Event Notification Report for September 29, 2025

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.

LOST SOURCE

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

"This loss of material report is prepared per 10 CFR 20.2201(a)(1)(ii) for a loss of material of a Ra-223 dichloride (Xofigo) radiopharmaceutical package that was lost on 8/25/2025, by a [common carrier]. The package left the facility of RAM license 34-31473-03MD at 1353 EDT on 8/25/2025, to be sent to a customer location in Lincoln, NE. The package was sent through [the common carrier] in Memphis, TN, where it was declared lost on 9/3/2025. The package contained one vial of Ra-223 dichloride with a total activity at time of shipment of 92.8 microcuries. The shipment was planned to arrive in Lincoln, NE, by 1200 MST on 8/27/2025."

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

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."

EN Revision Imported Date: 9/30/2025

EN Revision Text: AGREEMENT STATE REPORT - STOLEN DENSITY GAUGE

The following information was provided by the licensee via email:

"On the morning of 8/31/2025, an employee of Terracon Consultants discovered that a portable nuclear gauge (Troxler model 3440) was stolen from their vehicle overnight. The gauge was stored in the bed of a pickup truck that had a canopy cover. The gauge was also chained to the bed of the truck. The vehicle was parked inside of a parking garage with camera surveillance. Unfortunately, the cameras were [decoys] and were not operating.

"An individual gained access to the gauge by breaking through a canopy window and using a bolt cutter to cut the chain securing the Troxler gauge. The density gauge was the only nuclear material stolen. A toolbox was also taken which contained various non-nuclear equipment.

"The employee contacted Seattle Police, who at 1401 [PDT], had not arrived on scene to generate a report. The licensee will ensure that a report is generated and work with local law enforcement to recover the gauge. A full report will follow within 30 days."

Device Information:
Manufacturer: Troxler
Model: CDCW556
Serial Number: 14086

Source Information:
Manufacturer: AEA Technology/QSA
Model: CDCW556 (Cs-137) and AMNV.997 (Am-241:Be)
Isotopes and Activity: 9 mCi of Cs-137, 44 mCi of Am-241:Be, 0.066 mCi of Cf-252



* * * UPDATE ON 09/29/2025 AT 1747 EDT FROM DANE BLAKINGER TO JOSUE RAMIREZ * * *

The Washington State Department of Health, Office of Radiation Protection provided a 30-day written report regarding the incident (WA-25-010).
The gauge has not been located at this time. The licensee has an open case with the Seattle Police Department. In addition, the gauge is being actively looked for by the licensee.

Notified R4DO (Vossmar), NMSS Event Notification (email), ILTAB (email), and CNSC (email).



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 SOURCE

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

"As a result of an ongoing Agency investigation into unresponsive general licensees, the Agency became aware of one (1) generally licensed fluorescence analyzer device containing 40 millicuries of Cd-109 (Cat 4 source) that is missing.

"Reportedly, in 2023, RCM Laboratories Inc (Hinsdale, Il) ceased operation, per a former employee. There is no indication of intentional theft/diversion, rather the result of an office closure and poor accountability.

"The licensee failed to properly transfer or dispose of the device, a Niton LLC XLp-300A (serial number: 24555). The Agency investigated, and per the real estate agency [which owns the building], the building is empty and confirmed no equipment is in the building.

"The quantity of radioactive material involved is reportable immediately to the Agency and the U.S. NRC."

Illinois Event Number: IL250041

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