Event Notification Report for February 27, 2025
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/26/2025 - 02/27/2025
Agreement State
Event Number: 57574
Rep Org: North Carolina Department of HHS
Licensee: IQS Inspections
Region: 2
City: Kernersville State: NC
County:
License #: 041-0766-1
Agreement: Y
Docket:
NRC Notified By: Travis Cartoski
HQ OPS Officer: Natalie Starfish
Licensee: IQS Inspections
Region: 2
City: Kernersville State: NC
County:
License #: 041-0766-1
Agreement: Y
Docket:
NRC Notified By: Travis Cartoski
HQ OPS Officer: Natalie Starfish
Notification Date: 02/27/2025
Notification Time: 11:00 [ET]
Event Date: 02/27/2025
Event Time: 09:35 [EST]
Last Update Date: 02/27/2025
Notification Time: 11:00 [ET]
Event Date: 02/27/2025
Event Time: 09:35 [EST]
Last Update Date: 02/27/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Defrancisco, Anne (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Smith, Todd (INES)
Logan, Allen (NMSS)
Defrancisco, Anne (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Smith, Todd (INES)
Logan, Allen (NMSS)
EN Revision Imported Date: 3/12/2025
EN Revision Text: AGREEMENT STATE REPORT - LOST INDUSTRIAL RADIOGRAPHY CAMERA
The following is a summary of an email received from the North Carolina Department of Health and Human Services, North Carolina Radioactive Materials Branch (NC RMB):
"The NC RMB is currently investigating a missing industrial radiography camera. It is unknown at this time whether the camera was missing or stolen. The licensee reported that they stayed the night at a hotel in Kernersville, NC, and discovered the next morning that the camera was missing. They immediately notified NC RMB and the local police department. They are currently reviewing hotel surveillance cameras and waiting for the police to arrive."
NC Event Number: 250003
Device Info:
Model: Spec 150
S/N: 0320
Source: Ir-192
Activity: 74.0 Ci
Notified external: DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, DHS CISA Central, EPA EOC, FDA EOC, and FEMA National Watch Center. Emailed: Nuclear SSA and CWMD Watch Desk.
THIS MATERIAL EVENT CONTAINS A 'Category 2' LEVEL OF RADIOACTIVE MATERIAL
Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
EN Revision Text: AGREEMENT STATE REPORT - LOST INDUSTRIAL RADIOGRAPHY CAMERA
The following is a summary of an email received from the North Carolina Department of Health and Human Services, North Carolina Radioactive Materials Branch (NC RMB):
"The NC RMB is currently investigating a missing industrial radiography camera. It is unknown at this time whether the camera was missing or stolen. The licensee reported that they stayed the night at a hotel in Kernersville, NC, and discovered the next morning that the camera was missing. They immediately notified NC RMB and the local police department. They are currently reviewing hotel surveillance cameras and waiting for the police to arrive."
NC Event Number: 250003
Device Info:
Model: Spec 150
S/N: 0320
Source: Ir-192
Activity: 74.0 Ci
Notified external: DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, DHS CISA Central, EPA EOC, FDA EOC, and FEMA National Watch Center. Emailed: Nuclear SSA and CWMD Watch Desk.
THIS MATERIAL EVENT CONTAINS A 'Category 2' LEVEL OF RADIOACTIVE MATERIAL
Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
Agreement State
Event Number: 57576
Rep Org: Texas Dept of State Health Services
Licensee: Exon Mobile Corporation
Region: 4
City: Mont Belvieu State: TX
County: Chambers
License #: L 03119
Agreement: Y
Docket:
NRC Notified By: Arthur L Tucker
HQ OPS Officer: Troy Johnson
Licensee: Exon Mobile Corporation
Region: 4
City: Mont Belvieu State: TX
County: Chambers
License #: L 03119
Agreement: Y
Docket:
NRC Notified By: Arthur L Tucker
HQ OPS Officer: Troy Johnson
Notification Date: 02/27/2025
Notification Time: 17:11 [ET]
Event Date: 02/27/2025
Event Time: 00:00 [CST]
Last Update Date: 02/27/2025
Notification Time: 17:11 [ET]
Event Date: 02/27/2025
Event Time: 00:00 [CST]
Last Update Date: 02/27/2025
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 SHUTTER
The following report was received from the Texas Department of State Health Services:
"On February 27, 2025, the licensee reported that the shutter on a Vega model SH-F2C-45 containing a 500 millicurie (original activity) cesium-137 source was found stuck in the open position during routine testing. Open is the normal operating position. 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-10175
NMED number: TX250014
The following report was received from the Texas Department of State Health Services:
"On February 27, 2025, the licensee reported that the shutter on a Vega model SH-F2C-45 containing a 500 millicurie (original activity) cesium-137 source was found stuck in the open position during routine testing. Open is the normal operating position. 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-10175
NMED number: TX250014
Power Reactor
Event Number: 57575
Facility: Susquehanna
Region: 1 State: PA
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: John Teck
HQ OPS Officer: Troy Johnson
Region: 1 State: PA
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: John Teck
HQ OPS Officer: Troy Johnson
Notification Date: 02/27/2025
Notification Time: 13:34 [ET]
Event Date: 02/27/2025
Event Time: 08:00 [EST]
Last Update Date: 02/27/2025
Notification Time: 13:34 [ET]
Event Date: 02/27/2025
Event Time: 08:00 [EST]
Last Update Date: 02/27/2025
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Defrancisco, Anne (R1DO)
FFD Group, (EMAIL)
Defrancisco, Anne (R1DO)
FFD Group, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 2 | N | Y | 93 | Power Operation | 93 | Power Operation |
FITNESS FOR DUTY
The following information was provided by the licensee via phone and email:
A non-licensed supervisor 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 non-licensed supervisor 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: 57584
Rep Org: California Radiation Control Prgm
Licensee: Keck Hospital of USC
Region: 4
City: Los Angeles State: CA
County:
License #: 5592-19
Agreement: Y
Docket:
NRC Notified By: L. Robert Greger
HQ OPS Officer: Adam Koziol
Licensee: Keck Hospital of USC
Region: 4
City: Los Angeles State: CA
County:
License #: 5592-19
Agreement: Y
Docket:
NRC Notified By: L. Robert Greger
HQ OPS Officer: Adam Koziol
Notification Date: 03/04/2025
Notification Time: 07:38 [ET]
Event Date: 02/27/2025
Event Time: 00:00 [PST]
Last Update Date: 03/04/2025
Notification Time: 07:38 [ET]
Event Date: 02/27/2025
Event Time: 00:00 [PST]
Last Update Date: 03/04/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Gepford, Heather (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Gepford, Heather (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was provided by the California Department of Public Health, Radiologic Health Branch, via email:
"On February 28, 2025, the radiation safety officer (RSO) at Keck Hospital of University of Southern California, contacted the Los Angeles County Radiation Management office to report a possible medical event that occurred on February 27, 2025, during a Y-90 Therasphere radioembolization treatment of a liver cancer patient. The RSO indicated that due to abnormally high readings from the waste container associated with one of two dosage vials, he was unable to confirm the dosage administered to the patient. He sent the waste container to the vendor, Boston Scientific, for evaluation, in order to determine the administered dosage.
"On March 3, 2025, [the RSO] reported via e-mail that the patient was prescribed a total dose of 1300 Gy, but only 695.5 Gy was delivered during the treatment, which was attributed to the dosage from one of two dosage vials being stuck in the tubing. The underdosage meets the criteria for a reportable medical event. The incident did not cause any harm to the patient. Further analysis will be conducted by Boston Scientific to determine the reason for the dosage being stuck in the tubing."
CA Event Number: 022825
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 California Department of Public Health, Radiologic Health Branch, via email:
"On February 28, 2025, the radiation safety officer (RSO) at Keck Hospital of University of Southern California, contacted the Los Angeles County Radiation Management office to report a possible medical event that occurred on February 27, 2025, during a Y-90 Therasphere radioembolization treatment of a liver cancer patient. The RSO indicated that due to abnormally high readings from the waste container associated with one of two dosage vials, he was unable to confirm the dosage administered to the patient. He sent the waste container to the vendor, Boston Scientific, for evaluation, in order to determine the administered dosage.
"On March 3, 2025, [the RSO] reported via e-mail that the patient was prescribed a total dose of 1300 Gy, but only 695.5 Gy was delivered during the treatment, which was attributed to the dosage from one of two dosage vials being stuck in the tubing. The underdosage meets the criteria for a reportable medical event. The incident did not cause any harm to the patient. Further analysis will be conducted by Boston Scientific to determine the reason for the dosage being stuck in the tubing."
CA Event Number: 022825
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: 57591
Rep Org: Kentucky Dept of Radiation Control
Licensee: Cardinal Health 414, LLC
Region: 1
City: Louisville State: KY
County:
License #: KY 202-206-32
Agreement: Y
Docket:
NRC Notified By: Angela Wilbers
HQ OPS Officer: Karen Cotton-Gross
Licensee: Cardinal Health 414, LLC
Region: 1
City: Louisville State: KY
County:
License #: KY 202-206-32
Agreement: Y
Docket:
NRC Notified By: Angela Wilbers
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 03/05/2025
Notification Time: 14:44 [ET]
Event Date: 02/27/2025
Event Time: 08:00 [CST]
Last Update Date: 03/05/2025
Notification Time: 14:44 [ET]
Event Date: 02/27/2025
Event Time: 08:00 [CST]
Last Update Date: 03/05/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Ford, Monica (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Ford, Monica (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - ELUATE EXCEEDED PERMISSIBLE CONCENTRATION
The following information was summarized from an email submitted by the Kentucky Department of Radiation Control:
An eluate exceeded the permissible concentration listed in 10 CFR 35.3204(a) at the time of generator elution. The permissible concentration cannot exceed a ratio of 0.15 microcuries of molybdenumm-99 per millicurie of technetium-99m. The eluate measured 34.6 microcuries Mo-99 to 16.6 millicuries Tc-99m which is a ratio of 2.1.
No doses went out to patients from this elution. The generator had been eluted earlier in the week without incident.
The manufacturer of the generator (Curium, lot number 914-025-023) was notified. The generator has been segregated awaiting return to Curium.
The following information was summarized from an email submitted by the Kentucky Department of Radiation Control:
An eluate exceeded the permissible concentration listed in 10 CFR 35.3204(a) at the time of generator elution. The permissible concentration cannot exceed a ratio of 0.15 microcuries of molybdenumm-99 per millicurie of technetium-99m. The eluate measured 34.6 microcuries Mo-99 to 16.6 millicuries Tc-99m which is a ratio of 2.1.
No doses went out to patients from this elution. The generator had been eluted earlier in the week without incident.
The manufacturer of the generator (Curium, lot number 914-025-023) was notified. The generator has been segregated awaiting return to Curium.