Event Notification Report for December 26, 2025

EN Revision Imported Date: 12/26/2025<br><br>EN Revision Text: AGREEMENT STATE REPORT - EXTREMITY EXPOSURE EXCEEDING LIMITS

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

The Agency was contacted the morning of November 26, 2025, by Mistras Group, Inc., to report a radiography overexposure that occurred on 11/24/25. Reportedly, a trainee stood over a collimated, exposed 37 Ci Ir-192 source for an unreported period of time, before also grabbing the collimator (containing the exposed source) in his right hand and positioning it for the next shot. After checking the camera and recognizing the incident, he continued to work for ten additional shots, and the following day, before reporting the incident. Based on the report, the lead radiographer also failed to properly supervise and/or report the matter. The trainee was not wearing his dosimetry/alarming rate meter or referring to his survey meter throughout the incident. The radiographer reports symptoms consistent with an acute exposure to his right hand [sunburn, skin erythema, and tingling in the hand] and is being directed to medical treatment this morning. Oak Ridge Associated Universities (REAC-TS) was contacted by the licensee the evening of November 25, 2025, for direction on appropriate medical treatment.

"The trainee has been removed from all work for, at a minimum, exceeding his occupational exposure limits. The Agency has requested updates on medical assessment and is coordinating a full re-enactment with involved personnel for an accurate dose assessment at the beginning of next week. Agency staff, using the limited data available at this time, estimate an exposure in excess of 50 R but likely less than 250 R to the right hand. The source was in a 4 half-value layers tungsten collimator which the trainee states was pointed down. Based on the licensee's description, exposures to the groin and feet are estimated to be less than 50 R. Time/motion studies will allow refinement of these estimates. Based on the description of the exposure, this incident likely has a 24-hour reporting requirement, which the licensee failed to meet. Results of the time/motion study and refined dose estimates will be used to determine if the incident meets the criteria for an abnormal occurrence.

"Updates will be provided as they become available."

Illinois item number: IL250048

* * * UPDATE FROM GARY FORSEE TO BRIAN P. SMITH AT 1644 EST ON DECEMBER 2, 2025 * * *

The following is an update received from the Illinois Emergency Management Agency (the Agency) via phone and email:

"Agency inspectors completed a reactive inspection on Dec. 2, 2025. Based on a re-enactment of the incident, statements collected and time-motion studies, Agency staff do not believe the radiographer received a dose in excess of regulatory limits (50 rem). Inspector observations and inspection findings indicate a likely dose of 30 rem to the radiographer's right hand and an additional 1 rem to other portions of the skin.

"After repeated observations of the trainee's handling and securing of the collimated source, it was determined the guide tube was being held rather than the collimated (shielded) source. As a result, the exposure rate used for dose calculations was changed (increased) to that of an unshielded 37 Ci source at a distance of 1.25 inches. After ten recorded re-enactments, the act of picking up and securing the collimator to the pipe consistently resulted in an exposure to his right hand with a duration of 5-7 seconds. It would take an exposure of approximately twice this duration to result in a 50 rem dose to his extremity (11.7 seconds).

"Exposures to feet, groin, whole body and eyes were also calculated. In aggregate, the skin dose from this incident is estimated to be equal to or less than 31 rem. Total annual extremity exposure is also estimated to be less than the annual limit. Whole body dose for this incident is estimated to be less than one hundred millirem (15 second exposure, 14 inches away from shielded source at 0.31 R/hour). Prior to this incident, the individual's annual whole-body dose was 131 millirem; however, the trainee admitted to not wearing dosimetry.

"While lab results are pending, there was no appearance of deterministic effects (skin reddening/erythema). This incident will remain open pending the licensee's written report. If their investigation supports inspector findings, this incident may be retracted. Agency address of noncompliance with administrative rules will proceed concurrently."

Notified R3DO (Hills), NMSS (Fisher), IRMOC (Grant) and NMSS _Events via email.

* * * UPDATE FROM GARY FORSEE TO ADAM KOZIOL AT 1555 EST ON DECEMBER 24, 2025 * * *

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

Medical report indicated no abnormal results. The licensee estimates the dose to the worker's hand at 49 rem, below reportable criteria. The Agency considers this matter closed.

Notified R3DO (Stoedter), NMSS (Fisher), IRMOC (Whited) and NMSS _Events via email.

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 one exit sign, containing 7.62 Ci of tritium, was lost in Englewood, Colorado.

Manufacturer: Isolite Corporation
Model number: SLX60

Colorado event number: CO250047

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 Wisconsin Department of Health Services (the Department) via email:

"On November 20, 2025, the Department received notification that the licensee was unable to locate a RONAN Engineering model RLL-1 source holder (serial number 203389-D) containing an aggregate 0.72 millicuries of cesium-137. The source holder was discovered as missing by the licensee on November 14, 2025. The source holder contains eight cesium-137 sources, each with an activity of 0.09 millicuries. The source holder had been removed from service in September 2025 and was placed in storage. However, based on the licensee's internal investigation, it appears that a third-party contractor removed the source holder from storage, mistaking it as scrap metal. The source holder is believed to have been transported to a local scrap yard. The licensee performed multiple searches for the device at their site and at the scrap yard. The source holder has not been located but is believed to be intact. The Department performed a reactive inspection and physically verified the remainder of the licensee's inventory. The licensee has arranged for the manufacturer to dispose the remaining devices."

Wisconsin Event Report Identification Number: WI250020

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

POSSIBLE OVEREXPOSURE

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

On December 18, 2025, at 1010 MST, a three-person crew was manipulating the digital radiology panel while setting up for their next shot. When the assistant attempted to push the lock slide on the camera, he noticed it was already in the unlocked position and realized the source was exposed. The crew did not hear their rate alarms activate. A survey was not performed at the time, as the survey meter was located at the cranks during the incident. Based on initial estimates, the crew was approximately one foot from the source. Work was stopped immediately. The licensee performed preliminary dose calculations assuming the crew was on the shielded side of the collimator for approximately 5 minutes at 1 foot, resulting in an estimated dose of 1.7 rem. All three film badges are currently en route for rush processing.

Camera Information:
Model - D8039
Source Serial Number: 24751P
Activity - 64 curies of Ir-192

AGREEMENT STATE REPORT - MEDICAL EVENT

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


"On 12/19/2025, at 1647 PST, the Department was notified of a misadministration of a 200 mCi Lu-177 prostate-specific membrane antigen dose for a patient on a research protocol.

"During the infusion, there was some pressure buildup in the system causing an alarm from the infusion pump. The infusion was halted as a blockage was suspected in the intravenous line. After troubleshooting attempts, it was decided to attempt the manual syringe injection method, but during the manipulations there was concern that the vial's sterility was compromised and the remaining infusion was aborted. Imaging was immediately performed, and it was estimated that only 50-75 mCi was infused.

"A detailed report will follow within 15 days."

Washington Incident Number: WA-25-019

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.