Event Notification Report for February 26, 2025
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/25/2025 - 02/26/2025
Agreement State
Event Number: 57621
Rep Org: New York City Bureau of Rad Health
Licensee: Mount Sinai Medical Center
Region: 1
City: New York City State: NY
County:
License #: 75-2909-04
Agreement: Y
Docket:
NRC Notified By: Erik Finkelstein
HQ OPS Officer: Robert A. Thompson
Licensee: Mount Sinai Medical Center
Region: 1
City: New York City State: NY
County:
License #: 75-2909-04
Agreement: Y
Docket:
NRC Notified By: Erik Finkelstein
HQ OPS Officer: Robert A. Thompson
Notification Date: 03/24/2025
Notification Time: 10:49 [ET]
Event Date: 02/26/2025
Event Time: 00:00 [EDT]
Last Update Date: 03/24/2025
Notification Time: 10:49 [ET]
Event Date: 02/26/2025
Event Time: 00:00 [EDT]
Last Update Date: 03/24/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Arner, Frank (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Arner, Frank (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL EVENT
The following is a summary of information provided by the New York City Department of Health via email:
On February 26, 2025, the licensee reported a dose administered differed by more than 20 percent of the prescribed dose. During an administration of Lu-177-PSMA [lutetium-177-prostate specific membrane antigen], the administration was stopped because it was determined that the patient's creatine level was significantly elevated. The administered activity was estimated as 49 mCi, out of an intended/prescribed activity of 162 mCi.
New York Identification Number: NYC-25-0226.
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 is a summary of information provided by the New York City Department of Health via email:
On February 26, 2025, the licensee reported a dose administered differed by more than 20 percent of the prescribed dose. During an administration of Lu-177-PSMA [lutetium-177-prostate specific membrane antigen], the administration was stopped because it was determined that the patient's creatine level was significantly elevated. The administered activity was estimated as 49 mCi, out of an intended/prescribed activity of 162 mCi.
New York Identification Number: NYC-25-0226.
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.
Power Reactor
Event Number: 57572
Facility: Waterford
Region: 4 State: LA
Unit: [3] [] []
RX Type: [3] CE
NRC Notified By: Lillian Brown
HQ OPS Officer: Kerby Scales
Region: 4 State: LA
Unit: [3] [] []
RX Type: [3] CE
NRC Notified By: Lillian Brown
HQ OPS Officer: Kerby Scales
Notification Date: 02/26/2025
Notification Time: 17:12 [ET]
Event Date: 02/26/2025
Event Time: 11:56 [CST]
Last Update Date: 02/26/2025
Notification Time: 17:12 [ET]
Event Date: 02/26/2025
Event Time: 11:56 [CST]
Last Update Date: 02/26/2025
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Roldan-Otero, Lizette (R4DO)
FFD Group, (EMAIL)
Roldan-Otero, Lizette (R4DO)
FFD Group, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 3 | N | Y | 94 | Power Operation | 94 | Power Operation |
FITNESS FOR DUTY
The following information was provided by the licensee via phone and email:
A licensed operator had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.
The NRC Resident Inspector has been notified.
The following information was provided by the licensee via phone and email:
A licensed operator had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated.
The NRC Resident Inspector has been notified.
Agreement State
Event Number: 57573
Rep Org: Texas Dept of State Health Services
Licensee: Ascend Performance Materials Inc.
Region: 4
City: Alvin State: TX
County:
License #: L06630
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Brian P. Smith
Licensee: Ascend Performance Materials Inc.
Region: 4
City: Alvin State: TX
County:
License #: L06630
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Brian P. Smith
Notification Date: 02/26/2025
Notification Time: 18:56 [ET]
Event Date: 02/26/2025
Event Time: 00:00 [CST]
Last Update Date: 02/26/2025
Notification Time: 18:56 [ET]
Event Date: 02/26/2025
Event Time: 00:00 [CST]
Last Update Date: 02/26/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Roldan-Otero, Lizette (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Roldan-Otero, Lizette (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - STUCK SHUTTERS
The following report was received from the Texas Department of State Health Services (the Department):
"On February 26, 2025, the Department was notified by the licensee that during routine testing, the shutters on three nuclear gauges were found stuck in the open position. Open is the normal operating position for the gauges. The gauges are all Texas Nuclear gauge models; a '5200' model containing a 20 millicurie source, a '5201' model containing a 100 millicurie source, and a '5208' model containing a 4,000 millicurie source. All sources are cesium - 137 sources. The licensee reported that there is no risk of additional radiation exposure to members of the general public or radiation workers due to this on/off mechanism failure. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Number: I-10173
The following report was received from the Texas Department of State Health Services (the Department):
"On February 26, 2025, the Department was notified by the licensee that during routine testing, the shutters on three nuclear gauges were found stuck in the open position. Open is the normal operating position for the gauges. The gauges are all Texas Nuclear gauge models; a '5200' model containing a 20 millicurie source, a '5201' model containing a 100 millicurie source, and a '5208' model containing a 4,000 millicurie source. All sources are cesium - 137 sources. The licensee reported that there is no risk of additional radiation exposure to members of the general public or radiation workers due to this on/off mechanism failure. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Number: I-10173
Agreement State
Event Number: 57972
Rep Org: Texas Dept of State Health Services
Licensee: UT SW Medical Center - Dallas
Region: 4
City: Houston State: TX
County:
License #: 05947
Agreement: Y
Docket:
NRC Notified By: Sindiso Ncube
HQ OPS Officer: Robert A. Thompson
Licensee: UT SW Medical Center - Dallas
Region: 4
City: Houston State: TX
County:
License #: 05947
Agreement: Y
Docket:
NRC Notified By: Sindiso Ncube
HQ OPS Officer: Robert A. Thompson
Notification Date: 10/06/2025
Notification Time: 19:53 [ET]
Event Date: 02/26/2025
Event Time: 00:00 [CDT]
Last Update Date: 10/06/2025
Notification Time: 19:53 [ET]
Event Date: 02/26/2025
Event Time: 00:00 [CDT]
Last Update Date: 10/06/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Vossmar, Patricia (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Andrea Kock (NMSS)
Vossmar, Patricia (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Andrea Kock (NMSS)
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 October 6, 2025, the Department received notification from the licensee regarding a treatment error during stereotactic radiosurgery with the gamma knife system for a patient with a brain arteriovenous malformation (AVM). The patient was prescribed 2 treatment sessions of 12 Gy each. The licensee stated that an error during the transfer from the frame coordinate system to the mask coordinate system resulted in radiation being delivered to an incorrect site in the brain. As a result, the dose delivered to the treatment site was less than the prescribed dose. The licensee stated that the event occurred in February 2025 and was discovered by the radiation oncology team during an internal review exercise of all AVM treatments provided by the licensee since 2016. This review was initiated following a similar incident involving the same procedure which the licensee had previously discovered on October 2, 2025, and reported to the Department on October 3, 2025 (see EN 57966). The licensee conducted this review to determine whether other patients had been affected by the same system error. According to the licensee, out of all cases reviewed, only this one met the criteria to be classified as a reportable event.
"Additional information will be provided in accordance with SA300 Reporting requirements."
Texas incident number: 10235
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 provided by the Texas Department of State Health Services (the Department) via phone and email:
"On October 6, 2025, the Department received notification from the licensee regarding a treatment error during stereotactic radiosurgery with the gamma knife system for a patient with a brain arteriovenous malformation (AVM). The patient was prescribed 2 treatment sessions of 12 Gy each. The licensee stated that an error during the transfer from the frame coordinate system to the mask coordinate system resulted in radiation being delivered to an incorrect site in the brain. As a result, the dose delivered to the treatment site was less than the prescribed dose. The licensee stated that the event occurred in February 2025 and was discovered by the radiation oncology team during an internal review exercise of all AVM treatments provided by the licensee since 2016. This review was initiated following a similar incident involving the same procedure which the licensee had previously discovered on October 2, 2025, and reported to the Department on October 3, 2025 (see EN 57966). The licensee conducted this review to determine whether other patients had been affected by the same system error. According to the licensee, out of all cases reviewed, only this one met the criteria to be classified as a reportable event.
"Additional information will be provided in accordance with SA300 Reporting requirements."
Texas incident number: 10235
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.