Event Notification Report for April 29, 2026

EN Revision Imported Date: 4/28/2026

EN Revision Text: PART 21 - DEFECTIVE SOLENOID VALVE ASSEMBLY

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

Forty incorrectly assembled solenoid valve assemblies were sent to Trillium Flow Technologies (TFT). On September 19, 2025, following a report by TFT that one of their customers was experiencing functionality issues, testing showed that these parts contain a defective bottom insert seal that has not been fully seated into the plunger area. This could result in improper functioning of the solenoid valve. Trillium Flow Technologies has been informed, and a recall of the potentially defective parts has been initiated.

Corrective actions include a recall of effected parts, implementation of additional training and quality control processes

Hanna Part Number: N606-00200-000
TFT Part Number: 27791650C003

Contact Information:
Mujtaba Khan
Quality Manager
262-764-8262

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

Hana Cylinders is unaware of any sites being affected.

EN Revision Imported Date: 4/28/2026

EN Revision Text: AGREEMENT STATE REPORT - OVEREXPOSURE

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

"On April 17, 2026, the Agency received a notification from the licensee regarding a dosimetry badge overexposure report submitted by its dosimetry processor. The licensee stated that the report indicated that a worker had received a deep dose equivalent reading of 5952 millirem during the reporting period between September 15, 2023, to November 14, 2023. The licensee stated that the worker involved is a cardiologist. The dosimetry processor reported that the pattern on the dosimeter indicated dynamic exposure. The dosimeter was also reanalyzed on a different instrument, and the new results confirmed the original reading. The licensee has initiated an investigation to determine the cause of the overexposure.

"Additional information will be provided in accordance with SA 300 reporting results."

Texas Incident number: 10279
Texas NMED number: TX260007

* * * RETRACTION ON 04/27/2026 AT 1115 EDT FROM SINDISO NCUBE TO CHRISTOPHER PRESCOTT * * *

The following is a summary of information that was provided by the licensee via email:

"On Friday 24 April, 2026, the radiation safety officer (RSO) reported that his investigation had been concluded. He determined that the dosimeter's recorded dose resulted from x-rays in the lab, with no contribution from radioactive materials. The RSO stated that the badge was discovered in the lab during a spring cleaning and had been sent to Landauer [dosimeter vendor] without his knowledge. The recorded dose was localized to a single area and reflects exposure to the dosimeter itself over time, not to the assigned individual."

Notified: R4DO (Drake) and NMSS (email)

EN Revision Imported Date: 4/28/2026

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT

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

"On April 21, 2026, the Department was notified by the licensee that a medical event had occurred at their facility. The licensee reported that it had received a unit dose of Indium-111, properly labeled, from its supplier on April 20, 2026. The unit dose was administered to the patient later that day. The next morning, the licensee was contacted by the pharmaceutical company providing the unit dose and informed that the radionuclide had not been tagged to any carrier. As a result, the licensee determined that the patient would receive a whole-body dose of 6.3 rem. No organ dose limit would be exceeded. The licensee reported no adverse effects will be suffered by the patient. The prescribing physician has been notified, and the patient will be notified of the event. The radiopharmaceutical company is performing an investigation. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: 10282
Texas NMED Number: TX260008

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.

EN Revision Imported Date: 4/28/2026

EN Revision Text: AGREEMENT STATE REPORT - DAMAGED GAUGE

The following information was provided by the California Department of Public Health, Radiation Health Branch (RHB) via email:

"On April 20, 2026, at 1623 PDT, the radiation safety officer (RSO) for RMA Group (Rancho Cucamonga, RCM), Radioactive Materials License #2700-36, contacted the RHB Brea office concerning a moisture/density gauge, CPN model MC-3, serial #M38128625 (Cs-137, 370 MBq (10 mCi); Am-241:Be, 1.9 GBq (50 mCi)), that had been run over by construction equipment. The incident occurred in Mission Viejo, CA, at a temporary job site at the junction of Gavilan Ridge Road and Legado Road at approximately 1545 PDT. The gauge was not performing a test, and the source rod was in the safe position when it was run over by construction equipment, likely an asphalt paver.

"The authorized user (AU) did not observe the gauge being run over. The AU was on a phone call in their vehicle facing the opposite direction at the time of the incident. The area around the gauge was cleared, and the RSO was contacted. The gauge source rod assembly was broken off from the base of the gauge. The Cs-137 end of the source rod was broken off and remained in the lead shielding in the base of the unit. The gauge was surveyed by the RSO, and exposure rate levels on the base of the gauge were in the normal range for a shielded Cs-137 source. The Am-241/Be source was also still attached to the base.

"The gauge base was bagged, and all parts were collected and then placed into the gauge transport case and returned to the RMA Group RCM office. The RSO contacted Troxler, and their trained staff will come to the RMA office to collect a leak-test swab on the sources and send it in for analysis. Once the sources are determined to not be leaking, the gauge will be taken to Troxler's office in RCM for damage assessment and disposition. A copy of the incident report from the RSO and AU of RMA Group will be forwarded to the RHB Brea office and will be included as part of this investigation.

"This is a preliminary report; more information will follow."

California 5010 number: 042026

EN Revision Imported Date: 4/28/2026

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was provided by the Texas Department of State Health Services [the Agency] via phone and email:

"On April 21, 2026, the Agency received notification from the licensee regarding a medical event involving a patient undergoing Lutetium-177 dotatate therapy. The patient was prescribed four treatment fractions, each administered approximately eight weeks apart. The licensee stated that the standard prescribed activity for this procedure is 200 millicuries (mCi) per fraction; however, due to clinical reasons, a reduced activity of 160 mCi per fraction was selected for this patient.

"On April 20, 2026, during administration of the first fraction, the reduced activity was not implemented, and the full 200 mCi dose was delivered, resulting in an excess activity of 40 mCi (25 percent) above the intended dose. The licensee estimated that this excess activity resulted in an additional dose of 125.5 rem to the spleen. This estimate was based on dosimetry data provided by the manufacturer, which identifies the spleen as the organ receiving the highest absorbed dose and was therefore used as the critical organ for dose assessment.

"The radiation safety officer determined that the error resulted from a failure by clinical staff to verify the prescribed activity against the written directive prior to administration. The physician, the patient, and the referring provider were notified of the event on April 21, 2026.

"Additional information will be provided in accordance with SA-300 reporting criteria."

Texas Incident Number: 10281
Texas NMED Number: TX260009

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 - STUCK SOURCE

The following information was provided by the North Dakota Department of Health via email:

"Apave America Inc., North Dakota license number 33-56806-01, reported an incident that occurred on April 21, 2026, at 2200 CDT involving an irretrievable source at the Marathon refinery in Mandan, North Dakota. The event involved a SPEC-150 industrial radiography device (serial no. 2800) containing a 71 Ci (2638 GBq) sealed Ir-192 source (serial no. GC1214).

"During an exposure on the Ultra Former Unit, the radiographer discovered that the crank had become stuck and could not return the source to its shielded position after the exposure. The radiographer immediately established a barricade at the public-dose distance for a one-hour exposure, maintained continuous surveillance, and notified the company radiation safety officer and Marathon Operations.

"The radiographer then obtained the necessary tools and moved the crank assembly to a shielded area behind a concrete wall for disassembly. After removing the crank handle and the faceplate screws, the radiographer found that a small roll pin had become wedged between the drive cable and the gear. This pin was not part of the crank assembly and is not normally attached to it.

"After removing the pin, the radiographer successfully cranked the source back into the shielded position. The crank assemblies were then tagged out for repair."

North Dakota Event Number: ND260002