Event Notification Report for February 14, 2025
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/13/2025 - 02/14/2025
Agreement State
Event Number: 57548
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Exxon Mobil Oil Corp.
Region: 3
City: Joliet State: IL
County:
License #: IL-01742-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Ernest West
Licensee: Exxon Mobil Oil Corp.
Region: 3
City: Joliet State: IL
County:
License #: IL-01742-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Ernest West
Notification Date: 02/14/2025
Notification Time: 14:33 [ET]
Event Date: 02/14/2025
Event Time: 00:00 [CST]
Last Update Date: 02/14/2025
Notification Time: 14:33 [ET]
Event Date: 02/14/2025
Event Time: 00:00 [CST]
Last Update Date: 02/14/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Orlikowski, Robert (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Orlikowski, Robert (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - STUCK OPEN SHUTTER
The following information was provided by the Illinois Emergency Management Agency (the Agency) via phone and email:
"The Agency was contacted on 2/14/25 by representatives for ExxonMobil Oil Corp. (IL-01742-01) in Joliet, IL, to report a fixed gauge shutter stuck in the open position. The 20 mCi Cs-137 source is oriented into a process vessel that will not be entered. The gauge is normally in the `open' position and the vessel remains in use and full of commodity.
"The manufacturer's representative is being contacted to coordinate a site visit and make appropriate repairs. There are no exposures reported or anticipated as a result of this issue. The shutter condition was discovered [on 2/14/25] and reporting requirements were met. Inspectors are coordinating a site visit to gather supporting details. This matter is reportable within 24 hours under 32 Illinois Administrative Code 340.1220(c)(2). Updates will be provided as they become available."
Illinois Item Number: IL250007
The following information was provided by the Illinois Emergency Management Agency (the Agency) via phone and email:
"The Agency was contacted on 2/14/25 by representatives for ExxonMobil Oil Corp. (IL-01742-01) in Joliet, IL, to report a fixed gauge shutter stuck in the open position. The 20 mCi Cs-137 source is oriented into a process vessel that will not be entered. The gauge is normally in the `open' position and the vessel remains in use and full of commodity.
"The manufacturer's representative is being contacted to coordinate a site visit and make appropriate repairs. There are no exposures reported or anticipated as a result of this issue. The shutter condition was discovered [on 2/14/25] and reporting requirements were met. Inspectors are coordinating a site visit to gather supporting details. This matter is reportable within 24 hours under 32 Illinois Administrative Code 340.1220(c)(2). Updates will be provided as they become available."
Illinois Item Number: IL250007
Agreement State
Event Number: 57556
Rep Org: MA Radiation Control Program
Licensee: Beth Israel Deaconess Medical Center
Region: 1
City: Boston State: MA
County:
License #: 60-0432
Agreement: Y
Docket:
NRC Notified By: Robert Locke
HQ OPS Officer: Kerby Scales
Licensee: Beth Israel Deaconess Medical Center
Region: 1
City: Boston State: MA
County:
License #: 60-0432
Agreement: Y
Docket:
NRC Notified By: Robert Locke
HQ OPS Officer: Kerby Scales
Notification Date: 02/18/2025
Notification Time: 09:31 [ET]
Event Date: 02/14/2025
Event Time: 00:00 [EST]
Last Update Date: 02/18/2025
Notification Time: 09:31 [ET]
Event Date: 02/14/2025
Event Time: 00:00 [EST]
Last Update Date: 02/18/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
DeBoer, Joseph (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
DeBoer, Joseph (R1DO)
AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was received from the Massachusetts Radiation Control Program (the Agency) via email:
"On 02/14/25, at 0549 EST, the licensee, Beth Israel Deaconess Medical Center reported a medical event involving Yttrium-90 Theraspheres (Nordion BWXT ITG Canada, Inc. Model TheraSphere Y-90 Glass Microsphere System, SSD NR-0220-D-131-S). The total administered activity differed from prescribed treatment activity as documented in the written directive by 20 percent or more.
"The medical event occurred on 2/14/2025. The patient received two doses. For the first dose, the activity delivered was calculated to be 58.4 percent of the prescribed activity (prescribed activity: 1.84 GBq, delivered activity: 1.075 GBq). For the second dose, the activity delivered was calculated to be 68.6 percent of the prescribed activity (prescribed activity: 0.8 GBq, delivered activity: 0.549 GBq). The event was identified on 2/14/25. The licensee did not report if there were any adverse effects on the patient. The licensee did not report whether the authorized user, referring physician, and patient have been notified.
"The Agency will follow up with the licensee radiation safety officer to determine the event cause and corrective actions. This is the second medical event during this week involving Theraspheres from this licensee. The licensee has ceased Therasphere procedures at the facility.
"The Agency considers this event open. The Agency will follow up with a special inspection of the licensee."
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.
The following information was received from the Massachusetts Radiation Control Program (the Agency) via email:
"On 02/14/25, at 0549 EST, the licensee, Beth Israel Deaconess Medical Center reported a medical event involving Yttrium-90 Theraspheres (Nordion BWXT ITG Canada, Inc. Model TheraSphere Y-90 Glass Microsphere System, SSD NR-0220-D-131-S). The total administered activity differed from prescribed treatment activity as documented in the written directive by 20 percent or more.
"The medical event occurred on 2/14/2025. The patient received two doses. For the first dose, the activity delivered was calculated to be 58.4 percent of the prescribed activity (prescribed activity: 1.84 GBq, delivered activity: 1.075 GBq). For the second dose, the activity delivered was calculated to be 68.6 percent of the prescribed activity (prescribed activity: 0.8 GBq, delivered activity: 0.549 GBq). The event was identified on 2/14/25. The licensee did not report if there were any adverse effects on the patient. The licensee did not report whether the authorized user, referring physician, and patient have been notified.
"The Agency will follow up with the licensee radiation safety officer to determine the event cause and corrective actions. This is the second medical event during this week involving Theraspheres from this licensee. The licensee has ceased Therasphere procedures at the facility.
"The Agency considers this event open. The Agency will follow up with a special inspection of the licensee."
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
Event Number: 57550
Rep Org: SC Dept of Health & Env Control
Licensee: Mitsubishi Chemical America, Inc.
Region: 1
City: Greer State: SC
County:
License #: 036
Agreement: Y
Docket:
NRC Notified By: Adam L. Gause
HQ OPS Officer: Ernest West
Licensee: Mitsubishi Chemical America, Inc.
Region: 1
City: Greer State: SC
County:
License #: 036
Agreement: Y
Docket:
NRC Notified By: Adam L. Gause
HQ OPS Officer: Ernest West
Notification Date: 02/15/2025
Notification Time: 12:24 [ET]
Event Date: 02/14/2025
Event Time: 00:00 [EST]
Last Update Date: 03/05/2025
Notification Time: 12:24 [ET]
Event Date: 02/14/2025
Event Time: 00:00 [EST]
Last Update Date: 03/05/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Henrion, Mark (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Henrion, Mark (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
EN Revision Imported Date: 3/6/2025
EN Revision Text: AGREEMENT STATE REPORT - DAMAGED FIXED GAUGE
The following information was provided by the South Carolina Department of Environmental Services (the Department) via phone and email:
"The licensee informed the Department on February 14, 2025, via telephone, that it had discovered damage (tear) to the film covering the window of the source side of a fixed gauging device. The licensee discovered this event on February 14, 2025. The licensee reported that a representative from the manufacturer of the fixed gauging device was on-site and repaired/replaced the source side window on February 14, 2025. The licensee reported that the the fixed gauging device shutter closed as expected, and the licensee did not report any ongoing health and safety concerns or overexposures.
"The fixed gauging device is a Thermo EGS Gauging LLC, Model TFC-185 (source holder serial number KA2196), housing a 1250 mCi Kr-85 sealed source. The sealed source is a Isotope Product Laboratories Model NER-588. This event is still under investigation by the Department."
South Carolina Event Number: TBD
* * * UPDATE ON 03/05/2025 AT 1423 FROM ADAM GAUSE TO ROBERT THOMPSON * * *
The following information was provided by the South Carolina Department of Environmental Services (the Department) via email:
"The licensee submitted a 30-day written report on February 26, 2025. The details of the written report were consistent with the initial notification. The serial number of the source is also KA2196. The internal South Carolina Event Number is SC250002. This event/investigation is considered closed. The report for NMED item number SC250002 was uploaded today."
Notified R1DO (Ford) and NMSS Events Notification (email).
EN Revision Text: AGREEMENT STATE REPORT - DAMAGED FIXED GAUGE
The following information was provided by the South Carolina Department of Environmental Services (the Department) via phone and email:
"The licensee informed the Department on February 14, 2025, via telephone, that it had discovered damage (tear) to the film covering the window of the source side of a fixed gauging device. The licensee discovered this event on February 14, 2025. The licensee reported that a representative from the manufacturer of the fixed gauging device was on-site and repaired/replaced the source side window on February 14, 2025. The licensee reported that the the fixed gauging device shutter closed as expected, and the licensee did not report any ongoing health and safety concerns or overexposures.
"The fixed gauging device is a Thermo EGS Gauging LLC, Model TFC-185 (source holder serial number KA2196), housing a 1250 mCi Kr-85 sealed source. The sealed source is a Isotope Product Laboratories Model NER-588. This event is still under investigation by the Department."
South Carolina Event Number: TBD
* * * UPDATE ON 03/05/2025 AT 1423 FROM ADAM GAUSE TO ROBERT THOMPSON * * *
The following information was provided by the South Carolina Department of Environmental Services (the Department) via email:
"The licensee submitted a 30-day written report on February 26, 2025. The details of the written report were consistent with the initial notification. The serial number of the source is also KA2196. The internal South Carolina Event Number is SC250002. This event/investigation is considered closed. The report for NMED item number SC250002 was uploaded today."
Notified R1DO (Ford) and NMSS Events Notification (email).