Event Notification Report for August 08, 2025

EN Revision Imported Date: 8/8/2025

EN Revision Text: AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE

The following information was provided by the Texas Department of State Health Services (the Department) via phone and email:

"On April 4, 2025, the Department was notified by the licensee of a telephonic overexposure report they received from their dosimetry provider. The licensee radiation safety officer stated the report had one of their employees with an exposure of 7.7 rem for the month of February 2025. The licensee had other readings (pocket dosimeters) that did not match this level of exposure. The licensee removed the employee from the work environment until the dose can be confirmed. The employee affected is an assistant, and neither of the other two radiographers had any exposure near this level. The licensee is still investigating.

"More information will be made available according to SA-300 requirements."

Texas incident number: 10189
NMED number: TX250022

* * * RETRACTION ON 08/07/2025 AT 1600 EDT FROM TEXAS DEPARTMENT OF STATE HEALTH SERVICES TO JORDAN WINGATE * * *

The following retraction was provided by the Texas Department of State Health Services (the Department) via email:

"After review by the radiation safety officer (RSO) and corporate RSO it was determined to be an anomaly in the processing of the dosimeter. The person was not near anything capable of that [level of] exposure and no one the person worked with was exposed to anything above expected numbers. The licensee assigned a dose of 285 mR for the period in question and notified the dosimetry provider."

Notified R4DO (Bywater) and NMSS Events Notifications (email).

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

EN Revision Imported Date: 8/11/2025

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT

The following report was provided by the Georgia Radioactive Materials Program via email:

"The licensee called and stated that during a post treatment review with the physician conducted today, it was identified that a patient receiving yttrium-90 therapy on July 7, 2025, was underexposed due to a kink in the catheter. The prescribed dose was 0.439 GBq (11.853 mCi), but the administered dose was determined to be 0.177 GBq (4.779 mCi). This represents a 40.32 percent deviation from the prescribed dose, which exceeds the 20 percent reporting threshold. Upon further review of the patient's treatment history, it was additionally discovered that two prior underdosing events occurred on August 20, 2024, and September 30, 2024. Both events were also attributed to catheter kinking and involved dose delivery to small treatment volumes in limited target areas. [The licensee] stated that a formal written report detailing all three underdosing events, along with supporting documentation, will be submitted via email on Monday, August 4, 2025."

* * * UPDATE ON 8/8/2025 AT 1047 EDT FROM ANASTASIA BENNETT TO TENISHA MEADOWS * * *

The following is a summary of information provided by the Georgia Radioactive Materials Program via email:

The licensee provided three updated official incident reports, including two prior underdosing events that occurred on August 20, 2024, and September 30, 2024.

The July 7, 2025, incomplete Y-90 dose delivery was attributed to clumping of the microspheres within the microcatheter. As part of corrective actions, the specific type of microcatheter involved in this incident has been discontinued for use in Y-90 procedures.

During the administration of Y-90 microspheres on August 20, 2024, the prescribed dose was 0.224 GBq (6.0 mCi) and the administered dose was 0.150 GBq (4.1 mCi).

During the Y-90 treatment performed on September 30, 2024, the prescribed dose was 0.290 GBq (7.83 mCi) and the administered dose was 0.166 GBq (4.5 mCi).

Both the August 20, 2024, and September 30, 2024, underdosing events were attributed to anatomical limitations. Specifically, a small treatment volume and narrow treatment vessels, which restricted adequate flow of microspheres. As part of the corrective actions taken, it was determined that more than 30 psi of pressure is required to deliver microspheres into small vessels. Therefore, future cases involving small treatment vessels will consider the use of delivery systems capable of generating higher pressure to ensure effective dose administration.

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

Georgia Incident Number: 105

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 - DAMAGED GAUGE

The following information was provided by the California Radiation Control Program via email:

"[The licensee] contacted the California Department of Emergency Services to report a moisture density gauge was run over at a worksite. The gauge was a CPN MC-3, S/N M30019316 (10 mCi cesium-137, 50mCi americium-241/beryllium). After placing the gauge with the cesium-137 source in the locked and shielded position on the ground, the operator went to retrieve some equipment from his vehicle when the bulldozer ran over the gauge snapping the source rod off and damaging the plastic housing on the top of the gauge. The bottom of the gauge was intact, and the americium-241/beryllium source was still attached and undamaged. The licensee was instructed to place the gauge in the transport case and wait until the Riverside County Department of Environmental Health inspector arrived at the scene.

"Upon arrival, the inspector performed a radiation survey (model and serial number not reported) and found there were no significant radiation levels above background. The gauge will be transported to Maurer Technical Services for disposal. The investigation into the incident by the California Department of Public Health is ongoing."

California 5010 Number: 080125

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."

AGREEMENT STATE REPORT - STUCK SHUTTER

The following report was received from the North Carolina Division of Radiation Protection via email:

"[The] licensee reports that while they were performing routine shutter tests, the handle to a fixed nuclear gauge broke, leaving the gauge in the stuck open position. Operational doses are considered low and the area has been cordoned off to any unauthorized access. The licensee is currently arranging with the gauge manufacturer for assistance on repair."

Device: Fixed Nuclear Gauge
Manufacturer: Ohmart Vega
Model: SH-F1B
S/N: 6133CN

Source: cesium-137
Manufacturer: TBD
S/N: TBD
Activity: 66.2 mCi

North Carolina Event Number: TBD

AUTOMATIC REACTOR TRIP

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

"At 1113 EDT on August 9, 2025, with Unit 3 in mode 1 at 100 percent power, the reactor automatically tripped due to a turbine control system failure. The trip was uncomplicated with all systems responding normally post-trip. Operations stabilized the plant in mode 3. Decay heat is being removed by steam generators. Unit 4 is not affected. This event is being reported pursuant to 10CFR50.72(b)(2)(iv)(B).

"An actuation of the auxiliary feed water system (AFW) occurred during the Unit 3 reactor trip. The AFW system automatically started as designed. This event is being reported pursuant to 10CFR50.72(b)(3)(iv)(A).

"The NRC Resident Inspector has been notified."

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

The cause of the turbine control system failure is under investigation.