Event Notification Report for September 01, 2026

LOST FIXED GAUGES

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

On August 3, 2026, the licensee discovered 10 missing Industrial Dynamics Co. fixed radiation gauges during inventory. The gauge models lost were: two CI-2GV/3/VDE gauges containing 300 mCi of Am-241 each, two FT-100/2/SFVM-B gauges containing 100 mCi of Am-241 each, one FT-50 containing 100 mCi of Am-241, four CI-2GV1/VDE gauges containing 100 mCi of Am-241 each, and one FT-100/1/SFVM-B containing 100 mCi of Am-241.

The licensee performed a search of their facility and could not locate the missing sources.

No known exposures have occurred.

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 information was provided by the Wisconsin Radiation Protection Section (the Department) via phone and email:

"On August 11, 13, and 18, 2026, a patient received the first 3 of 6 fractions using a Nucletron Corporation Model 106.990 remote afterloader and a Leipzig applicator. The Ir-192 source was 5.8 Ci at the time of the first fraction. The intended dose to be delivered to the tip of the nose was 700 cGy per fraction; however, the licensee delivered the entirety of the dose to the left nasal ala. On August 20 another authorized user was overseeing the 4th fraction and identified that the written directive was not clear what the target site was. They cancelled the 4th fraction prior to administration. On August 21 the two physicians conferred and determined that the first 3 fractions had been administered to the incorrect site. The patient was notified on August 21 of the error. The Department became aware of the medical event on August 24.

"The licensee's calculations indicate they delivered zero cGy of the intended 2100 cGy (2100 rad) over the first 3 fractions to the nasal tip. The intended 2100 cGy dose was delivered to the incorrect site, the left nasal ala.

"The licensee has begun a root cause analysis and will confer with the patient to determine future treatment plans. The Department will be performing a reactive inspection".

Wisconsin Event Report ID Number: WI260015

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 - LOST EXIT SIGNS

The following is a summary of information provided by the Colorado Department of Public Health and Environment via email:

Forty-six tritium exit signs were declared lost by the licensee during the 2017 - 2021 timeframe. The exit signs are manufactured by SRB Technologies, Safety Light Corp., and Best Lighting Products. The total activity is 18.71 Ci of H-3.

Colorado Event Report ID Number: CO260019

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 Pennsylvania Department of Environmental Protection, Bureau of Radiation Protection (the Department), via email:

"A Troxler model 3430 (S/N 28741) nuclear density gauge containing an 8 mCi Cs-137 source and a 40 mCi Am-241/Be source was run over by a passing vehicle on a dead-end road, where it was dragged several feet. A flagger attempted to stop the vehicle but could not. The gauge was stuck under the front bumper of the car. The plastic casing and electronics were clearly damaged, however, the rod and handle were not affected. The technician immediately pulled the gauge out from the car, retracted the source from the backscatter position (still in the gauge body) to the shielded position, and moved it to the side of the road before calling the field manager. The licensee field manager then arrived onsite with a meter. Surveys were performed of the gauge outside the transportation case, inside the case, and the areas where the gauge was struck and then moved to after impact. A wipe of the outside of the gauge where the shutter is located was taken, and no external contamination was present. The gauge outside the case was reading 4 mR/hr on contact; the case with the gauge inside was reading 2 mR/hr on contact and 0.4 mR/hr at 1 meter. The road and roadside were background. The gauge was transported back to the company headquarters to be sent to Troxler for repair.

"The Department performed a reactive inspection on August 24, 2026. More information will be provided as received."

Event report ID number: PA260017

AGREEMENT STATE REPORT - STUCK RADIOGRAPHY SOURCE

The following is a summary of information provided by the Colorado Department of Health via email:

On August 24, 2026, at approximately 1400 MDT, a radiography crew experienced a source disconnect. During the first crank-out of the day, the radiographer encountered unusual resistance and needed multiple attempts to position the source. When retracting the cable, initial resistance was followed by free movement, but the locking mechanism failed to engage, indicating that the source had not fully returned. Survey measurements showed elevated radiation levels, and personnel withdrew and notified the radiation safety officer (RSO). The RSO, who is authorized to perform recoveries, retrieved the disconnected source with an estimated dose of 50 mrem. Dosimetry for all involved individuals was sent for emergency processing.
The recovered source passed the go/no-go test. The source cranks were sent for evaluation, the guide tube was removed from service, and the licensee's initial assessment identified human error as the probable cause.