Event Notification Report for December 03, 2025

AGREEMENT STATE REPORT - LEAKING SOURCE

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

"On November 21, 2025, the licensee was performing a routine sealed source leak test and discovered that a Cs-137 vial reference standard (model RV-137-200U, S/N 1710-68-8) was leaking. The licensee used a Capintec CRC 55tW well counter to determine if the source was leaking or contaminated. The source container was wipe-tested on the inside and found to also be contaminated. The dose calibrator dipper was very slightly contaminated and also removed from service. All other equipment associated with the source was wipe tested and found to be free of contamination. The source was immediately removed from service. The sealed source was replaced in the original lead container and placed into gloves and a plastic bag along with all associated wipes and the dose calibrator dipper. The licensee will package the material and send it for disposal. The estimated activity of the source was 170 microcuries, and the leak test results were 0.0139 microcuries.

"The Department will perform a reactive inspection. More information will be provided as it is received."

Event report number: PA250016

AGREEMENT STATE REPORT - PACKAGE LOST IN TRANSIT

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

"The Agency was notified on November 25, 2025, by G.E. Healthcare that a shipment containing one shielded, 10 mL vial of an indium-111 radiopharmaceutical has been reported as lost after arriving at the [common carrier's] Memphis, TN hub. This package was shipped from the licensee's Arlington Heights facility on Friday, November 7, 2025, for delivery to Leesar, Inc. of Fort Myers, FL. The package contained 3.201 mCi at time of shipment, which has now decayed to 0.03 mCi.

"The package is likely lost within the sorting facility and there is little likelihood of public exposures exceeding regulatory limits. The customer has acknowledged that the package was not received. There has been no indication that the package was damaged or that the contents were separated from its packaging. The loss has a 30-day reporting requirement, which was met by the licensee.

"Absent any new information, this matter is considered closed pending the licensee's written report."

Illinois item number: IL250047

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 - 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.

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was provided by the Ohio Bureau of Radiation Protection via email:

"A patient was scheduled to receive 30 mCi Y-90 to the right lobe of the liver in segments 5/6, but only 11.2 mCi was delivered. This is an underdose of 63 percent.

"The authorized user (AU) and interventional radiologist physician verified catheter placement by contrast injection and fluoroscopy prior to the procedure and continued to monitor the catheter position during the treatment. During the procedure, the AU noted that saline was leaking from the top of the acrylic vial holder inside the delivery box and that there was insufficient pressure to mix/suspend the microspheres in the dose vial. It was also noted the catheter had moved from the original target. The AU determined the dose could not be delivered as prescribed and abandoned the procedure.

"The patient and referring physician were notified.

"Investigation is pending."

Ohio item number: OH250004

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.

60-DAY OPTIONAL TELEPHONIC NOTIFICATION OF INVALID SPECIFIED SYSTEM ACTUATION

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

"At 0913 CDT, on October 6, 2025, a partial actuation of the division 1 emergency diesel generator (DG1) occurred during the performance of the 4160-volt bus 1F undervoltage relay channel functional test. The DG1 automatic start in the emergency mode was the result of the inadvertent contact between a jumper and another component. However, due to the test configuration, the output breaker for DG 1 did not close and pick up the load of the 4160-volt bus 1F since no actual undervoltage condition was present. DG1 components functioned as expected in response. Following the actuation, DG1 was restored to a standby lineup in accordance with plant procedures.

"This event is considered an invalid system actuation reportable under 10 CFR 50.73(a)(2)(iv)(A). The actuation was not initiated in response to actual plant conditions or parameters and was not a manual initiation. Therefore, in accordance with 10 CFR 50.73(a)(1), this telephone notification is provided within 60 days after discovery of the event instead of submitting a written licensee event report. The NRC Resident lnspector has been notified."