Event Notification Report for July 24, 2025
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/23/2025 - 07/24/2025
Agreement State
Event Number: 57826
Rep Org: Georgia Radioactive Material Pgm
Licensee: Tanner Health System
Region: 1
City: Carrollton State: GA
County:
License #: GA 120-2
Agreement: Y
Docket:
NRC Notified By: Jake Chesser
HQ OPS Officer: Ernest West
Licensee: Tanner Health System
Region: 1
City: Carrollton State: GA
County:
License #: GA 120-2
Agreement: Y
Docket:
NRC Notified By: Jake Chesser
HQ OPS Officer: Ernest West
Notification Date: 07/24/2025
Notification Time: 16:22 [ET]
Event Date: 07/24/2025
Event Time: 00:00 [EDT]
Last Update Date: 08/11/2025
Notification Time: 16:22 [ET]
Event Date: 07/24/2025
Event Time: 00:00 [EDT]
Last Update Date: 08/11/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Dentel, Glenn (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Dentel, Glenn (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 8/12/2025
EN Revision Text: AGREEMENT STATE REPORT - POTENTIAL OVER EXPOSURE
The following report was received by the Georgia Radioactive Materials Program via email:
"The licensee's radiation safety officer called and stated that, during a high dose rate procedure, the nurse got stuck in the vault and was behind the CT [computed tomography] lead shielding. The licensee plans to send out her dosimetry badge to be processed for dose received and perform a pregnancy test.
"[The Georgia Radioactive Materials Program] will follow up with more information as we receive it."
Additional information: The equipment involved was a GammaMedPlus 3/24iX remote brachytherapy afterloader containing a Ir-192 source with an activity of 3.158 curies.
* * * UPDATE ON 08/11/2025 AT 1305 EDT FROM STACY ALLMAN TO TENISHA MEADOWS * * *
The following report was received by the Georgia Radioactive Materials Program via email:
"The licensee sent in the final report along with the dosimetry for the nurse involved in the incident. The nurse was in an adjacent procedure room that connects to the HDR [high dose rate] vault. It is used for gynecologic preparation and is shielded for CT [computed tomography] energy, but not Ir-192. The nurse was restocking the room and did not realize the treatment had started. The procedure was interrupted by the team upon hearing [the nurse] call out. [The nurse] was in the room 10 out of the 11 minutes. [The nurse] estimated unshielded dose was 12 mRem. The nurse's TLD [thermoluminescent dosimeter] badge read minimum exposure after the incident. The licensee is updating their procedures and check list to include checking all adjacent rooms before beginning the procedure. They will be retraining the staff on HDR safety procedures and plan to evaluate an audible alarm to accompany the beam on lights for the vault. This has been determined not to be a reportable event."
Notified R1DO (Bickett) and NMSS Events (email)
Georgia Incident Number: 104
EN Revision Text: AGREEMENT STATE REPORT - POTENTIAL OVER EXPOSURE
The following report was received by the Georgia Radioactive Materials Program via email:
"The licensee's radiation safety officer called and stated that, during a high dose rate procedure, the nurse got stuck in the vault and was behind the CT [computed tomography] lead shielding. The licensee plans to send out her dosimetry badge to be processed for dose received and perform a pregnancy test.
"[The Georgia Radioactive Materials Program] will follow up with more information as we receive it."
Additional information: The equipment involved was a GammaMedPlus 3/24iX remote brachytherapy afterloader containing a Ir-192 source with an activity of 3.158 curies.
* * * UPDATE ON 08/11/2025 AT 1305 EDT FROM STACY ALLMAN TO TENISHA MEADOWS * * *
The following report was received by the Georgia Radioactive Materials Program via email:
"The licensee sent in the final report along with the dosimetry for the nurse involved in the incident. The nurse was in an adjacent procedure room that connects to the HDR [high dose rate] vault. It is used for gynecologic preparation and is shielded for CT [computed tomography] energy, but not Ir-192. The nurse was restocking the room and did not realize the treatment had started. The procedure was interrupted by the team upon hearing [the nurse] call out. [The nurse] was in the room 10 out of the 11 minutes. [The nurse] estimated unshielded dose was 12 mRem. The nurse's TLD [thermoluminescent dosimeter] badge read minimum exposure after the incident. The licensee is updating their procedures and check list to include checking all adjacent rooms before beginning the procedure. They will be retraining the staff on HDR safety procedures and plan to evaluate an audible alarm to accompany the beam on lights for the vault. This has been determined not to be a reportable event."
Notified R1DO (Bickett) and NMSS Events (email)
Georgia Incident Number: 104
Non-Power Reactor
Event Number: 57824
Rep Org: Massachusetts Institute Of Tech (MITE)
Licensee: Massachusetts Institute Of Technology
Region: 0
City: Cambridge State: MA
County: Middlesex
License #: R-37
Agreement: Y
Docket: 05000020
NRC Notified By: Edward Lau
HQ OPS Officer: Ernest West
Licensee: Massachusetts Institute Of Technology
Region: 0
City: Cambridge State: MA
County: Middlesex
License #: R-37
Agreement: Y
Docket: 05000020
NRC Notified By: Edward Lau
HQ OPS Officer: Ernest West
Notification Date: 07/24/2025
Notification Time: 15:24 [ET]
Event Date: 07/24/2025
Event Time: 12:00 [EDT]
Last Update Date: 07/24/2025
Notification Time: 15:24 [ET]
Event Date: 07/24/2025
Event Time: 12:00 [EDT]
Last Update Date: 07/24/2025
Emergency Class: Non Emergency
10 CFR Section:
10 CFR Section:
Person (Organization):
Montgomery, Cindy (NRR)
Lin, Brian (NRR)
Montgomery, Cindy (NRR)
Lin, Brian (NRR)
TECHNICAL SPECIFICATION VIOLATION
The following information was provided by the licensee via phone and email:
On July 24, 2025, the licensee reported that it had violated Technical Specification 3.4.1.A. which requires the reactor to be secured when containment is not maintained. The console key switch was inserted while not having containment integrity. Prior to and at the time of the occurrence, the reactor was shutdown for more than two weeks for scheduled outage maintenance activities. Nuclear safety of the reactor was never challenged. This event did not cause the existence or development of an unsafe condition.
The NRC Project Manager was notified.
The following information was provided by the licensee via phone and email:
On July 24, 2025, the licensee reported that it had violated Technical Specification 3.4.1.A. which requires the reactor to be secured when containment is not maintained. The console key switch was inserted while not having containment integrity. Prior to and at the time of the occurrence, the reactor was shutdown for more than two weeks for scheduled outage maintenance activities. Nuclear safety of the reactor was never challenged. This event did not cause the existence or development of an unsafe condition.
The NRC Project Manager was notified.