Event Notification Report for June 18, 2025

EN Revision Imported Date: 6/18/2025

EN Revision Text: AGREEMENT STATE REPORT - POTENTIAL EXTREMITY OVEREXPOSURE

The following information was provided by the Pennsylvania Department of Radiation Protection (the Department) via email:

"On May 6, 2025, and May 7, 2025, the licensee informed the Department of a possible high ring badge exposure of a nuclear medicine technologist. It is reportable per 10 CFR 20.2202(b)(1)(iii).

"On May 6, 2025, the licensee was notified by Mirion (their dosimetry provider) of a high ring badge exposure to a nuclear medicine technologist in the first quarter (Q1) of 2025. The exposure reading was 57,448 millirem, exceeding the allowable annual limit. The technologist also received a higher-than-normal dose to their whole-body badge of 405 millirem. The nuclear medicine technologist was notified about the exposure. The licensee interviewed the technologist to determine what may have caused the high reading on the ring badge. It was determined that the most likely source of the high reading was American College of Radiology phantom accreditation testing. The technologist performed the test twice in Q1 2025. The test involved injecting 15-25 mCi of Tc-99m into a water-filled phantom. The technologist does not recall injecting or handling the phantom without gloves on but thinks they must have handled the phantom without gloves and touched a small amount of contamination on the outside of the phantom. They also recall carrying the phantom from the hot lab to the camera and back, holding it to their body. This is believed to be the source of the higher-than-normal whole-body badge.

"The licensee believes that the nuclear medicine technologist may have handled the phantom without gloves on and picked up a small amount of contamination on their ring as a result.

"The Department will perform a reactive inspection. More information will be provided as received."

* * * RETRACTION ON 06/17/2025 AT 1403 EDT FROM JOHN CHIPPO TO TENISHA MEADOWS * * *

The following information was provided by the Pennsylvania Department of Radiation Protection (the Department) via email:

"Upon receiving the licensee's report and after being inspected for this event, the Department believes there is not a regulatory event to report. The corrective actions include the nuclear medicine technologist will always wear gloves when handling the phantom, injecting the Tc-99m into the phantom, and doing phantom testing. Also, the technologist will transport the phantom on a cart in the future. Information regarding this event will be shared with all technologists during annual training. Emphasis will be placed on always wearing gloves when handling phantoms and diligent hand or area monitoring upon completion of work. They will also stress the high concentrations of some radiopharmaceutical and quality control doses and how much Tc-99m can be present in a drop. They will also review the doses that can result from the presence of these amounts on the skin if not removed promptly."

Pennsylvania Event Report ID: PA250007

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

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

The following is a summary of information provided by the Colorado Department of Health (the Department) via email:

The Department received a notification from Consolidated Electrical Distributors that one exit sign with 10 Ci of H-3 was lost in Denver, CO. The exit sign is an Isolite Corporation Exit Sign, Model #: SLX60.

Colorado Event Report ID Number: CO250017

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

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.

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.

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

STUCK OPEN SHUTTER

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

On June 11, 2025, at 1104 EDT, the licensee discovered a stuck open shutter while performing daily checks on an x-ray gauge. The gauge is in an area that is taped off and poses no exposure risk to personnel or the public. The manufacturer is planning an on-site inspection and assessment of the gauge.

Gauge Model Number: Thermo Rm200EM
Gauge Serial Number: 543893
Source Activity: 1000 mCi (Americium-241)
Source Model Number: AM1.GXX
Source Serial Number: G44/004/09

* * * UPDATE ON 06/12/25 AT 1355 EDT FROM WAYNE LANGDON TO KERBY SCALES * * *

The following is a summary of information received from the licensee via phone and email:

The manufacturer (Thermo EGS Gauging) was on-site and inspected the unit. They identified that the magnetic coil position holding the shutter flag when it de-energized needed to be adjusted. Adjustments to its position were made, and the shutter is now working as designed.

Notified R3DO (Ziolkowski) and NMSS Events Notifications via email.

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.

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was received from the California Department of Public Health via email:

"University of California, Los Angeles (UCLA) Health reported that a patient being treated for liver cancer underwent a Y-90 brachytherapy microsphere treatment on June 9, 2025. The written directive by the authorized user called for 120 Gy each [to be administered] to both the middle section (a 3 GBq vial) and the right liver section (a 20 Gbq vial). Post therapy evaluations determined that the administered dose to the right section of the liver was 88.9 Gy (74.08 percent of the prescribed dose), which is an underdose of more than 20 percent. The administered dose to the middle section of the liver was 114.2 Gy (95.17 percent of the prescribed dose) and was in accordance with the written directive. UCLA Health is conducting an investigation and will submit a 15-day report to the California Radiation Health Branch.

California 5010 Number: 060925

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.

MANUAL REACTOR SCRAM

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

"On June 17, 2025, at 0426 CDT, Grand Gulf Nuclear Station (GGNS) was operating at 70 percent power when a manual scram was initiated due to degraded main condenser vacuum caused by the loss of the 'A' circulating water pump.

"All control rods fully inserted, there were no complications, and all plant systems responded as designed. Immediately after the scram, an expected reactor water Level 3 isolation signal was received. Reactor pressure is being maintained via the turbine bypass valves. Reactor level is being maintained via main feedwater. GGNS is currently in Mode 3. No radiological releases have occurred due to the event.

"The cause of the circulating water pump trip is under investigation.

"The manual reactor protection system actuation is being reported in accordance with 10 CFR 50.72(b)(2)(iv)(B). The expected reactor water Level 3 isolation signal is being reported in accordance with 10 CFR 50.72(b)(3)(iv)(A).

"The NRC Resident Inspector was notified."

UNPLANNED MAINTENANCE OF TECHNICAL SUPPORT CENTER SUPPLY FAN

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

"This is an eight-hour, non-emergency notification for a loss of emergency assessment capability. This event is reportable in accordance with 10 CFR 50.72(b)(3)(xiii) because the technical support center (TSC) supply fan belt failed [at approximately 1257 CDT on 6/17/2025] which affects the functionality of an emergency response facility.

"Corrective maintenance activities have been completed as of 6/17/25 at 1619 [CDT] to replace the TSC supply fan belt. The TSC supply fan has been re-started and this condition is no longer applicable.

"If an emergency would have been declared requiring TSC activation during this period, the TSC would have been staffed and activated using existing emergency planning procedures unless the TSC became uninhabitable due to ambient temperature, radiological, or other conditions. If relocation of the TSC were necessary, the Emergency Director would have relocated the TSC staff to an alternate location in accordance with applicable site procedures. The emergency response organization team was notified of the maintenance and the possible need to relocate during an emergency.

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."