Event Notification Report for February 10, 2025

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was provided by the Georgia Radioactive Materials Program via email:

"On February 11, 2025, the radiation safety officer reported a misadministration which occurred on February 10, 2025 at Northside Hospital Gwinnett in Lawrenceville, Georgia. A patient was prescribed a reduced dose of 160 mCi of lutetium-77 under the brand name Pluvicto, used for the treatment of metastatic prostate cancer, but the regular dose of 200 mCi was accidentally administered rather than the lower dose. The referring physician was notified, and the patient will be seen before the end of the week to ensure that no adverse effects have been caused by the higher dosage."

NMED Incident number: 91

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: 8/15/2025

EN Revision Text: LOST CHEMICAL AGENT DETECTORS

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

On February 18, 2025, Naval Sea System Command Detachment, Radiological Affairs Support Office was notified of the following information:

On February 10, 2025, Marine Corps Logistics Command declared the loss of ten automatic chemical agent detector alarm (ACADA) systems (model no. NSN 6665-01-438-3673). Each ACADA contains 30 mCi of Ni-63. The loss was identified by the Marine Corps Logistics Command Radiological Control Office during October 2024 actions to terminate their Ni-63 permit (10-67004-T1NP). The last known reference to the detectors were during an October 2022 shipment from command distribution in Albany, GA to a force storage battalion where the detectors never arrived. Various interviews, search, and tracking efforts occurred with the detectors being removed from inventory in April 2024.

No known exposures have occurred.

To prevent recurrence, RFIDs are being utilized to ensure tracking and accountability along with adherence to GCSS-MC tracking standards.

* * * RETRACTION ON 08/14/2024 AT 1552 EDT FROM CDR MATT BEERY TO ROBERT THOMPSON * * *

The following information was provided by the licensee via email:

"The Naval Radiation Safety Committee (NRSC) requests to retract the report made 11 Feb 2025.

"The NRSC has determined that the automatic chemical agent detector alarm (ACADA) [systems], originally deemed as lost, were actually shipped to the Army Joint Munitions Command (Department of Defense Low Level Radioactive Waste Office) for disposal in March 2022. This is based on the discovery of errors noted on a shipping document that forwarded ACADAs from the Defense Logistics Agency to the Second Force Storage Battalion, which mistakenly led to an inventory error and ultimately the report to the NRC."

Notified R1DO (Bickett), NMSS Events Notification (email), ILTAB (email).

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 OPEN SHUTTER

The following information was received from the Minnesota Department of Health, Radioactive Materials Unit via email:

"During the licensee's semi-annual wipe and shutter check for their fixed gauges, the licensee identified a radiation source with a shutter that is stuck in the [open] position. The device is a Vega/Omart SHF1-45 containing 2 mCi of Cs-137. The gauge is not readily accessible."

Minnesota Event Report ID number: MN250001

EN Revision Imported Date: 10/17/2025

EN Revision Text: AGREEMENT STATE REPORT - LOST EXIT SIGN

The following information was provided by the New York State Department of Health (NYSDOH) via email:

"NYSDOH received a phone call from the general manager of AMC Theatres 8, to report a missing tritium exit sign. The device was no longer functioning and was removed for replacement on or about December 4, 2024. The sign was set aside for pick up by the contractor. On February 10, 2025, at approximately 1100 EST, the general manager discovered the sign was missing. The make/model/serial number of the sign is unknown. However, the theater is attempting to gather additional information.

"No further information on the device, source, or incident is available at this time.

"It is suspected that the tritium exit sign may have been disposed of in the regular trash, but AMC Theatres is investigating the potential whereabouts and causes for this lost device. It is not believed that the tritium exit sign is damaged and/or leaking and it is not believed that this event led to any exposure or dose to members of the public.

"Given the normal activity of these devices and the 12.3-year half-life, it is suspected that the quantity of H3 exceeds the reportability threshold required by 10 CFR 20.2201(a)(1)(i).

"NYSDOH is monitoring this event and has assigned NYSDOH Incident No. 1515 to internally track this event."

Event Report ID No.: NY-25-02

* * * UPDATE ON 10/16/2025 AT 1018 EDT FROM NATHAN KISHBAUGH TO ERNEST WEST * * *

"NYSDOH was monitoring this event and assigned NYSDOH Incident number 1515 to internally track the event. Following the original notification of this event, a report was requested and received from the general manager. The theater staff searched for the missing exit sign, but exit sign was not found. As a corrective action, should the situation arise in the future, where any exit signs are removed and stored on site, the general manager will secure the items in his personal office. The general manager was notified in writing that should the exit sign be located; our office must be notified. Subsequently, Incident number 1515 has been closed. Should this device be located/found, the licensee has been instructed to notify NYSDOH and this incident will be reopened and updated. The licensee has been made aware of the notification requirements in 10 CFR 20.2201(d)."

Notified R1DO (Young), NMSS Events Notification (Email), ILTAB (Email), and CNSC (Email)

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

EN Revision Imported Date: 2/13/2025

EN Revision Text: MANUAL REACTOR TRIP DUE TO ELECTROHYDRAULIC CONTROL SYSTEM LEAK

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

"At 1216 EST, on 2/10/2025 with Unit 1 in mode 1 at 66.5 percent power, the reactor was manually tripped due to an electro-hydraulic control power system leak. The trip was not complex with all systems responding normally post-trip.

"Operations responded and stabilized the plant. Decay heat is being removed by the emergency feedwater system.

"Due to the reactor protection system actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR50.72(b)(2)(iv)(B) and an eight-hour, non-emergency notification per 10CFR 50.72(b)(3)(iv)(A) resulting from a valid actuation of the reactor protection and emergency feedwater systems.

"There was no impact on the health and safety of the public or plant personnel.

"The NRC Resident Inspector has been notified."