * * *

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

"This report retracts the 8-hour notification made on March 18, 2025, for NRC Event Number EN #57615.
"NRC Event report number 57615 describes a condition at Millstone Power Station Unit 3 (MPS3) where a secondary containment boundary door was found fully open, rendering the secondary containment boundary inoperable. This condition was reported in accordance with 10CFR 50.72(b)(3)(v)(D) as a condition that could have prevented the fulfillment of a safety function to mitigate the consequences of an accident.
"Upon further review of the conditions that existed at the time, MPS3 has concluded that the door was not blocked open. The time duration from the activation of the door security alarm to the arrival of security personnel and the subsequent closure of the door was less than four minutes. The door was left unattended for less than 40 seconds, which is less than the five-minute criteria for entry and egress without special provisions. The supplementary leak collection and release system drawdown test has sufficient margin to accommodate this unattended door time. The evaluation concluded that the secondary containment boundary remained operable throughout this event and did not lose the ability to perform its safety function to control the release of radioactive material and mitigate the consequences of an accident.

"The basis for this conclusion will be provided to the NRC Resident Inspector."

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

This event was originally reported in accordance with 10CFR 50.72(b)(3)(v)(D) and 10CFR 50.72(b)(3)(v)(C). The licensee confirmed that the retraction is applicable to both notifications.

Notified R1DO (Bickett)

EN Revision Imported Date: 4/7/2025

EN Revision Text: UNABLE TO RETRACT SOURCE

The following is a summary of information provided by Protect, LLC via phone:

At 1043 CDT on 3/21/2025, the radiography crew was unable to retract the source for a radiography camera while performing work at a customer's manufacturing facility in Joplin, MO. The crew went to retract the source into the radiography camera, but the source did not move. The crew established boundaries to limit exposure to less than 2 millirem/hr. The crew notified site personnel and is monitoring the posted boundaries until the source is secured. Additional licensee personnel are enroute to retrieve the source. No personnel exposures due to the malfunction have occurred.

Additional information:
Manufacturer and model number: QSA Global 880
Serial number: A424-9
Source: Ir-192
Activity: 13 Ci

* * * UPDATE ON 03/21/2025 AT 1712 EDT FROM MATT SLAYMAKER TO TENISHA MEADOWS * * *

The following information was provided by Protect, LLC via email:

"On 3/21/2025, Protect, LLC had an industrial radiography source disconnect incident occur while at a customer's manufacturing facility in Joplin, MO. At approximately 1043 CDT, during the crew's first source retraction, it was determined that the source had become disconnected from the drive cable. The crew immediately recognized the situation through the use of their dosimetry equipment and established the emergency 2 millirem/hr boundaries. The regional radiation safety officer (RRSO) was immediately notified of the issue. The RRSO informed the crew to maintain surveillance of the restricted area barricades and to wait until the RRSO and corporate radiation safety officer (CRSO) arrived before any further actions were taken. The CRSO and RRSO arrived at the jobsite at approximately 1340 CDT to retrieve the source. The source was secured back into the exposure device at 1404 CDT. The CRSO received 4.5 millirem during the retrieval procedure and the RRSO received 0.6 millirem.

"Additional information on the manufacturer and model number of equipment involved in the incident:
"QSA Global 880 delta exposure device
"QSA Global Ir-192 source (13 curies), model A424-9
"QSA Global 35 ft control cables
"QSA Global 7 ft extreme weather source tube with a 4 half-value layer (HVL) collimator

"All three personnel on the job are carded radiographers."

Notified R3DO (Havertape) and NMSS Events Notifications (email)

* * * UPDATE ON 04/04/2025 AT 1142 EDT FROM MATT SLAYMAKER TO ROBERT THOMPSON * * *

The following is a summary of information provided by Protect, LLC via email:

A thorough inspection of the exposure device, source pig tail and associated equipment was performed. The crank assembly failed the misconnect test but passed all of the no-go gauge checks. The extreme weather source tube showed minimal signs of wear with a slight bend on the end swaged connection. It is not exactly clear if the disconnect was caused by an operator error when the drive cable was connected to the exposure device or if somehow the source was able to become disconnected in the source tube while retracting the source back to the camera. As a precautionary measure the associated equipment was taken out of service.

A corrective action report was issued related to this incident. Notifications to all employees will be conducted in a mandatory in-person attendance safety stand down and will be documented. Safety stand downs and re-training will be completed by April 18, 2025.

Notified R3DO (Hills), NMSS Events Notifications (email).

SPECIFIED SYSTEM ACTUATION

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

"At 0002 EDT on 4/4/25, Unit 2 was in mode 3 with all three reactor coolant pumps (RCPs) running in preparation for a reactor startup when an alarm for the 'B' RCP vibration alert/danger was received due to the indication of elevated vertical proximity vibrations. At 0014, the 'B' RCP vertical proximity vibration indication exceeded the pump trip setpoint and the reactor trip breakers were manually opened, followed by the 'B' RCP being manually tripped. All rods were fully inserted prior to the reactor protection system (RPS) actuation, and all required equipment responded as designed.

"This event is reportable in accordance with 10 CFR 50.72(b)(3)(iv)(A) as an event that results in a valid actuation of the RPS."

NRC Resident has been notified.

BOTH TRAINS OF REACTOR BUILDING TO SUPPRESSION CHAMBER VACUUM BREAKERS INOPERABLE
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The following information was provided by the licensee via phone and email:

"At 0400 CDT on 4/05/2025, it was discovered that both trains of reactor building to suppression chamber vacuum breakers were simultaneously inoperable. Due to this inoperability, the system was in a condition that could have prevented the fulfillment of a safety function; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D). 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:

Both trains were restored to operable on discovery. The inoperability was a result of a configuration control issue following their refueling outage. The licensee will investigate the cause of the configuration control issue.