Event Notification Report for August 19, 2026

EN Revision Imported Date: 8/19/2026

EN Revision Text: AGREEMENT STATE REPORT - LOST MEDICAL SEED

The following is a summary of information provided by the PA Bureau of Radiation Protection (the Department) via email:

On July 24, 2026, the licensee notified the Department of a lost prostate seed. It was discovered that the seed was missing on July 23, 2026. It is reportable under 10 CFR 20.2201 and 10 CFR 35.3045(a)(2)(i).

On July 23, 2026, a patient was receiving a prostate treatment with Theragenics Cs-131 seeds (3.31 mCi per seed). During the treatment, the Mick applicator became disengaged from the needle hub. The total number of seeds to be implanted was five. However, it was discovered after post implant imaging that only two seeds were implanted. The rest of the seeds were thought to have ended up in the needle or the stabilization equipment. A survey located an additional two seeds with one seed left missing. At the time of discovery, the procedure room, equipment, patient transport bed, linens, trash and surrounding areas to the procedure room were surveyed with a survey meter to attempt to locate the missing seed. The survey was unsuccessful in locating the remaining seed. The Department will perform a reactive inspection. More information will be provided as received.

Pennsylvania Event Number: PA260013

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.

* * * UPDATE ON 08/18/2026 AT 1211 EDT FROM JOHN S. CHIPPO TO SEBASTIEN BRUNEAU * * *

The following is a summary of information provided by the PA Bureau of Radiation Protection (the Department) via email:

"76 seeds were brought to the operating room to implant 48 seeds, as described in the written directive."

"Seeds number forty-six and forty-seven were not implanted as intended. Radiation surveys were conducted, and the two seeds were located. Imaging performed after the treatment indicated that 45 seeds were implanted. Since 48 seeds were brought into the operating room, the additional 3 seeds should have remained un-implanted. Only two seeds (number forty-six and forty-seven) were discovered - one seed was unaccounted for."

"The applicator was an older model, and that may have contributed to the event. The licensee will discontinue use of the older applicator model and replace it with the current recommended applicator for Cs-131 seed implantation."

One seed remains unlocated.

Notified NMSS Events Notifications (email), ILTAB (email), CNSC Canada (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 Texas Department of State Health Services (the Department) via phone and email:

"On August 11, 2026, the Department received notification from the licensee regarding a missing industrial radiography camera. The camera, an Industrial Nuclear Company [model] IR 100, contains a 90 Curie iridium-192 sealed source. The licensee stated that the trainer placed the camera at the back of the truck around 0600 CDT while preparing to leave the licensee's Wichita Falls office for a temporary jobsite in Weatherford [Texas]. The trainer did not place the camera inside the transport box and did not close the vehicle tailgate before departing. The trainer drove to the destination and realized upon arrival that the camera was missing and that the vehicle's tailgate was down. The radiation safety officer (RSO) stated that a team has been searching for the camera since this morning and will continue the search throughout the evening. The RSO stated that local law enforcement has been notified of the missing radioactive source in Wichita Falls. Additional information will be made available in accordance with SA-300 Reporting requirements."

Texas Incident number: 10318
Texas NMED number: TX260033

Notified DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, CISA Central Watch Officer, EPA EOC, FEMA NWC, FDA EOC (email), DHS Nuclear SSA (email), FEMA NRCC SASC (email), CWMD Watch Desk (email).


* * * UPDATE FROM ART TUCKER TO ERNEST WEST ON 08/12/2026 AT 1510 EDT * * *

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

"On August 12, 2026, two department investigators conducted a search for the missing camera and found it in Mineral Wells [Texas] at 1342 CDT. The source was found in a culvert at the intersection of highway 281 and 1821. The licensee has been informed and is enroute to collect the camera. Based on the location where the source was found, it does not appear that any individual would have received an exposure that would have approached any limit"

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

The source was found in the fully shielded position and there was no damage to the radiography camera.

Notified NMSS (Allen), RGLO (Alexander), ILTAB Branch Chief (Brown), IR MOC (Grant), INES National Officer (Smith via email), ILTAB (email), NMSS Event Notification (email), CNSNS (email).

Notified DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, CISA Central Watch Officer, EPA EOC, FEMA NWC, FDA EOC (email), DHS Nuclear SSA (email), FEMA NRCC SASC (email), CWMD Watch Desk (email).

THIS MATERIAL EVENT CONTAINS A 'Category 2' LEVEL OF RADIOACTIVE MATERIAL

Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

AGREEMENT STATE REPORT - STUCK SHUTTER

The following information was provided by the Pennsylvania Bureau of Radiation Protection (the Department) via email:

"On August 10, 2026, [at approximately] 1930 [EDT], a radiographer was working at the licensee's permanent location and could not fully retract the source into the camera. The camera is a QSA Model 880 with a source assembly model QSA Model A424-9. It contains approximately 22 Ci [0.8 TBq] of Ir-192. The source was stuck [approximately] one inch from the locked position, so it was partially shielded. They were able to disconnect the crank and pull the source back into the locked position. Since then, the camera seems to be operating correctly, and the issue was with the crank. The licensee spoke with the manufacturer (QSA), and the maintenance technician they spoke to [also] seemed to think it was an issue with the crank. They will be sending the crank to QSA on August 12, 2026, for inspection and repair if possible."

PA NMED number: PA260015

* * * UPDATE FROM JOHN S. CHIPPO TO SEBASTIEN BRUNEAU ON 08/13/2026 AT 0826 EDT * * *

"The camera is a QSA Model 880 (Serial Number: D16035) with a source assembly model QSA Model A424-9 (Serial Number: 30570P)."

"The licensee installed a new drive cable assembly on August 12, 2026."

"The licensee estimates that the radiographer on duty received 3.5 mR during the 14-hour shift."

Notified NMSS Events Notifications (email)