Event Notification Report for November 28, 2025

AGREEMENT STATE REPORT - MEDICAL EVENT

The following is a summary of the information provided by the Washington State Department of Health Office of Radiation Protection (Department) via email:

At 1651 PST, the Department was notified of the misadministration of a 200 mCi Lu-177 prostate membrane specific antigen dose for a patient on a research protocol. The dose was administered using an infusion pump. The principal investigator (PI) of the study was present for the administration and verified the dose. The PI is an authorized user on the license.

The pump began malfunctioning shortly after the infusion began. There were attempts to reset the pump and change the pump and patient catheter lines, but the situation did not improve. The decision was made to abort the procedure due to the ongoing difficulties. It is believed that the infusion lines failed due to blockage or pressure buildup, which caused the pump to alarm.

A small amount of contamination was noted on the infusion pump stand, on a side table that held the infusion lines, as well as near the sink in the room, likely due to initial decontamination efforts. The room was easily decontaminated and reopened.

Residuals measured from the remaining vial and tubing totaled approximately 145 mCi. The patient had imaging immediately after the aborted infusion that confirmed some administration of the drug was successful, which was estimated at 55 mCi. This represents 27.5 percent of the prescribed dose injected.

The research protocol includes an additional dose. Patient protocols are being reviewed for possible changes.

A detailed report will follow within 15 days.

WA incident number: WA-25-015

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 OPEN SHUTTER

The following is a summary of the information provided by the Alabama Office of Radiation Control via email:

During routine bi-annual shutter checks, the licensee noted that their device had a malfunctioning shutter. The device's shutter failed in its normal open position. The licensee attempted to address the malfunction by spraying the shutter with lubricant, but the shutter's mechanism still presented a high resistance. The area has been barricaded off and procedures are in place to ensure that no one approaches the device or pipe until the malfunctioning device is replaced. The licensee plans to replace the source holder. Once the replacement is installed, the malfunctioning device will be put into safe state, removed from service, and securely stored until disposal. The estimated date for repair is January 31, 2026.

Model: Ohmart/Vega SH-F2
S/N: 8829GK
Source: 500 mCi Cs-137

Alabama incident: 25-06

MEDICAL EVENT

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

"A medical event occurred on November 17, 2025, at the Veterans Administration Medical Center in Lebanon, Pennsylvania. A patient was to be administered Lu-177 (Lutathera) by intravenous infusion for a neuroendocrine tumor. The written directive prescribed a dose of 200 mCi. During the administration, there was a leak from the administration apparatus onto absorbent material. It is estimated that only about half of the prescribed activity was delivered to the patient. The medical event was discovered on November 19, 2025, after reviewing post-treatment imaging.

"The referring physician and patient were notified of the medical event on November 19, 2025. No short-term harm to the patient is expected."

The NRC Region 3 project manager will be notified.

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 - MEDICAL EVENT

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

"On 10/30/25, the licensee was treating a patient with Y-90 microspheres to a liver lobe in 3 dosages. The first two dosages were successfully administered, but the third dosage did not deliver successfully, with essentially none of the dosage reaching the target. Instead, the majority of the dosage was retained in the administration apparatus with some having leaked out, resulting in contamination of the treatment room and treating personnel. While the licensee reported this event to RHB on 11/1/25, it was reported by email and not directed to the correct RHB sub-organization, nor was the email clear regarding the event. This resulted in the significant delay in reporting this event to the NRC.

"RHB is still investigating this event."

California 5010 Number: 110125


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.

SHIPMENT EXCEEDS SURFACE CONTAMINATION LIMITS

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

"On November 21, 2025, at 0835 CST, River Bend Station (RBS) was operating at 78 percent reactor power when the [radioactive waste] shipping department received a cask from the Waste Control Specialists disposal facility in Andrews County, TX via [a common carrier]. A smear sample was collected and exhibited surface contamination above the Department of Transportation (DOT) limits, specified in 49 CFR 173. The carrier was notified at 1713 CST.

"The surface contamination exceeded 24,000 [disintegrations per minute per centimeter squared] for beta gamma [activity].

"Supervision was immediately contacted and placed the shipment into a radiological controlled area.

"An investigation was performed to the extent of the condition of the loose surface contamination of the cask to determine if it was isolated to the immediately accessible areas of the cask due to an installed rain cover. The investigation concluded that the condition was extended to the surface of the cask where the average surface area exceeded DOT limits.

"This condition is immediately reportable to the NRC headquarters operations center per 10 CFR 20.1906(d)(1)."

EN Revision Imported Date: 11/26/2025

EN Revision Text: PART 21 - ROSEMOUNT PRESSURE TRANSMITTERS ELECTRONIC ASSEMBLY FAIULRES

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

Rosemount Nuclear Instruments, Inc. reported that certain Rosemount model 3154 pressure transmitters have exhibited a higher field return rate as a result of electronics assembly failure caused by an open circuit condition in certain precision wire wound resistors. This notification pertains to certain transmitters or spare electronics assemblies manufactured between November 2015 and November 2022. Specific parts affected are being identified to customers. Rosemount does not have complete information relating to specific plant applications and therefore cannot determine the potential effects of this condition on plant operation.

Failure analysis determined the open circuit condition is a result of corrosion of the resistive wire element, which leads to an annunciated off-scale low failure of the 4-20 mA analog output signal. In some cases, the off-scale low failure may be preceded by observable erratic behavior of the analog output and/or analog output drift outside of published specifications. If the analog output is erratic or drifting outside of published specifications, the transmitter output should be considered unreliable.

Rosemount investigation has determined the higher failure rate is associated with certain lots of wire wound resistors. As of this notice, 70 percent of model 3154 wire wound resistor failures occurred at two reactor sites, suggesting higher failure rates may be experienced at individual locations.

Rosemount has revised the design of all Rosemount 3150-series nuclear qualified pressure transmitters to utilize higher reliability precision resistor technologies. This revision is fully qualified and implemented for all Rosemount 3150 series models including, but not limited to, Rosemount model 3154.

Rosemount recommends that users review the application where any of the model 3154 pressure transmitters affected are used to determine any safety consideration in the operation of the plant and report any observed failures. Rosemount model 3154 pressure transmitters within the scope of this notification are considered fully functional unless failure symptoms consistent with the description are identified.

Responsible company officer:
Gerard Hanson
Vice President and General Manager
8200 Market Blvd
Chanhassen, MN

Affected plants:
Region I: Beaver Valley, Calvert Cliffs, Ginna, Hope Creek, Indian Point, Millstone, North Anna, Salem, Seabrook, Surry, VC Summer
Region II: Browns Ferry, Catawba, Farley, Harris, Hatch, McGuire, Oconee, Robinson, Sequoyah, St. Lucie, Turkey Point, Vogtle, Watts Bar
Region III: Braidwood, Byron, Davis Besse, DC Cook, Dresden, LaSalle, Monticello, Point Beach, Prairie Island, Quad Cities
Region IV: ANO, Callaway, Columbia, Commanche Peak, Diablo Canyon, River Bend, South Texas Project, Waterford, Wolf Creek

TECHNICAL SPECIFICATION ABNORMAL OCCURRENCE

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

"On November 26, 2025, during a review of past flux trap loadings, it was identified that during the period from July 22, 2024, through August 4, 2024, the University of Missouri Research Reactor (MURR) exceeded the requirements of Technical Specification (TS) 3.8, 'Experiments.' Specifically, TS 3.8.b requires that 'The absolute value of the reactivity worth of all experiments in the center test hole shall be limited to 0.006 delta-k/k.' A review of the center test hole flux trap loading for those two weeks determined that the reactivity worth of experiments exceeded the 0.006 delta-k/k and has been re-estimated to have been approximately between 0.0061 and 0.0063 delta-k/k (from initial estimates of 0.0046 and 0.0048 delta-k/k). This underestimation of flux trap worth occurred due to inadequate programmatic controls applied to TS 4.8, 'Experiments,' specification b, which requires that 'The reactivity worth of an experiment shall be estimated or measured, as appropriate, before reactor operation with said experiment.' Specifically, multiple center test hole flux trap irradiation samples were run in the reactor without adequate prior reactivity worth estimation or measurement.

"As corrective actions to this issue, MURR is performing additional sample measurements and revising the process used for measuring and determining flux trap irradiation samples to prevent this issue from recurring.

"While the TS 3.8.b limitation is 0.006 delta-k/k, the analytical limit of the supporting safety analysis is 0.007 delta-k/k. This limitation is based upon the step insertion limits evaluated within the MURR Safety Analysis Report, Chapter 13. As a result, exceeding the 0.006 delta-k/k TS limitation by less than 0.001 delta-k/k does not result in an impact to reactor safety.

"This error does not impact any current operation or flux trap loading. This issue is being reported under TS 6.6.c(1) as it meets the TS 1.1.b and TS 1.1.f definitions for an abnormal occurrence. Specifically, TS 1.1.b defines an abnormal occurrence as an 'Operation in violation of limiting conditions for operations established in Section 3.0,' and TS 1.1.f defines abnormal occurrence as 'An observed inadequacy in the implementation of an administrative or procedural controls such that the inadequacy causes or could have caused the existence or development of an unsafe condition involving operation of the reactor.'"

The NRC Project Manager has been informed.