Event Notification Report for June 10, 2025

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was received from the Arizona Department of Health Services (the Department) via email:

"On June 11, 2025, the Department received notification from the licensee about a medical event occurring on June 10, 2025, involving a Nucletron Micro Selectron, Model 106.990, high dose rate (HDR) afterloader brachytherapy unit with a 10.4 Ci iridium-192 source. A patient was being treated for skin cancer on the right cheek and the prescription was for 4000 centigray (cGy) in 10 fractions of 400 cGy per fraction. The patient was treated on the left cheek for the first fraction. When the patient returned for the second treatment and the therapist was preparing them for treatment, the patient indicated that they thought the treatment should have been on the right cheek and not the left cheek. The authorized user immediately stopped the setup and verified that they had treated the wrong site. The Department has requested additional information and continues to investigate the event."

Arizona Incident Number: 25-011

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.

STUCK OPEN SHUTTER

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

On 6/10/2025 at approximately 1300 EDT, the licensee discovered that a Thermo Fisher density gauge containing 10 mCi of Cs-137 had a stuck open shutter while conducting routine checks on the gauge. Open is the normal position of the shutter. Surveys indicated the dose rate at 1 foot from the gauge is less than 1 mrem/hr. The gauge is on a pipe approximately 30 feet in the air, is not normally accessible, and poses no risk to personnel. The licensee has contacted a third party, Applied Health Physics, to assist them in decommissioning and disposing of the gauge.

EN Revision Imported Date: 6/20/2025

EN Revision Text: AGREEMENT STATE REPORT - FOUND SOURCE

The following is a summary of information provided by the Maryland Department of Environment via email:

On June 10, 2025, at 1600 EDT, the Maryland Department of the Environment's Radiological Health Program (MDE/RHP) was notified by the Maryland State Police that a cesium-137 source was found at the Shady Grove Solid Waste Transfer Facility. It was reported that a waste truck arrived at the waste transfer facility on Friday afternoon with the source inside. It was first misidentified as iodine-131 (as a bit of medical waste). It was then compacted and placed in a container express (CONEX) box. A second survey was performed and identified the source as cesium-137. The box was then held to prevent incineration. Wipe samples were taken on the surface of the container. There were no signs of leakage. The facility also used a high-purity germanium (HPGe) radiation detector to confirm the identity of the source. The highest measurement observed was 463 microroentgen per hour at about 1 foot from the estimated source position. The Department of Energy contact person was notified, and the source activity was estimated to be approximately 0.3 Ci. The facility plans to transfer the container to the Covanta Energy facility and attempt to locate the source and remove it from the container on June 11, 2025, at 1130.


* * * UPDATE ON 6/18/2025 AT 1729 EDT FROM KRISHNAKUMAR NANGEELIL TO ERNEST WEST * * *

The following information was provided by the Maryland Department of Environment via email:

"On June 11, 2025, representatives from the Maryland Department of the Environment (MDE), in coordination with FBI officials and the safety and environmental compliance manager at the Shady Grove Waste Transfer Facility, convened to execute the recovery plan for a missing sealed radioactive source. The team accompanied the transport of the suspect container to the Covanta Energy facility for inspection. Following a safety briefing, the container was unloaded in a slow, controlled manner. Maryland State Police were present to support the operation. Radiation surveys were conducted after each stage of unloading. The sealed source was located in the final portion of debris. A preliminary leak test confirmed only background radiation levels, indicating no removable contamination on the exterior of the source.

"The recovered item was identified as a benchmark Cs-137 sealed source, serial number BM06E-37-019-32. Originally manufactured with an activity of 8.325 MBq (0.225 mCi) on July 6, 2007, the current activity was calculated to be approximately 5.5 MBq (0.149 mCi), based on standard decay calculations. The source was secured in a sealed plastic bag, placed into a lead pig for shielding. All readings in other areas remained at background levels, and the container was released from further radiological control.

"On June 12, 2025, RadQual, the manufacturer, confirmed that the source had been shipped on September 28, 2007, to a licensed medical facility in Maryland. This information was provided by the commercial manager at RadQual.

"The source is currently being stored in a shielded, access-controlled area at the Shady Grove facility, pending final disposal through a licensed radioactive waste broker. All associated documentation will be completed and submitted to MDE in accordance with applicable regulatory requirements."

Maryland Event ID Number: 78276

Notified R1DO (Warnek) and NMSS Events Notification (email)

FITNESS FOR DUTY

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

At 1230 EDT on June 10, 2025, a non-licensed supervisor failed a fitness for duty test. The NRC Resident Inspector has been notified.

AGREEMENT STATE REPORT - LOST GAUGE

The following information was provided by the North Carolina Radioactive Materials Branch (NC RMB) via email:

"The NC RMB reports the loss of a generally licensed fixed nuclear gauge source (Manufacturer: Industrial Dynamics Co. Ltd. (Filtec), Model: 06110, SN: 2234, 100 mCi, Am-241).

"The licensee believes the entire device may have accidentally been thrown into the trash or scrap. The device was stored in a maintenance trailer and was being used for spare parts. The device was last seen on June 17, 2024, during routine preventive maintenance by a field service engineer. Upon discovering the missing source, the licensee searched the site, and the device could not be found. The licensee does not possess a survey meter. The incident was reported to the NC RMB on June 10, 2025. On June 24, 2025, an NC RMB inspector conducted an on-site search for the source and the source could not be located.

"Licensee believes the device was accidentally thrown away due to staff not understanding the radiological importance of the device. A thorough search was performed by both the licensee and agreement state staff and the source could not be located."

NC Event Number: NC250008

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 - STUCK OPEN SHUTTERS

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

"The licensee informed the Department via email on July 3, 2025, (a phone notification was not made to the Department), that two fixed gauging devices were disabled or failed to function as designed. The licensee reported that a 2 curie cesium-137 Kay-Ray/Sensall Inc. model number: 7700Y-1000, serial number: S95K1307 was stuck in the open position (exposed), and a 100 millicurie Cs-137 Texas Nuclear model number: 570-571157C, serial number: B2988 is stuck in a partially open position (exposed). Both of the devices are attached to a process vessel.

"The licensee also informed the Department that a 100 millicurie Cs-137 Texas Nuclear model number: 570-571157C, serial number: B2987 has a visible crack in the source housing and is attached to a process vessel.

"The licensee performed ambient dose rate surveys and reported results similar to the Sealed Source and Device Registry (SSDR) certificates.

"The licensee did not report any overexposures or ongoing health/safety concerns.

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

South Carolina Event Number: TBD

AGREEMENT STATE REPORT - LOSS OF LICENSED MATERIAL

The following information was received from the Wisconsin Department of Health Services (the Department) via email:

"On June 11, 2025, the Department received a telephone notification that the licensee was unable to locate two vials of carbon-14, with an aggregate activity of 1.92 mCi. The vials were identified by the licensee as missing on June 10, 2025. The licensee completed an investigation by June 26, 2025, and submitted a written report to the Department. The licensee determined the package in the original transport box was mistakenly picked up by a third-party cleaning service and disposed of as normal trash. The landfill was contacted. There are no suspected health or safety risks to any worker or member of the public. The Department will perform an investigation into this incident."

WI Event Report ID No: WI250006

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

60-DAY OPTIONAL TELEPHONIC NOTIFICATION FOR INVALID CONTAINMENT ISOLATION

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

"This 60-day telephone notification is being made per the reporting requirements specified by 10 CFR 50.73(a)(2)(iv)(A) and 10 CFR 50.73(a)(1) to describe an invalid actuation of a general containment isolation signal affecting more than one system.

"On June 10, 2025, Unit 2 operations personnel received an `A' channel half scram and entered 2-AOI-99-1. Motor generator set 2A was shut down and reactor protection system `A' was swapped to alternate. This resulted in primary containment isolation system (PCIS) groups 2, 3, 6, and 8 isolations, and initiation of standby gas treatment (SGT) trains `A', `B', and `C' and control room emergency ventilation system (CREV) train `A'. All affected safety systems responded as expected.

"Plant conditions which initiate PCIS groups 2 and 8 actuations are reactor vessel low water level and high drywell pressure. Plant conditions which initiate PCIS group 3 actuations, are reactor vessel low water level and reactor water cleanup area high temperature.

"Plant conditions which initiate PCIS group 6, CREV and SGT actuations, are reactor vessel low water level, high drywell pressure, or reactor building ventilation exhaust high radiation (reactor zone or refuel zone). At the time of the event, these conditions did not exist; the actuation was due to a loss of power and not due to a low reactor water level or drywell pressure. Therefore, the actuation of the PCIS, CREV, and SGT was invalid.

"Upon investigation, the 2A2 circuit protector was found to have charred wire on the top right lug. The terminal block was replaced.

"There were no safety consequences or impact to the health and safety of the public as a result of this event.

"This event was entered into the corrective action program as condition report 2019406."