Event Notification Report for August 07, 2025

AGREEMENT STATE REPORT - MEDICAL EVENT

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

"On July 31, 2025, the licensee was treating the third of five fractions for a gynecological cylinder HDR (high dose rate) treatment. The authorized user placed the cylinder prior to treatment and confirmed that they believed it was snug and fully inserted. The licensee also utilized briefs with Velcro straps to hold the cylinder in place. Following the completion of the treatment, the authorized user identified that the cylinder was no longer snug, and that it had shifted by up to one centimeter. It is unclear whether the shift happened during or after treatment. The prescribed dose was 6 Gy for the fraction. The licensee performed a dose reconstruction and determined that if the cylinder had shifted immediately, the cervix would have only received 2.6 Gy (44 percent) of the dose. The licensee believes that the shift would not have resulted in a dose to other organs above regulatory limits, and that the completion of the remaining fractions will result in the desired clinical outcome. The authorized user notified the patient immediately. The Department will perform an investigation."

Wisconsin Item Number: WI250007

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 SOURCE

The following information was provided by the Florida Bureau of Radiation Control via email:

"Adventist Health Systems radiation safety officer (RSO) called today at 1603 EDT to report a lost source while in transit with [common carrier]. The source was a rod source of Gd-153 being shipped in a lead sleeve. The activity of the Gd-153 source at the beginning of July 2025 was 0.04 mCi. The RSO was first notified on July 8, 2025, of the source not arriving at the destination of Eckert and Zeigler in Burbank, California. An employee with Eckert and Zeigler confirmed the box was empty when received on July 7, 2025. There was no source or lead sleeve in the box. They took one picture of the box, then disposed of the box. The RSO has been investigating this incident since July 8. He said the [common carrier] told him that the box was weighed at the midpoint of the shipment in Memphis and the box weight was unchanged from when it left Orlando. He also said anti-tamper tape was placed on the box, but it was unknown if the tape was intact upon arrival at Eckert and Zeigler. There is an ongoing investigation between Adventist Health and the [common carrier]."

Florida Incident Number: FL25-074


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."

AUTOMATIC REACTOR TRIP

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

"Surry Unit 1 reactor automatically tripped at 1847 EDT on August 6, 2025, due to a spurious actuation of high consequence limiting safeguards train `B' [due to a false high containment pressure trip signal]. Reactor coolant temperature is being maintained at 547 degrees Fahrenheit on the main steam dumps with main feedwater supplying the steam generators.

"All systems operated as required. The trip was uncomplicated and all control rods fully inserted into the core. Reactor protection system, emergency core cooling system, auxiliary feedwater system, emergency diesel generators, phase I and phase II containment isolation signals all actuated as designed. Offsite power remains available. There is no impact to Surry Unit 2.

"This notification is being made pursuant to 10 CFR 50.72(b)(2)(iv)(B) for 4-hour notification of reactor protection system activation and 10 CFR 50.72(b)(3)(iv)(A) for 8-hour notification of specified system actuation. The NRC Resident Inspector has been notified via cell phone."