Event Notification Report for March 20, 2026

AGREEMENT STATE REPORT - OCCUPATIONAL DOSE LIMIT EXCEEDED

The following is a summary of information provided by the NJ Radiation Protection and Reliability Prevention Program (NJDEP) via email:

On March 4, 2026, DMS Health Technologies, an NRC licensee from South Dakota working under reciprocity in New Jersey, reported that a worker's recorded whole-body dose had exceeded the occupational limits of 10 CFR 20.1201(a)(1)(i) for calendar year 2025. When the dosimetry reports for December 2025 were reviewed, it was discovered that the employee's cumulative dose for 2025 had exceeded the limit.

The root cause and contributing factors found were that the employee was not following established radiation safety protocols, not utilizing most appropriate equipment to administer material, and potentially allowing their dosimeter to be scanned at airport security when traveling. The corrective action was retraining the worker. Dosimeter results will be closely monitored in the future, and the worker will be assigned non-radiation related duties if recorded dose exceeds a warning threshold.

AGREEMENT STATE REPORT - IODINE-131 SPILL

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

"During a routine inspection conducted on March 10 and 11, 2026, inspectors identified an unreported event which occurred on April 29, 2024.

"The event involved a spill of 30 mCi of liquid I-131 on the floor of the pharmacy's iodine room. Once personal protective equipment was removed, surveys confirmed no personnel contamination. Response activities included the placement of additional tacky mats on the floor of the iodine room and restricting entry to all personnel except the radiation safety officer.

"Initial investigation findings indicate that no occupational dose limits were exceeded and that no adverse effects were noted to personnel involved.

"The investigation into the unreported incidents remains ongoing.

"Reporting requirements were not met by the licensee and will be addressed through forthcoming inspection correspondence. Pending satisfactory response to the notice of violation, this matter will be closed."

Illinois item number: IL260005

AGREEMENT STATE REPORT - UNPLANNED CONTAMINATION

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

"During a routine inspection conducted on March 10 and 11, 2026, inspectors identified an unreported event which occurred on April 30, 2024.

"The event involved contamination of a pharmacist as a result of an attempt to change out the stock vial, syringe, and needle in the I-131 SMART-FILL dispensing system. Despite wearing sleeves, double gloves, and double booties, personnel contamination of the individual's hands, wrist, top of head, chin, right ear, and nose resulted.

"Initial investigation findings indicate that no occupational dose limits were exceeded and that no adverse effects were noted to personnel involved.

"As a result of this incident, entry to the iodine room was restricted for an additional three weeks.

"The investigation into the unreported incidents remains ongoing.

"Reporting requirements were not met by the licensee and will be addressed through forthcoming inspection correspondence. Pending satisfactory response to the notice of violation, this matter will be closed."

Illinois item number: IL260006

AGREEMENT STATE REPORT - STUCK SHUTTER

The following report was received via email by the Tennessee Division of Radiation Health:

"During a scheduled 6-month shutter check, it was discovered that a gauge shutter was stuck in the open position. No abnormal levels of radiation were detected, and the position was consistent with normal operation. A VEGA field technician has been contacted to service the gauge.

Manufacturer: Ohmart/Vega
Source Holder Model: SHF2
Source SN: 64793
Isotope: Cs-137, 92.2 mCi (adjusted for decay)

"Corrective actions, reports, and any additional information will be provided in an NMED report within 30 days."

Tennessee Report ID number: TN-26-016

AGREEMENT STATE REPORT - FAILED AFTERLOADER DEVICE

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

"The Agency was contacted [on March 13, 2026,] by the radiation safety officer for OSF Healthcare System (doing business as St. Francis Medical Center) in Peoria, Illinois to report an equipment failure on a Bravos high dose rate (HDR) afterloader device. The failure involved a data communication error between the console and the HDR unit. This was discovered prior to use on patients and, according to the licensee, did not result in any administrations deviating from the written directive. Regardless, this matter is reportable under 32 Illinois Administrative Code 340.1220(c)(2) within 24 hours. Inspectors will be on site to gather necessary information on Tuesday, March 17.

"The licensee advised the manufacturer is already on site correcting the issue and identifying root cause. This report will be updated when additional data becomes available."

Illinois Event Number: IL260007

MEDICAL EVENT

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

The licensee reported a procedural error involving a written directive for an I-131 sodium iodide therapeutic administration, in potential violation of 10 CFR 35.41.

A patient presented to the facility on February 23, 2026, for a prescribed 29 mCi I-131 therapy. Prior to administration, the patient informed the supervising authorized user (AU) that they would be leaving the country for three days following the scheduled treatment. The AU and the radiation safety officer (RSO) determined that it would be more appropriate to delay the administration until the patient returned. The therapy was therefore not administered on that date.

The patient returned on March 11, 2026, for the rescheduled therapy. The originally assigned AU was unavailable. Another physician, who is board-certified and had prior residency training in nuclear medicine but is not listed on the license as an AU, was present during the administration. The technologist administered the therapy under this physician's observation.

Because the observing physician was not listed as an AU, they could not sign the written directive. The technologist believed the original AU could sign the required section upon returning, not recognizing this was not compliant with 10 CFR 35.41. The RSO was notified of the issue on March 13, 2026, at approximately 1400 CDT.

The referring physician was notified on March 13, 2026. The referring physician requested that the patient not be notified, stating that the situation did not affect the clinical outcome of the treatment. The licensee reported the event to the NRC Operations Center on March 13, 2026, within 24 hours of identifying the error.

The licensee has stated that a corrective action report will be submitted within 15 days.

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.

* * * RETRACTION ON 03/16/2026 AT 0912 EDT FROM NICHOLAS BELL TO ADAM KOZIOL * * *

The licensee is retracting this event after discussing the details with the NRC Inspector.

Notified R3DO (Edwards), NMSS Events (email)

INVALID SYSTEM ACTUATION

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

"This 60-day telephone notification is being made in lieu of a licensee event report (LER) in accordance with 10 CFR 50.73(a)(1) for an invalid actuation of the emergency service water (ESW) system reportable under 10 CFR 50.73(a)(2)(iv)(A) at the Prairie Island Nuclear Generating Plant Units 1 and 2.

"At 1343 CST on January 26, 2026, during post maintenance testing associated with the time delay relay replacement work for the 22 diesel driven cooling water pump (DDCLP), an ESW pump on `B' train, a jumper was installed to test an annunciator. The jumper bypassed part of the normal start circuitry and allowed a spurious start signal. As a result, the 22 DDCLP automatically started without operator command. At the time of the start, the pump was inoperable and return-to-service testing had not been completed; certain isolations, including DC control power, had been restored, which made the unintended actuation possible.

"This event is considered an invalid system actuation of the ESW system. The actuation was not initiated in response to actual plant conditions or parameters. The 22 DDCLP started and functioned as expected in response to the start signal.

"The NRC Resident Inspector has been notified."

UNUSUAL EVENT DECLARED FOR RCS LEAKAGE FOR GREATER THAN 15 MINUTES

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

At 0819 MST on 3/19/2026, with Palo Verde Unit 2 at 95 percent power, the site declared an Unusual Event under emergency action level 'SU5.1' due to identified reactor coolant system leakage for greater than 15 minutes. The leak was isolated by securing letdown. A manual reactor trip was inserted, and Unit 2 is currently shutdown in mode 3. Palo Verde Units 1 and 3 were unaffected.

State and local authorities were notified.

The NRC Senior Resident Inspector has been notified.

Notified DHS SWO, FEMA Ops Center, FEMA NWC, CISA Central, CWMD Watch Desk, DHS Nuclear SSA (email), and DHS NRCC THD Desk (email).


* * * UPDATE ON 03/19/2026 AT 1535 EDT FROM PEDRO REGUERA TO BETHANY CECERE * * *

The following update was provided by the licensee via phone:

This update is a 10 CFR 50.72(b)(2)(iv)(B) required report of a valid RPS actuation while critical due to operators tripping Palo Verde Unit 2 at 0841 MST.

Notified R4DO (Dixon), NRR EO (Feliz Adorno), IR MOC (Whited), R4RA (Monninger), NRR (Groom), R4 PAO (Smith), and NSIR (Williams).


* * * UPDATE ON 03/19/2026 AT 1717 EDT FROM COLLIN MILLER TO JOSUE RAMIREZ * * *

The following information was provided by the licensee via phone:

Palo Verde Unit 2 terminated the notice of unusual event 'SU5.1' at 1410 MST. The leak was isolated, the plant is stable, and there was no release.

State and local authorities were notified.

The NRC Senior Resident Inspector has been notified.

Internal notifications: R4DO (Dixon), NRR EO (Feliz Adorno), IR MOC (Whited), R4RA (Monninger), NRR (Groom), R4 PAO (Smith), and NSIR (Williams).

External notifications: DHS SWO, FEMA Ops Center, FEMA NWC, CISA Central, CWMD Watch Desk, DHS Nuclear SSA (email), and DHS NRCC THD Desk (email).