Event Notification Report for September 25, 2025

AGREEMENT STATE REPORT - PACKAGE PRESUMED MISSING IN TRANSIT

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

"The Agency was contacted on 9/12/25 by Bard Brachytherapy (Carol Stream, IL) to advise that a package of (95) I-125 brachytherapy seeds, which they shipped on 9/9/25, had been repeatedly delayed and was now presumed lost at the carrier's hub in Kernersville, NC. Each seed contains 0.889 millicuries, for a total package activity of 84.455 millicuries. According to email transcripts, the [common] carrier stated the packages were still on site but had not been released for unknown reasons. There were no concerns of exposures to persons in unrestricted areas. On Tuesday, 9/16/25, the packages were then released and shipped to the intended recipient.

"It is unclear if the carrier declared the packages as lost and the reporting criteria in 10 CFR 20.2201 had been met. However, as the quantity of material would have required immediate reporting if lost. The licensee met all reporting requirements. This matter is now considered closed."

Item Number: IL250038

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 - CONTAMINATION DETECTED IN SHIPPING VIAL

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

"The Agency was contacted on September 8, 2025, by Bard Brachytherapy in Carol Stream, Illinois, to advise that they had detected contamination in a shipment of (72) TheraSeed Model 200 Pd-103 brachytherapy seeds. This is the second shipment of brachytherapy seeds since August, 2025, in which contamination was identified. The first occurrence identified contamination within the shipping vial and no leaking seeds. That occurrence failed to meet reportable criteria. Both shipments had been received directly from the manufacturer, Theragenics, in Georgia. The contamination did not result in any public or occupational exposures, nor were the licensee's facilities contaminated. However, based on additional information provided on September 11, 2025, this matter is reportable to the Agency under 32 Ill. Adm. Code 340.1230(a)(3)(A), the State's equivalent of 10 CFR 20.2203(a)(3)(i). The seeds have been returned to the manufacturer for investigation and to determine if a seed was leaking or there is a repeat instance of a contaminated shipping vial.

"Details: The shipment consisted of (72) sources at 1.55 millicuries each, for a total consignment of 267.3 millicuries. The brachytherapy seeds are TheraSeed model 200's, under registry number NR-0645-S-101-S. Upon receipt and transfer of brachytherapy seeds to a sterile area, the Illinois licensee surveys the empty shipping vial. It is in this step they identified contamination, later quantified to be approximately 0.013 microcuries. The reportability stems from the fact their license requires testing for contamination prior to incorporating the sources into an implanting device. The reporting threshold is 0.005 microcuries, and thus, this represented the presence of contamination in a restricted area breaching an applicable limit in the license. It is noteworthy a previous incident reported to the Agency on August 21, 2025, also found contamination in a shipping vial, although it did not exceed 0.005 microcuries. The Georgia program was contacted and notified of the incident as well. The licensee met applicable reporting timelines. This report will be updated with any additional information provided by the manufacturer."

Item Number: IL250039

AGREEMENT STATE REPORT - DAMAGED GAUGE

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

"On September 17, 2025, the Department received a report from the licensee stating that, during routine testing, the screw for the shutter operating arm on a Ronan SA-1-F37 nuclear gauge containing a 100 millicurie (original activity) cesium-137 source had broken. The shutter is stuck in the open position. Open is the normal operating position. The licensee stated they will contact a service provider to repair the gauge.

"The licensee reported that there is no risk of additional radiation exposure to members of the general public or radiation workers, due to this on/off mechanism failure. The licensee reported a service provider has been contacted to repair the gauge.

"Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: 10230
Texas NMED Number: TX250049

AGREEMENT STATE REPORT - LOST GAS CHROMATOGRAPHY DEVICES

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

"As a result of an ongoing investigation into unresponsive general licensees, the Agency became aware that five (5) generally licensed Perkin-Elmer model n610-0063 gas chromatography devices, each containing 15 millicuries of Ni-63, are missing.

"Reportedly, in late 2024, the licensee went through a transition of layoffs and is currently being bought by another company. Due to the change in employees, the location of these devices is unknown.

"The licensee failed to properly transfer or dispose of the devices (serial numbers 4377, 6055, 6273, 6202, and 7067). The facility manager is currently trying to reach out to past employees for information. The Agency has reached out to the distributor to try and locate the devices.

"The quantity of radioactive material involved, while unlikely to be dangerous to the public, is reportable within 30 days to the Agency and the U.S. NRC. Investigation is ongoing, and any updates will be reported."

Illinois Event Number: IL250040

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 Radiation Health Branch of the Kentucky Department for Public Health and Safety (KY RHB) via email:

"KY RHB was notified on 9/18/2025 by the radiation safety officer (RSO) from the University of Louisville Hospital of an issue with five Sir-Sphere Y-90 doses.

"Due to a software issue that had a calculation error converting GBq to mCi, 5 patients were underdosed to a point that their dose was more than 20 percent outside of the prescribed dose, and the dose to the organ (liver) was more than 50 mSv from the prescribed dose.

"The RSO is meeting with the physician today to discuss the issues. The issue with the software has been fixed."

KY Event Number: TBD

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 9/22/25, Watts Bar Nuclear (WBN) Operations was informed that a WBN licensed operator had tested positive for a controlled substance during a pre-screening test to regain unescorted access, in violation of the Tennessee Valley Authority (TVA) fitness for duty policy.

"A pre-access screening was completed on 9/16/25 to regain unescorted access. The results were sent to the TVA medical review officer on 9/22/25. The test was declared positive for a controlled substance and WBN Operations was notified at 1500 EDT on 9/22/25.

"The individual's unescorted access remains revoked.

"The NRC Resident Inspector has been notified."

FITNESS FOR DUTY EVENT

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

"At 1300 CDT on September 15, 2025, it was determined that a non-licensed supervisor had tested positive for a controlled substance, in violation of South Texas Project's fitness for duty policy. Prior to this, the individual's unescorted access had been administratively withdrawn pending retesting. This is reportable under 10 CFR 26.719 and is a late 24-hour notification.

"The NRC Resident Inspector has been notified."

NON-POWER REACTOR - UNPLANNED HIGH-POWER TRIP

The following information was summarized from the licensee via phone and email:

On September 24, 2025, at 1511 MDT, a high-power trip occurred (operation of safety channels 2 and 3). The reactor was being operated by a senior reactor operator (SRO) and a student authorized operator. A positive-period excess reactivity measurement was being performed. The reactor power rose to 5.64 watts. The technical specifications power limit of 6 watts plus was not exceeded, and both safety channels functioned to shut the reactor down.

This prompt notification for a high-power trip is in accordance with current procedures and technical specification 6.9.2.a.7. The proximate cause of this event was operator distraction. The reactor room had two visitors at the time of the event, an NRC inspector and a University of New Mexico nuclear engineering instructor. The instructor was engaging the student authorized operator and the SRO on matters relating to a laboratory activity ongoing in another part of the building. The SRO responded to the rising power too slowly to avoid the high-power trip.

AUTOMATIC REACTOR TRIP

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

"On September 24, 2025, at 1347 CDT, Arkansas Nuclear One, Unit 1, (ANO-1) experienced an issue with the X-01B main phase transformer which led to an automatic trip on reactor protection system (RPS).

"ANO-1 is currently stable in mode 3, maintaining pressure and temperature with the P-1A and P-1B main feedwater pumps and steaming to the main condenser. All rods inserted and systems functioned as expected.

"There is no radiological release on either unit as a result of this event.

"This report satisfies the reporting criteria of 10 CFR 50.72(b)(2)(iv)(B) and 10 CFR 50.72(b)(3)(iv)(A) for the reactor protection system actuation.

"The NRC Senior Resident Inspector has been notified.

"Unit 2 was not affected."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
ANO-1 retains access to all normal sources of offsite power.

MANUAL REACTOR TRIP

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

"On September 24, 2025, at 1829 CDT, Comanche Peak, Unit 1, was manually tripped due to a trip of both main feed water (MFW) pumps. All auxiliary feedwater pumps started due to the trip of both MFW pumps. This event is being reported in accordance with 10 CFR 50.72(b)(2)(iv)(B) for a reactor trip and 10 CFR 50.72(b)(3)(iv)(A) for an actuation of auxiliary feedwater. Unit 1 is being maintained in mode 3 in accordance with integrated plant operating procedures. Decay heat is being rejected to the main condenser via the steam dump valves. The cause of both MFW pumps tripping is unknown and under investigation.

"The NRC Resident Inspector was notified."


The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
No evolutions were ongoing at the time of the event.

AGREEMENT STATE REPORT - MEDICAL EVENT

The following is a summary of information received from the Alabama Office of Radiation Control (the Agency) via email:

On September 3, 2025, an administering physician encountered resistance while delivering a dose of Y-90 Theraspheres. The patient received 67.2 mCi of a prescribed 90.7 mCi (24.4 percent underdose). The delivery apparatus was placed in storage to decay. Once decayed, it will be sent to the manufacturer (Boston Scientific) for evaluation. The patient was informed and advised that the delivered dose is acceptable therapeutically.

The Agency was informed of this incident on September 18, 2025, and will provide additional information as the investigation continues.

Alabama Incident Number: 25-04

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.

TWO TRAINS OF ECCS INOPERABLE

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

"On 9/23/2025 at 2214 CDT, the South Texas Project Unit 1 (STP-1) Train B reactor containment fan cooler (RCFC) chilled water supply outside containment isolation valve (OCIV) 1-CC-MOV-0137 was declared inoperable due to a material condition. This rendered Train B component cooling water inoperable which cascaded to Train B emergency core cooling system (ECCS) subsystem to render it inoperable. STP-1 entered Technical Specification (TS) 3.5.2 Action A for Train B ECCS, requiring restoration within 7 days or apply the requirements of the (Configuration Risk Management Program) CRMP.

"On 09/25/2025 at 1229, Train A essential chiller 12A was declared inoperable due to inability to maintain chiller water outlet temperature less than 52 Fahrenheit. This cascaded down to the Train A ECCS Subsystem to render it inoperable. STP-1 entered TS 3.5.2 Action B due to less than two of the required subsystems operable, within 1 hour restore at least two subsystems to operable status or apply the requirements of the CRMP, or be in at least Hot Standby within the next 6 hours and in Hot Shutdown within the following 6 hours.

"On 09/25/2025 at 1329, STP-1 entered CRMP based on two ECCS subsystems remaining inoperable longer than 1 hour. These subsystems are used for accident mitigation. Unit 1 remains in mode 1."