Event Notification Report for May 24, 2025

AGREEMENT STATE REPORT - STUCK SHUTTER

The following information was received from the Maine Radiological Control Program (RCP) via phone and email:

"On May 15, 2025, at 1142 EDT, Nine Dragons (ND) Paper contacted the Maine RCP and reported that the source shutter on a fixed nuclear level gauge was stuck in the open position and that the shutter on another gauge was failing to lock.

"While doing routine shutdown activities to dismount a unit for pipe replacement, it was discovered that one of the fixed mounted source units (source serial number: 551-2-90, 30 mCi of Cs-137) was not able to rotate the shutter to the closed position due to the shaft spinning for the shutter mechanism. Based on this finding, the lock and tag out of the unit was stopped and all work that was planned for the pipe replacement was cancelled. There was not any exposure to any personnel and the systems are still secure in the normal operation mode. ND Paper personnel barricaded the source holder and pipe piece so there would be no unintentional work on the pipe the unit is mounted to. The pipe diameter is too small to allow personnel entry, eliminating exposure risks.

"Later, while doing checks on other sources in the area it was discovered that another source (source serial number: 986-3-90, 20 mCi of Cs-137) was not able to lock its shutter. The shutter closes, as verified with a survey meter, but the locking mechanism will not operate to secure the shutter in the closed position. After discussing the issues with Berthold (the original equipment manufacturer), and mill operations, ND Paper decided to order a set of replacement holders and sources from Berthold. ND Paper will leave the units in place until Berthold is able to get replacement units and is able to schedule technicians to replace the malfunctioning gauges."

Maine RCP Event Report ID Number: ME (2025-003)

SOURCE LOST DURING SHIPMENT

The following information was provided by the licensee via phone:

A 0.182 TBq Ir-192 sealed source was lost in shipment by a common carrier. The package, a UN3332 Type A container with overpack, was picked up by the common carrier on April 25, 2025. The carrier's origin and interim sorting facilities have been searched and failed to locate the package. A search is on-going at the carrier's central sorting facility in Memphis, Tennessee. The source was in the process of being shipped to the source supplier in Vinton, LA for disposition.

THIS MATERIAL EVENT CONTAINS A 'Category 3' LEVEL OF RADIOACTIVE MATERIAL

Category 3 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 some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. 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 provided by the Illinois Emergency Management Agency (the Agency) via phone and email:

"The Agency was contacted on 5/16/2025 by Advocate Christ Medical Center (Oak Lawn, IL), to advise of a medical administration of Y-90 microspheres that resulted in 100% of the dose not being administered. The administration occurred earlier that day and the reporting requirements were met by the licensee. Both the patient and the referring physician were notified. Inspectors will follow up next week to gather relevant details.

"The licensee advised that a patient was to be administered 1.129 GBq of Y-90 Theraspheres on 5/16/25. The authorized user reportedly initiated the administration but noticed the radiation monitor did not decrease as the procedure continued. The manufacturer's representative was on site and began to assist with troubleshooting. Ultimately, the administration was aborted, and PET-CT scanning indicated the microspheres were unable to leave the vial. PET-CT imaging of the patient further indicated no microspheres were administered. However, as the administration had been initiated; this is being reported as an under-dose."

Illinois item number: IL250022

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 Illinois Emergency Management Agency (the Agency) via phone and email:

"Northwestern Memorial Healthcare contacted the Agency on 5/15/25 at 1525 CDT to advise of a potential reportable medical event. During the afternoon of 5/15/25, a patient was administered a therapeutic dosage of 200 mCi of Lu-177 (Lutathera) which resulted in a total delivered dose that differed from the prescribed dose by more than 20 percent. The event was reported within the required time by the licensee. A reactive inspection will be conducted next week. An update received today, 5/16/25, indicates that the patient is reporting no adverse effects. The licensee's investigation remains ongoing.

"Initial information indicates the intravenous administration of 200 mCi of Lu-177 (Lutathera) into the antecubital vein of the patient's right arm resulted in 142 mCi (less than 71 percent of the prescribed dosage) delivered to the target organ/tissue. The underdosing was confirmed after imaging the patient subsequent to the procedure on 5/15/25. The licensee is continuing their investigation and dose assessment. The patient and the referring physician were notified of the event as required."

Illinois item number: IL250021

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

The Agency communicated that this could be a possible extravasation, as some fraction of the administered activity was found in the patient's arm, but this has not been confirmed. The target organ was the pancreas.

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 MOISTURE DENSITY GAUGE

The following information was provided by the California Department of Public Health, Radiologic Health Branch (the Department) via email:

"The Department was notified by Krazan and Associates' radiation safety officer that a Troxler model 3430 gauge (8 mCi Cs-137, 40 mCi Am-241/Be, serial number 35944) was lost from a gauge operator's vehicle in the city of El Cajon, CA. The gauge operator finished work and placed the gauge into the Troxler transit case without engaging the trigger lock on the gamma source's handle or locking the transit box latch. The transit case was left in the pickup truck bed next to the security box that is normally used during transportation.

"The gauge operator was distracted by a cell phone call and failed to return to secure the gauge and lift/secure the tailgate. The gauge operator drove the vehicle until recalling that the gauge was not secured, but it had already fallen from the truck. The operator retraced the route and eventually found the Troxler transit case on the side of the road, but the moisture density gauge, all associated tools, and paperwork from inside were missing.

"The licensee has notified local law enforcement and posted a reward on the City of El Cajon's social media page."

California event number: 051625

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

NOTICE OF UNUSUAL EVENT- FIRE IN BATTERY BANK

The following information was provided by the licensee via phone:

At 0359 CDT, Quad Cities Unit 2 experienced a fire in one of their battery cells during a planned discharge test. An Unusual Event (HU.3) was declared at 0413 CDT and the fire was extinguished by the fire brigade at 0422 CDT.

The effected battery bank was isolated at the time of the event and all other electrical systems are functioning normally. Unit 2 remains in Mode 1 at 100 percent power and Unit 1 was unaffected. No injuries have been reported.

The NRC Senior Resident Inspector, state, and local authorities have been notified.

The event was terminated at 0520 CDT due to the fire being out and no other plant equipment being affected.

Notified DHS SWO, FEMA Operations Center, CISA Central Watch Officer, FEMA NWC (email), DHS Nuclear SSA (email), CWMD Watch Desk (email).

PART 21 REPORT- CIRCUIT BREAKER DEFECT

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

Twenty-one (21) breakers were installed at Arkansas Nuclear One (ANO) by Framatome Inc during a recent refurbishment. During the refurbishment, shorter bell cranks were installed to mitigate an identified interference. These shorter bell cranks result in a higher force being needed to close the breaker which could result in failure of the pushrods. In the event of a pushrod failure, the breaker may not trip when required, resulting in a substantial safety hazard.

Framatome has provided written correspondence to ANO to advise on this issue.

Model: 5-3AF-GEU-350-1200 Breaker

Affected plants: Arkansas Nuclear One

Gayle Elliott
Director, Licensing Regulatory Affairs
Framatome Inc.
gayle.elliott@framatome.com

TECHNICAL SPECIFICATION VIOLATION

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

"On May 22, 2025, at 1055 EDT, the Armed Forces Radiobiology Research Institue (AFRRI) TRIGA Mark F reactor experienced a high power scram during startup in steady-state mode under two rod automatic control. During power escalation, the log channel malfunctioned, failing to provide a period signal to the automatic control system. The reactor power level increased rapidly until high flux safety channels 1 and 2 caused an automatic scram, releasing control rods to shutdown the reactor. Due to rate of power increase, reactor power momentarily exceeded the steady-state limit of 1.1MW. All reactor protection systems functioned as designed. Reactor power was verified as decreasing; control rods were verified to be fully inserted. The safety limit, nor limiting safety system setting, were exceeded during the event.

"This event is reportable to the NRC under AFRRI Technical Specifications (T.S.) 6.5.2.b. and 6.5.2.c.

"The limiting condition of operations affected are T.S. 3.1.1. - Steady state power level exceeding 1.1MW, T.S. 3.2.1.a. - Log Channel inoperable, and T.S. 3.2.2. Table 3 - Failure of Rod Withdrawal Interlock for a period less than three (3) seconds.

"The NRC Project Manager will be notified."

AGREEMENT STATE REPORT - LOST TROXLER GAUGE

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

"During a state prompted inventory for license renewal, the licensee discovered the loss of a portable gauge. The last confirmed possession of the gauge was December 15, 2017, when it was marked in their logbook to be sent for maintenance. No manufacturers or service providers contacted have any record of the gauge past 2017."

Gauge description: Troxler Electronic Labs. Inc. model 3411-B, serial number: 18670, containing sealed sources: Cs-137, 9 mCi (max), Am-241/Be, 44 mCi (max)

New Jersey Incident Number: 506950 - INV250001



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 Washington State Department of Health (the Department) via email:

"On 5/19/2025, at 0939 PDT, the Department was notified of missing or lost sources meeting the reporting criteria of WAC-246-221-240. During a routine inventory, the [licensee's] radiation safety officer (RSO) identified the following missing sources.

"The RSO believes that the sources may have been disposed of appropriately but not removed from the inventory list. A full report is required within 30 days."

Sources:
Am-241, 0.148177 microcuries
Am-241, 0.004437 microcuries
Pu-238, 0.003889 microcuries
Pu-239, 0.004149 microcuries
Th-230, 0.001101 microcuries

WA incident number: WA-25-07

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

MEDICAL EVENT

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

A patient was administered two Y-90 Therasphere treatments to the liver, each with its own written directive. The first treatment was administered without issue. The second treatment, which was a prescribed 1,382 Gy dose to the liver, resulted in no dose delivered due to a catheter malfunction. Post-administration, the activity level of the second Y-90 container was unchanged.

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 - EXTERNAL RADIATION LEVEL ON SHIPMENT EXCEEDED LIMITS

The following information was provided by the Utah Division of Waste Management and Radiation Control (the Division) via email:

"Shipment 9075-01-0074 arrived at EnergySolutions' Clive disposal facility on May 19, 2025. As Division inspectors were performing incoming waste shipment inspections, [Division] staff surveyed and observed a trailer that exhibited a dose rate of 10.5 mrem/hour at 2 meters from the outer plane of the conveyance. Upon this discovery, the [Division] inspector informed EnergySolutions' shipping and receiving staff of the discrepancy, [who] indicated that they were already aware of said discrepancy.

"The transport vehicle is a curtain-side, flatbed trailer."

Additional license number UT 2300478.

Utah event report ID: UT 25001

AGREEMENT STATE REPORT - DAMAGED PORTABLE GAUGE

The following information was provided by the South Carolina Department of Environmental Services (Department) via phone and email:

"The licensee informed the Department via phone on May 19, 2025, at approximately 1546 EDT, that one of their authorized users backed over a Humboldt Model 5001 EZ portable gauging device (Serial No. 5732), containing 11 millicuries of Cs-137 and 44 millicuries of Am-241:Be. The licensee reported that no immediate health and safety concerns had been identified.

"The on-call duty officer was dispatched to the construction site to investigate the event. The Humboldt Model 5001 EZ portable gauging device was crushed on one side of the device and the securing rod (depth rod) was transversely broken off. The source rod was intact, remained in the shielded position, and did not appear to be visibly damaged. Dose rate surveys at the surface of the gauge and at 1 meter indicated no elevated exposure. The Department performed swipe tests of the affected areas in addition to ambient dose rate surveys. All results were background. The licensee packaged the gauge within its transport case and a survey was performed to ensure compliance with Department of Transportation requirements (Transportation Index) prior to transporting it back to the licensee's facilities to await disposal.

"This event is still under investigation by the Department."

LOST TRITIUM EXIT SIGNS

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

Two tritium exit signs were reported lost or missing during a recent safety emergency lighting audit conducted on April 24, 2025. Despite a thorough internal review and inspection of storage, disposal, and installation records, the devices were unable to be located or disposition verified.

The licensee is in the process of updating all emergency exit signage and lighting. Additionally, they are removing the remaining six (6) self-luminous exit signs from their facility and will return them to lsolite for proper disposal in accordance with regulatory guidelines. To prevent any recurrence, the facility will no longer purchase or utilize self-luminous signage in the future.

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

There is no information of previous inventory records since the initial delivery around April 2016. Information about this event was previously reported to the NRC Region III office on May 12, 2025.

Maker: Isolite
Model Number: SLX-60
Serial Numbers: H56081 and H56088
Estimated Activity: 0.281 TBq tritium (H-3) or 7.59 Ci/ sign (TOTAL: 0.562 TBq or 15.18 Ci)
Date of Manufacture: March 2016

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 - DAMAGED GAUGE

The following information was provided by the Arizona Department of Health Services (Department) via email:

"The Department received notification from the licensee that an Instrotek 3500 Xplorer nuclear moisture/density gauge was run over by a water truck on a construction site. The source rod was bent but the source was still in the shielded position. The gauge contains 10 millicuries of Cs-137 and 40 millicuries of Am-241:Be. The Department has requested additional information and continues to investigate the event.

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

DEGRADED RHR CHECK VALVE

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

"On May 22, 2025, at 2358 CDT, River Bend Station determined that a degraded condition existed following the performance of a VT-3 examination of E12-AOVF041A, Residual Heat Removal (RHR) 'A' injection line testable check valve. The cause of this event is currently being investigated. This examination was conducted following the plant shutdown, which was reported in Event Notification (EN) 57725.

"This event is being reported as an 8-hour reportable condition in accordance with 10 CFR 50.72(b)(3)(ii)(A) for the degraded condition of the pressure boundary.

"The NRC Resident Inspector has been notified."

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

This degraded condition resulted in a leakage rate of approximately 3.6 gallons per minute when at pressure. The plant is shutdown and depressurized which has caused the leakage to stop. No release is occurring or expected and possible corrective actions are being evaluated.