Event Notification Report for July 09, 2026

AGREEMENT STATE REPORT - STUCK OPEN GAUGE

The following is a summary of information provided by the Nevada Division of Rad Health via phone and email:

The licensee reported a stuck open shutter on a fixed gauge. A contractor has been contacted for repair, the immediate area around the gauge has been cordoned off, and an investigation will be conducted. The radiation safety officer will coordinate service. The workers in the immediate area did not receive a dose.

Gauge Information:
Manufacturer: Ronan Engineering
Model: SA1-C5
Serial Number: 0718CG
Source: 50 mCi Cs-137

Report number: NV260004

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:

The licensee reported a lost exit sign that contained 9.21 Ci of tritium.

Manufacturer: SRB Technologies Inc
Model number: BX-10-WH

Colorado event number: CO260008


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 - LOST EXIT SIGNS

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

The licensee reported eleven exit signs, with a total activity of 83.05 Ci of tritium, lost.

Two of the following:
Manufacturer: SRB Technologies
Model number: BX-10-GY
Activity: 9.21 Ci

Four of the following:
Manufacturer: Best Lighting Products, Inc.
Model number: SLXTU1GB10
Activity: 7.09 Ci

Three of the following:
Manufacturer: Best Lighting Products, Inc.
Model number: SLXTU1GW10
Activity: 7.09 Ci

Two of the following:
Manufacturer: Isolite Corporation
Model number: SLX60
Activity: 7.5 Ci

Colorado event number: CO260009

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 - UNRETRACTABLE SOURCE

The following is a summary of information provided by the New Jersey Department of Environmental Protection (NJDEP) via email:

On May 27, 2026, at approximately 0956 EDT, a licensee radiography crew contacted the radiation safety officer (RSO) regarding an 86.6 Ci Ir-192 source (serial number 29161P) which could not be retracted into the radiography camera (QSA D880 serial number D13840). The guide tube was likely crimped when a bar clamp attached to the guide tube became unattached and fell. The crew established a 2 mR/h barrier and secured access to the area. The RSO arrived on site around 1115 and secured the source back into the camera by 1411. The RSO received an estimated dose of 483 mR. Three additional staff received estimated doses of 120 mR, 200 mR, and 245 mR.

NJ Event Number: TBD

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was provided by the Pennsylvania Bureau of Radiation Protection (the Department) via email:

"On June 30, 2026, the licensee notified the Department of a medical event that occurred on June 29, 2026, at approximately 1545 EDT.

"A patient was being treated with high dose rate (HDR) Ir-192 to a 5 cc area using a vaginal cuff with vaginal cylinder. The original treatment was 600 cGy per fraction, 5 fractions, and this was her 2nd treatment. The applicator was installed but while waiting for the authorized user (AU), the patient started coughing. A nurse checked the patient, and it seemed like everything was fine. When the AU arrived, they informed them of the coughing and they asked some questions. The nurse said everything looked okay, so they went ahead with treatment without the AU checking for themselves. The treatment was delivered. When the AU went to pull the cylinder out, it was removed with no resistance which indicated it was further out of the patient than intended. The AU reinserted the cylinder to the area they thought it should have been located for the treatment and noted that when removing the cylinder after treatment it was 5-6 cm further out of the patient than it should have been. They suspect it moved when the patient coughed before treatment, but it could have moved during treatment. They performed an initial dose estimate and found that when the cylinder moved 5 cm the source did not provide any dose to the intended tissue and delivered all 600 cGy (600 rem) to the vaginal mucosa/vaginal wall. This area should have received 4 percent of the dose if the treatment was delivered as intended (24 cGy). This is reportable under 35.3045(a)(1)(i)(C) and 35.3045(a)(1)(iii).

"The AU does not expect any adverse effects. The patient and referring physician have been notified. The Department will perform a reactive inspection."

Pennsylvania Event Report ID Number: PA260009

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 SOURCE

The following information was received from the Virginia Radioactive Materials Program (VRMP) via email:

"On July 1, 2026, the licensee discovered and reported a lost generally licensed Cs-137 fixed gauge source with a current activity of 12.1 mCi. Source model number CDC.P4 with serial number MT563, gauge model Berthold LB7440. The gauge containing the source was reported to be locked out in the shielded position. It is believed the gauge was disposed of in scrap metal during demolition work conducted the week prior to July 1. The licensee has conducted a thorough search, including their site and visits to potential scrap metal facilities they use, but the source/gauge was not located. There is no indication of any exposures associated with this incident thus far.

"The source meets the reporting requirement of immediately after it becomes known. The licensee plans to continue searching for the source and will contact the agency if found. The licensee has been instructed to file a written report with the VRMP within 30 days."

* * * UPDATE ON 07/02/2026 AT 1035 EDT FROM SHEILA NELSON TO CHRISTOPHER PRESCOTT * * *

The following information was provided by the Virginia Radioactive Materials Program (VRMP) via email:

"The licensee has located the gauge/source. It has been locked in a secure storage building on their site since the demolition work occurred. The radiation safety officer has confirmed the gauge is still appropriately locked out in the shielded position and there have been no exposures to anyone."

Notified R1DO (Dentel), NMSS Events Notifications (Email), and ILTAB (Email).

Virginia Event Number: VA260003

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 - STUCK SHUTTER

The following is a summary of information provided by the Louisiana Radiation Protection Division via email:

On June 25, 2026, Dow Chemical Company notified the Division that a fixed gauge shutter was found in the open position and was not functioning properly during required six month operability checks. Because operators were concerned that the shutter might not reopen if closed, and the shutter was needed to remain open for the manufacturing process, they chose not to close it. The licensee plans to replace the device housing with a newly designed housing during a planned outage in February 2027.

Shutter Information:
Model: Vega SHF2B
Serial Number: 0368CR

Source Information:
Isotope and Activity: Cs 137, 500 mCi
Source Serial Number: 38953125

Louisiana Event Report ID No.: LA20260011