Event Notification Report for November 26, 2025

EN Revision Imported Date: 11/26/2025

EN Revision Text: AGREEMENT STATE REPORT - UNPLANNED CONTAMINATION

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

"The Agency was contacted on 10/15/25 by the radiation safety officer for Elmhurst Hospital (IL-01612-01) to advise of a contamination incident. Reportedly, a vial containing 200 millicuries of Lu-177 was dropped in the facility's hot lab and contaminated a technician. Decontamination efforts are ongoing. Inspectors are headed to the facility to gather additional details and determine the likelihood of exposures exceeding regulatory limits.

"Based on the information currently available, this matter is a reportable unplanned contamination event under 32 Illinois Administrative Code 340.1220(c)(1). It is reportable within 24 hours, which the licensee met.

"Additional updates will be provided as they become available."

Illinois Reference Number: IL250044

* * * UPDATE ON 11/25/2025 AT 1620 EST FROM KIM STICE TO ROBERT THOMPSON * * *

The following information was provided by the Illinois Emergency Management Agency and Office of Homeland Security (the Agency) via email:

"Inspectors verified that the one nuclear medicine technician that was initially contaminated was successfully decontaminated prior to inspectors leaving the site. No contamination or elevated exposure rates were identified in unrestricted areas. Contamination was contained in the hotlab. Some fixed contamination on the hot lab floor was covered with lead so patient care could continue.

"The licensee submitted an event report on 11/13/25, as required. A skin dose assessment of the individual contaminated was performed using Varskin+. The contamination did not result in a skin or other occupational dose in excess of regulatory limits. The contaminated individual was assigned a skin dose of 16 rem. There was no public exposure as a result of this incident.

"Root cause was reported as a breach in handling procedures and inadequate vial and pig design.

"Corrective action included retraining and a recommendation to the manufacturer to change the design of the pig. The licensee stated that the manufacturer has since redesigned the pig to now include a locking engineering control to prevent lid and base separation."

Notified R3DO (Hills), NMSS Events Notification (email)

AGREEMENT STATE REPORT - LOST SOURCES

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

"The Agency was contacted on November 17, 2025, to advise of four missing I-125 brachytherapy seeds with an activity of approximately 0.23 millicuries each. Three seeds remain missing with the most likely disposition being lost in transit from the Georgia shipper to the Illinois [common carrier] hub. The root cause appears to be poor packaging by the shipping licensee.

"On November 17, 2025, Bard Brachytherapy, Inc. received a package from Northside Hospital - Gwinnett (Lawrenceville, GA) with return shipping information indicating that there were twenty-four seeds being returned. Upon examination, ten were sealed inside their original packaging, nine were found loose inside the box, and one was found in the parking lot outside of the delivery door. Four sources remained unaccounted for when the Agency was contacted. [The common carrier] was called to return to the Bard facility, but surveys failed to identify any additional seeds within the delivery vehicle. Additional surveys were conducted at the local [common carrier] hub and on the truck that transported the package from O'Hare airport. The licensee was able to locate one additional seed at the [common carrier] hub, underneath a receiving conveyor belt, leaving three (3) seeds unaccounted for.

"The package is reported as having left Lawrenceville, GA on November 12, 2025. The package had no indication of damage from transit. The Georgia program will be notified. A similar incident was reported on May 13, 2024, as a result of inadequate packaging of seeds for transport by the same Georgia licensee. Agency outreach to O'Hare is still pending for additional surveys. A detailed listing of stops prior to delivery is also being sought.

"The brachytherapy seeds are classified as a Category 5 source, described by the IAEA as the least likely to be dangerous to a person. At the estimated activity, the exposure rate at one foot would be just under 0.5 mR/hour. Due to the small size as well as the proximity and duration of exposure required; it is highly unlikely any public exposures would exceed regulatory limits.

"The Illinois licensee followed reporting timelines, package receipt procedures, and performed all reasonable search efforts. Agency staff are pursuing additional avenues to attempt recovery of the sources. This report will be updated with any information available."

IL incident number: IL250045

* * * UPDATE ON NOVEMBER 19, 2025, AT 1653 EST FROM GARY FORSEE TO JORDAN WINGATE * * *

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

"Agency inspectors performed a reactive inspection at O'Hare airport on November 19, 2025. Search efforts located one of the three missing seeds, which will be returned to the Illinois licensee for disposal. Two I-125 brachytherapy seeds, containing approximately 0.23 mCi each, remain missing. A detailed listing of stops was obtained from the carrier but proved logistically impractical to fully survey (approximately 63 locations). Given the very low likelihood of public exposures exceeding any regulatory limit, the Category 5 classification of the sources, and high likelihood the remaining sources are out of state; the Agency is considering this matter closed."

Notified R3DO (Orlikowski) (email), NMSS Events Notification (email), and ILTAB (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 CHROMATOGRAPH

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

The licensee reported to the Agency that a generally licensed gas chromatograph could not be located. The device was listed as in use at the licensee's site in Lincolnwood, IL. No record could be found of the device's disposal, and search efforts have been unproductive. An investigation by the Agency is underway.

Device: Shimadzu Scientific Instrument ECD-17
S/N: 1721
Source: 10 mCi Ni-63
Source S/N: 618587

IL incident number: IL250046

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 Environment via email:

The licensee reported three exit signs, each containing 17.51 Ci of tritium, were lost in Longmont, Colorado.

Manufacturer: SRB Technologies
Model number: BXU20GS

Colorado event number: CO250043

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 Environment via email:

The licensee reported two exit signs, each containing 11.5 Ci of tritium, were lost in Allenspark, Colorado.

Manufacturer: Safety Light Corporation
Model number: 2040

Colorado event number: CO250044

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 is a summary of the information provided by the Washington State Department of Health Office of Radiation Protection (Department) via email:

At 1651 PST, the Department was notified of the misadministration of a 200 mCi Lu-177 prostate membrane specific antigen dose for a patient on a research protocol. The dose was administered using an infusion pump. The principal investigator (PI) of the study was present for the administration and verified the dose. The PI is an authorized user on the license.

The pump began malfunctioning shortly after the infusion began. There were attempts to reset the pump and change the pump and patient catheter lines, but the situation did not improve. The decision was made to abort the procedure due to the ongoing difficulties. It is believed that the infusion lines failed due to blockage or pressure buildup, which caused the pump to alarm.

A small amount of contamination was noted on the infusion pump stand, on a side table that held the infusion lines, as well as near the sink in the room, likely due to initial decontamination efforts. The room was easily decontaminated and reopened.

Residuals measured from the remaining vial and tubing totaled approximately 145 mCi. The patient had imaging immediately after the aborted infusion that confirmed some administration of the drug was successful, which was estimated at 55 mCi. This represents 27.5 percent of the prescribed dose injected.

The research protocol includes an additional dose. Patient protocols are being reviewed for possible changes.

A detailed report will follow within 15 days.

WA incident number: WA-25-015

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 - STUCK OPEN SHUTTER

The following is a summary of the information provided by the Alabama Office of Radiation Control via email:

During routine bi-annual shutter checks, the licensee noted that their device had a malfunctioning shutter. The device's shutter failed in its normal open position. The licensee attempted to address the malfunction by spraying the shutter with lubricant, but the shutter's mechanism still presented a high resistance. The area has been barricaded off and procedures are in place to ensure that no one approaches the device or pipe until the malfunctioning device is replaced. The licensee plans to replace the source holder. Once the replacement is installed, the malfunctioning device will be put into safe state, removed from service, and securely stored until disposal. The estimated date for repair is January 31, 2026.

Model: Ohmart/Vega SH-F2
S/N: 8829GK
Source: 500 mCi Cs-137

Alabama incident: 25-06

EN Revision Imported Date: 11/26/2025

EN Revision Text: PART 21 - ROSEMOUNT PRESSURE TRANSMITTERS ELECTRONIC ASSEMBLY FAIULRES

The following is a summary of information provided by the vendor via phone and email:

Rosemount Nuclear Instruments, Inc. reported that certain Rosemount model 3154 pressure transmitters have exhibited a higher field return rate as a result of electronics assembly failure caused by an open circuit condition in certain precision wire wound resistors. This notification pertains to certain transmitters or spare electronics assemblies manufactured between November 2015 and November 2022. Specific parts affected are being identified to customers. Rosemount does not have complete information relating to specific plant applications and therefore cannot determine the potential effects of this condition on plant operation.

Failure analysis determined the open circuit condition is a result of corrosion of the resistive wire element, which leads to an annunciated off-scale low failure of the 4-20 mA analog output signal. In some cases, the off-scale low failure may be preceded by observable erratic behavior of the analog output and/or analog output drift outside of published specifications. If the analog output is erratic or drifting outside of published specifications, the transmitter output should be considered unreliable.

Rosemount investigation has determined the higher failure rate is associated with certain lots of wire wound resistors. As of this notice, 70 percent of model 3154 wire wound resistor failures occurred at two reactor sites, suggesting higher failure rates may be experienced at individual locations.

Rosemount has revised the design of all Rosemount 3150-series nuclear qualified pressure transmitters to utilize higher reliability precision resistor technologies. This revision is fully qualified and implemented for all Rosemount 3150 series models including, but not limited to, Rosemount model 3154.

Rosemount recommends that users review the application where any of the model 3154 pressure transmitters affected are used to determine any safety consideration in the operation of the plant and report any observed failures. Rosemount model 3154 pressure transmitters within the scope of this notification are considered fully functional unless failure symptoms consistent with the description are identified.

Responsible company officer:
Gerard Hanson
Vice President and General Manager
8200 Market Blvd
Chanhassen, MN

Affected plants:
Region I: Beaver Valley, Calvert Cliffs, Ginna, Hope Creek, Indian Point, Millstone, North Anna, Salem, Seabrook, Surry, VC Summer
Region II: Browns Ferry, Catawba, Farley, Harris, Hatch, McGuire, Oconee, Robinson, Sequoyah, St. Lucie, Turkey Point, Vogtle, Watts Bar
Region III: Braidwood, Byron, Davis Besse, DC Cook, Dresden, LaSalle, Monticello, Point Beach, Prairie Island, Quad Cities
Region IV: ANO, Callaway, Columbia, Commanche Peak, Diablo Canyon, River Bend, South Texas Project, Waterford, Wolf Creek