NRC Proposes $9,000 Fine for Defense Health Agency for Loss of Radioactive Material

No: I-24-013 July 2, 2024
CONTACT: Diane Screnci, 610-337-5330
Neil Sheehan, 610-337-5331

NRC Proposes $9,000 Fine for Defense Health Agency for Loss of Radioactive Material

The Nuclear Regulatory Commission has proposed a $9,000 civil penalty to the Defense
Health Agency for loss of nuclear material used during medical procedures.

DHA, headquartered in Falls Church, Virginia, oversees medical treatment facilities within
the Department of Defense, including the Brooke Army Medical Center at Fort Sam Houston,
Texas.

In March 2023, DHA reported the loss of a single seed containing iodine-125 that is used to
help target the location of cancerous tissue. The seed could not be located after being removed from
a patient at Brooke Army Medical Center and sent to a laboratory for analysis. The NRC performed
an inspection at the medical center in June 2023, to review what occurred.

Later, DHA reported the loss of 10 additional iodine-125 seeds believed to be in storage.
The NRC then conducted a reactive inspection. Despite an investigation and multiple searches, the
material was not found.

In February, the NRC notified DHA that it had identified two apparent violations stemming
from the loss of the seeds and was considering escalated enforcement, including a civil penalty. The
violations include a failure to properly secure stored NRC-licensed materials and a failure to control
them when not in storage. DHA was informed it could submit a written response, request a
predecisional enforcement conference or seek to resolve the matter via the alternative dispute
resolution mediation process.

DHA provided a written response in April requesting the NRC reduce the proposed civil
penalty based in part on DHA’s prompt self-reporting of the loss, reviews DHA did to better
understand what occurred, and procedural and other changes DHA made to prevent recurrence.

24-013-i.pdf