Event Notification Report for October 09, 2025

AGREEMENT STATE REPORT - STUCK SOURCE

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

"The Agency was contacted on October 1, 2025, at 1415 CDT, by the radiation safety officer (RSO) for TEAM Industrial Services to advise of a radiography source stuck in the exposed position at a temporary worksite in Bethalto, IL. The RSO responded to the site, cut the guide tube and was able to place the source in a shielded position by 1500 CDT. No public or occupational exposures are anticipated as a result of this incident, but a reenactment will be independently conducted by Agency staff. Reportedly, the stuck source was caused by a heavy piece of pipe falling on the guide tube. Pending the Agency's investigation, this represents all available information at this time."

Manufacturer: QSA Global
Model #: A424-9
Source: 94 Ci Ir-192

IL Report #: IL250042

EN Revision Imported Date: 10/10/2025

EN Revision Text: AGREEMENT STATE REPORT - LOST RADIATION SHIELD

The following information was provided by the Florida Bureau of Radiation Control (BRC) via email:

"BRC received notification from Orlando Health on September 30, 2025, that a depleted uranium shield [weighing 120lbs] was disposed of alongside its Nuclear Medicine Adac Camera model MCD/AC. It was last accounted for in 2014. The shield was likely disposed of [during] the decommission and removal of the camera. No records of the [shield] removal are available."

FL Incident #: FL25-097

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 - DAMAGED MOISTURE DENSITY GAUGE

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

"The licensee had an InstroTek portable gauge containing 10 mCi Cs-137 and 40 mCi Am-241/Be sealed sources at a temporary jobsite. The gauge was run over by a compaction roller. The work site was cordoned off and the roller shut off. The roller [pushed] the rod with the Cs-137 source out of the shielded position and into the ground. The local radiation safety officer responded to the site. They maintained the cordoned off area until they were able to secure the gauge. The gauge was packaged and labeled according to the manufacturer's instructions and returned to the licensee's storage location. The accident area was surveyed after the gauge was secure and the readings were at background. The licensee leak tested the sources and sent them in to be analyzed."

State event report ID: MN250006

AGREEMENT STATE REPORT - STUCK OPEN GAUGE SHUTTER

The following information is a summary of information provided by the Arkansas Department of Health (the Department) via email:

During routine gauge shutter checks conducted by the licensee on October 2, 2025, the licensee found the shutters of three Berthold Technologies model LB300L fixed gauges stuck in the open position. The licensee has flagged the gauges, placed barriers around the gauges, and suspended any work in the area. The licensee is arranging for a Berthold field representative to perform maintenance on the gauges to attempt to close the gauges.

Gauge 1: 0.2 mCi Co-60
Gauge 2: 0.5 mCi Co-60
Gauge 3: 1.8 mCi Co-60

Arkansas event: AR-2025-013

AGREEMENT STATE REPORT - MEDICAL EVENT

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

"On October 3, 2025, the Department received notification from the licensee regarding a treatment error during stereotactic radiosurgery with a gamma knife system for a patient with a brain arteriovenous malformation (AVM). The patient was prescribed a total dose of 20 Gy over 2 fractions. The licensee stated that the event occurred on September 25, 2025, when during the first fraction, a coordinate system error between the stereotactic frame and immobilization masking resulted in radiation being delivered to an incorrect site in the brain, completely missing the AVM target volume. As a result, the prescribed 12 Gy for the first fraction was delivered to non-target brain tissue and 0 Gy reached the intended AVM target. The error was discovered on October 2, 2025, just before the patient was scheduled to undergo the second and final treatment fraction. Treatment was immediately suspended and both the referring physician, who is the surgeon, and the patient were immediately informed.

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

Texas incident number: 10231

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.

MANUAL REACTOR SCRAM

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

"On October 9, 2025, at 1207 CDT, River Bend Station (RBS) was operating at 100 percent reactor power when a manual reactor protection system (RPS) actuation was inserted as a result of a division-I balance of plant (BOP) isolation. The BOP isolation was a result of a blown fuse during surveillance activity. The BOP isolation resulted in the loss of instrument air system (IAS) and component cooling primary system (CCP) to containment.

"Following the isolation, control room operators entered the applicable abnormal operating procedures (AOP). In accordance with AOP guidance, control room operators inserted a manual reactor scram. All plant systems responded as designed. Immediately after the scram, a reactor water level 3 isolation signal was received as expected.

"Due to the swell from the main turbine trip, a reactor water high level 8 actuation signal was received at 1208 CDT. The level 8 actuation signal was reset at 1211 CDT. At 1237 CDT, control room operators entered the emergency operating procedure (EOP) for high containment pressure. The increase in containment pressure was due to the isolation of the containment vent flow path.

"The isolation signal for IAS and CCP was reset at 1255 CDT. Following the restoration of the isolation signal, control room operators lowered containment pressure and exited the EOP at 1305 CDT.

"Reactor pressure is being maintained by the main turbine bypass valves. Reactor level is being maintained by condensate and main feedwater. RBS is currently in mode 3. No radiological releases have occurred due to this event.

"The event is being reported under 10 CFR 50.72(b)(2)(iv)(B) and 10 CFR 50.72(b)(3)(iv)(A) as an event or condition that results in actuation of the RPS when the reactor is critical and as a specified system actuation due to the expected reactor water level 3 isolation signal immediately following the reactor scram, and a subsequent level 8 signal.

"The NRC Resident Inspector has been notified."