Event Notification Report for August 20, 2025

EN Revision Imported Date: 8/20/2025

EN Revision Text: AGREEMENT STATE REPORT - RUPTURED SEALED SOURCE

The following information was provided by the Georgia Radioactive Materials Program Environmental Protection Division (the State) via email:

"On June 27, 2025, a krypton-85 sealed source capsule ruptured while unloading a Honeywell model 2201 series thickness gauge. The manufacturing engineer immediately turned on the fume hood and left the room when it was noticed the radiation monitors in the area rapidly increased in dose. It was determined the capsule had ruptured. The highest dose rate in the area of the source was 7 mR/h. The source was placed in the fume hood to allow gas to escape. The dose rate returned to normal approximately an hour after the source was placed in the fume hood. The dose rate at the source was then indistinguishable from background. The empty capsule was placed in a paint can containing cat litter and placed in their radiation source storage area.

"As a corrective action, all persons performing this activity have been retrained on loading and unloading the model 2201 source capsule, and regarding the importance of safety when unloading sealed source capsules containing [radioactive material].

"The thermoluminescent dosimeter badge of the manufacturing engineer will be sent to Landauer [the manufacturer] and the licensee will notify the State when they receive those results. Respirators are not utilized in their daily operations. The State will continue to investigate the incident and will follow up with new information."

Additional information on the sealed source:
Model: KAC.D5
Serial number: TW911
Activity: 14.8 GBq of krypton-85 as of December 2, 2011

* * * UPDATE ON 8/19/2025 AT 1321 EDT FROM CHELSEA PARKERSON TO TENISHA MEADOWS * * *

The following information was provided by the Georgia Radioactive Materials Program (RMP) via email:

"The licensee submitted the dosimetry report for the manufacturing engineer involved in the incident. The individual received a deep dose equivalent of 36 mrem for the monitoring period of April 1, 2025 - June 30, 2025. RMP considers the incident closed with no further follow up needed."

Notified R1DO (Dimitriadis) and NMSS Events Notification (email).

Georgia incident number: 101

AGREEMENT STATE REPORT - LOST RADIOACTIVE SOURCE

The following is a summary of information provided by the New Mexico Environment Department, Radiation Control Bureau (RCB) via phone:

The RCB was notified that a 10 mCi sealed Ni-63 source from a gas chromatograph has been lost. The loss was first discovered on March 5, 2025, during a routine audit. The licensee conducted a thorough search of the premises and could not locate the source. The loss was reported to RCB on July 30, 2025. The last confirmed physical accounting of the source was in 1995.

RCB is investigating this incident.

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 GAUGE SHUTTER

The following information was provided by the SC Department of Environmental Services (the Department) via email:

"The licensee informed the Department via telephone on August 12, 2025, that a fixed gauging device was disabled or failed to function as designed. The licensee reported that the brass shaft that operates the shutter of a fixed gauging device broke in the open position. The device is located on a process vessel. The licensee reported that a representative from a licensed service provider is on-site and is in the process of shielding the device so that it can be removed from service and placed in storage.

"The device is a 5 millicurie cesium-137 Berthold Systems, LLC model 7440.

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

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

DAMAGED MOISTURE DENSITY GAUGE

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

A Troxler model 3440 Plus (serial number 85009) moisture density gauge (8 mCi Cs-137, 40 mCi Am-241/Be) was damaged when it fell out of the back of a pickup truck. The source rod and track were damaged, and the source was dislodged from its safe position. The gauge was placed in temporary shielding until the source rod was returned to its safe position by a technician. No contamination or excessive exposures resulted from this event.

AGREEMENT STATE REPORT - STUCK RADIOGRAPHY SOURCE

The following is a summary of information provided by the New York State Department of Health (NYSDOH) via email:

On August 12, 2025, the licensee was conducting radiography with a Sentinal 880 Delta (serial number 4955) containing a 73.9 Ci Ir-192 source when it was discovered that the source was stuck in the unshielded position. The radiography crew called the radiation safety officer (RSO) and ensured the cordoned off area was clear of personnel. With assistance from the RSO, the crew was able to retract the source to the shielded position approximately 3.75 hours later.

TLD badges for personnel present were sent for expedited analysis, and direct reading dosimeter readings are listed below:

RSO: 345 mrem
Radiographer: 320 mrem
Operations manager: 210 mrem
Assistant radiographer: 150 mrem

NY incident number: 1540
NMED number: NY-25-07

AGREEMENT STATE REPORT - SEALED SOURCE SEPARATED FROM GAUGE

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

"On August 12, 2025, the Department was notified by the licensee that a sealed source had become dislodged from a Vega2 fixed gauge containing a 1,000 mCi Cs-137 source that was being removed by their contractor. The housing had been damaged and the gauge was being replaced. The source was not damaged. The area is at a well site and the source has been cordoned off with a person posted to ensure no one accesses the area.

"The radiation safety officer has contacted Vega and they are sending personnel to retrieve the source. The dose rate reading is 1.5 mR/hr at the barrier.

"There is no immediate threat to the public.

"Additional information will be provided in accordance with SA-300 reporting requirements."

Texas incident number: 10216

AGREEMENT STATE REPORT - MEDICAL EVENT

The following is a summary of information provided by the Nebraska Department of Health and Human Services via phone and email:

The licensee reported that on August 12, 2025, a patient was to receive a 200 mCi Lu-177 (Pluvicto) treatment for prostate cancer per a written directive, but was administered a 156 microcurie Ra-223 (Xofigo) treatment for metastatic prostate cancer instead. The licensee's initial estimate is that the patient received a 13 rem whole-body dose and 665 rem to the bone marrow. There were no immediate implications for patient health reported. The referring physician and patient have been notified of the event.

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.

FITNESS FOR DUTY EVENT

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

"On August 18, 2025, a licensed operator violated the station's Fitness for Duty policy. The event was determined to be reportable under 10 CFR 26.719(b)(2)(ii)."

The NRC Resident Inspector has been notified.

FITNESS FOR DUTY EVENT

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

"On August 18, 2025, a licensed supervisor tested positive on a follow-up test. The test was conducted on August 13, 2025, and sent to the Health and Human Services certified laboratory on August 14, 2025. The results were reported out as positive by the medical review officer on August 18, 2025, at 0945 CDT. The individual's access has been terminated and a notification to the NRC Resident inspector was made."