Event Notification Report for September 18, 2025

AGREEMENT STATE REPORT - LOST EXIT SIGNS

The following is a summary of information provided by the Colorado Department of Public Health and Environmental (the Department) via email.

The Department received a notification from LDS Church that seventeen (17) exit signs, each with 14.5 Ci of tritium were lost in Woodland Park, Colorado.

Manufacturer: SRB Technologies
Model Number: BXU20BS

Colorado Event Report ID Number: CO250025

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 - LOST EXIT SIGNS

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

The Department received a notification from the licensee that eight (8) exit signs, containing a total of 65.65 Ci of tritium were lost in Denver, Colorado.

Manufacturer: SRB Technologies & Isolite Corporation
Model Number: BXU10GS (1 sign), BR-10-BK (2 signs), BRU10S (2 signs), BETALUX (3 signs).

Activities:
Models - BXU10GS & BR-10-BK: 9.21 Ci each
Model - BRU10S: 7.76 Ci each
Model - BETALUX: 7.5 Ci each

Event Report ID No.: CO250026


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 - LOST EXIT SIGN

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

The Department received a notification from the licensee that one (1) exit sign containing 10 Ci of tritium was lost in Meeker, Colorado.

Manufacturer: Isolite Corporation
Model Number: SLX60
Isotope: H-3
Activity: 10 Ci

Event Report ID No.: CO250027

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 - FOUND DENSITY GAUGE

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

"On September 11, 2025, at 0412 CDT, the Agency received a notification from the Austin Fire Department that it had recovered a Humboldt 5001EZ moisture density gauge. The gauge contained a 40 Am-241:Be sealed source and a 10 millicurie cesium-137 source and had reportedly been found by a member of the public at a convenience store, who immediately contacted the fire department. The fire department provided contact details retrieved from the transport case which showed that the gauge is owned by the licensee who is based in San Antonio, Texas.

"The Agency then contacted the radiation safety officer (RSO) who confirmed that the gauge had been checked out by a technician between 0230 - 0245. The technician was unaware that the gauge was missing until they were informed that the gauge had been recovered and was in the possession of the RSO. The technician believes the gauge may have fallen out of the truck during transport because the tailgate had not been secured. When the gauge was recovered, both locks on the transport container were still intact. There is no risk of exposure to any members of the public because of this event. Additional information will be provided in accordance with SA - 300 reporting."


Texas Incident #: 10226
Texas NMED # TX250045

EN Revision Imported Date: 9/18/2025

EN Revision Text: BOTH TRAINS OF CENTRIFUGAL CHARGING SYSTEM INOPERABLE

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

"On September 11, 2025, Callaway was performing a planned maintenance window causing the 'B' train emergency diesel generator and the 'B' train essential service water system to be inoperable. At 0255 CDT the 'A' train centrifugal charging pump was declared inoperable due to an unexpected loss of control room indication for the 'A' train centrifugal charging pump miniflow valve.

"Therefore, both trains of the centrifugal charging (high head injection) system were simultaneously inoperable. This condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D). A fuse was replaced on the 'A' train centrifugal charging pump miniflow valve breaker, restoring operability of that system at 0500.

"There was no impact on the health and safety of the public or plant personnel.

"The NRC Resident Inspector has been notified."

* * * RETRACTION ON 9/17/2025 AT 1747 EDT FROM ZACHARY MILLIGAN TO KAREN COTTON * * *

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

"Event Notification (EN) 57919, made on 09/11/25, pursuant to 10 CFR 50.72(b)(3)(v)(D), is being retracted based on further review of the timing of when the 'B' train essential service water (ESW) system was operable and capable of performing its support function for the 'B' train centrifugal charge pump (CCP).

"Further review of restoration procedures/processes determined that the 'B' train ESW system was operable by 0232 CDT on 9/11/25, which was prior to the loss of the 'A' train CCP mini-flow valve (0255 on 09/11/25). Thus, the 10 CFR 50.72(b)(3)(v)(D) reporting criterion was not met.

"The NRC Resident Inspector has been notified of this retraction."

Notified R4DO (Agrawal)

AGREEMENT STATE REPORT - DAMAGED PORTABLE MOISTURE DENSITY GAUGE

The following information was provided by the Virginia Department of Health, Office of Radiologic Health (RMP) via email:

"On September 10, 2025, at approximately 1500 EDT, RMP was notified of an incident involving damage to a portable nuclear gauge.

"Earlier, at approximately 1230, a Troxler Model 4640 B portable nuclear moisture density gauge, containing 9 mCi Cs-137, (SN #2256) was struck by a roller on a paving site at Westmoreland, VA. The authorized user notified the radiation safety officer (RSO) who went to the site to evaluate the gauge condition, and he notified RMP.

"Per the RSO, the gauge was clipped on the side by a CB-13 roller during the construction of a roller pattern and control strip. There was damage to the gauge cover and one battery pack. The source rod was not out when it was struck. There is no apparent [damage] to the source or the capsule. The gauge was surveyed onsite using with a TroxAlert 3105 (#64502) [meter] and readings were within acceptable ranges. The gauge was placed in its transport case and returned to the licensee's storage facility to be leak tested. Then the gauge will be sent to Troxler for evaluation.

"The Radioactive Materials Program will follow up with an investigation."

Event Report ID No.: VA250003

AGREEMENT STATE REPORT - EQUIPMENT FAILURE

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

"On September 11, 2025, at 1306 CDT, the Department received a telephone notification that the licensee's Jubilant DraxImage Inc. RUBY-FILL Rb-82 generator (Serial Number: GLO03160183) was unable to deliver a patient dose at approximately 1000 CDT on September 11, 2025.

"The device provided an error during the infusion stating that the dosage could not be delivered to the patient. The generator stated that 0.2 millicuries of Rb-82 was delivered to the patient out of an intended 20 millicuries. At approximately 1300 CDT on the same day, the licensee completed the daily quality control tests on the generator and simulated a patient infusion with a shielded vial. The device delivered the intended dosage to the vial and appears to be in working order. The licensee has a scheduled visit with the manufacturer the week of September 15-19, 2025, to evaluate the cause of failure. No contamination resulted from the incident."

Event Report ID No.: WI250012

EN Revision Imported Date: 9/19/2025

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT

The following report was received via phone and email from the South Carolina Department of Health and Environmental Control (the Department):

"The licensee informed the Department via telephone on June 6, 2025, that a medical event had occurred on June 5, 2025. The licensee reported that a Y-90 microsphere procedure resulted in 71 percent of the prescribed dose being administered to a patient (a difference of 29 percent), and that a spill also occurred during the administration. The licensee is reporting that the spill originated from the delivery system and likely caused the medical event.

"The licensee reported that the spill in the administration area was cleaned, and the area was released. The licensee is not reporting any overexposures or ongoing health or safety concerns. The referring physician was notified on June 6, 2025. This event is still under investigation by the Department."

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.

South Carolina Event Report ID Number: TBD

* * * UPDATE ON 06/27/2025 AT 0904 EDT FROM JACOB PRICE TO ROBERT THOMPSON * * *

The following is a summary of information provided by the South Carolina Department of Environmental Services (the Department) via email:

In the initial verbal notification, the licensee indicated that the patient received a dose of 29 percent less than prescribed. The written report submitted on June 6, 2025, indicates that the patient received a dose of 31.6 percent less than prescribed. This event is still under investigation.

South Carolina Event Number: SC250007

Notified R1DO (Arner), NMSS Events (email)

* * * UPDATE ON 09/18/2025 AT 1414 EDT FROM JACOB PRICE TO ERNEST WEST * * *

The following report was received via email from the South Carolina Department of Health and Environmental Control (the Department):

"Department inspectors conducted an on-site visit between July 2 and July 3, 2025. Interviews with the licensee's representatives were consistent with the details outlined in the written report. The licensee has provided additional training to the authorized user.

"This event/investigation is considered closed."

South Carolina Event Number: SC250007

Notified R1DO (Schussler), NMSS Events (email)

AGREEMENT STATE REPORT - LOST/RECOVERED MOISTURE DENSITY GAUGE

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

"On September 11, 2025, at approximately 1930 MDT, the Department received a phone call from the Jefferson County Sheriff's Office regarding a vehicle that was stolen in Silverthorne, CO. Within the vehicle was a InstroTek Model 3500 portable nuclear density gauge (SN:5664). The vehicle was involved in a police chase and eventually crashed on Interstate-70 East, near mile marker 258.

"Photos of the gauge were sent to the Department and the gauge was inside of the transport case, which did not appear to be damaged. Colorado State Patrol was also on scene and recorded a reading of 4mR/hr on contact of the transport container. Additional information about the meter that was used to record that value was not available at the time of the call as the scene was unfolding.

"At approximately 2114, the Department reached out to the Branch Manager of CTL/Thompson, Inc. The Branch Manager informed the Department that a technician was on route to retrieve the portable nuclear density gauge.

"At approximately 2138, the Jefferson County Sheriff's Office called and notified the department that the technician was now in possession of the gauge.

"The licensing information for the InstroTek Model 3500 was reviewed to verify that the surface readings taken at the scene did not exceed the expected dose rate.

"Based on the information provided by law enforcement, no exposures above public dose limits are expected. The department will follow-up with the licensee to verify the gauge was not damaged in the incident and review subsequent leak tests.

"Radioactive material summary: Make/Model: InstroTek, Inc. Model 3500 moisture density gauge radionuclide/activity: not more than 408 MBq (11 mCi) of cesium-137 and 1.63 GBq (44 mCi) of americium-241:beryllium. Serial Number: 5664."

Colorado Event Report ID No.: CO250028

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The following is a summary of information provided by the Illinois Emergency Management Agency (the Agency) via email:

On September 11, 2025, the licensee reported a moisture density gauge, an Instrotek model 3500 (serial number: 5208), was damaged in Macoupin County, Illinois. The source rod was reported to be intact.

Agency staff responded to the site the same day to perform a reactive inspection. The sources in the gauge (10 mCi Cs-137, 40 mCi Am-241/Be) were undamaged and there was no indication of contamination or unexpected exposure rates. The gauge was repackaged and will be returned to the manufacturer for repair or disposal.

Illinois item number: IL250036

AGREEMENT STATE REPORT - STUCK OPEN GAUGE SHUTTER

The following information was provided by the Illinois Emergency Management Agency (the Agency) via phone and email:

"The Agency was notified on September 12, 2025, by Equistar Chemicals LP of Morris, IL, regarding a stuck shutter. During the performance of the routine semi-annual inventory, the following nuclear gauge was found to have the shutter stuck in the open position.

"The gauge is in its normal operating shutter position (open) and no vessel entry or potential elevated exposures are likely. This matter is reportable within 24 hours under 32 Illinois Administrative Code 340.1220(c)(2). Updates will be provided as they become available."

Gauge: Vega model SH-F2 (serial number: 2767CO)
Source: 300 mCi Cs-137

Illinois item number: IL250037

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

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

"On September 12, 2025, the Department received a report of a stolen Troxler model 3440 moisture density gauge (8 mCi Cs-137, 40 mCi Am-241/Be). The gauge was stolen from a licensee vehicle outside of a hotel in Humble, Texas. The theft was witnessed [by a member of the public] but by the time police (Humble Police Department) arrived, the perpetrator was gone. The licensee personnel were not notified, and they called the police again. A written report was received at 0948 hours. The [licensee's] radiation safety officer stated they think the handle lock was in place; accordingly, there is no immediate threat to the general public.

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

Texas incident number: 10227, NMED number TX250046

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 - MEDICAL EVENT

The following information was provided by the Minnesota Department of Health via email:

"On September 11, 2025, a TheraSphere treatment (yttrium-90 microspheres) was performed where the activity in the written directive was 66.15 mCi [and] the measured activity was 64.4 mCi. After the procedure, the licensee measured the residual activity left in the tubing at 33 mCi. Only 47.5 percent of the prescribed activity was delivered. The patient and referring physician were notified. The cause is under review.

"Notification: 24-hour notification - TheraSphere treatment where the total dose or activity delivered differs from the prescribed dose or activity, as documented in the written directive, by 20 percent or more."

State event report ID: MN250005

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 - PACKAGE EXCEEDED EXTERNAL RADIATION LIMIT

The following is a summary of information provided by the Louisiana Department of Environmental Quality (the Department) via phone:

The licensee reported that a package received from the Colorado School of Mines, containing a 1.166 mCi Co-57 source (model MC07.122, serial number: 31.23, manufacturer unknown at the time of the report) had measured external dose rates of 50 mr/hr on contact and 0.2 mr/hr at 1 meter. When the external packaging was opened, it was discovered that the internal shipping container had been damaged. It is believed that the damage to the internal shipping container degraded the effectiveness of the shielding, resulting in the external radiation levels measured. The Department will follow-up with additional information as it is developed.

* * * UPDATE ON 09/15/2025 AT 1319 EDT FROM JAMES PATE TO ROBERT THOMPSON * * *

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

The package was supposed to be an excepted package. The package was damaged. The package received contained one source with the lid off the transport container inside the package. The activity of the source initially reported was the current activity; the original activity of the source was 10 mCi. The source was manufactured by Ritverc JSC and is used in a Mossbauer spectroscopy device. The Colorado School of Mines is licensed by the State of Colorado, license number CO 627-01.

Event report ID number: LA20250010

Notified R4DO (Agrawal), NMSS Events Notification (email)