Event Notification Report for August 31, 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

FITNESS FOR DUTY

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

"On August 28, 2026, at 0942 EDT, it was determined that a contract non-licensed supervisor failed a test specified by the fitness-for-duty testing program.

"This event is being reported pursuant to 10 CFR 26.719(b).

"The NRC Resident Inspector has been notified."

PART 21 - ASME CODE CERTIFICATION PROCESS NOT FOLLOWED

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

AAF sells filters containing acid-resistant media that is certified for compliance with a number of ASME AG1 sections. Compliance with these ASME sections requires that the media is qualified by a third-party laboratory every five years.

AAF made the decision to not requalify acid resistant media using a third party based on sales volume in 2020 but did not update all associated internal documentation to remove the reference to the ASME code. Documentation provided to customers continued to indicate the filters complied with the ASME code. The materials of construction and processes, including testing, did not change when third-party testing was discontinued. AAF does not recognize this as a defect in the quality or construction of the products shipped.

A root cause investigation was launched. Samples of the media have been sent to a third party for qualification. Current orders have been placed on hold pending the results of the third-party testing. Affected customers have been notified; none of the customers affected are NRC licensees.

This notification is being made per 10 CFR 21 requirements and in accordance with AAF's 10 CFR 50 Appendix B quality assurance program.

Contact information:
Gene Lupton
Quality Engineer, AAF
531 Flanders Filter Road
Washington, NC 27889

FITNESS FOR DUTY

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

"On August 28, 2026, at 0842 MST, it was determined that a licensed operator supervisor failed a test specified by the fitness-for-duty testing program.

"The individual's unescorted access authorization has been terminated.

"The Palo Verde NRC Resident Inspector has been notified."