Event Notification Report for May 07, 2025
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/06/2025 - 05/07/2025
Agreement State
Event Number: 57738
Rep Org: Colorado Dept of Health
Licensee: HCA HealthONE Sky Ridge
Region: 4
City: Lone Tree State: CO
County:
License #: CO 1053-01
Agreement: Y
Docket:
NRC Notified By: Maggie Schnettler
HQ OPS Officer: Ernest West
Licensee: HCA HealthONE Sky Ridge
Region: 4
City: Lone Tree State: CO
County:
License #: CO 1053-01
Agreement: Y
Docket:
NRC Notified By: Maggie Schnettler
HQ OPS Officer: Ernest West
Notification Date: 06/03/2025
Notification Time: 15:19 [ET]
Event Date: 05/07/2025
Event Time: 00:00 [MDT]
Last Update Date: 06/03/2025
Notification Time: 15:19 [ET]
Event Date: 05/07/2025
Event Time: 00:00 [MDT]
Last Update Date: 06/03/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Dodson, Doug (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Dodson, Doug (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
LOST BRACHYTHERAPY SEED
The following information was provided by the Colorado Department of Public Health and Environment via email:
"On May 30, 2025, the radiation safety officer (RSO) at HCA HealthONE Sky Ridge notified the Colorado Department of Public Health and Environment via phone call that a prostate brachytherapy seed containing 2.5 mCi of palladium-103 was discovered to be missing during the licensee's inventory. The inventory was conducted on May 7, 2025, but the actual date of loss is unknown."
Colorado Event Number: CO250015
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
The following information was provided by the Colorado Department of Public Health and Environment via email:
"On May 30, 2025, the radiation safety officer (RSO) at HCA HealthONE Sky Ridge notified the Colorado Department of Public Health and Environment via phone call that a prostate brachytherapy seed containing 2.5 mCi of palladium-103 was discovered to be missing during the licensee's inventory. The inventory was conducted on May 7, 2025, but the actual date of loss is unknown."
Colorado Event Number: CO250015
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
Event Number: 57697
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Bard Brachytherapy
Region: 3
City: Carol Stream State: IL
County:
License #: IL-02062-01
Agreement: Y
Docket:
NRC Notified By: Kimberly Stice
HQ OPS Officer: Jordan Wingate
Licensee: Bard Brachytherapy
Region: 3
City: Carol Stream State: IL
County:
License #: IL-02062-01
Agreement: Y
Docket:
NRC Notified By: Kimberly Stice
HQ OPS Officer: Jordan Wingate
Notification Date: 05/07/2025
Notification Time: 17:35 [ET]
Event Date: 05/07/2025
Event Time: 00:00 [CDT]
Last Update Date: 05/08/2025
Notification Time: 17:35 [ET]
Event Date: 05/07/2025
Event Time: 00:00 [CDT]
Last Update Date: 05/08/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Ruiz, Robert (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Ruiz, Robert (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
AGREEMENT STATE REPORT - MISSING PACKAGES
The following information is a summary provided by the Illinois Emergency Management Agency (Agency) via phone and email:
On May 7th, 2025, the Agency received a notification from Bard Brachytherapy in Carol Stream, IL to advise of four missing packages of I-125.
Package A: 39 sources, activity - 1457.430 MBq (39.39 mCi)
Package B: 39 sources, activity - 1457.430 MBq (39.39 mCi)
Package C: 39 sources, activity - 1457.430 MBq (39.39 mCi)
Package D: 40 sources, activity - 1494.800 MBq (40.40 mCi)
Source model number: STM 1251
The package was sent via [common carrier] from Chicago O'Hare Airport on May 2nd, 2025. The package destination was East London, Africa.
An investigation by the Agency is ongoing.
Illinois Item Number: IL250018
* * * UPDATE ON 05/08/2025 AT 1501 EDT FROM GARY FORSEE TO JORDAN WINGATE * * *
"On May 7, 2025, Bard Brachytherapy reported to the Agency the apparent loss of (4) packages containing a total of (158) I-125 brachytherapy seeds with an activity of 0.59 mCi each. The packages were shipped to a client in South Africa via [common carrier] at Chicago O'Hare Airport on May 2, 2025. Data available at the time of the report indicated the packages had been lost while in the possession of the carrier. The following day, May 8, 2025, the licensee advised the packages had actually arrived timely in South Africa on May 4, 2025. No public exposures resulted from this incident. Pending the licensee's written report and explanation on gaps in accountability, this matter is considered closed."
Notified R3DO (Ruiz), NMSS Events Notification (email) and ILTAB (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
The following information is a summary provided by the Illinois Emergency Management Agency (Agency) via phone and email:
On May 7th, 2025, the Agency received a notification from Bard Brachytherapy in Carol Stream, IL to advise of four missing packages of I-125.
Package A: 39 sources, activity - 1457.430 MBq (39.39 mCi)
Package B: 39 sources, activity - 1457.430 MBq (39.39 mCi)
Package C: 39 sources, activity - 1457.430 MBq (39.39 mCi)
Package D: 40 sources, activity - 1494.800 MBq (40.40 mCi)
Source model number: STM 1251
The package was sent via [common carrier] from Chicago O'Hare Airport on May 2nd, 2025. The package destination was East London, Africa.
An investigation by the Agency is ongoing.
Illinois Item Number: IL250018
* * * UPDATE ON 05/08/2025 AT 1501 EDT FROM GARY FORSEE TO JORDAN WINGATE * * *
"On May 7, 2025, Bard Brachytherapy reported to the Agency the apparent loss of (4) packages containing a total of (158) I-125 brachytherapy seeds with an activity of 0.59 mCi each. The packages were shipped to a client in South Africa via [common carrier] at Chicago O'Hare Airport on May 2, 2025. Data available at the time of the report indicated the packages had been lost while in the possession of the carrier. The following day, May 8, 2025, the licensee advised the packages had actually arrived timely in South Africa on May 4, 2025. No public exposures resulted from this incident. Pending the licensee's written report and explanation on gaps in accountability, this matter is considered closed."
Notified R3DO (Ruiz), NMSS Events Notification (email) and ILTAB (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